What are the pharmacological treatments for Heart Failure (HF)?

From the Guidelines

Pharmacological treatment for heart failure should prioritize the use of sacubitril/valsartan, beta-blockers, and mineralocorticoid receptor antagonists to reduce morbidity, mortality, and improve quality of life, as recommended by the most recent and highest quality study 1. The treatment of heart failure focuses on reducing symptoms, preventing hospitalizations, and improving survival.

Key Medications

• Sacubitril/valsartan: an angiotensin receptor-neprilysin inhibitor that can replace ACE inhibitors in patients with persistent symptoms, as it has been shown to reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker, and an MRA 1.
• Beta-blockers: including carvedilol, metoprolol succinate, or bisoprolol, which reduce heart rate and myocardial oxygen demand, and have been shown to prolong life and reduce the risk of sudden death 1.
• Mineralocorticoid receptor antagonists: such as spironolactone or eplerenone, which are added for patients with reduced ejection fraction to reduce the risk of HF hospitalization and death 1.

Additional Treatments

• Diuretics: particularly loop diuretics like furosemide, are used for fluid overload and to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion 1.
• Angiotensin-converting enzyme (ACE) inhibitors: or angiotensin receptor blockers (ARBs) are alternatives for patients who cannot tolerate sacubitril/valsartan, but have a more modest benefit on the risk of death compared to sacubitril/valsartan, beta-blockers, and mineralocorticoid receptor antagonists 1.

Monitoring and Titration

Regular monitoring of renal function, electrolytes, and blood pressure is essential when initiating and titrating these medications to minimize adverse effects and optimize treatment outcomes. Some medications, such as hydralazine and isosorbide dinitrate, may be considered in specific patient populations, but their use is based on limited evidence and should be individualized 1. SGLT2 inhibitors, such as dapagliflozin or empagliflozin, have shown benefit across the spectrum of heart failure, but their role in the treatment of heart failure is still evolving and requires further study 1.

From the FDA Drug Label

14 CLINICAL STUDIES Dosing in clinical trials was based on the total amount of both components of sacubitril and valsartan, i.e., 24/26 mg, 49/51 mg, and 97/103 mg were referred to as 50 mg, 100 mg, and 200 mg, respectively.

1. 1 Adult Heart Failure PARADIGM-HF PARADIGM-HF was a multinational, randomized, double-blind trial comparing sacubitril and valsartan and enalapril in 8,442 adult patients with symptomatic chronic heart failure (NYHA class II to IV) and systolic dysfunction (left ventricular ejection fraction ≤40%)

The pharmacological treatments for Heart Failure (HF) include:

• Sacubitril and valsartan: a combination of sacubitril and an RAS inhibitor (valsartan)
• Enalapril: an RAS inhibitor
• Beta-blockers: used by 94% of patients in the PARADIGM-HF trial
• Mineralocorticoid antagonists: used by 58% of patients in the PARADIGM-HF trial
• Diuretics: used by 82% of patients in the PARADIGM-HF trial 2

From the Research

Pharmacological Treatments for Heart Failure (HF)

The following are some of the pharmacological treatments for Heart Failure (HF):

• ACE inhibitors:
  • Improve hemodynamics, reduce symptoms of fatigue and dyspnea, increase exercise capacity, correct hyponatremia, reduce diuretic requirements and ventricular arrhythmias, and conserve potassium and magnesium 3
  • Equally effective in patients with mild to moderate heart failure and in patients with severe cardiac impairment 3
  • Improve prognosis in patients with severe heart failure and in patients with hyponatremia 3
• Angiotensin receptor blockers (ARBs):
  • May be considered for patients who remain symptomatic despite ACE inhibitor therapy 4
  • Candesartan cilexetil in addition to standard HF therapy results in a further reduction of cardiovascular mortality 4
• Sacubitril/valsartan:
  • Reduces the risk of death from cardiovascular causes by 20% and HF hospitalizations by 21% 5
  • Reduces the risk of all-cause mortality by 16% 5
• Beta-blockers:
  • Part of the evidence-based mnemonic BANDAID(2) for the treatment of systolic heart failure 6
• Diuretics:
  • Part of the evidence-based mnemonic BANDAID(2) for the treatment of systolic heart failure 6
• Aldosterone antagonists:
  • Part of the evidence-based mnemonic BANDAID(2) for the treatment of systolic heart failure 6
• Ivabradine:
  • Part of the evidence-based mnemonic BANDAID(2) for the treatment of systolic heart failure 6
• Devices (automatic implantable cardioverter defibrillator, cardiac resynchronisation therapy or both):
  • Part of the evidence-based mnemonic BANDAID(2) for the treatment of systolic heart failure 6
• Digoxin:
  • Part of the evidence-based mnemonic BANDAID(2) for the treatment of systolic heart failure 6
• Nitrates and hydralazine:
  • Improve survival of patients with moderate-severe heart failure 7
  • Part of the evidence-based mnemonic BANDAID(2) for the treatment of systolic heart failure 6
• Neprilysin inhibitors:
  • May be considered as an alternative to nitrates and hydralazine 6