CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction
Michael Mcdonald
(1)
,
Sean Virani
(2)
,
Michael Chan
(3)
,
Anique Ducharme
(4)
,
Justin A Ezekowitz
(3)
,
Nadia Giannetti
(5)
,
George A Heckman
(6)
,
Jonathan G Howlett
(7)
,
Sheri L Koshman
(3)
,
Serge Lepage
(8)
,
Lisa Mielniczuk
(9)
,
Gordon W Moe
(10)
,
Eileen O’meara
(4)
,
Elizabeth Swiggum
(2)
,
Mustafa Toma
(2)
,
Shelley Zieroth
(11)
,
Kim Anderson
(12)
,
Sharon A Bray
(1)
,
Brian Clarke
(13)
,
Alain Cohen-Solal
(14, 15)
,
Michel D’astous
(16)
,
Margot Davis
(2)
,
Sabe De
(17)
,
Andrew D M Grant
(7)
,
Adam Grzeslo
(18)
,
Jodi Heshka
(19)
,
Sabina Keen
(18)
,
Simon Kouz
(20)
,
Douglas Lee
(1)
,
Frederick A Masoudi
(21)
,
Robert Mckelvie
(17)
,
Marie-Claude Parent
(4)
,
Stephanie Poon
(22)
,
Miroslaw Rajda
(12)
,
Abhinav Sharma
(23)
,
Kyla Siatecki
(11)
,
Kate Storm
(12)
,
Bruce Sussex
(24)
,
Harriette van Spall
(18)
,
Amelia Ming Ching Yip
(6)
1
PMCC -
TGH Peter Munk Cardiac Centre [Toronto, ON, Canada]
2 UBC - University of British Columbia
3 University of Alberta
4 Montreal Heart Institute - Institut de Cardiologie de Montréal
5 MUHC - McGill University Health Center [Montreal]
6 University of Waterloo [Waterloo]
7 University of Calgary
8 UdeS - Université de Sherbrooke
9 University of Ottawa [Ottawa]
10 St. Michael's Hospital
11 University of Manitoba [Winnipeg]
12 Dalhousie University [Halifax]
13 The Pirbright Institute
14 Hôpital Lariboisière-Fernand-Widal [APHP]
15 MASCOT (UMR_S_942 / U942) - Marqueurs cardiovasculaires en situation de stress
16 CHUDGLD - Dr. Georges-L.-Dumont University Hospital Centre
17 Western University [London, ON, Canada]
18 McMaster University [Hamilton, Ontario]
19 ICUO - Institut de cardiologie de l'Université d'Ottawa [Ottawa, ON, Canada]
20 CHRDL - Centre Hospitalier Régional de Lanaudiere [Joliette, QC, Canada]
21 University of Colorado Anschutz [Aurora]
22 Sunnybrook Health Sciences Centre
23 McGill University = Université McGill [Montréal, Canada]
24 MUN - Memorial University of Newfoundland = Université Memorial de Terre-Neuve [St. John's, Canada]
2 UBC - University of British Columbia
3 University of Alberta
4 Montreal Heart Institute - Institut de Cardiologie de Montréal
5 MUHC - McGill University Health Center [Montreal]
6 University of Waterloo [Waterloo]
7 University of Calgary
8 UdeS - Université de Sherbrooke
9 University of Ottawa [Ottawa]
10 St. Michael's Hospital
11 University of Manitoba [Winnipeg]
12 Dalhousie University [Halifax]
13 The Pirbright Institute
14 Hôpital Lariboisière-Fernand-Widal [APHP]
15 MASCOT (UMR_S_942 / U942) - Marqueurs cardiovasculaires en situation de stress
16 CHUDGLD - Dr. Georges-L.-Dumont University Hospital Centre
17 Western University [London, ON, Canada]
18 McMaster University [Hamilton, Ontario]
19 ICUO - Institut de cardiologie de l'Université d'Ottawa [Ottawa, ON, Canada]
20 CHRDL - Centre Hospitalier Régional de Lanaudiere [Joliette, QC, Canada]
21 University of Colorado Anschutz [Aurora]
22 Sunnybrook Health Sciences Centre
23 McGill University = Université McGill [Montréal, Canada]
24 MUN - Memorial University of Newfoundland = Université Memorial de Terre-Neuve [St. John's, Canada]
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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