J Am Coll Cardiol 2020;76:1117-1145. "A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure". HF diagnosis and monitoring for progression, Treatment prescription, titration, and monitoring, Patient and caregiver education on disease and treatments, Lifestyle prescription (e.g., diet, exercise), education, and monitoring, Psychological and social support assessment, treatment, and monitoring, Palliative and end-of-life counseling and care, Coordination of care for concomitant comorbidities. "The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998-2001". It is important to consider the cost-effectiveness of any new therapy to justify out-of-pocket costs. Relationships in this table are modest unless otherwise noted. JBI Libr Syst Rev 2012;10:4647-4658. 149. Myhre P.L., Vaduganathan M., Claggett B., et al. Abnormal renal function and/or hyperkalemia are common barriers to initiation and titration of GDMT. They use both established and emerging methods to disseminate information for CV conditions and their related management. Se encontró adentro – Página 110Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. JAm Coll Cardiol. ... American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, ... "Rationale and design of a navigator-driven remote optimization of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction". To limit inconsistencies in interpretation, specific assumptions (e.g., treatment effects in varied populations) were considered by the writing group in development of the ECDP. Structured medication titration plans embedded in disease management programs that articulate a strategy for drug initiation and strategies for follow-up have been shown to be useful in obtaining target doses of GDMT within 6 months of hospital discharge (35). "2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Professor Carlos Aguiar, Chair of the European Society of Cardiology (ESC) Communication Committee and spokesperson for Heart Failure, outlines the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. American College of Cardiology Se encontró adentroRetrieved April 6, 2021, from https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack/ ... the American College of Cardiology and American Heart Association's 2017 Hypertension Guideline—NHANES 2013–2016. In the 2016 ACC/AHA/HFSA HF guideline update (6), ivabradine was recommended as a Class IIa, Level of Evidence: B-R (3,4) therapy to reduce the risk of HF hospitalization in patients with HFrEF (LVEF ≤35%) already receiving GDMT (including a beta-blocker at the maximally tolerated dose), and who are in sinus rhythm with a heart rate greater than 70 beats/min at rest (Figures 2 and 3, Tables 1, 2, and 5). Conn V.S., Ruppar T.M. 2021 ESC guideline on Heart Failure: SGLT2 inhibitors finally entering the centre stage and more. In a similar manner, empagliflozin slowed the decline of kidney function among patients treated in the EMPEROR-Reduced study (13). The following are important points to consider regarding palliative care and transition to hospice. J Am Coll Cardiol 2019;74:2969-2979. Se encontró adentro – Página 308European Society of Cardiology (ESC), Acute and Chronic Heart Failure Guidelines ○ Very thorough in terms of pharmacological treatment options (how, when, why) and extremely similar to the guidelines presented by the NICE chronic HF ... 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. Summary: New guidelines for the diagnosis and treatment of acute and chronic heart failure . "2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America". For persistent hypotension, consider referral to an advanced HF specialist. 35. Health Policy 2017;121:363-377. 131. ∗ Required information may vary depending on payer and state. "Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study". "Health literacy and outcomes among patients with heart failure". The formal peer-review process was completed consistent with ACC policy and included a public comment period to obtain further feedback. However, given the benefits of this combination (43% relative reduction in mortality and 33% relative reduction in HF hospitalization) and the favorable impact on health status (47), African-American patients should receive these drugs once target or maximally tolerated doses of beta-blocker, ARNI/ACEI/ARB, and aldosterone antagonists are achieved (3). Lancet 2020;395:497-506. Simplify medication regimens whenever possible, 5. This can be used in place of official income documentation, although this option is not clearly apparent on many of the patient assistance program websites. N Engl J Med 2011;365:2088-2097. Clinical assessment and renal stability in each patient dictates whether clinicians may need to monitor certain patients more closely than others. This document, however, was not specifically focused on the emerging role of SGLT2 inhibitors for HFrEF care. Table 1 Starting and Target Doses of Select GDMT and Novel Therapies for HF (choice and timing of each therapy and in whom they should be added discussed in the text)∗. Following the publication of the 2017 ECDP focused on optimizing therapy for HFrEF, more data have emerged to