From the Guidelines
Medications for heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) differ, with HFrEF treatment including ACE inhibitors, ARBs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, while HFpEF treatment focuses on symptom management and addressing underlying conditions, with SGLT2 inhibitors showing recent benefit. For HFrEF, the cornerstone medications include ACE inhibitors (like lisinopril 10-40 mg daily), ARBs (such as valsartan 40-320 mg daily), beta-blockers (metoprolol succinate 12.5-200 mg daily or carvedilol 3.125-25 mg twice daily), mineralocorticoid receptor antagonists (spironolactone 25-50 mg daily), and SGLT2 inhibitors (empagliflozin 10 mg daily or dapagliflozin 10 mg daily) 1. Newer additions include sacubitril/valsartan (24/26 mg to 97/103 mg twice daily) and ivabradine (5-7.5 mg twice daily) for specific cases, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. These medications have proven mortality benefits in HFrEF by targeting neurohormonal pathways that contribute to cardiac remodeling. For HFpEF, treatment options are more limited, with a focus on symptom management and addressing underlying conditions, such as blood pressure control, rate control for atrial fibrillation, and management of comorbidities, as outlined in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Diuretics like furosemide (20-80 mg daily) are used for volume control in both types. SGLT2 inhibitors have recently shown benefit in HFpEF, as noted in the 2024 ESC guidelines for the management of chronic coronary syndromes 1. Treatment should be initiated at lower doses and titrated gradually while monitoring renal function, electrolytes, and blood pressure. Key considerations for HFpEF management also include the use of SGLT2 inhibitors, as recommended by the 2024 systematic review of clinical practice guidelines and recommendations for HFpEF management 1. In terms of specific medication classes, the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure provide recommendations for the use of ACE inhibitors, ARBs, beta-blockers, and mineralocorticoid receptor antagonists in HFrEF, as well as the use of diuretics and other medications for symptom management in HFpEF 1. Overall, the management of HFrEF and HFpEF requires a tailored approach, taking into account the individual patient's needs and underlying conditions, with a focus on improving morbidity, mortality, and quality of life.
From the FDA Drug Label
1.1 Adult Heart Failure 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. The medication sacubitril and valsartan is indicated for patients with heart failure with reduced ejection fraction (HFrEF), but there is no information in the provided drug labels that directly supports its use in patients with heart failure with preserved ejection fraction (HFpEF).
- The main difference between HFrEF and HFpEF is the ejection fraction, which is the percentage of blood that is pumped out of the left ventricle with each contraction.
- HFrEF is characterized by a reduced ejection fraction, typically less than 40%, while HFpEF is characterized by a preserved ejection fraction, typically greater than or equal to 50%.
- The provided drug labels do not provide a direct comparison of the medication's effectiveness in HFrEF versus HFpEF patients 2, 2, 2.
From the Research
Medications for Heart Failure with Reduced Ejection Fraction (HFrEF)
- The primary treatment for HFrEF includes the use of diuretics to relieve symptoms, as well as disease-modifying drug and device therapies 3.
- Unless contraindicated, patients with HFrEF should be treated with a β-blocker and one of an angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy 3.
- Additional medications such as ivabradine, hydralazine/isosorbide dinitrate, and sodium-glucose cotransporter 2 (SGLT2) inhibitors may also be used to improve disease outcomes in certain patients with HFrEF 3, 4, 5.
- Vericiguat, a soluble guanylate cyclase stimulator, has been shown to reduce heart failure hospitalization in high-risk patients with HFrEF 3, 5.
Medications for Heart Failure with Preserved Ejection Fraction (HFpEF)
- Unlike HFrEF, there are no approved treatments specifically indicated for HFpEF, and current therapy is largely focused on management of symptoms and comorbidities 6, 7.
- Treatment strategies for HFpEF focus on control of volume status and comorbidities, but future research aimed at individualized therapies holds promise to improve outcomes in this increasingly prevalent form of cardiac failure 7.
- Primary care providers play a pivotal role in the delivery of holistic, patient-centric care from diagnosis to management and palliative care for patients with HFpEF 6.
Comparison of Medications for HFrEF and HFpEF
- While there are several medications available for the treatment of HFrEF, the treatment options for HFpEF are limited and primarily focused on symptom management and control of comorbidities 3, 6, 7.
- Further research is needed to develop effective treatments for HFpEF and to improve outcomes for patients with this condition 6, 7.