Pharmacotherapy in patients with HF

Harriette Van Spall, MD, MPH, is an associate professor in the Division of Cardiology at McMaster University.

Are there differences in pharmacotherapy for patients with heart failure (HF) depending on their age (advanced vs very advanced)? Which potential adverse effects of drugs should be kept in mind in those groups?

Harriette Van Spall, MD, MPH: There are no age limitations to the use of guideline-directed medical therapy in patients with HF. In fact, age should not be a limitation whatsoever. Of course, there are comorbid conditions that limit therapies and these could be considered when prescribing therapies for patients with HF.

It’s important to note, however, that some of the conditions that limit HF therapies, such as chronic kidney disease (CKD), actually portend a worse prognosis in patients with HF and require therapies that we tend to withhold from patients. For example, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, renin-angiotensin system (RAS) inhibitors, and mineralocorticoid receptor antagonists (MRAs) improve outcomes in patients with HF and also in patients with CKD, but they are paradoxically underutilized in these patients, even though CKD portends a worse prognosis in patients with HF. We need to be mindful of the broad indications for these therapies and apply them to the patients who qualify for therapies.

I think that addressing comorbid conditions and treating HF based on these phenotypes can also be effective. For example, patients who are obese benefit from exercise therapy as well as caloric reduction and there may be a role for glucagon-like peptide 1 (GLP-1) [agonists] or angiotensin-converting enzyme inhibitors (ACEIs) to reduce the burden of obesity in these patients. Those with hypertensive heart disease could benefit from MRAs early on in the disease course, as well as angiotensin receptor blockers (ARBs) or ACEIs.

Patients who have other common comorbidities could have targeted therapies for those comorbidities. For example, patients with diabetes could receive SGLT-2 inhibitors earlier on in the disease course. We know from the cardiovascular outcome trials that SGLT-2 inhibitors prevent the incidence of HF, so they should be considered early in patients with diabetes and of course when patients have HF.

Phenotypes can help guide care and should be part of the strategy in improving outcomes in patients with HFpEF.