Heart Failure Due to Reduced Ejection Fraction: Medical Management

 

Am Fam Physician. 2017 Jan 1;95(1):13-20.

  Patient information: See related handout on heart failure.

Author disclosure: No relevant financial affiliations.

Heart failure is an increasingly common condition resulting in high rates of morbidity and mortality. For patients who have heart failure and reduced ejection fraction, randomized clinical trials demonstrate consistent mortality benefit from angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, direct-acting vasodilators, beta blockers, and aldosterone antagonists. Additionally, some data show benefits from two new classes of drugs: angiotensin receptor blocker/neprilysin inhibitor and sinus node modulator. Diuretics and digoxin can be used as needed for symptom control. Statins are not recommended solely for treatment of heart failure. Implantable cardioverter-defibrillators and biventricular pacemakers improve mortality and function in selected patients. For patients who have been hospitalized for heart failure, disease management programs and telemonitoring can reduce hospitalizations and mortality.

American adults 40 years and older have about a 20% lifetime risk of developing heart failure.1 The diagnosis is associated with significant morbidity and mortality. Over the past three decades, the prevalence of heart failure in the United States has continued to increase, largely because the population is aging, and older individuals are at higher risk of developing the disease.2

WHAT IS NEW ON THIS TOPIC: HEART FAILURE

Based on limited high-quality evidence, American College of Cardiology/American Heart Association/Heart Failure Society of America guidelines recommend ARB/neprilysin inhibitor therapy as a first-line alternative to ACE inhibitors for those with symptomatic heart failure who are not hypotensive or intolerant of angiotensin system antagonists.

Disease management programs and telemonitoring can reduce hospitalizations and mortality, especially for patients who have previously been hospitalized for heart failure.


ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The combination of sacubitril/valsartan (Entresto) may be an alternative to angiotensin-converting enzyme inhibitors in patients with heart failure.

B

13

Aldosterone antagonists and beta blockers decrease mortality in patients with symptomatic heart failure.

A

510

The sinus modulator ivabradine (Corlanor) decreases the risk of cardiovascular death or hospitalization in patients with sinus rhythm, with a heart rate of more than 70 beats per minute, and who are taking the tolerated or target dosage of a beta blocker.

B

14

Consider referral for device therapy (implantable cardioverter-defibrillators and cardiac resynchronization therapy) in patients with reduced ejection fraction and symptomatic heart failure or ischemic cardiomyopathy whose life expectancy is more than one year.

A

2224, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The combination of sacubitril/valsartan (Entresto) may be an alternative to angiotensin-converting enzyme inhibitors in patients with heart failure.

B

13

Aldosterone antagonists and beta blockers decrease mortality in patients with symptomatic heart failure.

A

510

The sinus modulator ivabradine (Corlanor) decreases the risk of cardiovascular death or hospitalization in patients with sinus rhythm, with a heart rate of more than 70 beats per minute, and who are taking the tolerated or target dosage of a beta blocker.

B

14

Consider referral for device therapy (implantable cardioverter-defibrillators and cardiac resynchronization therapy) in patients with reduced ejection fraction and symptomatic heart failure or ischemic cardiomyopathy whose life expectancy is more than one year.

A

2224, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Clinical trials of patients with left ventricular systolic dysfunction, also called heart failure with reduced ejection fraction, have demonstrated that angiotensin-converting enzyme (ACE) inhibitors,3 angiotensin receptor blockers (ARBs),4 beta blockers,57 aldosterone antagonists,810 and in selected populations isosorbide dinitrate/hydralazine (Bidil)11,12 reduce all-cause mortality and hospitalizations for heart failure. More recent clinical trials have demonstrated benefit from an ARB/neprilysin inhibitor and from a sinus node modulator.13,14

Overall adjusted hospitalization rates

The Authors

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WILLIAM E. CHAVEY, MD, MS, is an associate professor and service chief in the Department of Family Medicine at the University of Michigan in Ann Arbor....

