What are the optimal choices and doses for Angiotensin-Converting Enzyme inhibitors (ACEi), Angiotensin Receptor Blockers (ARB), Beta-blockers (B-blocker), Mineralocorticoid Receptor Antagonists (MRA), and Sodium-Glucose Linked Transporter 2 inhibitors (SGLT2) for patients with Heart Failure with Reduced Ejection Fraction (HFrEF)?

From the Guidelines

For heart failure patients with reduced ejection fraction (HFrEF), the optimal medication choices include ACE inhibitors, ARBs, beta-blockers, MRAs, and SGLT2 inhibitors, with the goal of improving morbidity, mortality, and quality of life. The three best options for ACE inhibitors are lisinopril (target dose 20-40 mg daily) 1, enalapril (target dose 10-20 mg twice daily) 1, and ramipril (target dose 10 mg daily) 1. If ACE inhibitors are not tolerated, ARB alternatives include valsartan (target dose 160 mg twice daily) 1, candesartan (target dose 32 mg daily) 1, and losartan (target dose 150 mg daily) 1. For beta-blockers, carvedilol (target dose 25-50 mg twice daily) 1, metoprolol succinate (target dose 200 mg daily) 1, and bisoprolol (target dose 10 mg daily) 1 are preferred. The MRA options include spironolactone (25-50 mg daily) 1 and eplerenone (50 mg daily) 1. For SGLT2 inhibitors, dapagliflozin (10 mg daily) 1 and empagliflozin (10 mg daily) 1 are recommended. Some key points to consider when prescribing these medications include:

• Initiating at lower doses and gradually titrating to target doses as tolerated
• Monitoring for potential side effects and adjusting doses accordingly
• Considering combination therapy to target multiple pathophysiological mechanisms in heart failure
• Regularly assessing cardiac function, hospitalizations, and survival in HFrEF patients to optimize treatment plans. The choice of medication and dosing should be individualized based on patient-specific factors, such as comorbidities, renal function, and potential drug interactions. Some of the benefits of these medications include:
• Improved cardiac function
• Reduced hospitalizations
• Enhanced survival
• Improved quality of life. It is essential to note that there are no direct data showing that use of lower doses of HFrEF medications among patients, where higher target doses could be tolerated, would produce the same or similar degree of clinical benefit 1. Therefore, target doses should be used whenever possible, as composite event rates were lower with target doses compared with lower doses in clinical trials 1.

From the Research

Optimal Choices and Doses for Heart Failure Patients with Reduced Ejection Fraction

The following are the optimal choices and doses for ACEi, ARB, B-blocker, MRA, and SGLT2 for heart failure patients with reduced ejection fraction:

• ACEi:
  • Enalapril: 10-20 mg twice daily 2, 3
  • Lisinopril: 20-40 mg once daily 2, 3
• ARB:
  • Losartan: 50-100 mg once daily 2, 3
  • Valsartan: 160-320 mg once daily 2, 3
• B-blocker:
  • Metoprolol succinate: 100-200 mg once daily 2, 4
  • Carvedilol: 25-50 mg twice daily 2, 4
• MRA:
  • Spironolactone: 25-50 mg once daily 2, 4
  • Eplerenone: 25-50 mg once daily 2, 4
• SGLT2:
  • Empagliflozin: 10-25 mg once daily 5, 4
  • Canagliflozin: 100-300 mg once daily 5, 4

Considerations for Dosing

When determining the optimal dose for each medication, consider the following:

• Start with a low dose and titrate up to the target dose as tolerated 5, 4
• Monitor blood pressure, renal function, and hyperkalemia when using ACEi, ARB, and MRA 3, 4
• Consider the patient's overall clinical status and adjust the dose accordingly 2, 4