Managing Heart Failure in the Longer Term

After initial diagnosis and treatment, patients presenting to hospital with acute heart failure (HF) are assessed and managed by the hospital HF team. Further investigations are carried out to confirm the diagnosis; existing guideline-directed medical therapies are optimised; and new treatments are initiated to stabilise the condition, manage symptoms, and reduce morbidity and mortality.

A wide range of diagnostic tests and therapeutics are established for HF with reduced ejection fraction, while options for HF with preserved ejection fraction have been limited. However, repurposing of drugs originally developed for other conditions (e.g. sodium-glucose co-transporter 2 inhibitors and glucagon-like receptor 1 antagonists) for use in people with heart failure and extended use of medications traditionally restricted to reduced ejection fraction, such as mineralocorticoid receptor antagonists (e.g. spironolactone) and angiotensin-neprilysin inhibitors (e.g. sacubitril–valsartan) in those with an EF >40% is challenging established practice and increasing the options for optimisation of long-term management of patients with HF, across the entire ejection fraction spectrum.

Integral to the management of chronic HF is the need to consider approaches to identify deterioration between scheduled visits, including annual electrocardiography and N-terminal pro B-type natriuretic peptide monitoring in primary care. Remote monitoring, including alert-based monitoring for patients with implanted devices, may help to identify worsening HF or deterioration between scheduled clinic visits.

Questions remain around optimal diuretic treatment (e.g. infusion versus bolus dosing during periods of decompensation and converting to oral furosemide or bumetanide); use of beta blockers in HF patients with atrial fibrillation (AF) and higher normal ejection fraction; optimal use and monitoring of digoxin for rate control in patients with HF and AF; whether mineralocorticoid receptor antagonists should be used in HF patients with higher ejection fraction beyond the control of blood pressure, and the choice between spironolactone and eplerenone; how sacubitril–valsartan should be used in patients with ejection fraction >40%; in which setting drugs should be optimised following discharge, and whether cessation of medications is appropriate after recovery in ejection fraction.