Heart Failure Management

Medication Therapy

• The European Society of Cardiology and American College of Cardiology recommend ACE inhibitors/ARBs or preferably ARNI, beta-blockers, Mineralocorticoid Receptor Antagonists, and SGLT2 inhibitors for patients with Heart Failure with Reduced Ejection Fraction (HFrEF), with a mortality benefit of 5-16% reduction with ACE inhibitors, and greater with ARNIs 1, 2, 3, 4
• Simultaneous initiation of all four medication classes is recommended rather than sequential addition, according to the American College of Cardiology, to reduce morbidity and mortality 5, 2, 3, 4
• A forced titration strategy was used in landmark trials to achieve target doses, as reported by the European Journal of Heart Failure, with a strength of evidence based on landmark trials 1
• The following medications have recommended starting and target doses:

2

• Contraindications for ACE inhibitors/ARBs include renal impairment and hyperkalemia, while beta-blockers are contraindicated in severe bradycardia, hypotension, and decompensated heart failure, and MRAs are contraindicated in severe renal dysfunction and hyperkalemia, as noted by the American College of Cardiology 6
• SGLT2 Inhibitors, such as Dapagliflozin and Empagliflozin, are recommended with a dosage of 10mg daily to improve outcomes regardless of diabetic status (Class 1) 2, 4, 5

Adverse Events and Medication Management

• Landmark trials show similar rates of adverse events between active medication and placebo groups, with 75-85% in both, as reported by JACC: Heart Failure 7
• The American College of Cardiology recommends monitoring renal function and potassium before and 1-2 weeks after dose adjustment of MRA (Spironolactone) to minimize adverse effects 8
• Medications should be spaced out to reduce synergistic hypotensive effects, prioritizing those with the least impact on blood pressure, such as SGLT2 inhibitors and MRAs, if symptomatic hypotension occurs during titration, as recommended by the European Journal of Heart Failure guidelines 9
• The European Journal of Heart Failure guidelines advise against discontinuing medications due to mild, asymptomatic hypotension, as the benefits of guideline-directed medical therapy (GDMT) outweigh the risks of adverse events in most patients 9

Device Therapy

• Implantable Cardioverter-Defibrillators (ICDs) are recommended for primary prevention in patients with LVEF ≤35% and NYHA class II-III symptoms despite optimal GDMT, with patients receiving GDMT having lower 1-year mortality after ICD implantation 10, 11, 12, 13
• Cardiac Resynchronization Therapy (CRT) is recommended for patients with LVEF ≤35%, QRS duration ≥150 ms, LBBB, and NYHA class II-IV symptoms on GDMT 10, 14, 11, 15, 13

Comprehensive Management

• Implementation of comprehensive GDMT significantly reduces all-cause mortality, cardiovascular mortality, heart failure hospitalizations, and improves quality of life, with the evidence demonstrating that a multimodal combination strategy with all four medication classes provides the greatest mortality benefit compared to partial implementation of GDMT 2, 5
• Regular laboratory assessments during titration, monitoring for hypotension, worsening renal function, and hyperkalemia, and scheduling multiple early post-discharge visits (in-person or virtual) are recommended 2, 5, 9, 16, 17, 8, 18
• Regular monitoring (every 1-2 weeks initially) of vital signs, volume status, renal function, and electrolytes is recommended 5, 9, 16, 17, 8, 18
• Renal function and electrolytes (particularly potassium) should be monitored before initiation and 1-2 weeks after starting or titrating MRAs 4
• SGLT2 inhibitors improve outcomes regardless of diabetic status and are associated with improved health-related quality of life (HRQoL) in patients with HFrEF, according to the European Heart Journal and American College of Cardiology (Level of Evidence: A) 5, 19, 13