What is the initial management approach for heart failure with reduced ejection fraction (HFrEF)?

Initial Management Approach for Heart Failure with Reduced Ejection Fraction (HFrEF)

For patients with heart failure with reduced ejection fraction (HFrEF), the initial management should include starting all four core medication classes simultaneously at low doses and titrating gradually, with SGLT2 inhibitors and mineralocorticoid receptor antagonists (MRAs) initiated first due to their minimal effect on blood pressure. 1

Core Medication Classes for HFrEF

The four foundational medication classes for HFrEF treatment include:

1. SGLT2 Inhibitors

   • Start early as they have minimal effect on blood pressure but provide rapid benefits 1
   • No dose titration required, making them easy to implement 1
   • Effective even with moderate kidney dysfunction (eGFR ≥30 ml/min/1.73 m² for empagliflozin, ≥20 ml/min/1.73 m² for dapagliflozin) 1

2. Mineralocorticoid Receptor Antagonists (MRAs)

   • Start early as they have minimal effect on blood pressure 1
   • Monitor renal function and potassium levels 1
   • Indicated especially for patients with LVEF ≤35% and NYHA class II-IV symptoms 1

3. Beta-Blockers

   • Consider starting at low dose if heart rate >70 bpm 1
   • Selective β₁ receptor blockers may be preferred due to lesser BP-lowering effect 1
   • If beta-blockers are not tolerated hemodynamically, ivabradine may be used as an alternative in patients with sinus rhythm 1

4. Renin-Angiotensin System Inhibitors

   • ARNi (sacubitril/valsartan) is recommended for NYHA class II-III symptoms 1
   • Start with low dose (25-50 mg twice daily) of sacubitril/valsartan 1
   • If ARNi is not tolerated, use ACE inhibitor (or ARB if ACE inhibitor is contraindicated) 1

Implementation Strategy

Step 1: Initial Assessment

• Evaluate blood pressure, heart rate, volume status, and renal function 1
• Adjust diuretics according to volume status 1
• Consider stopping or decreasing non-essential antihypertensive medications 1

Step 2: Medication Initiation

• For patients with adequate blood pressure:

  • Start SGLT2 inhibitor and MRA first 1
  • Add low-dose beta-blocker if heart rate >70 bpm 1
  • Add low-dose ARNi (or ACEi/ARB if ARNi not feasible) 1

• For patients with low blood pressure (SBP <100 mmHg):

  • Start with SGLT2 inhibitor and MRA as they have minimal BP-lowering effects 1
  • Consider very low starting doses of other medications 1
  • Monitor closely for hypotension 1

Step 3: Titration Strategy

• Increase one medication at a time using small increments 1
• Allow 1-2 weeks between dose adjustments 1
• Target highest tolerated dose or guideline-recommended target dose 1, 2
• Monitor blood pressure, heart rate, renal function, and electrolytes with each dose increase 1, 3

Special Considerations

• Diuretics: Use as needed for congestion but adjust according to volume status to avoid overdiuresis which can lead to hypotension 1, 3

• Low Blood Pressure: For patients with low baseline BP, consider starting with medications that have minimal BP-lowering effects (SGLT2i and MRA) 1

• Renal Function: Monitor closely, especially when using ACEi/ARB/ARNi and MRAs 1, 3

• Heart Rate Control: If beta-blockers cannot be tolerated and patient is in sinus rhythm, consider ivabradine 1

• Monitoring Schedule: Close follow-up is essential during initiation and titration phases, with more frequent monitoring for patients with comorbidities or borderline hemodynamics 1, 3

Common Pitfalls to Avoid

• Sequential approach: Avoid the traditional step-by-step approach that delays benefits of comprehensive therapy 1, 2

• Undertreatment: Don't be overly cautious with dosing - even lower-than-target doses provide significant benefits 2

• Overdiuresis: Excessive diuresis can lead to hypotension and impair tolerance of other HF medications 1, 3

• Failure to adjust therapy: Medications should be adjusted based on clinical response, with one drug at a time to identify the source of any adverse effects 1

• Delaying SGLT2 inhibitors: These should be initiated early due to their favorable safety profile and early benefits 1