How should the four pillars of therapy for heart failure be prescribed?

Current thinking advocates the use of ‘four pillars of heart failure therapy’. Paul Forsyth, Lead Pharmacist, Clinical Cardiology at NHS Greater Glasgow and Clyde, explains how this treatment can be used effectively.

“If you have the dominant variation of heart failure, which is the heart failure because of LVSD,  ….. this is where we know that there are four main classes of medicine that improve your survival chances and decrease things like your readmission to hospital and risk – and also improve the signs and the symptoms of the clinical manifestation of the syndrome of heart failure”, says Mr Forsyth.

The four pillars of therapy comprise:

• A renin-angiotensin system inhibitor (RASi) which could be either and angiotensin converting enzyme (ACE) blocker or an angiotensin receptor–neprilysin inhibitor (ARNi)
• A beta-blocker
• A mineralocorticoid agonist (MRA)
• A sodium-glucose co-transporter 2 inhibitor (SGLT2i)

The four drug groups all work differently and have additive effects and slow the progression of the disease. ”The order in which you go probably isn’t as important as to really trying to get people onto them as quickly as possible and we try and tailor the approach to the individual in front of you”,  he says.

For someone who also has high blood pressure this could mean starting with an ARNI because this will have the biggest effect in reducing blood pressure; for someone who is diabetic, the starting point could be an SGLT2i. For someone who has recently suffered a heart attack, an MRA – eplerenone – is a good option. If the heart rate is high or there is some angina pain, a beta blocker might be the best starting point.

“We have to look at the patient in front of you and look at what the risks of that individual patient are, and to understand them and their kind of unique constellation of signs and the symptoms – and that ….. lets us make some kind of judgment on what order to get you onto these four pillars”, Mr Forsyth emphasises.  In the past treatment used to be started in a specified order but experience has shown that this takes many months and “causes a lot of inertia” leading to patchy follow-up and failure to “get on to all four pillars”.  The process is quicker now but it remains a challenge to help patients to understand the complex treatment pathway and to start treatment promptly.

“We have a team-based approach with medics, with nurses, with pharmacists, …… that can quite intensively and quickly see them in these first few months of treatment to try and get them onto all four of these drugs. I think most of us don’t really care [about] the order you go in, as long as we treat you as an individual and trying to get them on over this this first few months”, he says.

“Over the last few years our international guidelines and some of our local guidelines really have flipped to trying to get these four drugs started, maybe at lower doses, as quickly as possible and then do the nudging with the doses rather than maximize one ….. and then the next one …….. and then the next one”, he adds.

Reaching the optimum doses

Optimum doses are derived from the seminal clinical trials, Mr Forsyth explains. However, treatment must be tailored to the individual and this involves frequent follow up and monitoring for therapeutic and adverse effects.

“So, it’s a mixture of quite cold therapeutic things about numbers but also talking to the patient and looking at their quality of life and symptoms while trying, where possible, to get them on to the dose closest to the target dose in the seminal clinical trials …… because that’s the dose that we know from the evidence that prevents the type of things like future heart failure events or improves …… survival. So, again, this is a complicated kind of moving dynamic and that’s why it’s quite labour intensive and that’s why, you know, it takes a long time to get people onto full treatment – or sometimes people stall and …. don’t quite get there. ….This is why a team-based approach with lots of different stakeholders is probably the better model for doing that”, he says.

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