Can You Deprescribe After Ejection Fraction Improvement?

Drs Ileana Piña and Deborah Belfort discuss the CATHEDRAL-HF trial in patients with improved ejection fraction which had some stay on the beta-blocker carvedilol but discontinue other HF meds.
https://www.medscape.com/viewarticle/...

-- TRANSCRIPT --
Ileana L. Piña, MD, MPH: Hello. I'm Ileana Piña, the quality chief for the cardiovascular line at Thomas Jefferson University, and a lifelong heart failure transplant doc.

I'm here at the ESC. With me today is a researcher from Sao Paulo, Brazil, from the Institute of the Heart, which is a wonderful institution in Sao Paulo. I have visited them. She is here to tell us about their work with reverse remodeling.

Deborah Belfort, MD: Thank you very much. I'm Deborah. I'm from Heart Institute. It's a pleasure to be here talking about our research, which is, " Carvedilol as single maintenance therapy for heart failure with improved ejection fraction: the CATHEDRAL-HF trial. "

Piña: How did you come up with this idea? How did you start?

Belfort: In clinical practice, we always wonder if we have to maintain all medications for heart failure once the patient improves ejection fraction.

Piña: If they improve.

From TRED-HF to CATHEDRAL HF
Belfort: If they improve. Current guidelines recommend we keep all medications since the TRED-HF trial, in which 44% of patients experienced relapse of dilated cardiomyopathy after suspension of all medications, signaling that probably these patients are in remission rather than this being a cure of a disease. We have to keep some degree of neurohormonal blockade to prevent them from relapsing.

Piña: If you know the etiology, if it happens maybe from hypertension or something else?

Belfort: For some etiologies, we have to give medications for other reasons. For example, ischemic cardiomyopathy or hypertensive, they require antihypertensive. Maybe for those etiologies it doesn't change much, but we have patients with idiopathic dilated cardiomyopathy or myocarditis or peripartum cardiomyopathy, which are etiologies that may make us think we can suspend or reduce medications lifelong.

Piña: Tell me about the structure of your study.

Belfort: We selected patients with reverse remodeling, and we considered patients with previous HFrEF — so previously their left ventricular ejection fraction (LVEF) was lower than 40%, and their current LVEF was greater or equal to 50% with normal NT-proBNP ( 250 pg/mL) — without symptoms of heart failure, and on carvedilol in optimized doses, as well as ACE inhibitors or ARBs, and with or without spironolactone.

Then we randomized patients in two groups, one to maintain usual treatment and the other one to withdraw heart failure treatment, maintaining carvedilol. We suspended ACE inhibitors, spironolactone, and furosemide. Then we followed both groups initially for 24 weeks, and then we extended follow-up for 52 weeks.

Piña: It was still a highly selected group.

Belfort: Yes, we excluded some etiologies of heart failure such as ischemic cardiomyopathy, hypertensive, valvular, infiltrative cardiomyopathy, and patients with Chagas, which is common in Brazil.

Piña: Yes, that's pretty common.

Belfort: Patients with creatinine clearance less than 30 mg/dL were also excluded.

Piña: You didn't want the CKD sick patients in there?

Belfort: No, especially because these patients have indication for ACE inhibitors or ARBs because they have proteinuria.

Piña: It's protective of the kidney.

Belfort: We excluded these patients. We had a population with a median age of 55 years old, and the most common etiology for heart failure was idiopathic dilated cardiomyopathy in 60% of cases. The median LVEF at diagnosis was 30% at diagnosis and the current LVEF was 58% in both groups, with NT-proBNP less than 100 pg/mL in both groups, and a slightly reduced global longitudinal strain.

Piña: Those are low NT-proBNPs.

Belfort: We included below 250, and the two groups had around 80 pg/mL.

Piña: The NT-proBNPs that I see are in the thousands.

Belfort: We selected patients that were asymptomatic.

Piña: They had improved, obviously, at some point.

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https://www.medscape.com/viewarticle/...