From the Guidelines
Management of heart failure with mildly reduced ejection fraction (HFmrEF, EF 41-49%) should prioritize the use of SGLT2 inhibitors, such as dapagliflozin or empagliflozin, to reduce the risk of HF hospitalization and cardiovascular death, as recommended by the most recent guidelines 1. The treatment approach for HFmrEF is similar to that of HFrEF, with a focus on reducing morbidity, mortality, and improving quality of life.
- First-line medications include:
- SGLT2 inhibitors (dapagliflozin 10mg daily or empagliflozin 10mg daily) to reduce the risk of HF hospitalization and cardiovascular death 1
- ACE inhibitors (like enalapril 2.5-20mg twice daily or lisinopril 10-40mg daily) or ARBs (such as losartan 25-100mg daily or valsartan 40-160mg twice daily) to reduce the risk of HF hospitalization and cardiovascular death 1
- Beta-blockers (metoprolol succinate 12.5-200mg daily, carvedilol 3.125-25mg twice daily, or bisoprolol 1.25-10mg daily) to reduce the risk of HF hospitalization and cardiovascular death 1
- Mineralocorticoid receptor antagonists (spironolactone 12.5-50mg daily or eplerenone 25-50mg daily) to reduce the risk of HF hospitalization and cardiovascular death 1
- Diuretics (furosemide 20-80mg daily or as needed) should be used for fluid overload symptoms to alleviate symptoms, improve exercise capacity, and reduce HF hospitalizations 1
- Lifestyle modifications are essential, including:
- Sodium restriction (<2-3g daily)
- Fluid restriction if needed
- Regular physical activity
- Smoking cessation
- Limited alcohol intake These medications and lifestyle modifications reduce mortality and hospitalizations by blocking neurohormonal activation, reducing cardiac remodeling, and improving hemodynamics. Regular follow-up every 2-4 weeks during medication titration is recommended, with attention to symptoms, vital signs, and laboratory values. It is also recommended that patients with HFmrEF be enrolled in a multidisciplinary HF management programme to reduce the risk of HF hospitalization and to improve survival 1.
From the Research
HFmrEF Management
The management of heart failure with mildly reduced ejection fraction (HFmrEF) involves the use of pharmacological therapies to improve outcomes and reduce mortality risk.
- Current guidelines recommend the use of disease-modifying pharmacological therapies, such as beta-blockers and renin-angiotensin inhibitors, for patients with HFmrEF 2.
- Studies have shown that patients with HFmrEF who receive these therapies have lower adjusted all-cause mortality risk compared to those with heart failure with reduced ejection fraction (HFrEF) 2.
- The use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and angiotensin receptor-neprilysin inhibitors (ARNIs) has been shown to be effective in reducing mortality risk and hospitalization for heart failure in patients with HFmrEF 3.
- Sodium-glucose cotransporter 2 (SGLT2) inhibitors have also been shown to be effective in reducing the risk of hospitalization for heart failure in patients with HFmrEF 3.
- The optimal pharmacological treatment for HFmrEF involves the use of a combination of these therapies, including ACE inhibitors or ARBs, beta-blockers, and SGLT2 inhibitors 3, 4.
Pharmacological Therapies
The following pharmacological therapies are recommended for the management of HFmrEF:
- Beta-blockers: have been shown to reduce mortality risk and improve outcomes in patients with HFmrEF 2, 4.
- Renin-angiotensin inhibitors: have been shown to reduce mortality risk and improve outcomes in patients with HFmrEF 2, 4.
- ACE inhibitors: have been shown to be effective in reducing mortality risk and hospitalization for heart failure in patients with HFmrEF 3, 5.
- ARBs: have been shown to be effective in reducing mortality risk and hospitalization for heart failure in patients with HFmrEF 3.
- ARNIs: have been shown to be effective in reducing mortality risk and hospitalization for heart failure in patients with HFmrEF 3, 4.
- SGLT2 inhibitors: have been shown to be effective in reducing the risk of hospitalization for heart failure in patients with HFmrEF 3, 4.