support an expanded role for ARNIs in patients with HFrEF. Principle 3: Palliative care consultation and complementary approaches to care may further ameliorate refractory HF symptoms of dyspnea, fatigue, and pain, although study results have been mixed. "Use of renin-angiotensin-aldosterone system inhibitors and risk of COVID-19 requiring admission to hospital: a case-population study". "Temporal trends and factors associated with diabetes mellitus among patients hospitalized with heart failure: findings from Get With The Guidelines-Heart Failure registry". The writing committee recognizes that glucosuric effects of SGLT2 inhibitors may be attenuated in those with eGFRs below these thresholds; benefits of SGLT2 inhibitors for HFrEF management in those with more advanced renal dysfunction than the patients in these recent studies remains less clear. breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. Felker G.M., Anstrom K.J., Adams K.F., et al. The MITRA-FR (Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary MR) and COAPT (CV Outcomes Assessment of the MitraClip Percutaneous Therapy for HF Patients with Functional MR) trials reported divergent results. Social barriers to GDMT and optimal HFrEF management should be assessed and, where present, addressed to avoid health inequities in HFrEF outcomes (137). Boehringer Ingelheim Pharmaceuticals. "Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction". End-of-life care in HF involves meticulous management of HF therapies, and palliative care consultation may help with other noncardiac symptoms such as pain. Poppas A., Rumsfeld J.S., Wessler J.D. Most palliative care is provided by nonpalliative care specialists. Annual review needed for patients with established advanced HF in which patients/caregivers and clinicians discuss current and potential therapies for both anticipated and unanticipated events, possible HF disease trajectory and prognosis, patient preferences, and advanced care planning, 6. Careers. "Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial". GDMT: Guideline-directed medical therapy, representing treatment options supported for use by clinical practice guidelines. As there is no existing predicate data to suggest an aldosterone antagonist is mandatory before ARNI therapy, lack of treatment with an aldosterone antagonist should not delay initiating or switching a patient to an ARNI. In a recent study (21), a comparison between condensed and conservative approaches to initiation of sacubitril/valsartan was explored. Relevant disclosures for the writing group, external reviewers, and SSOC members can be found in Appendixes 1 and 2. Gourzoulidis G., Kourlaba G., Stafylas P., "Association between copayment, medication adherence and outcomes in the management of patients with diabetes and heart failure", "Heart failure in non-Caucasians, women, and older adults: a white paper on special populations from the Heart Failure Society of America Guideline Committee", "Frailty assessment in the cardiovascular care of older adults", "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 of global mortality and morbidity in heart failure (PARADIGM-HF) trial", "Comparison of angioedema in heart failure patients treated with sacubitril/valsartan or enalapril in the PARADIGM-HF Study", "Factors related to physician clinical decision-making for African-American and Hispanic patients: a qualitative meta-synthesis". Prior to the full guideline release, the organization recently printed their updated Expert Consensus Decision . Se encontró adentro – Página 45Palpitations are common Stout KK, Daniels CJ, Aboulhosn JA, et al: 2018 AHA/ACC guideline for the management of adults with congenital heart disease: executive summary: a report of the American College of Cardiology/American Heart ... The economic burden of HF is substantial and is expected to increase markedly in parallel with increases in HF prevalence. Heart failure (HF) is a complex clinical syndrome that results from either functional or structural impairment of ventricles resulting in symptomatic left ventricle (LV) dysfunction. Pandey A., Kitzman D., Reeves G. "Frailty is intertwined with heart failure: mechanisms, prevalence, prognosis, assessment and management". Eur J Heart Fail 2017;19:1401-1409. "Factors related to physician clinical decision-making for African-American and Hispanic patients: a qualitative meta-synthesis". 