From the Guidelines
The initial management of Heart Failure with Reduced Ejection Fraction (HFrEF) should prioritize a combination of medications that reduce mortality and improve symptoms, starting with an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, and a mineralocorticoid receptor antagonist, as recommended by the most recent guidelines 1.
Key Medications
- An ACE inhibitor such as lisinopril (starting at 2.5-5mg daily) or enalapril (2.5mg twice daily) to reduce cardiac workload and inhibit harmful neurohormonal activation 1
- A beta-blocker such as carvedilol (3.125mg twice daily), metoprolol succinate (12.5-25mg daily), or bisoprolol (1.25mg daily) to reduce the risk of HF hospitalization and death 1
- A mineralocorticoid receptor antagonist like spironolactone (25mg daily) or eplerenone (25mg daily) to reduce the risk of HF hospitalization and death 1
Additional Considerations
- Diuretics, typically furosemide (20-40mg daily), should be added to manage fluid overload and relieve congestion 1
- For patients who remain symptomatic despite these medications, consider adding an angiotensin receptor-neprilysin inhibitor (ARNI) like sacubitril/valsartan (24/26mg twice daily) to replace the ACE inhibitor, or a sodium-glucose cotransporter-2 (SGLT2) inhibitor such as dapagliflozin (10mg daily) or empagliflozin (10mg daily) 1
Monitoring and Titration
- Doses should be titrated gradually to target doses as tolerated, with regular monitoring of blood pressure, renal function, and electrolytes, particularly potassium levels 1
From the FDA Drug Label
In trials in patients treated with digitalis and diuretics, treatment with enalapril resulted in decreased systemic vascular resistance, blood pressure, pulmonary capillary wedge pressure and heart size, and increased cardiac output and exercise tolerance. The recommended starting dose of sacubitril and valsartan tablet is 49/51 mg orally twice-daily. Use of enalapril was associated with an 11 percent reduction in all-cause mortality and a 30 percent reduction in hospitalization for heart failure.
The initial management of Heart Failure with Reduced Ejection Fraction (HFrEF) may include:
- Angiotensin-Converting Enzyme (ACE) inhibitors like enalapril, which have been shown to reduce mortality and hospitalization rates in patients with HFrEF.
- Angiotensin Receptor-Neprilysin Inhibitors (ARNI) like sacubitril and valsartan, which can be used to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction. Key considerations for initial management include:
- Starting with a low dose and titrating up as tolerated
- Monitoring for potential side effects and adjusting the treatment plan as needed
- Considering the use of other medications, such as digitalis and diuretics, as part of a comprehensive treatment plan 2 3.
From the Research
Initial Management of HFrEF
The initial management of Heart Failure with Reduced Ejection Fraction (HFrEF) involves a comprehensive approach to identify and treat underlying and precipitating causes of heart failure 4.
- Identification and Treatment of Underlying Causes: It is essential to identify and treat hypertension, which is a common underlying cause of HFrEF.
- Pharmacological Treatment: The initial pharmacological treatment includes:
- Diuretics as the first-line drugs for patients with volume overload
- Angiotensin-converting enzyme (ACE) inhibitors and β-blockers (such as carvedilol, sustained-release metoprolol succinate, or bisoprolol)
- Angiotensin II receptor blockers (ARBs) (such as candesartan or valsartan) if patients are intolerant to ACE inhibitors
- Sacubitril/valsartan as an alternative to ACE inhibitors or ARBs in patients with chronic symptomatic HFrEF class II or III
- Aldosterone antagonists (such as spironolactone or eplerenone) in selected patients with class II-IV HF
- Isosorbide dinitrate plus hydralazine in African American patients with class II-IV HF
- Ivabradine in selected patients with HFrEF 4, 5, 6
Device Therapy
In addition to pharmacological treatment, device therapy plays a crucial role in the management of HFrEF.
- Cardiac Resynchronization Therapy (CRT): CRT is the therapy of choice for symptomatic patients with HFrEF and a broad QRS complex with a left bundle branch block (LBBB) morphology 7, 8
- Implantable Cardioverter-Defibrillators (ICDs): ICDs are also established for the treatment of HFrEF 7, 8
- Alternative Electrical Therapies: Baroreflex activation therapy (BAT) and cardiac contractility modulation (CCM) may be considered in patients who are not candidates for CRT 7