Interview With Paul Heidenreich, MD: Insight from the Writing Committee Chair of the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure

Paul Heidenreich, MD: One thing that the ACC/AHA (American College of Cardiology/American Heart Association) is now doing with their guidelines, and we included a lot with the [2022 ACC/AHA/Heart Failure Society of America (HFSA)] Guideline [for the Management of Heart Failure (HF)],1 are value statements. And so, clinicians will see these value statements in the guideline, where we have taken the published data on cost-effectiveness and made a statement about whether this fits with the ACC/AHA’s definition for what is considered high, medium, or low value based on how much it costs to obtain a given outcome. These value statements are primarily aimed at policymakers, payers, and industry. Although we also think clinicians should be aware of them, the primary guidance for clinicians should be the clinical recommendations. But we do want [clinicians] to be aware that such value estimates have been made for many of the therapies. And, importantly, for the vast majority of the HF treatments, the treatments are of very high economic value. The clinicians can be confident that not only is this improving care, it’s also a wise use of resources.

There were several advances since our past update to the guideline in 2017. Primary among these are those focused around SGLT2 [sodium-glucose cotransporter-2] inhibitors, [which] were shown clearly to improve outcomes for those with reduced [left ventricular] ejection fraction (EF). But,…also for the first time, [SGLT2 inhibitors] were…shown to improve outcomes for those with preserved EF (EF > 40%). One of the major changes with the guideline is that we now have SGLT2 inhibitors recommended as the preferred drug for patients with an EF greater than 40%.

The SGLT2 [inhibitors] have clearly already impacted the management of HF. They are now 1 of 4 pillars of HF care for those with reduced EF (EF ≤ 40%), the other 3 being either ARNIs (angiotensin receptor inhibitors), ACE [inhibitors], or ARBs (angiotensin receptor blockers) as the second; MRAs (mineralocorticoid receptor antagonists) as the third; and β-blockers as the fourth pillar. That [was] standard even … before this guideline, that those are now the 4 pillars for treatment of HFrEF (heart failure with reduced ejection fraction).

It is still challenging for the clinician to know exactly how to implement these 4 pillars of therapy for HFrEF. We have not had a large number of trials comparing different strategies about starting with 1 drug over another. Traditionally, the recommendations have been to start with an ARNI and a β-blocker and then [to] add on an SGLT2 inhibitor and an MRA. Also, the general recommendation is to start with [a] lower [dose] and once you get drugs on, titrate up, although, again, we don’t have a lot of randomized trial data to say exactly which way is going to be more successful.

There is reason to believe that having an SGLT2 inhibitor onboard may make it easier to add on an MRA, or even an ARNi if SGLT2 [inhibitor] is the first drug, because of potentially opposite effects on potassium loss. There are reasons to consider SGLT2 [inhibitors] earlier rather than waiting and to definitely not wait for it to be the last of those 4 to start. It also seems to be fairly well tolerated, and, for patients who are hospitalized, it would, again, be reasonable to try to get patients on an SGLT2 inhibitor during hospitalization and not wait until after discharge, since there’s a lot of data to show that busy clinicians often do not change therapy for patients discharged from the hospital. And so, using that time as the opportunity to start an SGLT2 [inhibitor] is probably important.

This transcript has been edited for clarity.


1. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure. J Card Fail. 2022;28(5):e1-e167. doi:10.1016/j.cardfail.2022.02.010

For other articles and videos in this AJMC® Perspectives publication, please visit “Implementing the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure: SGLT2 Inhibitors, Treatment Sequencing, and Value Statements.

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