Table 7.1. Recommendations for pharmacological treatment of HFrEF previously consolidated in 2018.
| Recommendations | Class | LE | Comments | Table 2018 |
Ref. |
|---|---|---|---|---|---|
| Bisoprolol, carvedilol or metoprolol succinate for symptomatic LV dysfunction to reduce morbidity and mortality. | I | A | 2018 recommendation remains current. | Item 7.2 (page 457) |
See 2018 |
| ACEI for symptomatic LV dysfunction to reduce morbidity and mortality. | I | A | 2018 recommendation remains current. | Item 7.1 (page 456) | See 2018 |
| ARB for symptomatic LV dysfunction (for those intolerant to ACEI due to coughing/angioedema) to reduce morbidity and mortality. | I | A | 2018 recommendation remains current. | Item 7.1 (page 456) |
See 2018 |
| Mineralocorticoid receptor antagonists for symptomatic LV dysfunction, associated with standard treatment with ACEI/ARB/ARNI and BB, to reduce morbidity and mortality. | I | A | MODIFIED: The use of mineralocorticoid receptor antagonists is justified for patients using ACEI/ARB as well as ARNI. | Item 7.3 (page 457) |
80–84 |
| Sacubitril-valsartan, instead of ACEI (or ARB), for patients with symptomatic LV dysfunction, already receiving optimal medical therapy for HF with triple therapy to reduce morbidity and mortality. | I | B | 2018 recommendation remains current. | Item 7.4 (page 458) |
See 2018 |
| Hydralazine and nitrate combination for symptomatic systolic dysfunction, NYHA II-IV, with contraindication for ACEI/ARB (renal failure and/or hypercalcemia) regardless of race or for self-declared black patients with symptomatic systolic dysfunction, NYHA III-IV, despite optimized therapy. | I | B | 2018 recommendation remains current. | Item 7.7 (page 459) |
See 2018 |
| Ivabradine for symptomatic LV dysfunction in patients with optimal medical therapy for HF, sinus rhythm, and HR above 70 bpm to reduce hospitalization, cardiovascular death, and HF death. | IIA | B | 2018 recommendation remains current. | Item 7.5 (page 458) |
See 2018 |
| Digoxin for symptomatic LV dysfunction despite optimal medical therapy for HF, to reduce symptoms and hospitalizations. | IIA | B | 2018 recommendation remains current. | Item 7.6 (page 458) |
See 2018 |
| Loop diuretic for congestion control. | I | C | 2018 recommendation remains current. | Item 7.7 (page 459) |
See 2018 |
| Thiazide diuretic, associated with loop diuretic for persistent congestion. | I | C | 2018 recommendation remains current. | Item 7.7 (page 459) |
See 2018 |
| In recent decades, advances in pharmacological treatment and in the use of implantable devices have changed the prognosis of HFrEF patients.80–91 However, there is still a high risk of morbidity and mortality, even with the adoption of optimal medical therapy. In this new era, drugs acting on various pathophysiological mechanisms of HF have emerged to supplement the inhibition of the neurohormonal system. It should be noted that the benefits observed with the new drugs add to the optimal medical therapy, highlighting the need to maintain triple therapy, including beta-blockers, renin-angiotensin-aldosterone system (RAAS) blockers, and mineralocorticoid antagonists. Once triple therapy has been initiated and disease-modifying new therapies (with proven benefits in reducing cardiovascular death, all-cause mortality, and hospitalizations for HF) added, we can also include medications impacting morbidity. The choice of additional therapies should take into consideration each patient's profile. | |||||
ACEI: angiotensin-converting enzyme II inhibitors; ARB: angiotensin II receptor blockers; ARNI: angiotensin II receptor-neprilysin inhibitors; HF: heart failure; HFrEF: heart failure with reduced ejection fraction; HR: heart rate; LV: left ventricle; RAAS: renin-angiotensin-aldosterone system.