Society GuidelinesCCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction
Section snippets
Standard Therapies
On the basis of new and emerging evidence for the pharmacologic treatment of HFrEF, updated treatment recommendations are provided herein. In the current era, patients with HFrEF should treated with 4 standard therapies, in the absence of contraindications, each representing a different class of medication with unique mechanism of action. Placing a high priority on reducing cardiovascular (CV) mortality and hospitalization for HF (HHF) in most patients, these medications include: (1) an ARNI,
Sinus Node Inhibition
Resting heart rate independently predicts CV events, including HHF and death.52, 53, 54 Studies have shown that the effect of elevated heart rate on outcomes becomes apparent within 30 days of discharge from hospital.55 In systematic reviews it has been postulated that a major contributor to the benefits of β-blocker therapy in patients with HFrEF might be their rate-lowering effect.56, 57, 58
Ivabradine selectively inhibits the depolarizing If current in the sinus node. It thus requires sinus
When to refer for ICD/CRT in the current era of medical therapy for HFrEF
The decision regarding when and if an ICD should be implanted must include evaluation of the short- and long-term risks of sudden death due to a ventricular arrhythmia and death from nonarrhythmic causes. This is often a complex assessment and must integrate many factors including the presence of ischemic heart disease, burden of scar, frailty, advancing dementia, comorbidities, and adequacy of background medical therapy. In addition to ICD considerations, CRT further improves mortality and
Areas of Uncertainty and Evolving Evidence
The CCS HF Guidelines Panel identified a number of unresolved questions relevant for the management of patients with HFrEF. For the purposes of this guideline update, systematic evidence reviews were limited in scope to the therapies and settings discussed herein. However, on the basis of emerging evidence, some additional considerations are worth noting, and further research will likely inform future guidelines.
Conclusion
This CCS HF guideline update heralds a shift in the clinical approach to management of patients with HFrEF and will likely have significant practice implications. Although many areas of uncertainty remain and there is continued need for evidence to inform our approach to best practice, it is clear that knowledge translation strategies and change management will be essential to ensure that patients with HFrEF, regardless of practice setting, consistently receive the new standard for optimal
Acknowledgements
The authors acknowledge the contributions and support of Christianna Brooks (CCS staff) for her ongoing help with the guideline writing and dissemination process.
The authors also thank Dr Matthew Bennett and Dr Larry Sterns (Canadian Heart Rhythm Society) for their expertise and input into this guideline.
The authors appreciate the support of Ani Orchanian-Cheff for her assistance and expertise with evidence search and review.
The authors acknowledge the volunteer contributions of panel members,
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This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.