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Table 10 Ten Considerations to Improve Adherence, In-hospital/pre-discharge initiation following decompensation, Start with the goals of therapy (feeling better and living longer) and then discuss how specific actions (medication initiation, intensification, monitoring, and adherence) support those goals (example: ACC's My Heart Failure Action Plan), Use decision aids when available (example: CardioSmart Heart Failure Resources), Ask patient how they learn best and provide education accordingly, Use culturally relevant patient education materials, Become familiar with and advocate for systems that help make cost sharing automatic, immediate, and transparent, Prescribe lower-cost medications if of similar efficacy, Provide a written explanation of the purpose of each medication prescribed, Plan pharmacist visits for complex medication regimens, Use the “teach back” principle to reinforce education, Pill boxes to be filled by patient or care partner a week at a time, Alarms for each time of the day medications are due, Smartphone or other mobile health applications that provide an interactive platform for education, reminders, warnings, and adherence tracking, Provide instructions on when to call for refills or report problems, Remind patients using pharmacy assistance programs that refills/reorders are not automatic, Inquire patients directly (e.g., “How many times in a week do you miss taking your medications?” “Have you run out of your medications recently?”), Carry out medicine reconciliation at visits, with focus on discrepancies, Assess remaining dosage units (i.e., count excess remaining tablets), Monitor pharmacy fills, using available clinical databases or automated alerts for failed fills and refills, Review available drug levels (e.g., digoxin, INR) or concentrations of BNP/NT-proBNP, Plan home-based nursing visits for appropriate patients. January 28, 2021. All rights reserved. As a result, only approximations of risks and benefits can guide therapy in the least-studied populations (Table 11) (133). Prev Med 2017;99:269-276. Comorbidities are particularly common in the elderly. Renal function and potassium should be checked within 1-2 weeks of initiation or dose up-titration of ACEI/ARB/ARNI. "Patient selection for advanced heart failure therapy referral". Health Policy 2015;119:384-394. Gerhard-Herman M.D., Gornik H.L., Barrett C., et al. Eur J Heart Fail 2016;18:1193-1202. Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, CardioSource Plus for Institutions and Practices, Annual Scientific Session and Related Events, ACC Quality Improvement for Institutions Program, National Cardiovascular Data Registry (NCDR). June 29 - July 01, 2021 Virtual. B-type natriuretic peptide (BNP) and NT-proBNP are the most studied biomarkers in HF. Since the publication of the 2017 ECDP, numerous clinical trials have been reported, providing updated knowledge to inform the clinical management of patients with HFrEF. "Triage of patients with moderate to severe heart failure: who should be referred to a heart failure center? GDMT should continue to be up-titrated to achieve maximally tolerated or targeted doses of these therapies. Yancy C.W., Jessup M., Bozkurt B., et al. Participants are discouraged from acquiring relevant RWI throughout the writing process. "Discharge education improves clinical outcomes in patients with chronic heart failure". 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). A systematic review and meta-analysis of 771 intervention trials on medication adherence demonstrated that the most effective interventions were delivered face-to-face by pharmacists and administered directly to patients, with a specific focus on habit-based interventions (118). Team management also facilitates serial assessments and longitudinal care, including management of comorbidities. In patients with moderate renal impairment (eGFR ≥30 mL/min/1.73 m2 and <60 mL/min/1.73 m2), no adjustment is needed when deciding the starting dose of the ARNI sacubitril/valsartan. Source Reference: Maddox TM, et al "2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with . A dose-response relationship for evidence-based beta-blockers used in HFrEF has been demonstrated (i.e., the higher the dose, the better the outcome) (27). Myhre P.L., Vaduganathan M., Claggett B., "B-type natriuretic peptide during treatment with sacubitril/valsartan: the PARADIGM-HF trial", "Impact of systolic blood pressure on the safety and tolerability of initiating and up-titrating sacubitril/valsartan in patients with heart failure and reduced ejection fraction: insights from the TITRATION study", "Association between sacubitril/valsartan initiation and health status outcomes in heart failure with reduced ejection fraction", "Association of change in N-terminal pro-B-type natriuretic peptide following initiation of sacubitril-valsartan treatment with cardiac structure and function in patients with heart failure with reduced ejection fraction". It is not yet clear that de novo initiation is best for all patients with HFrEF (such as those with hypotension or very advanced HF), and we do recognize access challenges for some patients with regards to payer coverage and associated costs of ARNIs. "J Am Coll Cardiol 2020;75:2989-2991. Rosenstock I.M., Strecher V.J., Becker M.H. Ho P.M., Bryson C.L., Rumsfeld J.S. A team-based approach may be necessary to best deploy this monitoring strategy (see Section 5.8). Mehra M.R., Canter C.E., Hannan M.M., et al. "Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study". 