Stable but Progressive Nature of Heart Failure: Considerations for Primary Care Physicians

Abstract

For patients who are resistant to diuretics, intravenous administration or combination with different diuretic classes may be considered [2]. Because of the risk for electrolyte disturbances, azotemia, and hypotension with diuretics, aldosterone antagonists, ACEIs, and ARBs, it is recommended that renal function and serum electrolytes should be monitored within 2 weeks of initiating or modifying therapy and periodically thereafter (COR I, LOE C) [2]. The beneficial effects of sacubitril/valsartan compared with enalapril were consistent across all subgroups, regardless of patient baseline demographics and clinical characteristics [e.g., age, sex, ethnicity, geographic region, NYHA class, comorbidities, EF, N-terminal pro-BNP (NTproBNP) level, HF treatment history, or hospitalization history] [53]. [...]a recent analysis showed that optimal implementation of ARNI therapy in the appropriate community-based population of patients with NHYA class II-III HFrEF who tolerate ACEI/ARB therapy would prevent approximately 28,000 deaths per year [46]. Similar patient characteristics and outcomes were observed in the prespecified subgroup analyses for North America (including both Canada and the USA); 54% of these patients had an ICD, 19% were Black, and a somewhat greater beneficial effect with sacubitril/valsartan compared with enalapril on the primary outcome was observed (HR 0.67; 95% CI 0.50-0.90) compared with that of the entire cohort (HR 0.80; 95% CI 0.73-0.87) sacubitril/valsartan [65]. Because the evidence for the 20% reduction in the primary endpoint (P < 0.001) and for the 20% lower risk of cardiovascular death (P < 0.001) with sacubitril/valsartan compared with enalapril was very strong [53], randomizing patients to treatment with enalapril to replicate PARADIGM-HF trial results would not be ethical [64]. [92] found that collaboration between a PCP and a cardiologist within 30 days of a patient's hospital discharge improved rates of follow-up testing, use of GDEM, and survival compared with PCP care alone. [...]multidisciplinary HF disease-management programs are recommended to facilitate the implementation of GDEM, prevent readmissions to hospital, and address barriers to behavior change (COR I, LOE B) [2].