The Food and Drug Administration (FDA) recently approved two new agents for use in patients with HF. Entresto is an angiotensin receptor–neprilysin inhibitor (ARNi). This combination agent consists of a neprilysin inhibitor (sacubitril) and an angiotensin 2 receptor blocker (valsartan). Entresto was shown to reduce cardiovascular or HF hospitalization by 20% in comparison with enalapril alone.13,14 The PARADIGM-HF (Prospective Comparison of ARNi with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial was stopped early because of evidence of significant benefit in the treatment arm, in which patients received the combination of an ARB and ARNi therapy. Suitable candidates are those identified as having NYHA class II to IV heart failure.13 Before initiating treatment with Entresto, the clinician must have the patient stop any use of an ACE inhibitor or ARB for a minimum of 36 hours as a washout period to minimize the possibility of angioedema, hypotension, or hyperkalemia.14 Entresto is contraindicated for concomitant use in those who are taking aliskiren for diabetes.15
The second agent is ivabradine, which works by selectively inhibiting the funny channel current of the sinoatrial node. The recommended indication is to reduce hospitalization for HF in patients with NYHA class II or III HF. Clinicians must first maximize beta-blocker treatment, and the patient’s resting heart rate must be faster than 70 beats per minute.13
Advanced therapeutic options: implantable devices
Cardiac resynchronization therapy. Cardiac resynchronization therapy with biventricular pacemakers has been shown to improve the quality of life and functional status of those with NYHA class III or IV HF who have a wide QRS complex on their electrocardiogram and life-threatening arrhythmias.16
CardioMEMSTM HF system. This is an implantable device for monitoring pulmonary artery pressure. It is the first and only FDA-approved HF monitoring system proven to reduce hospitalization significantly and improve quality of life in patients with NYHA class III HF regardless of their ejection fraction status.17
Preventing an exacerbation of HF is a high priority for clinicians and patients alike. Significant improvements in quality of life and survival rates and reductions in hospitalization rates can be achieved with close and aggressive outpatient management. Encouraging and supporting a patient’s efforts to maintain a healthful lifestyle and follow a daily exercise routine, and ensuring preventive care such as up-to-date immunizations, will contribute to the achievement of this goal. Social and emotional support are essential to help patients maintain constructive lifestyle changes and remain compliant with medication regimens. Using social network and community outreach programs to keep patients engaged and involved in their own care can be a highly effective strategy.
Patients with HF are often unable to perform the activities of daily living without experiencing some degree of dyspnea. Cardiac rehabilitation is a critical component of the management of HF to improve patient quality of life. Until recently, cardiac rehabilitation was approved only for patients with coronary artery disease. The decision by the US Centers for Medicare and Medicaid Services to include HFrEF as a reimbursable diagnosis for cardiac rehabilitation is expected to increase its utilization by providers and patients alike.18