Chiefs’ Inquiry Corner – 5/2/22

May 2, 2022

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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 There are no prospective RCTs specifically designed for patients with mid-range EF (EF of 41-49%). All data we have at this time has come from post-hoc or subset analyses from other heart failure trials. That being said, evidence suggests that at the lower end of this spectrum (closer to 41%), patients may respond to therapies similarly as those with a reduced EF <40%. The trajectory of these patients also matters, and it is dynamic – some will progress over time to overt HFrEF, while others may improve their ejection fraction. Guidelines now recommend initiating SGLT2 inhibitors in patients with HFmrEF as a Class 2a recommendation. In patients who are currently or have previously been symptomatic, there is a Class 2b recommendation for the use of beta blockers, ARNI, ACE/ARB, and MRAs, particularly those at the lower end of the spectrum. This is an evolving pathology, but the evidence suggests we should be thinking about them differently than patients with HFpEF and and EF of 50% or greater. 

References: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
 Many are likely aware of therapies available for the treatment of TTR amyloid – particularly tafamidis, a transthyretin tetramer stabilizer therapy. The guidelines currently recommend therapy to reduce cardiovascular morbidity and mortality as a Class I recommendation. Of note, as we think about striking a balance with high-value care, they note this is a low-value intervention ($180,000 per quality-adjusted life year gained). In patients with cardiac amyloidosis and atrial fibrillation, they also state that it is reasonable to consider anti-coagulation (Class 2a) to reduce the risk of stroke, regardless of the CHADS2VASC score.

References: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure
 In the absence of clinical status change, treatment interventions that may have had a significant impact on cardiac function, or candidacy for an invasive procedure or device therapy, there is not a role for routine reassessment of the left-ventricular function (noted to be a class recommendation of no benefit).

References: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure