New approach to heart failure therapy upends conventional treatment, saves lives

A “transformative” approach to the management of heart failure, a common but complex medical condition, is keeping more Canadians out of hospital and helping them live longer, healthier lives. The 2021 Heart Failure Guidelines, released in the spring by the Canadian Cardiovascular Society (CCS) and the Canadian Heart Failure Society (CHFS) upend conventional treatment for HFrEF (Heart Failure reduced Ejection Fraction), a condition where the left side of the heart is pumping poorly.

What’s new and exciting about the guidelines is a recommendation to administer all four standard drug therapies to people with HFrEF “right out of the gate,” instead of using a stepped approach, says Dr. Sean Virani, head of cardiology at Providence Health Care, a past-president of the CHFS and CCS Council member. Dr. Virani co-chaired the CCS expert panel that developed the 2021 Heart Failure Guidelines.

“With this new approach, we will see thousands of patients in Canada with improved outcomes. On the ground, we are seeing the benefits of it literally every day.”

According to Dr. Virani, the new HFrEF recommendations were developed in response to the rapid evolution of science and data in the field. “Clinical trials abound and new information compelled us to redefine best care for this patient population.”

Before releasing the update, the CCS/CHFS expert panel rigorously reviewed, evaluated and graded all evidence, concluding that early combination drug treatment was a necessary and critical revision to the established standard approach.

“It flattened our previous algorithm of how patients with heart failure are treated… It is transformative. We are really ahead of the curve globally,” Dr. Virani says. A recent editorial in the New England Journal of Medicine praised the Canadian approach, which has also been adopted by the European guidelines.

After treatment with drugs from four foundational classes of medications, clinicians use a customized lens to personalize the next level of care to meet individual patient needs and characteristics.

Heart failure is one of the most pervasive and costly conditions facing Canada’s health-care system. More than 600,000 Canadians are living with heart failure and more than 90,000 people are diagnosed with the condition each year. Numbers are increasing as the population ages.

A person with heart failure has a damaged or weakened heart that doesn’t pump as strongly as it should. Heart failure may have come as a result of a heart attack, high blood pressure, stiffening of the heart muscle, infection or inflammation of the heart, a heart valve abnormality, a heart rhythm problem, alcohol consumption, or some unknown cause.

“Heart failure is a major reason for crowding in emergency rooms and for admission and readmission to hospital,” says Dr. Simon Kouz, a Quebec community cardiologist with the Centre Hospitalier de Lanaudière. With the recent experience of COVID-19, he says hospitals need to do whatever they can to keep people out of the ER and in the community.

“The new elements in the 2021 Heart Failure Guidelines are a game-changer and will cut in half the U-turn readmission rate, help manage people with heart failure as outpatients, and improve the use of hospital resources,” says Dr. Kouz. “We can save lives.”

Updated recommendations build on earlier comprehensive guidelines for which he served on expert panels.

With up to four per cent of the population living with heart failure, the burden of disease not only falls on the patients, but also on caregivers, the economy, and health-care budgets, Dr. Virani adds.

“That’s why guidelines are really important,” Dr. Virani explains. “When you have a complex disease, clinicians need to have ready access to the best evidence, curated in a usable way, so they can aspire to deliver the best care for their patients.”

Another benefit of the CCS/CHFS Heart Failure Guidelines Update is it provides heart-failure care providers with information to benchmark performance, evaluate the quality of care delivered, and advocate for their patients using good data. “We are finding there are significant variations in provinces and territories,” says Dr. Virani, who wants to see a national data infrastructure for heart failure to track improvements and identify gaps.

Regional variations are also a concern for Rody Pike, a nurse practitioner in St. John’s, NL, who works in an outpatient heart-failure clinic. Guidelines need to reach all health-care providers “whether they are in a small community of 20 people or an urban area of five million. You should have the best possible medical therapies for heart failure, regardless of where you live in Canada.”

“While heart failure is an individual disease, it affects everyone in the family,” says Pike, who is a member of the executive of the CHFS and co-chair of its committee for nursing and allied health. “Once diagnosed with heart failure, families are involved in appointments, changes in lifestyle, disease management, and missed time from work. We try to encompass whole-family care.”

For nurses and allied health, treatment guidelines help them understand, implement, and press for new therapies, he says. “It’s so important to have a toolkit to help establish a treatment plan.”

He often takes time to review treatment guidelines with the patient and family and, when requested, will refer them to the CCS website to review the published guidelines. “Our goal is always to provide the best possible medical therapy for people with heart failure,” Pike says.

The new approach to HFrEF is already delivering results in Canada’s most easterly province. “There’s no better day than to sit down with a patient to say there has been a dramatic improvement in heart function due to this new regimen,” he says.

The full 2021 CCS/CHFS Heart Failure Guidelines Update can be found in the CCS guidelines library.

CCS also offers a number of practical and tangible tools as companions to the recommendations –such as the HF Pocket Guide and On Demand Webinars. Both feature diagnostic and management recommendations based on the CCS HF Comprehensive Guidelines (2017), and the CCS/CHFS HF Guideline updates (2020 and 2021).

Additional supports such as a web app and interactive website will be added to our growing list of knowledge translation tools.