cardiovascular disorders
Drugs for Heart Failure
Selection of drugs for heart failure
Choice of drug depends on the type of heart failure along with individual patient characteristics. The most common classification of heart failure currently in use stratifies patients into Heart failure with preserved ejection fraction (HFpEF) ("systolic HF") Heart failure with preserved ejection fraction (HFpEF) ("diastolic HF") Heart failure with mildly reduced ejection fraction (HFmrEF) None Heart failure with reduced ejection fraction (HFrEF) In HFrEF standard of care includes the following four classes of therapies, considered to be 'foundational therapies' for HFrEF management: Beta-blocker Renin-angiotensin-aldosterone system (RAAS) inhibitor(typically an ARNI, although an ACE inhibitor or ARB could also used if ARNI is not tolerated) Aldosterone antagonist SGLT2 These four drug classes have been studied and have shown benefit for long-term management of HFrEF. Therapy is typically titrated up to maximal tolerated doses. Patients are typically given a drug from each class. Because patients may already be taking one of these classes of drugs prior to developing heart failure, the order of therapy initiation and rate of up-titration are generally patient specific. Addition of a Sodium-glucose co-transporter 2 inhibitors , either Other therapies are used in patient-specific settings (eg, sinus node inhibitors for lowering heart rate if patients cannot tolerate beta blockers). Heart failure with preserved ejection fraction (HFpEF) In HFpEF fewer drugs have been adequately studied. However, ACE inhibitors, ARBs, or aldosterone antagonists (mineralocorticoid receptor antagonists) are often used to treat HFpEF and/or associated comorbidities (such as hypertension and renal dysfunction), although survival benefit has not been demonstrated in clinical trials and, therefore, are not considered a standard of care. ARNIs may reduce hospitalizations for heart failure but do not improve other outcomes. to usual therapy was shown to reduce mortality and hospitalizations for HFpEF ( Drug selection references ). Beta blockers should be used only when there is another existing indication (eg, control of heart rate during atrial fibrillation, angina, following myocardial infarction). In patients with severe HFpEF (in contrast to HFrEF), lowering the heart rate (eg, with a beta-blocker) can exacerbate symptoms because they have a relatively fixed stroke volume due to severe diastolic dysfunction. In these patients, cardiac output (CO) is heart rate dependent, and lowering heart rate can thus lower CO at rest and/or with exertion. In patients with infiltrative, restrictive, or Hypertrophic Cardiomyopathy , Heart failure with mildly reduced ejection fraction (HFmrEF) In HFmrEF there may be a specific benefit from ARNIs, although this possibility requires confirmation. Patients with HFmrEF also benefit from the addition of an SGLT2 inhibitor such asempagliflozinto standard care. 