What is the medical management for Heart Failure with Reduced Ejection Fraction (HFrEF), Heart Failure with Preserved Ejection Fraction (HFpEF), and post ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

The medical management for Heart Failure with Reduced Ejection Fraction (HFrEF), Heart Failure with Preserved Ejection Fraction (HFpEF), and post ST-Elevation Myocardial Infarction (STEMI) involves a multidisciplinary approach, with a focus on reducing morbidity, mortality, and improving quality of life. The cornerstone therapy for HFrEF includes an ACE inhibitor, an MRA, an SGLT2 inhibitor (such as dapagliflozin or empagliflozin), and a beta-blocker, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

• Key medications for HFrEF include:
  • ACE inhibitors or ARBs to reduce the risk of HF hospitalization and death
  • SGLT2 inhibitors to reduce the risk of HF hospitalization and cardiovascular death
  • Beta-blockers to reduce the risk of HF hospitalization and death
  • Mineralocorticoid receptor antagonists to reduce the risk of HF hospitalization and death
• For HFpEF, management focuses on symptom control with diuretics and treating underlying conditions like hypertension and diabetes, with SGLT2 inhibitors showing benefit in reducing the risk of HF hospitalization or cardiovascular death 1.
• Post-STEMI management is not explicitly outlined in the provided guidelines, but generally involves dual antiplatelet therapy, high-intensity statins, beta-blockers, and ACE inhibitors/ARBs to reduce the risk of further cardiovascular events. The use of sacubitril/valsartan, an ARB, and an SGLT2 inhibitor (such as dapagliflozin or empagliflozin) is recommended for patients with HFrEF to reduce the risk of HF hospitalization and death, as well as for patients with HFpEF to reduce the risk of HF hospitalization or cardiovascular death 1.
• Additional considerations include:
  • Diuretics to alleviate symptoms and improve exercise capacity in patients with HF and signs of congestion
  • Implantable cardioverter-defibrillators (ICDs) to reduce the risk of sudden death and all-cause mortality in patients with symptomatic HF and an LVEF ≤35%
  • Cardiac resynchronization therapy (CRT) to improve symptoms and survival in patients with symptomatic HF, sinus rhythm, and an LVEF ≤35% despite optimized medical treatment.

From the Research

Medical Management for HFrEF

• The European Society of Cardiology (ESC) guidelines recommend the use of Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) and Beta Blockers (BB) in the treatment of HFrEF 2.
• Newer medications targeting combining an ARB with a neprilysin inhibitor (ARNI) sacubitril/valsartan have shown benefits in mortality and can be used in place of an ACE inhibitor or an ARB 2.
• Dapagliflozin, a medication targeting the sodium-glucose cotransporter 2 (SGLT2) can be used in addition to current therapies 2.
• The life-saving effect of these therapies has been shown to be additive and becomes apparent within weeks, which is why maximally tolerated or target doses of all drug classes should be strived for as quickly as possible 3.

Medical Management for HFpEF

• Continued use of ACEi/ARBs in hospitalized patients with HFpEF was associated with lower 1-6-year mortality risk (pooled HR 0.86 [0.78-0.94] p = 0.002) 4.
• However, the effect size is lower among those with HFpEF with more heterogeneous outcomes 4.
• Basic pharmacological treatment of patients with HFpEF is not as well established as for HFrEF, but ACEi/ARBs may still be beneficial 4.

Medical Management for Post STEMI

• There is no direct evidence in the provided studies for the medical management of post STEMI.
• However, the management of HFrEF and HFpEF may be relevant for patients with post STEMI who develop heart failure.

Common Considerations

• Guideline-directed medical therapy (GDMT) implementation is a challenge, with generally low adherence rates 3.
• Sequencing strategies for GDMT implementation can help improve adherence 3.
• Treatment initiation of all four drug classes (ACEi/ARNI, BB, MRA, and SGLT2 inhibitors) should be fast and simultaneous 5.
• Further HF treatment has to be individualized, and comorbidities should be treated accordingly 5.