The American College of Cardiology (ACC) released updated expert consensus guidance on managing patients hospitalized with heart failure.

The 2024 focused update, published in the Journal of the American College of Cardiology, emphasized early initiation of guideline-directed medical therapy and provided new recommendations on the use of sodium-glucose cotransporter 2 (SGLT2) inhibition.

The document noted that heart failure affects nearly 6.7 million U.S. patients, with increasing prevalence. Patients admitted with heart failure have a 20% to 30% risk of mortality within 1 year.

Data from the Get with the Guidelines–Heart Failure Registry involving 50,170 Medicare patients hospitalized from 2017 to 2020 with heart failure with reduced ejection fraction and diabetes showed:

• Patients were eligible for a mean of 3.9 medications and were receiving 2.1 ± 1.3 at admission and 3.0 ± 1.0 at discharge.
• 70% of patients were deemed eligible for ARNIs/ACE inhibitors/ARBs, with 59% receiving them on admission and 91% on discharge.
• 50% were considered eligible for MRAs, with 26% on MRAs at admission and 56% at discharge.

The SGLT2 inhibitor trial results demonstrated that:

• Patients who participated in the EMPULSE trial experienced improved clinical outcomes and decongestion in acute heart failure with empagliflozin.
• In the DAPA-Resist trial, dapagliflozin enhanced diuretic response compared with metolazone.

Diuretic therapy outcomes:

• The CLOROTIC trial found that adding hydrochlorothiazide to IV loop diuretics resulted in increased diuretic response and more weight loss without changing patient-reported dyspnea.
• In the ADVOR trial, acetazolamide added to loop diuretics for 3 days as well as exhibited a greater rate of successful decongestion (42.2% vs 30.5%, P < .001) and a shorter duration of hospital stay (8.8 days vs 9.9 days, P = .016).

Patient profiles:

• The PIONEER-HF trial included 34% of patients with a new heart failure diagnoses (mean systolic blood pressure [SBP] = 118 mmHg).
• In the LIFE trial, patients had a mean duration of heart failure of 6 years before enrollment, with an average left ventricular ejection fraction of 0.20.

Sacubitril/valsartan tolerability:

• In the PARADIGM trial, symptomatic hypotension occurred in 25.5% of patients with baseline SBP < 110 mmHg on sacubitril/valsartan compared with 13.7% on enalapril.
• In the LIFE trial, 18% of patients did not tolerate the lowest dose (24 to 26 mg) of sacubitril/valsartan during the 3- to 7-day run-in period.

A 2020 study demonstrated a significantly reduced hazard of multiple readmissions in a cohort who received palliative care consultations compared with usual care.

Further, a meta-analysis of hospital-at-home programs for patients with heart failure suggested increased time to readmission, lower costs, and improved health-related quality of life, with no significant differences in adverse outcomes.

These additional statistics and data points provided a more comprehensive overview of the current state of heart failure management and the evidence supporting the updated recommendations in the ACC guidance.