ROBERT V. HOGIKYAN, MD, MPH, is an associate professor in the Department of Internal Medicine at the University of Michigan. He is also section chief of geriatric medicine, director of the Advanced Fellowship in Geriatrics, and medical director of the Healthcare System Community Living Center at the Veterans Affairs Hospital in Ann Arbor.

R. VAN HARRISON, PhD, is a professor emeritus at the University of Michigan Health System in Ann Arbor.

JOHN M. NICKLAS, MD, is an associate professor in the Department of Internal Medicine, Division of Cardiology, at the University of Michigan Health System.

Address correspondence to William E. Chavey, MD, MS, 1150 W. Medical Center Dr., M7300 Med Sci I – SPC5625, Ann Arbor, MI 48109-5625 (e-mail: wchavey@umich.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. Lloyd-Jones DM, Larson MG, Leip EP, et al.; Framingham Heart Study. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. Circulation. 2002;106(24):3068–3072....

2. Curtis LH, Whellan DJ, Hammill BG, et al. Incidence and prevalence of heart failure in elderly persons, 1994–2003. Arch Intern Med. 2008;168(4):418–424.

3. Cohn JN, Johnson G, Ziesche S, et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med. 1991;325(5):303–310.

4. Pfeffer MA, Swedberg K, Granger CB, et al.; CHARM Investigators and Committees. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme [published correction appears in Lancet. 2009;(9703):1744]. Lancet. 2003;362(9386):759–766.

5. Packer M, Bristow MR, Cohn JN, et al.; U.S. Carvedilol Heart Failure Study Group. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med. 1996;334(21):1349–1355.

6. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999;353(9169):2001–2007.

7. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999;353(9146):9–13.

8. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med. 1999;341(10):709–717.

9. Pitt B, White H, Nicolau J, et al.; EPHESUS Investigators. Eplerenone reduces mortality 30 days after randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. J Am Coll Cardiol. 2005;46(3):425–431.

10. Zannad F, McMurray JJ, Krum H, et al.; EMPHASIS-HF Study Group. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364(1):11–21.

11. Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med. 1986;314(24):1547–1552.

12. Taylor AL, Ziesche S, Yancy C, et al.; African-American Heart Failure Trial Investigators. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure [published correction appears in N Engl J Med. 2005;352(12):1276]. N Engl J Med. 2004;351(20):2049–2057.

13. McMurray JJ, Packer M, Desai AS, et al.; PARADIGM-HF Investigators and Committees. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371(11):993–1004.

14. Swedberg K, Komajda M, Böhm M, et al.; SHIFT Investigators. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study [published correction appears in Lancet. 2010; 376(9757):1988]. Lancet. 2010;376(9744):875–885.

15. Chen J, Normand SL, Wang Y, Krumholz HM. National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998–2008. JAMA. 2011;306(15):1669–1678.

16. Fonarow GC, Albert NM, Curtis AB, et al. Improving evidence-based care for heart failure in outpatient cardiology practices: primary results of the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF). Circulation. 2010;122(6):585–596.

17. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the International Society for Heart and Lung Transplantation; Endorsed by the Heart Failure Society of America. Circulation. 2001;104(24):2996–3007.

18. King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012;85(12):1161–1168.

19. Satpathy C, Mishra TK, Satpathy R, Satpathy HK, Barone E. Diagnosis and management of diastolic dysfunction and heart failure [published correction appears in Am Fam Physician. 2008;78(4):434]. Am Fam Physician. 2006;73(5):841–846.

20. Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med. 1997;336(8):525–533.

21. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240–e327.

22. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G; Multicenter Unsustained Tachycardia Trial Investigators. A randomized study of the prevention of sudden death in patients with coronary artery disease [published correction appears in N Engl J Med. 2000; 342(17):1300]. N Engl J Med. 1999;341(25):1882–1890.

23. Moss AJ, Zareba W, Hall WJ, et al.; Multicenter Automatic Defibrillator Implantation Trial II Investigators. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346(12):877–883.

