Resident Survival Guide |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Rim Halaby, M.D. [3]
Pharmacotherapy is the mainstay of therapy for heart failure with reduced ejection fraction (HFrEF) and should be initiated before considering device therapy.Three major goals of therapy for patients with HFrEF including reduction in mortality, prevention of hospitalization due to worsening HF, and improvement in clinical status. Suppression of renin-angiotensin-aldosterone (RAAS) and sympathetic nervous systems with angiotensin-converting enzyme inhibitors (ACE-I) or an angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, and mineralocorticoid receptor antagonists (MRA) have been shown to improve survival, reducing the risk of HF hospitalizations, and reducing symptoms in patients with HFrEF. ACE-I/ARNI, a beta-blocker, and an MRA are recommended as cornerstone therapies for these patients, unless the drugs are not tolerated or contraindicated. 2021 ESC Guideline recommends the use of ARNI as a replacement for ACE-I in symptomatic patients with ACE-I, beta-blocker, and MRA therapies. ARNI may be considered as a first-line therapy instead of an ACE-I. Angiotensin-receptor blockers (ARBs) are recommended in patients intolerant to ACEI or ARNI. The sodium-glucose co-transporter 2 (SGLT2) inhibitors including dapagliflozin and empagliflozin added to therapy with ACE-I/ ARNI/ beta-blocker/ MRA to reduce the risk of cardiovascular death and worsening HF in patients with HFrEF.
Betablockers | Starting dose | Target dose |
---|---|---|
Bisoprolol | 1.25 mg once daily | 10 mg once daily |
Carvedilol | 3.125 mg twice daily | 25 mg twice daily for weight <85 kg and 50 mg
twice daily for weight≥ 85 kg |
Metoprolol succinate | 12.5–25 mg daily | 200 mg daily |
ARNIs | ||
Sacubitril/valsartan | 24/26 mg–49/51 mg twice daily | 97/103 mg twice daily |
ACEI | ||
Captopril | 6.25 mg 3× daily | 50 mg 3× daily |
Enalapril | 2.5 mg twice daily | 10–20 mg twice daily |
Lisinopril | 2.5–5 mg daily | 20–40 mg daily |
Ramipril | 1.25 mg daily | 10 mg daily |
ARBs | ||
Candesartan | 4–8 mg daily | 32 mg daily |
Losartan | 25–50 mg daily | 150 mg daily |
Valsartan | 40 mg twice daily | 160 mg twice daily |
Aldosterone antagonists | ||
Eplerenone | 25 mg daily | 50 mg daily |
Spironolactone | 12.5–25 mg daily | 25–50 mg daily |
SGL2 ihibitors | ||
Dapagliflozin 10 mg daily | 10 mg daily | 10 mg daily |
Empagliflozin | 10 mg daily | 10 mg daily |
Vasodilators | ||
Hydralazine | 25 mg 3× daily | 75 mg 3× daily |
Isosorbide dinitrate | 20 mg 3× daily | 40 mg 3× daily |
Fixed-dose combination isosorbide dinitrate/hydralazine | 20 mg/37.5 mg (1 tab) 3× daily | 2 tabs 3× daily |
Ivabradine | ||
Ivabradine | 2.5–5 mg twice daily | Titrate to heart rate 50–60 beats/min, Maximum dose 7.5 mg twice daily |
The above table adopted from 2021 AHA/ACC Guideline |
---|
Recommendations for HFrEF and NYHA class II–IV |
(Class I, Level of Evidence A): |
❑ ACE-I is recommended for patients with HFrEF to reduce the risk of HF hospitalization and death |
(Class I, Level of Evidence B): |
❑ Sacubitril/valsartan is recommended as a replacement for an ACE-I in patients with HFrEF to reduce the risk of HF hospitalization and death |
The above table adopted from 2021 ESC Guideline |
---|
and a reduction in the decline in eGFR [7]as well as a reduced rate of hyperkalemia[8].
Recommendations for heart failure with reduced ejection fraction and NYHA 2-4 |
Loop diuretics (Class I, Level of Evidence C): |
❑ Loop diuretics are recommended in patients with HFrEF with signs and/or symptoms of congestion to improve HF symptoms, exercise
capacity, and reduce HF hospitalizations |
ARB (Class I, Level of Evidence B): |
❑ ARB is recommended in symptomatic patients to reduce the risk of HF hospitalization and cardiovascular death for whom unable to tolerate an ACE-I or ARNI (patients should also receive a beta-blocker and MRA) |
If-channel inhibitor :(Class IIa, Level of Evidence B) : |
❑Ivabradine should be considered in symptomatic patients with LVEF ≤35%, sinus rhythm on ECG and a resting heart rate≥ 70 b.p.m despite treatment with maximum tolerated beta-blocker, ACE-I/(or ARNI), and an MRA, to reduce the risk of HF hospitalization and cardiovascular death |
If-channel inhibitor : (Class IIa, Level of Evidence C) |
❑ Ivabradine should be considered in symptomatic patients with LVEF≤ 35%, in sinus rhythm and a resting heart rate≥ 70 b.p.m. when can not tolerate
or have contraindications for a beta-blocker, for reduction the risk of HF hospitalization and cardiovascular death. Patients should also receive an ACE-I (or ARNI) and MRA |
Soluble guanylate cyclase receptor stimulator: (Class IIb, Level of Evidence B) |
❑ Vericiguat may be considered in patients in NYHA class II-IV with worsening HF despite therapy with an ACE-I (or ARNI), a beta-blocker and MRA to reduce the risk of cardiovascular death or HF hospitalization |
Hydralazine, isosorbide dinitrate : (Class IIa, Level of Evidence B) |
❑ Hydralazine and isosorbide dinitrate should be considered in black patients with LVEF ≤35% or with an LVEF<45% combined with a dilated left ventricle in NYHA class III-IV despite therapy with an ACE-I (or ARNI), a beta-blocker and an MRA to reduce the risk of HF hospitalization and death.1 |
Hydralazine, isosorbide dinitrate (Class IIb, Level of Evidence B): |
❑ Hydralazine and isosorbide dinitrate may be considered in patients with symptomatic HFrEF who unable to tolerate any of an ACE-I, an ARB, or
ARNI (or they are contraindicated) to reduce the risk of death |
Digoxin: (ClassIIb, Level of Evidence B) |
❑ Digoxin may be considered in patients with symptomatic HFrEF in sinus rhythm despite treating with an ACE-I (or ARNI), a beta- blocker and an MRA, to reduce the risk of hospitalization (both all-cause and HF hospitalizations) |
The above table adopted from 2021 ESC Guideline |
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