Pharmacologic therapy of heart failure with reduced ejection fraction
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Heart failure (HF) is a common clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. HF may be caused by disease of the myocardium, pericardium, endocardium, heart valves, vessels, or by metabolic disorders . HF due to left ventricular dysfunction is categorized according to left ventricular ejection fraction (LVEF) into HF with reduced ejection fraction (with LVEF ≤40 percent, known as HFrEF; also referred to as systolic HF) and HF with preserved ejection fraction (with LVEF>40 percent; known as HFpEF; also referred to as diastolic HF).
Pharmacologic therapy of HFrEF will be presented here [1,2]. An overview of the management of HFrEF, the management of acute HF, drugs that should be avoided or used with caution in patients with HF, management of HF during pregnancy, the management of refractory HF, and therapy of HFpEF (diastolic HF) are discussed separately. (See "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment of acute decompensated heart failure: General considerations" and "Treatment of acute decompensated heart failure: Components of therapy" and "Drugs that should be avoided or used with caution in patients with heart failure" and "Management of heart failure during pregnancy" and "Management of refractory heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)
GOALS OF THERAPY
The goals of pharmacologic therapy of heart failure with reduced ejection fraction (HFrEF) are to improve symptoms (including risk of hospitalization), slow or reverse deterioration in myocardial function, and reduce mortality (figure 1 and table 1) [1,2]:
●Improvement in symptoms can be achieved by diuretics, beta blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), angiotensin receptor neprilysin inhibitor (ARNI), hydralazine plus nitrate, digoxin, and aldosterone antagonists.
●Prolongation of patient survival has been documented with beta blockers, ACE inhibitors, ARNI, hydralazine plus nitrate, and aldosterone antagonists. More limited evidence of survival benefit is available for diuretic therapy.
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- GOALS OF THERAPY
- OUR APPROACH
- INITIAL THERAPY
- ACE inhibitor
- Angiotensin II receptor blocker
- Beta blocker
- ACE inhibitors or beta blockers first
- ADDITIONAL THERAPY
- Mineralocorticoid receptor antagonist
- Angiotensin receptor-neprilysin inhibitor
- Hydralazine plus nitrate
- - N-3 polyunsaturated fatty acids
- OTHER DRUGS
- Antithrombotic therapy
- Calcium channel blockers
- DRUGS TO AVOID
- MANAGEMENT DURING PREGNANCY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS