Management of heart failure with reduced ejection fraction in 2021: an update for GPs.

Abstract

In February 2021, the National Institute for Health and Care Excellence (NICE) approved the use of dapagliflozin, a sodium-glucose co-transporter-2 inhibitor (SGLT2i) for patients with or without diabetes and with a left ventricular ejection fraction (LVEF) of <40%.1 This article provides some practical guidance for GPs on implementing the recommendation. Until recently, three groups of drugs were recommended by NICE as standard therapy to improve symptoms and prognosis in heart failure with reduced ejection fraction (HFrEF). The aspiration is for patients to receive them at the maximal tolerated doses (Table 1). The groups are: angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) or angiotensin-neprilysin inhibitors (ARNI); beta-blockers (BB); and — for patients remaining symptomatic — mineralocorticoid receptor antagonists (MRA). View this table: Table 1. First- and second-line pharmacotherapy groups (’the four pillars’) known to reduce mortality in HFrEF and approved by NICEa In patients with persistent or worsening symptoms whose LVEF is <35%, any ACEI/ARB should be replaced with sacubitril–valsartan (Entresto®), the current sole licensed member of ARNI, as both symptoms and prognosis are improved.2 Chronic heart failure still carries a poor prognosis, worse than some cancers, with a mortality of 42% at 5 years after the diagnosis in the UK.3 In part this reflects incomplete optimisation of existing therapies. GPs have a major role to play in spotting the need for medicines optimisation (Table 1), considering non-pharmacological interventions, and liaising with the community heart failure nurse and cardiac rehabilitation teams. In the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial, addition of dapagliflozin reduced the composite cardiovascular endpoint (hospitalisation for heart failure, urgent outpatient diuretic, therapy, or cardiovascular death) by 26% with a Number …