Recommended Chronic Therapy by HF Stage

(JACC 2021;77:772)

• Utility of BNP-guided Rx (inPt and outPt) remains debated (Eur Heart J 2014;35:16)
• Implantable PA pressure sensor in sx Pts: ~19-37% ↓ risk of hosp (Lancet 2016;387:453 & 2021;398:991)

Stage (not NYHA Class) Therapy

• A

  • at ↣ risk for HF (eg, HTN); but asx & w/o struct. dis.
  • Rx HTN, lipids, DM;
    • stop smoking, EtOH;
    • ↑ exercise
  • ACEI/ARB if HTN/DM/CAD/PAD

• B

  • ⊕ Struct. heart dis.
  • (eg, CMP, LVH), but asx
  • As per stage A + ACEI/ARB + βB if MI/CAD or ↓ EF. ? ICD.

• C

  • ⊕ Struct. heart dis.
  • ⊕ Any h/o Sx of HF
  • As per stage A + diuretics, ↓ Na.
  • If ↓ EF:
    • ARNI, ACEI or ARB;
    • βB;
    • aldo antag;
    • SGLT2i;
    • ICD;
    • ? CRT;
    • ± nitrate/hydral;
    • ± dig.
  • If preserved EF:
    • ? ARNI;
    • ? aldo antag: Eplerenone (Inspra) Spirinolactone (Aldactone)
    • SGLT2i

• D

  • Refractory HF requiring specialized interventions
  • All measures for stages A-C. Consider IV inotropes, VAD, transplant, end-of-life care (4-y mortality >50%)