Table 1.4. HFmrEF treatment recommendations.
| Recommendations | Class | LE | Comments | Table 2018 |
Ref. |
|---|---|---|---|---|---|
| Bisoprolol, carvedilol or metoprolol succinate for HFmrEF patients in sinus rhythm to reduce morbidity and mortality. | IIa | A | NEW: Currently available data indicate that the response of patients with HFmrEF to the treatment for HF is similar to that of patients with HFrEF. | New | 13 |
| ACEI or ARB to reduce morbidity and mortality | IIa | B | New | 11 | |
| Spironolactone to reduce morbidity and mortality | IIa | B | New | 12 | |
| Sacubitril-valsartan, instead of ACEI (or ARB), for symptomatic patients using guideline-directed medical therapy (GDMT) including triple therapy to reduce hospitalization. | IIa | B | New | 14 | |
| Despite the absence of studies assessing therapeutic interventions directed specifically to patients with heart failure with mildly reduced ejection fraction (HFmrEF), secondary analyses of clinical trials with patients with HFrEF and HFpEF indicate HFmrEF patients (LVEF 41-49%) may benefit from interventions currently indicated for HFrEF patients (LVEF ≤ 40%). A meta-analysis of 11 randomized controlled trials found beta-blockers are associated with lower mortality in patients with HFmrEF and in sinus rhythm.13 A subanalysis of the TOPCAT trial identified the beneficial effect of spironolactone for cardiovascular mortality in patients with LVEF ranging between 44 and 50 percent;12 a subanalysis of the CHARM trial found benefits from candesartan on combined endpoints of cardiovascular mortality and hospitalization for patients with LVEF from 40 to 49%.11 The combined analysis of the PARAGON-HF (Angiotensin–Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction) and PARADIGM-HF (Prospective Comparison of ARNi with ACE-I to Determine Impact on Global Mortality and Morbidity in Heart Failure) trials suggest that sacubitril-valsartan is associated with lower hospitalizations for mildly reduced LVEF levels, and that the effect is more intense for female patients with higher LVEF levels.14 | |||||
ACEI: angiotensin-converting enzyme inhibitors; ARB: angiotensin recepter blockers; HFpEF: heart failure with preserved ejection fraction;15HFmrEF: heart failure with mildly reduced ejection fraction; HFrEF: heart failure with reduced ejection fraction; LVEF: left ventricular ejection fraction.