What is the initial treatment for patients with cardiac failure, specifically Heart Failure with Reduced Ejection Fraction (HFrEF) and Heart Failure with Preserved Ejection Fraction (HFpEF)?

Initial Treatment for Heart Failure with Reduced and Preserved Ejection Fraction

For patients with heart failure, the initial treatment should include SGLT2 inhibitors for both HFrEF and HFpEF, along with ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists for HFrEF, while diuretics should be used for symptom management in both types. 1

Treatment for Heart Failure with Reduced Ejection Fraction (HFrEF)

First-Line Quadruple Therapy

The cornerstone of HFrEF management is quadruple therapy, which includes:

1. SGLT2 Inhibitors

   • Dapagliflozin 10 mg daily or Empagliflozin 10 mg daily
   • Can be started early due to minimal effect on blood pressure
   • Monitor renal function and electrolytes 2

2. Beta-Blockers

   • Carvedilol (3.125 mg twice daily, target 25-50 mg twice daily)
   • Metoprolol succinate (12.5-25 mg daily, target 200 mg daily)
   • Bisoprolol (1.25 mg daily, target 10 mg daily)
   • Titrate every 2 weeks as tolerated 1, 2

3. ACE Inhibitors/ARBs/ARNIs

   • ACE inhibitors: Lisinopril, Enalapril, Ramipril
   • ARBs: Candesartan, Losartan, Valsartan
   • ARNIs: Sacubitril/Valsartan (preferred over ACE inhibitors when possible)
   • Start at low doses and titrate gradually 1, 2

4. Mineralocorticoid Receptor Antagonists (MRAs)

   • Spironolactone (12.5-25 mg daily, target 25-50 mg daily)
   • Eplerenone (25 mg daily, target 50 mg daily)
   • Particularly beneficial for NYHA class II-IV symptoms 1, 2

Adjunctive Therapies for HFrEF

• Diuretics: Use as needed for congestion and volume overload
• Ivabradine: For patients in sinus rhythm with heart rate ≥70 bpm despite beta-blockers
• Hydralazine/Isosorbide Dinitrate: Particularly beneficial for self-identified African American patients 1, 2

Device Therapy for HFrEF

• Implantable Cardioverter-Defibrillators (ICDs): For patients with LVEF ≤35% and NYHA Class II-III symptoms
• Cardiac Resynchronization Therapy (CRT): For patients with LVEF ≤35%, QRS ≥150ms, and left bundle branch block morphology 2

Treatment for Heart Failure with Preserved Ejection Fraction (HFpEF)

First-Line Therapy

1. SGLT2 Inhibitors

   • Dapagliflozin or Empagliflozin
   • Shown to reduce hospitalization and cardiovascular death in HFpEF 1

2. Diuretics

   • Use as needed for symptom relief in volume-overloaded patients
   • Titrate based on symptoms and signs of congestion 1

Additional Therapies for HFpEF (Based on Clinical Presentation)

• Mineralocorticoid Receptor Antagonists (MRAs)

  • Consider in patients with LVEF ≥45% with elevated BNP or recent HF hospitalization
  • May decrease hospitalization 1

• ARBs (particularly Candesartan)

  • May be considered to decrease hospitalizations
  • More beneficial in patients with LVEF closer to 50% 1

• ARNIs (Sacubitril/Valsartan)

  • May be beneficial in selected patients with HFpEF
  • Greater benefit in patients with LVEF closer to 50% 1

Management of Comorbidities in Both HFrEF and HFpEF

• Hypertension: Control according to guidelines (target <130/80 mmHg)
• Atrial Fibrillation: Rate control, anticoagulation, and consider rhythm control
• Coronary Artery Disease: Consider revascularization if symptoms or ischemia affecting HF
• Diabetes: Metformin as first-line therapy; SGLT2 inhibitors preferred 1

Titration Strategy and Monitoring

1. Start medications at low doses and titrate gradually
2. Increase one medication at a time every 1-2 weeks
3. Monitor blood pressure, heart rate, renal function, and electrolytes
4. For patients with low blood pressure (SBP <90 mmHg), start with SGLT2i and MRA first 2

Common Pitfalls to Avoid

• Underutilization of guideline-directed therapy: Only 1% of eligible patients receive target doses of all recommended medications
• Excessive concern about low blood pressure: Should not prevent initiation or uptitration of therapy
• Inappropriate discontinuation of medications during hospitalization
• Failure to switch from ACEi/ARB to ARNI in eligible patients 2
• Routine use of nitrates or phosphodiesterase-5 inhibitors in HFpEF is ineffective 1

Special Considerations

• Patients with HFrEF who improve their LVEF to >40% (HFimpEF) should continue HFrEF treatment to prevent relapse 1
• There is limited evidence to guide therapy for patients who improve from HFmrEF to LVEF ≥50% 1

By following this structured approach to heart failure management, clinicians can optimize outcomes by reducing mortality, hospitalizations, and improving quality of life for patients with both HFrEF and HFpEF.