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Heart failure with reduced ejection fraction foundational therapy: why should we follow the 2021 European Society of Cardiology Heart Failure Guidelines and forget the previous therapeutic algorithm?
Session:
Comunicações Orais (Sessão 12) - Insuficiência Cardíaca 2 - Tratamento
Speaker:
Joana Brito
Congress:
CPC 2022
Topic:
D. Heart Failure
Theme:
10. Chronic Heart Failure
Subtheme:
10.4 Chronic Heart Failure – Treatment
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Joana Brito; João Agostinho; Pedro Silva; Beatriz Silva; Ana Margarida Martins; Ana Beatriz Garcia; Catarina Simões de Oliveira; Sara Couto Pereira; Pedro Silvério António; Rafael Santos; Doroteia Silva; Fausto j. Pinto; Dulce Brito
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Introduction</strong>: Recently published European Society of Cardiology Heart Failure Guidelines (2021 HF GL) recommend early introduction of 4 pharmacological classes considered the foundational therapy (FT) for heart failure with reduced ejection fraction (HFrEF): sacubitril/valsartan (ARNi), beta-blocker (BB), mineralocorticoid receptor antagonist (MRA) and SLGT2 inhibitor. This approach contrasts with the sequential therapy suggested by previous guidelines (2016 HF GL). </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Purpose:</strong> To compare in the real-world practice the effect on 2-year all-cause mortality of the simultaneous use of every HFrEF FT class versus sequential therapy initiation and up-titration.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Methods</strong>: A population of patients (pts) included in a HF follow-up program was split in two groups: 1) pts started on all pharmacological classes of the HFrEF FT – “2021 HF GL”; 2) pts started on ACEi/ARB/ARNI, BB and MRA– “2016 HF GL group”. Chi-square and Mann-Whitney tests were used. Impact on all-cause mortality was established with Kaplan-Meier survival analysis and multivariate Cox regression. </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Results: </strong>A total of 276 pts with HFrEF were included and followed for 14.6±7.9 months. One hundred twenty-five patients were included in the FT group and 63 in the 2016 HF GL. The study population (71.3% males, 65.7±13.2 years) were mainly in NYHA class II (60.1%) and III (32.4%). The most common HF etiologies were ischemic heart disease (48.4%) and dilated cardiomyopathy (40.4%); mean left ventricular ejection fraction was 27.9±7.7%; 17% of the patients had a CRT and 29.3% an ICD. All-cause mortality rate during follow up was significantly different: 4% in the FT group and 12.7% in the 2016 HF GL group (p=0.046) – Figure 1. </span></span><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">The implementation of all foundational therapy classes was an independent protective factor for all-cause mortality (HR 0.29; IQR 0.086-0.948; P: 0.041). Statistical significance for mortality reduction was observed since month 6 (p=0.037).</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><strong>Conclusion: </strong>This real-world study suggests that simultaneous initiation of all pharmacological classes that nowadays are considered the foundational therapy as recommend by the 2021 HF GL may be more effective on reducing all-cause mortality in HFrEF than sequential therapy initiation as suggested by the 2016 HF GL. Considering the small size of the studied sample, demonstration of significant effect on mortality reduction since month 6 of follow-up supports the need for early introduction of all foundational therapy classes followed by a tailored titration.</span></span></p>
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