Update in Heart Failure Care
According to the American College of Cardiology, more than 6 million Americans are living with heart failure—the leading cause of hospital admission in patients aged 65 and older. Hundreds of learners filled the ballroom on day one of SHM Converge in March to hear about clinical updates in heart failure (HF) presented by Dr. Dustin Smith, who has a passion for teaching and cardiology.
He focused on updates in diuresis for acute decompensated HF management, the introduction of a new heart failure with preserved ejection fraction (HFpEF) diagnostic scoring tool, and a review of the recently released 2022 American Heart Association/American College of Cardiology HF guidelines, highlighting the use of sodium-glucose transporter-2 inhibitors (SGLT2i).
Updates in ejection classification from the 2022 guidelines help clarify the acronyms used in the remainder of this session update.
Dr. Smith posed questions to the audience with answers supported by clinical trial evidence:
1. Which initial diuresis strategy leads to the greatest incidence of decongestion in acute decompensated heart failure?
The acetazolamide in decompensated heart failure with volume overload, or ADVOR, trial examined the use of acetazolamide in acute decompensated heart failure with volume overload to answer the question, does acetazolamide in addition to standardized intravenous loop diuretics better achieve decongestion in patients admitted for congestive heart failure?
Key Point: Decongestion is safe, faster, and more successful when adding acetazolamide to loop diuretics. Acetazolamide was associated with higher urine output and natriuresis without worsening kidney function, hypokalemia, hypotension, or adverse events.
2. In addition to starting an SGLT2i, which oral loop diuretic is best to convert to upon discharge?
The Transform-HF trial, examining torsemide versus furosemide for the management of heart failure, posed the question, does torsemide decrease mortality compared with furosemide among patients hospitalized for HF? It is known that torsemide has increased bioavailability and downregulates the renin-angiotensin-aldosterone system, but furosemide is the most common loop diuretic used in HF. So, which is the better choice at discharge?
Key Point: All-cause mortality is equal at 26%, with no statistically significant difference between the two diuretics. Bottom line: either one is acceptable to use.
3. What is the probability a patient with unexplained dyspnea has heart failure with preserved ejection fraction (HFpEF)?
First published in Circulation in 2018, the authors developed and validated the H2FPEF score – a new diagnostic tool using demographics and echo parameters for the diagnosis of HFPEF in patients with unexplained dyspnea. A score of ≥6 indicates that the probability of HFPEF is 90% or more.
Key Point: H2FPEF should be used in the workup of unexplained dyspnea.
4. For which subgroups of patients with HF are SGLT2i not FDA-approved to improve outcomes?
Currently, patients with type 1 diabetes are not FDA-approved for the use of SGLT2i. However, two important trials now support the use of SGLT2i in patients with or without diabetes. The EMPEROR-Preserved or empagliflozin in heart failure with a preserved ejection fraction trial demonstrated empagliflozin reduced the risk of cardiovascular death or hospitalization for heart failure in patients with or without diabetes. The DELIVER trial (for dapagliflozin in heart failure with mildly reduced or preserved ejection fraction) used dapagliflozin in HFpEF and HFmrEF patients, and demonstrated it was also beneficial and safe for patients with or without diabetes.
Key Point: SGLT2i are beneficial in HFpEF for patients with and without diabetes, with the exclusion of patients with type 1 diabetes.
5. For which of the following outcomes are patients with HF on SGLT2i at higher risk?
A systematic review and meta-analysis found that SGLT2i reduce hospitalization by 32% and cardiovascular death by 14% at one year when used in the treatment of HF. Although considered a wonder drug for both its safety and efficacy, it is expensive and costs nearly $400 per month, and its side effect panel includes genital infection.
Key Point: SGLT2 inhibitors are beneficial in heart failure but are expensive and genital infections can occur.
The landscape of heart failure management has rapidly evolved and there have been many exciting advancements. Ongoing clinical trials and the application of guideline-directed medical therapy lend to a promising future for patients living with HF. For additional reading, check out the American College of Cardiology’s 2023 guidelines for the management of HFpEF.
Dr. Spaeth
Dr. Spaeth is a hospitalist at OhioHealth Riverside Methodist Hospital in Columbus, Ohio. She serves as a member of The Hospitalist magazine editorial board and is a member of the Physicians in Training committee.