Preview: Drugs for Chronic Heart Failure

The next issue of The Medical Letter will offer our readers an update on what’s new in the treatment of chronic heart failure, based largely on 2 other updates: the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACC/AHA Guideline for the Management of Heart Failure and a 2021 ACC Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment.

The biggest news in recent years in the treatment of heart failure has been the introduction of the angiotensin receptor-neprilysin inhibitor (ARNI), unfailingly referred to in the reverse order as sacubitril/valsartan (Entresto), which The Medical Letter first reviewed in 2015. In its pivotal clinical trial, after a median follow-up of 27 months, the combination, compared to the ACE inhibitor enalapril, significantly reduced the risk of the composite primary endpoint of first hospitalization for worsening heart failure and cardiovascular death (21.8% vs. 26.5%), first hospitalization for worsening heart failure alone (12.8% vs 15.6%), death from cardiovascular causes alone (13.3% vs 16.5%), and all-cause mortality (17.0% vs 19.8%), and slowed the progression of heart failure.

Entresto originally was approved by the FDA to reduce the risk of cardiovascular death and hospitalization for heart failure in adults with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction (HFrEF; LVEF <40%). This year the indication was expanded to include patients with chronic heart failure with any LVEF, but the label specifies that the benefits are most evident in patients with an LVEF below normal.  Some reviewers of our next issue doubted that the drug would be used for patients with LVEFs well into the normal range. Our upcoming article will include a discussion of vericiguat (Verquvo), a new oral drug approved this year for use in a subset of patients with symptomatic chronic heart failure; our reviewers pointed out some limitations of the clinical trial that led to its approval by the FDA. We also have a section on the SGLT2 inhibitors dapagliflozin and empagliflozin, including a recommendation for their use in the treatment of selected patients with chronic heart failure. And much more, all available online on June 2nd.

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