CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction |
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| Authors: | Michael McDonald Sean Virani Michael Chan Anique Ducharme Justin A Ezekowitz Nadia Giannetti George A Heckman Jonathan G Howlett Sheri L Koshman Serge Lepage Lisa Mielniczuk Gordon W Moe Eileen O’Meara Elizabeth Swiggum Mustafa Toma Shelley Zieroth Kim Anderson Sharon A Bray Amelia Ming Ching Yip |
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| Institution: | 1. Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada;2. University of British Columbia, Vancouver, British Columbia, Canada;3. University of Alberta, Royal Alexandra Hospital, Edmonton, Alberta, Canada;4. Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada;5. University of Alberta, Edmonton, Alberta, Canada;6. McGill University, Montréal, Québec, Canada;7. Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada;8. Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada;9. Université de Sherbrooke, Sherbrooke, Québec, Canada;10. University of Ottawa Heart Institute, Ottawa, Ontario, Canada;11. St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada;12. Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada;13. University of Manitoba, Winnipeg, Manitoba, Canada;14. Dalhousie University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada;15. Paris University, UMR-S 942, Hôpital Lariboisière, Paris, France;p. CHU Dumont UHC, Moncton, New Brunswick, Canada;q. London Health Sciences, Western University, London, Ontario, Canada;r. Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada;s. Ottawa Cardiovascular Centre, Ottawa, Ontario, Canada;t. Centre Intégré de Santé et de Services Sociaux de Lanaudière - Centre Hospitalier de Lanaudière, Joliette, Québec, Canada;u. University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA;v. St Joseph’s Health Care, Western University, London, Ontario, Canada;w. Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada;x. Memorial University, St John’s, Newfoundland, Canada;y. St Mary’s General Hospital, McMaster University, Kitchener, Ontario, Canada;1. Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada;2. Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada;3. Department of Medical Genetics, University of Alberta, Edmonton, Alberta, Canada;1. University of Calgary and Libin Cardiovascular Institute, Calgary, Alberta, Canada;2. Royal Alexandra Hospital, Edmonton, Alberta, Canada;3. University of Alberta, Edmonton, Alberta, Canada;4. Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada;5. University of Waterloo, Waterloo, Ontario, Canada;6. Centre Hospitalier Régional de Lanaudière and Université Laval, Quebec, Quebec, Canada;7. Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Quebec, Canada;8. St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada;9. Institut de Cardiologie de Montréal, Montreal, Quebec, Canada;10. University of Toronto, Toronto, Ontario, Canada;11. Centre Hospitalier Universitaire de Sherbrooke, Fleurimont, Quebec, Canada;12. University Health Network, University of Toronto, Toronto, Ontario, Canada;13. QE II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada;14. Royal Jubilee Hospital, Victoria, British Columbia, Canada;15. University of British Columbia, Vancouver, British Columbia, Canada;p. St Boniface General Hospital, Winnipeg, Manitoba, Canada;1. Department of Tuberculosis and Respiratory Diseases, GSVM Medical College, Kanpur, India;2. Apollo Spectra Hospital, Kanpur, India |
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| Abstract: | In this update of the Canadian Cardiovascular Society heart failure (HF) guidelines, we provide comprehensive recommendations and practical tips for the pharmacologic management of patients with HF with reduced ejection fraction (HFrEF). Since the 2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of HF, substantial new evidence has emerged that has informed the care of these patients. In particular, we focus on the role of novel pharmacologic therapies for HFrEF including angiotensin receptor-neprilysin inhibitors, sinus node inhibitors, sodium glucose transport 2 inhibitors, and soluble guanylate cyclase stimulators in conjunction with other long established HFrEF therapies. Updated recommendations are also provided in the context of the clinical setting for which each of these agents might be prescribed; the potential value of each therapy is reviewed, where relevant, for chronic HF, new onset HF, and for HF hospitalization. We define a new standard of pharmacologic care for HFrEF that incorporates 4 key therapeutic drug classes as standard therapy for most patients: an angiotensin receptor-neprilysin inhibitor (as first-line therapy or after angiotensin converting enzyme inhibitor/angiotensin receptor blocker titration); a β-blocker; a mineralocorticoid receptor antagonist; and a sodium glucose transport 2 inhibitor. Additionally, many patients with HFrEF will have clinical characteristics for which we recommended other key therapies to improve HF outcomes, including sinus node inhibitors, soluble guanylate cyclase stimulators, hydralazine/nitrates in combination, and/or digoxin. Finally, an approach to management that integrates prioritized pharmacologic with nonpharmacologic and invasive therapies after a diagnosis of HFrEF is highlighted. |
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