From the Guidelines
The initial treatment for heart failure with reduced ejection fraction (HFrEF) should include a combination of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), a beta-blocker, and a mineralocorticoid receptor antagonist (MRA), as these medications have been shown to reduce morbidity and mortality, and improve quality of life 1.
Key Medications
- An ACE inhibitor such as lisinopril (10-40 mg daily) or enalapril (2.5-20 mg twice daily), or an ARB like losartan (25-100 mg daily) if ACE inhibitors are not tolerated
- A beta-blocker such as carvedilol (3.125-25 mg twice daily), metoprolol succinate (12.5-200 mg daily), or bisoprolol (1.25-10 mg daily)
- An MRA such as spironolactone (12.5-50 mg daily) for patients who remain symptomatic despite treatment with an ACE inhibitor and a beta-blocker
Additional Considerations
- For fluid management, a diuretic like furosemide (20-80 mg daily or twice daily) is typically prescribed
- For patients who remain symptomatic, newer agents like sacubitril/valsartan (24/26 mg to 97/103 mg twice daily) may replace the ACE inhibitor or ARB
- Medication doses should be started low and gradually titrated upward as tolerated while monitoring blood pressure, kidney function, and electrolytes
Rationale
The use of ACE inhibitors, beta-blockers, and MRAs in patients with HFrEF is supported by high-quality evidence, which demonstrates a significant reduction in morbidity and mortality, and improvement in quality of life 1. The 2020 European Journal of Heart Failure guideline recommends the use of these medications as essential treatments for patients with HFrEF, with a focus on reducing the risk of death and hospitalization 1.
From the FDA Drug Label
Spironolactone tablets are indicated for treatment of NYHA Class III-IV heart failure and reduced ejection fraction to increase survival, manage edema, and reduce the need for hospitalization for heart failure. The initial dose of spironolactone was 25 mg once daily
The initial treatment for heart failure, particularly for patients with reduced ejection fraction, is spironolactone at a dose of 25 mg once daily. This is usually administered in conjunction with other heart failure therapies, such as loop diuretics and ACE inhibitors 2. The goal of treatment is to increase survival, manage edema, and reduce the need for hospitalization for heart failure 2.
- Key points:
From the Research
Initial Treatment for Heart Failure with Reduced Ejection Fraction
The initial treatment for heart failure with reduced ejection fraction (HFrEF) typically involves a combination of medications and lifestyle changes. According to the 2021 guidelines of the European Society of Cardiology, as discussed in 3, the basic therapy for HFrEF consists of four drugs with different mechanisms of action:
- An angiotensin-converting enzyme inhibitor
- A beta-blocker
- A mineralocorticoid antagonist
- A sodium glucose co-transporter-2 inhibitor
Role of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers
Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin-receptor blockers (ARB) are cornerstones in the treatment of HFrEF. As shown in 4, ACE inhibitors have been found to reduce mortality in patients with heart failure. Additionally, 5 found that continued use of ACEi/ARBs in hospitalized patients with HFrEF was associated with lower 1-year mortality risk.
Individualizing Treatment
Treatment for HFrEF should be individualized based on the patient's clinical profile, including congestion, blood pressure, heart rate, renal function, and electrolytes. As discussed in 6, HF therapy must be adapted to the clinical profile, and blood pressure, heart rate, and renal function should be closely monitored.
Benefits of Sacubitril/Valsartan
Sacubitril/valsartan has been found to be beneficial in patients with HFrEF, including those with chronic obstructive pulmonary disease (COPD). As shown in 7, the benefit of sacubitril/valsartan over enalapril was consistent in patients with and without COPD for all end points.
Key Considerations
When treating patients with HFrEF, it is essential to consider the following:
- The use of ACEi/ARBs and beta-blockers to reduce mortality and hospitalization risk
- The importance of individualizing treatment based on the patient's clinical profile
- The potential benefits of sacubitril/valsartan in patients with HFrEF, including those with COPD
- The need for close monitoring of blood pressure, heart rate, renal function, and electrolytes to adapt HF therapy accordingly, as discussed in 6