Is red light therapy beneficial for patients with heart failure with reduced ejection fraction (HFrEF)?

Red Light Therapy for Heart Failure with Reduced Ejection Fraction

Red light therapy is not recommended for patients with heart failure with reduced ejection fraction (HFrEF) as there is no evidence supporting its use in current heart failure guidelines, which instead emphasize established pharmacological and device therapies that have proven mortality and morbidity benefits.

Evidence-Based Treatment for HFrEF

The cornerstone of HFrEF management consists of well-established pharmacological therapies that have demonstrated significant improvements in mortality, morbidity, and quality of life:

First-Line Pharmacological Therapies

• Angiotensin-Converting Enzyme Inhibitors (ACEIs)/Angiotensin Receptor Blockers (ARBs) are recommended for all symptomatic patients with HFrEF to reduce the risk of HF hospitalization and death (Class I, Level A recommendation) 1
• Beta-blockers (specifically carvedilol, metoprolol succinate, and bisoprolol) are recommended in addition to ACEIs for patients with stable, symptomatic HFrEF to reduce mortality and hospitalization risk (Class I, Level A recommendation) 1
• Mineralocorticoid Receptor Antagonists (MRAs) are recommended for patients who remain symptomatic despite treatment with ACEIs and beta-blockers (Class I, Level A recommendation) 1
• Angiotensin Receptor-Neprilysin Inhibitors (ARNIs) such as sacubitril/valsartan are recommended as a replacement for ACEIs to further reduce the risk of HF hospitalization and death in patients who remain symptomatic despite optimal therapy (Class I, Level B recommendation) 1
• Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors have been added to the foundational quadruple therapy due to their proven benefits in reducing mortality and hospitalizations 2, 3

Additional Therapies for Specific Situations

• Diuretics are recommended to improve symptoms and exercise capacity in patients with signs of congestion (Class I, Level B recommendation) 1
• Ivabradine may be considered for patients in sinus rhythm with heart rate >70 bpm despite maximum tolerated beta-blocker doses 1
• Hydralazine and isosorbide dinitrate combination has shown mortality benefits in select populations 1
• Intravenous iron has demonstrated high-certainty evidence for improving health-related quality of life in HFrEF patients 1

Treatment Optimization Approach

The European Society of Cardiology guidelines provide a clear algorithm for HFrEF management:

• Initiate all four foundational drug classes (ACEIs/ARBs/ARNIs, beta-blockers, MRAs, and SGLT2 inhibitors) as soon as possible 1
• For patients with low blood pressure, start with SGLT2 inhibitors and MRAs first as they have minimal blood pressure-lowering effects 1
• Follow with low-dose beta-blockers (if heart rate >70 bpm) or low-dose sacubitril/valsartan, then gradually up-titrate 1
• Use a "forced-titration" strategy to achieve target doses, as most clinical trials demonstrated benefits with target doses rather than starting doses 1
• Up-titrate medications in small increments every 1-2 weeks, focusing on one drug at a time 1

Quality of Life Considerations

High-certainty evidence from meta-analyses demonstrates improved health-related quality of life with:

• SGLT2 inhibitors (SMD 0.16,95% CI 0.08-0.23) 1
• Intravenous iron (SMD 0.52,95% CI 0.04-1.00) 1
• ARBs (SMD 0.09,95% CI 0.02-0.17) 1
• Ivabradine (SMD 0.14,95% CI 0.04-0.23) 1
• Hydralazine-nitrate (SMD 0.24,95% CI 0.04-0.44) 1
• ARNIs compared to ACEIs (SMD 0.09,95% CI 0.02-0.17) 1

Common Pitfalls in HFrEF Management

• Underdosing of medications: Many patients remain on starting doses indefinitely, which may not provide the full mortality benefit seen in clinical trials 1
• Failure to use all four foundational drug classes: Guidelines recommend quadruple therapy with ACEIs/ARBs/ARNIs, beta-blockers, MRAs, and SGLT2 inhibitors 1, 3
• Inappropriate use of certain medications: Diltiazem or verapamil are not recommended in HFrEF patients as they increase the risk of worsening heart failure (Class III, Level C recommendation) 1
• Focusing on unproven therapies: Current guidelines do not mention red light therapy or similar alternative treatments, as they lack evidence for improving mortality, morbidity, or quality of life in HFrEF patients 1

Device Therapies When Appropriate

• Implantable Cardioverter Defibrillators (ICDs) are recommended for patients with symptomatic HF (NYHA Class II-III) and LVEF ≤35% despite optimal medical therapy for at least 3 months (Class I, Level A/B recommendation) 1
• Cardiac Resynchronization Therapy (CRT) should be considered in appropriate candidates with prolonged QRS duration 1

In conclusion, the management of HFrEF should focus on evidence-based pharmacological and device therapies that have demonstrated significant improvements in mortality, morbidity, and quality of life. Red light therapy is not included in current heart failure guidelines and should not be recommended for HFrEF patients.