New Heart Failure Guidelines
The American College of Cardiology (ACC), American Heart Association (AHA), and the Heart Failure Society of America (HFSA) recently updated the 2013 ACC/AHA guidelines for the management of heart failure (Yancy, et al., 2016). This update introduces two new pharmacological agents to the guidelines: Entresto™, which is an angiotensin receptor-neprilysin inhibitor (ARNI)and Corlanor®, a sinoatrial node modulator (Yancy, et.al. 2016).
Entresto™ contains the drug sacubitril, a prodrug that inhibits neprilysin, which causes a decrease in levels of peptides, including natriuretic peptides, bradykinin, adrenomedullin, and other vasoactive peptides. The primary side effects of Entresto™ include hypotension, hyperkalemia, and renal insufficiency (Novartis Pharma, 2015). The drug does carry a small risk of angioedema, and nurses should remind patients about this potential side effect. While Entresto™ is unlikely to be used in women of childbearing potential, it is important to know the drug can cause injury and death to the developing fetus. This drug, as well as other drugs acting on the renin-angiotensin-aldosterone system, should be abruptly discontinued once pregnancy is confirmed (Novartis Pharma, 2015).
Beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), and angiotensin receptor neprilysin (ARNI) have all been shown to decrease morbidity and mortality in heart failure patients (Solomon, et al., 2016). According to the new guidelines, ARNIs are acceptable alternatives to ACE inhibitors and ARBs in stable patients with symptomatic heart failure and a reduced ejection fraction (HFrEF). The guidelines go even further to state that in patients with chronic symptomatic HFrEF, NYHA class II or III, who tolerate an ACE inhibitor or ARB, be transitioned to an ARNI to further reduce the risk of morbidity and mortality (Solomon, et al., 2016).
Before initiation of an ARNI, patients must first be able to tolerate an ACE inhibitor or ARB (Solomon, et al., 2016). ACE inhibitors must be stopped 36 hours before ARNIs can be initiated in patients because any overlap of therapy has been associated with an increased risk of angioedema and morbidity (Solomon, et al., 2016). Both ACE inhibitors and ARNI cause the breakdown of bradykinin, which can cause the adverse event of angioedema. An ARNI should not be administered to anyone who has a history of angioedema with the use of an ACE inhibitor because it may increase the risk of recurrence of angioedema. The ARNI approved for use in heart failure based on clinical trials is sacubitril, which is made in a combination pill with valsartan in a study known as the PARADIGM-HF trial (Novartis Pharma, 2015). The target dose of valsartan/sacubitril is 97/103 mg twice daily (Novartis Pharma, 2015).
The second drug included in the heart failure guideline is Ivabradine, a sinoatrial (SA) node inhibitor, which slows the firing of the SA node and reduces the heart rate (Amgen Pharma, 2015). It has been demonstrated to decrease heart failure-related hospitalizations in heart failure patients with left ventricular ejection fraction (LVEF) of less than 35% (Amgen Pharma, 2015). Ivabradine, however, has not proven to decrease morbidity or mortality for heart failure patients (Amgen Pharma, 2015). Ivabradine should only be used in patients already on beta blockers that have titrated up to the target dose, as tolerated. These patients must also be in sinus rhythm with a heart rate of 70 bpm or greater (Amgen Pharma, 2015). Ivabradine should be taken with meals. Adverse reactions include bradycardia, hypertension, atrial fibrillation, heart block, and sinoatrial arrest (Amgen Pharma, 2015). This medication is contraindicated in patients with blood pressure less than90/50mmHg, sick sinus syndrome, third-degree heart block, pacemaker dependence, hepatic impairment, and resting heart rate of fewer than 60 beats per minute (Amgen Pharma, 2015).
Recent guidelines issued by the AHA, ACC, and HFSA introduced two new treatment options for patients experiencing heart failure. These guidelines offer nurses evidence-based recommendations that will enable them to make informed decisions when prescribing, administering, and monitoring patients taking these new medications.
Brush up on your knowledge of heart failure by taking the following courses from Rn.com: Diagnosis and Management of Heart Failure and Heart Failure Review and Medication Strategies for APRNs.
References:
Amgen Pharma. (2015). Corlanor®: Highlights of prescribing information. Thousand Oaks, Ca. Novartis Pharma. (2015). Entresto™: Highlights of prescribing information. New Jersey.
Solomon, S.D., Claggett, B., Desai, A.S., Packer, M., Zile, M., Swedberg, K. …McCurray, J.J. (2016).Influence of ejection fraction on outcomes and efficacy of sacubitril/valsartan (LCZ696) in heart failure with reduced ejection fraction: The prospective comparison of ARNI with ACEI to determine impact on global mortality and morbidity in heart failure (PARADIGM-HF) trial. Circulation 9 (3). doi:10.1161/CIRCHEARTFAILURE.115.002744.
Yancy, C.W., Jessup, M., Bozkurt, B., Butler, J., Casey, D.E., Colvin, M.M. … Westlake, C. (2016). 2016 ACC/AHA/HFSA Focused update on new pharmacological therapy for heart failure: An update of the 2013 ACCF/AHA guideline for the management of heart failure. Circulation 135 (2). doi:10.1161/CIR.0000000000000435
