Put New Heart Failure Guidelines in Perspective

Big changes in guidelines will lead to debate about managing heart failure with reduced ejection fraction (HFrEF).

We're used to "triple therapy" for HFrEF...an ACEI or ARB, an evidence-based beta-blocker (carvedilol, etc), and an aldosterone antagonist (spironolactone, etc)...to reduce hospitalizations and death.

Now Entresto (sacubitril/valsartan) is preferred INSTEAD of an ACEI or ARB when possible...since it prevents hospitalization or CV death in about 1 in 21 patients versus an ACEI.

Guidelines also suggest "QUAD therapy"...adding an SGLT2 inhibitor (Farxiga, etc) to triple therapy, regardless of diabetes. This prevents hospitalization or CV death in about 1 in 20 patients.

But med adherence in clinical trials is much higher than in real-world patients. Plus Entresto or an SGLT2 inhibitor each costs about $600/month.

Consider whether this new guidance is practical for your patient.

Continue to focus on optimizing traditional triple therapy first...this can cost under $30/month. And less than 1% of patients with HFrEF are on triple therapy at target doses.

If patients still have heart failure symptoms, suggest switching from an ACEI or ARB to Entresto. But point out that Entresto is taken bid...and causes low BP in 1 in 21 patients.

Educate patients to wait at least 36 hours after stopping an ACEI if switching to Entresto...to reduce risk of angioedema.

If symptomatic patients are already on optimized triple therapy with Entresto...or also have type 2 diabetes...suggest adding an SGLT2 inhibitor. Benefits are likely a class effect.

But weigh SGLT2 inhibitor downsides...genitourinary infections, dehydration, etc. Consider lowering diuretic doses when starting due to risk of hypovolemia and acute kidney injury.

Expect prior auths or high co-pays with these costly Rxs. Review our Guide for Helping Patients Afford Their Meds for ways to assist...such as whittling duplicate or unneeded meds.

See our resource, Improving Heart Failure Care, for patient education tools, strategies to improve adherence, and more.

Key References

  • J Am Coll Cardiol. 2022 Mar 24. doi: 10.1016/j.jacc.2021.12.012
  • N Engl J Med. 2020 Oct 8;383(15):1413-1424
  • N Engl J Med. 2014 Sep 11;371(11):993-1004
  • N Engl J Med. 2019 Nov 21;381(21):1995-2008
  • Medication pricing by Elsevier, accessed Apr 2022
Pharmacist's Letter. May 2022, No. 380501

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