25. Eur Heart J 2017;38:2739-2791. N Engl J Med 2014;371:993-1004. However, during treatment, either biomarker predicts the risk of major adverse outcomes in patients treated with sacubitril/valsartan (8). A systematic review of 27 studies of mobile health interventions for CV diseases including HF (120,121) found that mobile health significantly improved adherence to medical therapy (odds ratio: 4.51; p < 0.00001). In addition, recent innovations in HF care delivery, such as group visits, remote specialist video consultation, and telemonitoring programs, may also be useful (88–93). Testani J.M., Stevens S.R., Brisco M.A., et al. "Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke". These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARNI= angiotensin receptor-neprilysin inhibitor; eGFR = estimated glomerular filtration rate; FDA = Food and Drug Administration; PARADIGM-HF = Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in HF. "2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Clinicians should interpret natriuretic peptides in the context of GDMT; caution is advised when attempting to interpret BNP values in the context of ARNI treatment, and NT-proBNP measurement may be preferable in this setting. Cutler D.M., Everett W. "Thinking outside the pillbox—medication adherence as a priority for health care reform". Lastly, the considerable impact of the coronavirus disease 2019 (COVID-19) pandemic on outpatient management of chronic disease states such as HFrEF justifies its consideration in this document. What is needed in specific patient cohorts: African Americans, older adults, and the frail. The pharmacokinetic profile for GDMT as a function of age is not known, and higher risks of adverse events (133) have been described in older populations. Se encontró adentroPostoperative Management, 2021 Overview of Postoperative Response to Surgery, 2021 Postoperative Intensive Care, ... 2024 Nonpharmacological Interventions, 2026 References, 2027 Guidelines, 2028 INTRODUCTION Cardiovascular morbidity and ... An in-depth discussion on the clinical and economic burden of treatment for patients with heart failure, with special consideration to progressive disease. The reader is referred to already available guideline statements (3). Wiviott S.D., Raz I., Bonaca M.P., et al. "Initiation of sacubitril/valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: primary results of the randomised TRANSITION study". "Interventions linked to decreased heart failure hospitalizations during ambulatory pulmonary artery pressure monitoring". Both approaches were tolerated similarly, but the gradual titration approach maximized attainment of the target dose of sacubitril/valsartan in patients previously receiving low doses of an ACEI/ARB. J Heart Lung Transplant 2017;36:593-594. In patients on low-dose beta-blockers who may have heart rates below 70 beats/min, a beta-blocker should continue to be up-titrated to the maximum tolerated or target dose as long as the patients remain asymptomatic. "B-type natriuretic peptide during treatment with sacubitril/valsartan: the PARADIGM-HF trial". 2. Velazquez E.J., Morrow D.A., DeVore A.D., "Angiotensin-neprilysin inhibition in acute decompensated heart failure", "Initiation of sacubitril/valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: primary results of the randomised TRANSITION study", "Sacubitril/valsartan in advanced heart failure with reduced ejection fraction: rationale and design of the LIFE Trial", "Rationale and design of the comparIson of sacubitril/valsartan versus enalapril on effect on NT-Pro-BNP in patients stabilized from an acute heart failure episode (PIONEER-HF) trial", "Meta-analysis: beta-blocker dose, heart rate reduction, and death in patients with heart failure", "Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study", "Effects on outcomes of heart rate reduction by ivabradine in patients with congestive heart failure: is there an influence of beta-blocker dose? Se encontró adentro – Página 202Transitions of care in heart failure: A scientific statement from the American Heart Association. ... acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. This raises the risk of inefficiencies in care delivery, miscommunication, potential drug–drug interactions and drug–disease interactions, and missed opportunities to achieve optimal HF outcomes. Patients whose natriuretic peptide concentrations do not fall with GDMT (“nonresponders”) have a worse prognosis and more deleterious LV remodeling (7,57,58). Circulation 2009;119:3028-3035. Circulation 2020;141:e139-e596. Access event page. "Effect of dapagliflozin in patients with HFrEF treated with sacubitril/valsartan: the DAPA-HF Trial". Use of an SGLT2 inhibitor should also be considered as concomitant treatment for HFrEF in African Americans. Grundy S.M., Stone N.J., Bailey A.L., et al. