What is the best management of Heart Failure with Reduced Ejection Fraction (HFrEF)?

From the Guidelines

The best management of Heart Failure with reduced Ejection Fraction (HFrEF) involves a comprehensive approach using guideline-directed medical therapy (GDMT), as recommended by the most recent guidelines 1.

Key Components of GDMT

• An ACE inhibitor (or ARB/ARNI), such as lisinopril (10-40 mg daily) or enalapril (2.5-20 mg twice daily), or sacubitril/valsartan (ARNI) 24/26 mg to 97/103 mg twice daily
• 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)
• A mineralocorticoid receptor antagonist (MRA), such as spironolactone (12.5-50 mg daily) or eplerenone (25-50 mg daily)
• An SGLT2 inhibitor, such as dapagliflozin (10 mg daily) or empagliflozin (10 mg daily), which should be added regardless of diabetes status, as supported by recent studies 1

Additional Considerations

• Diuretics, such as furosemide (20-80 mg daily or twice daily), should be used as needed for volume management
• In African American patients, hydralazine plus isosorbide dinitrate should be considered
• Device therapy (ICD, CRT) should be considered for appropriate patients, along with lifestyle modifications including sodium restriction (<2-3g daily), fluid restriction if needed, regular physical activity, and management of comorbidities like hypertension, diabetes, and sleep apnea

Rationale

The use of GDMT has been shown to improve survival, reduce hospitalizations, and improve quality of life in patients with HFrEF, as demonstrated by recent guidelines and studies 1. The selection of specific medications and devices should be individualized based on patient characteristics, comorbidities, and preferences. Regular monitoring and adjustment of therapy are crucial to optimize outcomes.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1.1 Adult Heart Failure Sacubitril and valsartan tablets are indicated to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction.

The best management of Heart Failure with Reduced Ejection Fraction (HFrEF) includes the use of sacubitril and valsartan tablets to reduce the risk of cardiovascular death and hospitalization for heart failure.

• The treatment decision should be based on clinical judgment. 2

From the Research

Management of Heart Failure with Reduced Ejection Fraction (HFrEF)

The management of HFrEF involves a combination of pharmacological and device-based therapies. Some key points to consider include:

• The use of neurohormonal antagonists, such as angiotensin receptor-neprilysin inhibitors (ARNIs), beta blockers, and mineralocorticoid receptor antagonists, which have been shown to reduce morbidity and mortality in patients with HFrEF 3, 4, 5, 6
• The addition of sodium-glucose cotransporter 2 (SGLT2) inhibitors, which have been shown to improve outcomes in patients with HFrEF, regardless of their diabetic status 3, 5, 6
• The use of device-based therapies, such as implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT), which can help to improve survival and reduce symptoms in patients with HFrEF 7
• The potential benefits of other therapies, such as ivabradine, hydralazine/isosorbide dinitrate, digoxin, and vericiguat, which may be used as adjuncts to core therapies in selected patients 4, 6

Pharmacological Therapies

Some key pharmacological therapies for HFrEF include:

• ARNIs, which have been shown to reduce morbidity and mortality in patients with HFrEF 3, 5, 6
• Beta blockers, which have been shown to reduce morbidity and mortality in patients with HFrEF 3, 5, 6
• Mineralocorticoid receptor antagonists, which have been shown to reduce morbidity and mortality in patients with HFrEF 3, 5, 6
• SGLT2 inhibitors, which have been shown to improve outcomes in patients with HFrEF, regardless of their diabetic status 3, 5, 6

Device-Based Therapies

Some key device-based therapies for HFrEF include:

• ICDs, which can help to improve survival by preventing sudden cardiac death 7
• CRT, which can help to improve symptoms and reduce morbidity in patients with HFrEF 7
• Left ventricular assist device therapy, which can provide clinically meaningful survival benefits in patients with advanced HFrEF 7
• His-bundle pacing, which has emerged as a safe and viable pacing modality for patients with CRT indication 7
• Catheter ablation, which can be an effective strategy for managing cardiac arrhythmia in patients with HFrEF 7