24. Bardy GH, Lee KL, Mark DB, et al.; Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure [published correction appears in N Engl J Med. 2005;352(20):2146]. N Engl J Med. 2005;352(3):225–237.

25. McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol. 2004;44(4):810–819.

26. Inglis SC, Clark RA, McAlister FA, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. 2010;(8):CD007228.

27. Chavey WE, et al. University of Michigan Health System. Guidelines for clinical care. Heart failure – systolic dysfunction. August 2013. http://www.med.umich.edu/1info/FHP/practiceguides/heart/HF.pdf. Accessed August 22, 2016.

28. Sonnenberg JL, Sakane Y, Jeng AY, et al. Identification of protease 3.4.24.11 as the major atrial natriuretic factor degrading enzyme in the rat kidney. Peptides. 1988;9(1):173–180.

29. Mangiafico S, Costello-Boerrigter LC, Andersen IA, Cataliotti A, Burnett JC Jr. Neutral endopeptidase inhibition and the natriuretic peptide system: an evolving strategy in cardiovascular therapeutics. Eur Heart J. 2013;34(12):886–893c.

30. Institute for Clinical and Economic Review. ICER releases final report on CardioMEMS HF System and Entresto for management of congestive heart failure. https://icer-review.org/announcements/chf-final-report-released/. Accessed November 1, 2016.

31. Gaziano TA, Fonarow GC, Claggett B, et al. Cost-effectiveness analysis of sacubitril/valsartan vs enalapril in patients with heart failure and reduced ejection fraction. JAMA Cardiol. 2016;1(6):666–672.

32. Vodovar N, Paquet C, Mebazaa A, Launay JM, Hugon J, Cohen-Solal A. Neprilysin, cardiovascular, and Alzheimer's diseases: the therapeutic split? Eur Heart J. 2015;36(15):902–905.

33. U.S. Food and Drug Administration. FDA approves new drug to treat heart failure. July 7, 2015. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm453845.htm. Accessed November 1, 2016.

34. Yancy CW, Jessup M, Bozkurt B, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2016;68(13):1476–1488.

35. Carson P, Ziesche S, Johnson G, Cohn JN; Vasodilator-Heart Failure Trial Study Group. Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. J Card Fail. 1999;5(3):178–187.

36. Exner DV, Dries DL, Domanski MJ, Cohn JN. Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction. N Engl J Med. 2001;344(18):1351–1357.

37. McNamara DM, Tam SW, Sabolinski ML, et al. Endothelial nitric oxide synthase (NOS3) polymorphisms in African Americans with heart failure: results from the A-HeFT trial. J Card Fail. 2009;15(3):191–198.

38. U.S. Food and Drug Administration. FDA approves Corlanor to treat heart failure. Updated July 6, 2015. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm442978.htm. Accessed November 1, 2016.

39. Fox K, Ford I, Steg PG, Tendera M, Ferrari R; BEAUTIFUL Investigators. Ivabradine for patients with stable coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a randomised, double-blind, placebo-controlled trial. Lancet. 2008;372(9641):807–816.

40. Tavazzi L, Maggioni AP, Marchioli R, et al.; Gissi-HF Investigators. Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. Lancet. 2008;372(9645):1231–1239.

41. Kjekshus J, Apetrei E, Barrios V, et al.; CORONA Group. Rosuvastatin in older patients with systolic heart failure. N Engl J Med. 2007;357(22):2248–2261.

42. Bristow MR, Saxon LA, Boehmer J, et al.; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350(21):2140–2150.

43. Guirguis-Blake J. Transitional care interventions to prevent readmissions for patients with heart failure. Am Fam Physician. 2016;93(5):401–403.

44. Chavey WE, Bleske BE, Van Harrison R, Hogikyan RV, Kesterson SK, Nicklas JM. Pharmacologic management of heart failure caused by systolic dysfunction. Am Fam Physician. 2008;77(7):957–964.

 

 

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