From the Guidelines
Heart failure medications should include ACE inhibitors or ARBs, beta-blockers, and for patients with reduced ejection fraction, SGLT2 inhibitors, as these have shown to improve morbidity, mortality, and quality of life, as recommended by the 2022 AHA/ACC/HFSA guideline 1. The cornerstone medications are ACE inhibitors (like lisinopril, enalapril) or ARBs (losartan, valsartan) which reduce strain on the heart by relaxing blood vessels.
- Key medications for heart failure with reduced ejection fraction (HFrEF) include:
- ACE inhibitors: lisinopril, enalapril, with target doses of 20-40 mg once daily and 10-20 mg twice daily, respectively 1
- ARBs: losartan, valsartan, with target doses of 50-150 mg once daily and 160 mg twice daily, respectively 1
- Beta-blockers: metoprolol succinate, carvedilol, bisoprolol, with target doses of 200 mg once daily, 25-50 mg twice daily, and 10 mg once daily, respectively 1
- SGLT2 inhibitors: empagliflozin, dapagliflozin, with a dose of 10 mg once daily 1
- Aldosterone antagonists: spironolactone, eplerenone, with target doses of 25-50 mg once daily and 50 mg once daily, respectively 1 Regular monitoring of kidney function, electrolytes, and blood pressure is essential when using these medications, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. These drugs work by addressing the neurohormonal imbalances in heart failure, reducing cardiac remodeling, and improving cardiac output while decreasing congestion. The specific combination depends on heart failure type (reduced vs. preserved ejection fraction), severity of symptoms, and individual patient factors, with sacubitril/valsartan recommended as a replacement for an ACE-I to further reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment 1.
From the FDA Drug Label
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. Sacubitril and valsartan tablets are indicated for the treatment of symptomatic heart failure with systemic left ventricular systolic dysfunction in pediatric patients aged one year and older.
The medication used to treat heart failure is sacubitril and valsartan tablets.
- The tablets are used to reduce the risk of cardiovascular death and hospitalization for heart failure in adult patients with chronic heart failure and reduced ejection fraction.
- The tablets are also used for the treatment of symptomatic heart failure with systemic left ventricular systolic dysfunction in pediatric patients aged one year and older 2.
From the Research
Medications for Heart Failure
The following medications are used to treat heart failure:
- Diuretics: first-line drugs in the treatment of patients with heart failure with reduced ejection fraction (HFrEF) and volume overload 3
- Angiotensin-converting enzyme (ACE) inhibitors: used in treatment of HFrEF, examples include enalapril 3, 4
- β-blockers: used in treatment of HFrEF, examples include carvedilol, sustained-release metoprolol succinate, or bisoprolol 3
- Angiotensin II receptor blockers (ARBs): used if intolerant to ACE inhibitors, examples include candesartan or valsartan 3, 5
- Sacubitril/valsartan: may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III 3, 4
- Aldosterone antagonists: added in selected patients with class II-IV HF, examples include spironolactone or eplerenone 3
- Isosorbide dinitrate plus hydralazine: added in patients self-described as African Americans with class II-IV HF being treated with diuretics, ACE inhibitors, and β-blockers 3, 6
- Ivabradine: used in selected patients with HFrEF 3, 4
- Sodium glucose co-transporter-2 inhibitors: part of the basic therapy for patients with HFrEF, as proposed by the 2021 guidelines of the European Society of Cardiology 7
Treatment Algorithm
The treatment algorithm for heart failure with reduced ejection fraction (HFrEF) involves a basic therapy consisting of four drugs with different mechanisms of action:
- An angiotensin-converting enzyme inhibitor
- A β-blocker
- A mineralocorticoid antagonist
- A sodium glucose co-transporter-2 inhibitor Additional drugs and/or interventions/devices are indicated depending on the response to the four-drug basic therapy and the clinical phenotype 7