The TRED-HF trial considerably narrowed the population deemed as being low risk for heart failure relapse following the withdrawal of guideline-directed medical therapy (GDMT). However, several key subgroups were underrepresented and some patients may still wish to attempt GDMT withdrawal, especially in the setting of adverse effects or excess costs. In this post, we explore three questions that can be used to guide a shared decision-making process regarding GDMT withdrawal.
Although admitted patients with heart failure often have acute medical issues (e.g. acute kidney injury, acute decompensation) that may preclude them from certain therapies, many are appropriate candidates for guideline-directed medical therapy (GDMT) before they leave the hospital. This blog discusses the importance of initiating GDMT prior to discharge, whenever possible.
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One of the questions that remained unanswered after the PARADIGM-HF trial was whether the angiotensin receptor/neprilysin inhibitor sacubitril/valsartan could be safely initiated in patients with acute decompensated heart failure who had been previously stabilized on an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker. In this blog, Dr. Reed discusses the implications of the PIONEER-HF and TRANSITION studies, and provides a practical strategy for transitioning patients to sacubitril/valsartan.
Angioedema is a potentially life-threatening side effect of angiotensin converting enzyme inhibitor (ACEi) therapy. Once this side effect occurs, patients should not be reinitiated on an ACEi; an alternative agent is warranted. This blog will discuss the mechanism and risk factors for this adverse effect and will provide recommendations for selecting an alternative agent.
Initiation and titration of guideline-directed medical therapy is paramount for patients with heart failure with reduced ejection fraction (HFrEF), as it reduces the risk of death and other complications. Despite this, many patients do not receive the appropriate therapies or doses due to concerns and/or misconceptions about the use of these therapies. One reason often cited for not using or titrating inhibitors of the renin-angiotensin system is that blood pressure is already “at goal” or is “too low”. In this blog, the data surrounding titration of angiotensin converting enzyme inhibitors, angiotensin II receptor blockers and the angiotensin II receptor blocker/neprilysin inhibitor in patients with HFrEF will be addressed.
Agents such as patiromer and sodium zirconium cyclosilicate can reduce serum potassium concentrations. But do they have a role in patients with heart failure with reduced ejection fraction (HFrEF)? In this piece, we explore whether these agents could reduce the risk of hyperkalemia when initiating, continuing, or dose-titrating guideline-directed medical therapies in HFrEF.
Sacubitril/valsartan reduces the risk of hospitalizations and cardiovascular death in patients with symptomatic heart failure, but what is its role in advanced disease, as management strategies shift to a palliative plan of care? In this piece, we will discuss the role of sacubitril/valsartan in patients living with advanced disease.
In PARADIGM-HF, a combination of the neprilysin inhibitor sacubitril and the angiotensin receptor blocker valsartan reduced cardiovascular death and hospitalizations for heart failure compared to the ACE inhibitor enalapril. But by studying so few black patients, who have historically responded less favorably to many heart failure drugs, can we trust its widespread use in this population?