Heart Failure: What’s New? What’s Coming?
February 14-20 is designated as Heart Failure Awareness Week. It is a great time to review our evolving treatment paradigm in the management of patients with heart failure and to look ahead hopefully to the addition of new strategies under development.
In the past 6 years, a number of new therapies have become available for patients with heart failure. Two that have had a great impact on clinical practice are the angiotensin receptor neprilysin inhibitor, sacubitril/valsartan, and more recently, the SGLP-2 inhibitors.
In 2015, the combination therapy sacubitril/valsartan was approved for patients with HFrEF, the first in a new class of drugs, angiotensin receptor neprilysin inhibitors (ARNI).
In addition to improving clinical outcomes, sacubitril/valsartan shows benefit in improving quality of life measures in patients with heart failure. In late 2020, an FDA Advisory committee met to consider an expansion of the indication for sacubitril/valsartan for certain patients with HFpEF, based on data demonstrating that certain HFpEF patients benefit from sacubitril/valsartan, including women and patients in the lower range of the EF spectrum.
Based on the positive recommendation of the December advisory committee, on February 16, 2021, the expanded indication was granted. The language of the new label “…to reduce the risk of CV death and hospitalization for HF in adult patients with chronic HF, noted that the benefits are “most evident in patients with ‘below normal’ LVEH”; the document references the importance of clinical judgment in treatment decisions.
A newer player in the field, the SGLP-2 inhibitor class of medications, originally developed for diabetes, has now become part of the armamentarium of heart failure tools, in patients with diabetes and notably in those without diabetes as well.
The recently published 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction references the use of an SGLT2 Inhibitor in HFrEF (EF <40%) with or without diabetes in NYHA class II–IV HF, administered in conjunction with a background of guideline-directed medical therapy for HF.
On the horizon
There are also exciting new heart failure therapies a bit further out on the horizon. These include vericiguat, a novel oral soluble guanylate cyclase stimulator, ferric carboxymaltose for iron deficiency in heart failure patients, omecamtiv mecarbil, a cardiac myosin activator for systolic heart failure, and mavacamten, a first in class myosin inhibitor for hypertrophic cardiomyopathy.
Epidemiologic data published on February 12 confirmed that HF remains a serious public health problem worldwide. The expansion of our armamentarium of agents to manage heart failure has the potential to make a difference in the US and across the globe. We look forward to the opportunity to report on continued progress during Heart Failure Awareness Week in February 2022!