In a new guideline update, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America have detailed the groups’ recommendations for the use of two new heart failure medications. The update includes the addition of valsartan/sacubitril (Entresto, Novartis), an angiotensin receptor–neprilysin inhibitor (ARNI), and ivadrabine (Corlanor, Amgen), a sinoatrial node modulator, to the list of treatment options for stage-C heart failure patients with a reduced ejection fraction.
The previously determined drug options for these patients include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), aldosterone antagonists, beta blockers, the combination of isosorbide dinitrate and hydralazine, and diuretics. The goal of treatment with all of these medications is to relax blood vessels, reduce biological stress, and improve heart function.
“Not every patient is a good candidate for every drug; these guidelines can help physicians decide who best fits which treatment,” said Clyde W. Yancy, MD, MSc, MACC, FAHA, FHFSA, Professor of Medicine and Chief of Cardiology at the Northwestern University Feinberg School of Medicine and Chair of the writing committee. “This document details the benefits and risks of these new therapies so that patients at high risk can be directed towards alternative therapies.”
The updated guideline was published in the May 20 issue of Circulation. According to the new recommendations, a therapeutic regimen of an ACE inhibitor, an ARB, or an ARNI along with a beta blocker and an aldosterone antagonist is the new recommended therapy for patients with chronic symptomatic heart failure with a reduced ejection fraction. ARNIs should replace ACE inhibitors or ARBs when stable patients with mild-to-moderate heart failure receiving these therapies have adequate blood pressure and are otherwise tolerating standard therapies well. ARNIs, however, should not be used with an ACE inhibitor and should not be used by patients with a history of angioedema.
Ivabradine may be beneficial in reducing heart failure hospitalizations in patients with symptomatic, stable chronic heart failure with reduced ejection fraction who are receiving guideline-directed evaluation and management, including a beta blocker at a maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 beats per minute or greater at rest.
While a full update to the heart failure guideline is being developed, these recommendations were published early to coincide with the release of the 2016 European Society of Cardiology Guideline on the Diagnosis and Treatment of Acute and Chronic Heart Failure.