What is the treatment for heart failure with reduced ejection fraction (HFrEF)?

From the Guidelines

For a patient with heart failure and an ejection fraction (EF) of 35%, treatment should focus on improving symptoms, slowing disease progression, and reducing mortality.

Initial Treatment

The recommended initial treatment includes:

• An angiotensin-converting enzyme inhibitor (ACEi) such as lisinopril, started at a low dose (2.5-5 mg daily) and titrated up to a target dose of 20-40 mg daily, or an angiotensin II receptor blocker (ARB) like losartan (25-50 mg daily) if ACEi is not tolerated 1.
• A beta-blocker such as metoprolol succinate (12.5-25 mg daily) or carvedilol (3.125-6.25 mg twice daily), titrated up to a target dose of 200 mg daily for metoprolol succinate or 50 mg twice daily for carvedilol 1.

Additional Treatment

For patients who remain symptomatic despite optimal treatment with ACEi and beta-blockers, the addition of an aldosterone antagonist like spironolactone (12.5-25 mg daily) or eplerenone (25-50 mg daily) should be considered 1.

• An angiotensin receptor-neprilysin inhibitor (ARNI) such as sacubitril/valsartan (49/51 mg twice daily) can be used in place of ACEi for patients who remain symptomatic 1.
• Ivabradine (5 mg twice daily) may be considered for patients with a heart rate above 70 bpm despite optimal beta-blocker therapy 1.
• Diuretics like furosemide (20-40 mg daily) should be used as needed to manage fluid overload 1.
• Hydralazine (25-50 mg four times daily) and isosorbide dinitrate (20-40 mg three times daily) can be considered for African American patients who remain symptomatic despite optimal treatment with ACEi and beta-blockers, or for those who cannot tolerate ACEi or ARB 1.

Monitoring and Lifestyle Modifications

Regular monitoring of renal function, electrolytes, and blood pressure is crucial, and doses should be adjusted based on clinical response and tolerance 1. Lifestyle modifications, including a low-sodium diet, regular exercise, and smoking cessation, are also essential components of treatment. Some key points to consider when treating patients with HFrEF include:

• The use of ACEi or ARB as first-line treatment to reduce morbidity and mortality 1.
• The addition of beta-blockers to further reduce the risk of death and hospitalization 1.
• The consideration of ARNI as a replacement for ACEi in patients who remain symptomatic despite optimal treatment 1.
• The importance of regular monitoring and adjustment of treatment based on clinical response and tolerance 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1.1 Heart Failure Post-Myocardial Infarction Eplerenone tablets are indicated to improve survival of stable patients with symptomatic heart failure with reduced ejection fraction (≤40%) (HFrEF) after an acute myocardial infarction (MI).

1 INDICATIONS AND USAGE

1.1 Adult Heart Failure Sacubitril and valsartan tablets are indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction.

The treatment for heart failure with reduced ejection fraction (HFrEF) includes:

• Sacubitril and valsartan tablets to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction 2
• Eplerenone tablets to improve survival of stable patients with symptomatic heart failure with reduced ejection fraction (HFrEF) after an acute myocardial infarction (MI) 3 3

From the Research

Treatment for Heart Failure with Reduced Ejection Fraction (HFrEF)

• The provided studies do not directly address the treatment for HFrEF, but rather focus on heart failure with preserved ejection fraction (HFpEF) or normal ejection fraction (HFNEF) 4, 5, 6, 7.
• However, it can be inferred that the treatment for HFrEF may involve similar approaches to those used for HFNEF, such as reducing LV filling pressure, controlling hypertension, modifying ischemia, and improving LV relaxation 4.
• Additionally, therapies that have been found to improve patient morbidity and mortality for heart failure with reduced EF may be relevant, although the specific details are not provided in the given studies 6.
• It is worth noting that the study from 2006 provides some insight into the characteristics of patients who die with heart failure and a low ejection fraction, highlighting the importance of managing symptoms and comorbidities in these patients 8.

Comparison with HFpEF Treatment

• In contrast to HFrEF, the treatment for HFpEF is more challenging, with no proven effective treatment available 5, 6, 7.
• Current treatment strategies for HFpEF focus on control of volume status and comorbidities, but future research aimed at individualized therapies holds promise to improve outcomes in this increasingly prevalent form of cardiac failure 7.
• The vascular abnormalities present in patients with HFpEF may contribute to the pathophysiology of the disease, and targeting these abnormalities could potentially lead to the development of novel and effective treatment paradigms 6.