From the Guidelines
In the setting of undifferentiated shock with suspected Heart Failure with Reduced Ejection Fraction (HFrEF), the initial treatment approach should prioritize stabilization and diagnosis.
Initial Treatment
Administer oxygen as needed, and consider nitrates (e.g., nitroglycerin 10-20 mcg/min IV) if blood pressure allows, to reduce preload and afterload 1.
- For patients with evidence of volume overload, consider furosemide (20-40 mg IV) or other loop diuretics, as they can help improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion 1.
- If the patient is hypotensive, consider inotropes such as dobutamine (2.5-10 mcg/kg/min IV) or milrinone (0.25-0.75 mcg/kg/min IV) to support blood pressure and cardiac output.
Monitoring and Adjustments
It is crucial to monitor the patient's hemodynamic status closely, including blood pressure, cardiac output, and signs of organ perfusion 1.
- Early involvement of a cardiologist and consideration for advanced heart failure therapies, such as mechanical circulatory support, may be necessary.
- In the absence of clear contraindications, an ACE inhibitor or ARB (e.g., lisinopril 2.5-5 mg PO daily or enalapril 2.5-5 mg PO daily) should be initiated as soon as possible to reduce afterload and improve long-term outcomes 1.
- Beta-blockers (e.g., metoprolol succinate 12.5-25 mg PO daily) should also be started when the patient is stabilized, as they reduce morbidity and mortality in HFrEF 1.
Guideline-Directed Medical Therapy
The treatment should be tailored to the individual patient's response, and adjustments should be made based on clinical judgment and hemodynamic monitoring.
- Guideline-directed medical therapy (GDMT) for HFrEF now includes 4 medication classes, including sodium-glucose cotransporter-2 inhibitors (SGLT2i) 1.
- Consideration of other medications, such as hydralazine and isosorbide dinitrate, may be necessary for patients who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker, and an MRA 1.
From the Research
Treatment for Heart Failure with Reduced Ejection Fraction (HFrEF)
The treatment for HFrEF involves a combination of pharmacological and non-pharmacological approaches. The primary goal of treatment is to improve symptoms, reduce hospitalizations, and increase survival.
- Guideline-directed medical therapy (GDMT) is the cornerstone of treatment for HFrEF, targeting the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) 2, 3.
- Novel pharmacological therapies, such as angiotensin receptor-neprilysin inhibitors (ARNI), sodium-glucose cotransporter-2 inhibitors (SGLT2i), vericiguat, and omecamtiv mecarbil, have shown improved clinical benefits when added to traditional standard-of-care medical therapy in HFrEF 2, 4, 5.
- In the setting of undifferentiated shock, the treatment approach may involve rapid sequence or simultaneous initiation of quadruple GDMT for HFrEF, barring absolute contraindications for each individual medication 5.
Pharmacological Therapies
Pharmacological therapies play a crucial role in the management of HFrEF. These include:
- Beta blockers and aldosterone antagonists to improve ejection fraction 3
- Nitrates plus hydralazine, digoxin, statins, omega 3 polyunsaturated fatty acids, anticoagulants, and antiarrhythmics, which may be used as additional agents 3
- SGLT2i and non-steroidal mineralocorticoid receptor antagonists (MRA) for patients with HFpEF or HFrEF 5
Non-Pharmacological Therapies
Non-pharmacological therapies, such as cardiac resynchronization therapy and implantable cardioverter defibrillators, may also be considered in the treatment of HFrEF 4.
Initiation and Sequencing of GDMT
The initiation and sequencing of GDMT for HFrEF is critical to improving outcomes. Rapid sequence or simultaneous initiation of quadruple GDMT is recommended for substantially reducing the risk of mortality and hospitalization 5.