What are the four pillars of heart failure management?

The Four Pillars of Heart Failure Management

The four pillars of heart failure management are: 1) ACE inhibitors/ARBs/ARNIs, 2) Beta-blockers, 3) Mineralocorticoid receptor antagonists (MRAs), and 4) SGLT2 inhibitors. These form the cornerstone of pharmacological therapy for heart failure with reduced ejection fraction (HFrEF) 1, 2, 3.

First Pillar: ACE Inhibitors/ARBs/ARNIs

• ACE inhibitors are recommended as first-line therapy in patients with reduced left ventricular systolic function 4
• For patients intolerant to ACE inhibitors, ARBs are recommended as an alternative 1
• ARNIs (Angiotensin receptor-neprilysin inhibitors) may be considered for patients who remain symptomatic despite optimal therapy 1
• These medications target the renin-angiotensin-aldosterone system, which is overactivated in heart failure

Second Pillar: Beta-Blockers

• Beta-blockers are recommended in addition to ACE inhibitors for stable symptomatic heart failure patients with reduced ejection fraction 1
• They should be initiated at low doses and gradually titrated up to target doses shown to be effective in clinical trials
• Beta-blockers reduce sympathetic nervous system activation, which contributes to heart failure progression

Third Pillar: Mineralocorticoid Receptor Antagonists (MRAs)

• MRAs (such as spironolactone or eplerenone) are recommended for patients with HFrEF who remain symptomatic despite ACE inhibitor and beta-blocker therapy 1
• Close monitoring of potassium and renal function is essential when using these medications
• MRAs block aldosterone receptors, reducing sodium retention and myocardial fibrosis

Fourth Pillar: SGLT2 Inhibitors

• SGLT2 inhibitors are recommended for patients with heart failure regardless of ejection fraction 1
• They reduce the risk of heart failure hospitalization and cardiovascular death
• These medications were originally developed for diabetes but have shown significant benefits in heart failure patients regardless of diabetes status

Implementation Considerations

• Diuretics are essential for symptom management but are not considered disease-modifying therapy
• The optimal sequence for initiating these medications remains debated, with some experts suggesting starting with SGLT2 inhibitors and beta-blockers, others with ACE inhibitors or ARNIs 2
• Some recent approaches propose starting all four medications together at low doses 2
• Regular monitoring of renal function and electrolytes is crucial, especially with ACE inhibitors, ARBs, and MRAs 1

Additional Management Strategies

• Device therapy (CRT, ICD) for appropriate patients
• Lifestyle modifications including sodium restriction, fluid management, and exercise
• Patient education on symptom recognition and self-management
• Multidisciplinary disease management programs

Emerging Fifth Pillar

Recent research suggests vericiguat, a soluble guanylate cyclase stimulator, may become the "fifth pillar" of heart failure management, particularly beneficial in older and complex patients 5. However, this is not yet incorporated into major guidelines.

The comprehensive implementation of these four pillars of pharmacological therapy has dramatically improved outcomes for patients with heart failure, though adherence to guideline-directed medical therapy remains suboptimal in clinical practice 3.