Clinical Heart and Vascular Center
Great Debates in Heart Failure
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By Jennifer Thibodeau, M.D., M.S.C.S., Associate Professor of Internal Medicine; Medical Director, Heart Failure
Management of heart failure (HF) patients is not always straightforward and can lead to lively debates about which management strategy is most appropriate. I had the privilege of moderating an AHA session titled “Great Debates in Heart Failure” that addressed some controversial topics in HF management.
There were several “debates” in which the debaters actually agreed with each other. First, it was discussed that a rising creatinine during diuresis should not lead to cessation of diuretic therapy. In this setting, as demonstrated in the DOSE-AHF trial, a rise in serum creatinine is not associated with renal tubular injury as measured by validated urinary biomarkers. Furthermore, the increase in creatinine seen with aggressive diuresis is not always associated with adverse outcomes. Thus, the debaters agreed that a mild to moderate rise in creatinine should not halt diuresis in patients who are still congested.
The results of the COAPT and MITRA-HF trials were discussed to assess whether percutaneous mitral valve repair should be offered in the setting of secondary mitral regurgitation in heart failure with reduced ejection fraction (HFrEF) for “many” or for “few.” The presenters agreed that in a small but not insignificant number of patients with HFrEF and secondary mitral regurgitation who meet the criteria for percutaneous mitral valve replacement, the benefit of percutaneous mitral valve replacement is substantial and can significantly improve mortality, reduce hospitalizations for heart failure, and improve quality of life.
“It was argued that ARNI therapy is expensive and often requires pre-authorization, which could lead to some patients going without any renin-angiotensin aldosterone system blockade therapy while trying to obtain this therapy.”
The use of natriuretic peptides to guide therapy of HF was also debated. After the GUIDE-IT trial was stopped early for futility, showing that a strategy of NT-proBNP guided therapy was not more effective than usual care in improving outcomes in HFrEF, it has been argued that natriuretic peptides should no longer be used in the management of HF. However, the CHAMP-HF study demonstrated an inertia in uptitration of guideline-directed medical therapy (GDMT) with most HFrEF patients receiving sub-target doses of GDMT. Furthermore, elevated natriuretic peptide concentrations carry poor prognosis. Thus, it was argued that elevated natriuretic peptides should not be ignored but could be used to trigger a provider to be more aggressive with GDMT in appropriate patients or to acknowledge worsened prognosis and address this with other therapeutic options.
Whether ARNI should be used prior to ACE-I or ARB in HFrEF was another contested topic. As the benefit of sacubitril/valsartan has been shown in patients with both chronic stable HFrEF (PARADIGM-HF) and newly diagnosed and stabilized acute decompensated HF (PIONEER-HF), there is a push toward early adoption of ARNI therapy in lieu of ACE-I or ARB therapy. However, it was argued that ARNI therapy is expensive and often requires pre-authorization, which could lead to some patients going without any renin-angiotensin aldosterone system blockade therapy while trying to obtain this therapy. Furthermore, in patients with low socioeconomic status, the cost of ARNI therapy might be prohibitive. Thus, in some patients, ACE-I or ARB therapy may be preferred as the initial therapy, despite the demonstrated benefit of ARNI therapy over ACE-I or ARB.
Other debated topics included whether atrial fibrillation ablation should be first-line therapy in HFrEF and whether sodium should or should not be restricted in patients with heart failure, acknowledging that quality of life (including occasionally indulging in salty foods) is important in the management of HFrEF.
Overall, this was an entertaining and informative session to attend and moderate, and it highlighted some of the hot topics within contemporary heart failure management.