1. Abstract
In this update, we focus on selected topics of high clinical relevance for health care providers who treat patients with heart failure (HF), on the basis of clinical trials published after 2017. Our objective was to review the evidence, and provide recommendations and practical tips regarding the management of candidates for the following HF therapies: (1) transcatheter mitral valve repair in HF with reduced ejection fraction; (2) a novel treatment for transthyretin amyloidosis or transthyretin cardiac amyloidosis; (3) angiotensin receptor-neprilysin inhibition in patients with HF and preserved ejection fraction (HFpEF); and (4) sodium glucose cotransport inhibitors for the prevention and treatment of HF in patients with and without type 2 diabetes. We emphasize the roles of optimal guideline-directed medical therapy and of multidisciplinary teams when considering transcatheter mitral valve repair, to ensure excellent evaluation and care of those patients. In the presence of suggestive clinical indices, health care providers should consider the possibility of cardiac amyloidosis and proceed with proper investigation. Tafamidis is the first agent shown in a prospective study to alter outcomes in patients with transthyretin cardiac amyloidosis. Patient subgroups with HFpEF might benefit from use of sacubitril/valsartan, however, further data are needed to clarify the effect of this therapy in patients with HFpEF. Sodium glucose cotransport inhibitors reduce the risk of incident HF, HF-related hospitalizations, and cardiovascular death in patients with type 2 diabetes and cardiovascular disease. A large clinical trial recently showed that dapagliflozin provides significant outcome benefits in well treated patients with HF with reduced ejection fraction (left ventricular ejection fraction 40%), with or without type 2 diabetes.
The Canadian Cardiovascular Society (CCS) heart failure (HF) guidelines program provides guidance to clinicians, policy makers, and health systems as to the evidence supporting existing and emerging management of patients with HF. The 2019 update on clinical trial data is a brief set of guidelines incorporating new evidence from randomized controlled trials published after the 2017 update on topics of importance for health care providers in HF management. It updates the last version of the CCS HF guidelines on those specific topics. The constitution and roles of the primary and secondary panels, systematic review strategy, and methods for formulating the recommendations are described at www.ccs.ca. The recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) standards.1,2 Primary panelists were responsible for writing and reviewing the document, with writing participation of 3 secondary panelists and 6 external content experts. The objective of this update was to highlight new clinical trial evidence on 4 topics of high importance in terms of changes and evolution in the care of patients with HF: (1) transcatheter mitral valve repair; (2) potential treatments for transthyretin amyloidosis (ATTR) or transthyretin cardiac amyloidosis (CA); (3) the role of angiotensin receptor neprilysin inhibition in patients with HF and preserved ejection fraction (HFpEF); and (4) prevention of HF outcomes with sodium glucose cotransport (SGLT2) inhibitors. We collaborated with content experts on each topic who provided critical external input and perspective.