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P; Authors/Task Force Members; Document Reviewers. Zelniker T.A., Braunwald E. "Mechanisms of cardiorenal effects of sodium-glucose cotransporter 2 inhibitors: JACC state-of-the-art review". Epub ahead of print. For example, in patients who have refractory symptoms despite perceived adequate use of diuretic agents, those who develop worsening renal function with attempts to increase doses of diuretic agents, or those with repeated hospitalization for congestion, a better understanding of filling pressures and hemodynamics might assist in pivotal changes in HF therapies. Taylor A.L., Ziesche S., Yancy C., et al. Socioeconomic barriers pose a major barrier to use of ARNI, SGLT-2 inhibitors, and ivabradine. Desai A.S., Solomon S.D., Shah A.M., et al. N Engl J Med 2018;379:2307-2318. Chronic ambulatory pulmonary artery pressure monitoring may be considered in patients with hospitalizations in the past year who have persistent symptoms with minimal exertion. Ainara Lozano Bahamonde 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Presentación del ESC Congress 2021 Heart failure is a clinical syndrome consisting of cardinal symptoms (e.g. J Am Coll Cardiol HF 2020;8:469-480. 116. Guidelines support the Carillon Mitral Contour System® for the treatment of heart failure patients with secondary functional mitral regurgitation KIRKLAND, Wash., Sept. 22, 2021 /PRNewswire . Chaired by Colin Baigent, Professor of Epidemiology, University of Oxford . 122. An ideal time to consider therapy optimization is during hospitalization for HFrEF, and the reader is directed to the 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure (22). To this end, the ACC has evolved from developing isolated documents to developing integrated “solution sets.” Solution sets are groups of closely related activities, policy, mobile applications, decision support, and other tools necessary to transform care and/or improve heart health. J Am Coll Cardiol 2019;74:104-132. Crespo-Leiro MG, Metra M, Lund LH, Milicic D, Costanzo MR, Filippatos G, Gustafsson F, Tsui S, Barge-Caballero E, De Jonge N, Frigerio M, Hamdan R, Hasin T, Hülsmann M, Nalbantgil S, Potena L, Bauersachs J, Gkouziouta A, Ruhparwar A, Ristic AD, Straburzynska-Migaj E, McDonagh T, Seferovic P, Ruschitzka F. Eur J Heart Fail. Principle 7: The transition from “do everything” to “comfort only/hospice” is often bridged through a phase of “quality survival,” during which time patients increasingly weigh the benefits, risks, and burdens of initiating or continuing life-sustaining treatments. 70. "Effect of natriuretic peptide-guided therapy on hospitalization or cardiovascular mortality in high-risk patients with heart failure and reduced ejection fraction: a randomized clinical trial". 2016 Jul 14;37(27):2129-2200. doi: 10.1093/eurheartj/ehw128. Standard assessments of frailty are available (134). 8600 Rockville Pike Madrid - Spain. If echocardiography does not provide an assessment of LVEF, guidelines recommend other modalities including radionuclide ventriculography or magnetic resonance imaging (3). For example, diabetes is present in over 40% of all patients with HF, and polypharmacy for diabetes treatment is also growing rapidly (143). Guidelines support the Carillon Mitral Contour System® for the treatment of heart failure patients with secondary functional mitral regurgitation KIRKLAND, Wash., Sept. 22, 2021 /PRNewswire/ -- Cardiac Dimensions, a leader in the development of innovative, minimally invasive treatment 4 Although acute heart failure is not a topic that lends itself well to the types of detailed mechanistic studies that Circulation Research is recognized for publishing, I thought this was an important . N Engl J Med 2018;379:2297-2306. Close . As outlined in Section 5.9, the complexity of HF care is further exacerbated by the frequent coexistence of both cardiac and noncardiac comorbidities found in patients with HF. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. J Cardiovasc Nurs 2009;24:371-379. Angioedema was numerically higher but not statistically significantly different from enalapril in the sacubitril/valsartan group. Eur J Heart Fail 2005;7:405-410. Frailty. 75. Rosenstock I.M., Strecher V.J., Becker M.H. McAlister F.A., Stewart S., Ferrua S., et al. 38. Driscoll A., Currey J., Tonkin A.M. "Nurse-led titration of angiotensin-converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers in patients with heart failure with reduced ejection fraction". Clin Res Cardiol 2013;102:11-22. Initiation of an ARNI/ACEI/ARB (Table 1, Figures 2 and 3) is often better tolerated when the patient is still congested (“wet”), whereas beta-blockers are better tolerated when the patient is less congested (“dry”) with an adequate resting heart rate; beta-blockers should not be initiated in patients with decompensated signs or symptoms. 51. "2017 ESC/EACTS guidelines for the management of valvular heart disease". Notably, the TRANSITION (Comparison of Pre- and Post-discharge Initiation of LCZ696 Therapy in HFrEF Patients After an Acute Decompensation Event) study demonstrated that about one-half of the patients could achieve the target dose within 10 weeks after in-hospital initiation or soon after discharge (24). Afilalo J., Alexander K.P., Mack M.J., et al. 74. Mancia G., Rea F., Ludergnani M., et al. 2021.1 RCE and 2021.2 AKT results release on 1 September and 2021.2 KFP results release on 30 September 2021. J Am Coll Cardiol 2002;39:471-480. In the GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in HF) trial, among patients with HFrEF, lowering NT-proBNP to <1,000 pg/mL was associated with significant reverse remodeling and improved outcomes (59).

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