What is the guideline treatment for heart failure, particularly in patients with reduced ejection fraction?

Guideline Treatment for Heart Failure with Reduced Ejection Fraction

The cornerstone treatment for heart failure with reduced ejection fraction (HFrEF) consists of four foundational medication classes: ACE inhibitors/ARBs/ARNI, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and SGLT2 inhibitors, all of which should be initiated as soon as possible and titrated to target doses to reduce mortality and hospitalizations.

First-Line Pharmacological Therapy

Foundation Medications (Class I Recommendations)

1. ACE Inhibitors/ARBs/ARNI

   • ARNI (sacubitril/valsartan) is preferred over ACE inhibitors 1
     • Starting dose: 24/26 mg BID
     • Target dose: 97/103 mg BID 1, 2
     • Requires 36-hour washout period when switching from ACE inhibitor 2
   • ACE inhibitors (if ARNI not available/tolerated) 3
     • Example: Enalapril 2.5 mg BID, target 10-20 mg BID 1
   • ARBs (if ACE inhibitors not tolerated) 3

2. Beta-blockers 3, 1

   • Carvedilol: Start 3.125 mg BID, target 25-50 mg BID
   • Metoprolol succinate: Start 12.5-25 mg daily, target 200 mg daily
   • Bisoprolol: Start 1.25 mg daily, target 10 mg daily

3. Mineralocorticoid Receptor Antagonists (MRAs) 3, 1, 4

   • Spironolactone: Start 12.5-25 mg daily, target 25-50 mg daily
   • Eplerenone: Start 25 mg daily, target 50 mg daily
   • Monitor potassium and renal function

4. SGLT2 Inhibitors 3, 1

   • Dapagliflozin or empagliflozin 10 mg daily
   • Indicated regardless of diabetes status

Symptomatic Treatment

• Diuretics (for congestion/volume overload) 3, 1
  • Loop diuretics (furosemide, torsemide) titrated to relieve congestion
  • For persistent fluid retention, consider combining loop diuretics with thiazides 3

Additional Therapies for Selected Patients

1. Hydralazine and Isosorbide Dinitrate 1

   • For African American patients
   • Start at 20 mg/37.5 mg TID, target 40 mg/75 mg TID

2. Ivabradine 1

   • For patients with elevated heart rate (>70 bpm) in sinus rhythm
   • Start at 2.5-5 mg BID, target heart rate 50-60 bpm (max 7.5 mg BID)

Device Therapy

1. Implantable Cardioverter-Defibrillator (ICD) 3, 1

   • For patients with LVEF ≤35% despite optimal medical therapy
   • For primary prevention in patients with expected survival >1 year
   • Not recommended within 40 days of MI 3

2. Cardiac Resynchronization Therapy (CRT) 3, 1

   • For patients with LVEF ≤35%, QRS ≥130 ms, and LBBB
   • Improves symptoms, reduces hospitalizations and mortality

Medication Titration and Monitoring

1. Titration Strategy 1

   • Start with low doses and titrate gradually every 2-4 weeks
   • Aim for target doses used in clinical trials
   • Monitor blood pressure, heart rate, renal function, and electrolytes

2. Follow-up 1

   • Regular assessment of symptoms and volume status
   • Monitor renal function and electrolytes at each dose increment
   • Reassess LVEF 3-6 months after optimizing medical therapy

Important Cautions

1. Medications to Avoid 3

   • Diltiazem or verapamil (increase risk of HF worsening)
   • Combination of ARB with ACE inhibitor and MRA (increases risk of renal dysfunction and hyperkalemia)

2. Special Considerations

   • Discontinuation of ARNI and switching to ACE inhibitor/ARB may lead to clinical deterioration 5
   • ACE inhibitors/ARBs have not shown benefit in heart failure with preserved ejection fraction 6

Implementation Strategy

1. Initial Assessment

   • Confirm HFrEF diagnosis with echocardiography (LVEF ≤40%) 3
   • Assess volume status and symptoms

2. Medication Initiation Sequence

   • Begin all four foundational medications as soon as possible 1
   • For hemodynamically stable patients, ACE inhibitors/ARBs can be initiated early during hospitalization 7
   • Diuretics for symptom relief as needed

3. Quality Indicators for HF Management 3

   • Prescription of all four foundation medications
   • Early follow-up after hospital discharge
   • Regular assessment of health-related quality of life

By implementing this comprehensive approach to HFrEF management, clinicians can significantly reduce mortality, hospitalizations, and improve quality of life for patients with heart failure.