New ESC guideline recommends SGLT2 inhibitors for HFrEF
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SGLT2 inhibitors are now recommended treatments for patients with HF and reduced ejection fraction, according to the 2021 European Society of Cardiology Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure.

New guidance
The new guidelines, presented at the ESC Congress and published in the European Heart Journal, endorse SGLT2 inhibitors as medications that benefit patients with HFrEF, along with previously recommended classes including ACE inhibitors, angiotensin-receptor neprilysin inhibitors, beta-blockers and mineralocorticoid receptor antagonists.

“We now recommend an ACE or an ARNI, a beta-blocker, an MRA and an SGLT2 inhibitor to be uptitrated as safely as possible, plus using the lowest dose possible of a diuretic to relieve congestion” in patients with HFrEF, researcher said. “We know that cardiac function can improve and the risk of death falls with these key drugs, and normally we should wait at least 3 months before trying device therapy.”

The elevation of SGLT2 inhibitors to a class I, level of evidence A recommendation occurred as a result of the DAPA-HF trial of dapagliflozin (Farxiga, AstraZeneca) and the EMPEROR-Reduced trial of empagliflozin (Jardiance, Boehringer Ingelheim/Eli Lilly), which showed this therapy improved clinical outcomes of patients with HFrEF regardless of diabetes status, Gardner said.

Angiotensin receptor blockers are now only recommended in HFrEF “for those who are truly intolerant of an ACE inhibitor or an ARNI,” he said.

The guidelines state that at the time of publication, there were no medications shown to reduce morbidity and mortality in patients with HF with preserved ejection fraction; results of the EMPEROR-Preserved trial of empagliflozin were not available when they were written, Carolyn S.P. Lam, MBBS, PhD, senior consultant at the National Heart Centre Singapore and professor at Duke-NUS Singapore, said during a presentation. (Healio reported results of EMPEROR-Preserved, presented during the ESC Congress.)

“The task force acknowledges that the treatments for HFpEF are evolving even as the guidelines are being published,” she said. “For example, the FDA has approved the use of sacubitril/valsartan [Entresto, Novartis] in adults with chronic heart failure, particularly when ejection fraction is less than normal. For now, the recommendations for treatment of HFpEF have remained largely unchanged. It is important to screen for and treat etiologies and comorbidities. In the absence of disease-modifying therapies, diuretics are recommended for the management of congestion.”

Other recommendations
In contrast to previous ESC guidelines, the new one formally recommends heart transplantation for patients with advanced HF for whom drug and device therapy have not worked.

Patients with suspected chronic HF should have natriuretic peptide levels measured and, if they are high, the patient should be referred for an echocardiogram, the authors wrote.

The committee recommended that all patients with HF for whom it is feasible should exercise regularly, and those who are frail, have many comorbidities or have advanced HF should be considered for a supervised exercise-based cardiac rehabilitation program.

Patients with HF should also be encouraged to eat a healthy diet, avoid eating too much salt, maintain a healthy weight, not drink alcohol in excess, not smoke, not drink large volumes of fluid, communicate any sleeping problems, monitor changes in symptoms and know when to contact a health care provider, according to the authors.

“Reducing body weight and increasing exercise may further improve symptoms and exercise capacity, and should therefore be considered in appropriate patients,” Lam said during her presentation.

Because patients with HF are prone to infections which worsen their condition, they should be considered for influenza, pneumococcal and COVID-19 vaccinations, the committee wrote.