Heart Failure: Drug Management

Key points

• HFrEF first-line is now the "four pillars" together: ACE inhibitor (or ARNI) + beta-blocker (bisoprolol, carvedilol or nebivolol) + mineralocorticoid receptor antagonist + SGLT2 inhibitor — a change from the older ACE inhibitor + beta-blocker first, with other agents added later.
• Heart failure with mildly reduced ejection fraction (HFmrEF) now receives the same disease-modifying therapy as HFrEF — previously it was managed like HFpEF.
• HFpEF: an SGLT2 inhibitor plus an MRA are the prognostic therapies · other drug classes have no proven prognostic benefit · diuretics for congestion only.
• If an ACE inhibitor is not tolerated, switch to an ARNI (sacubitril-valsartan) · SGLT2 inhibitors (dapagliflozin, empagliflozin) are indicated in heart failure regardless of diabetes status.
• Assess iron status and anaemia in HFrEF and correct if appropriate · loop diuretics relieve congestion but have never shown a long-term mortality benefit · digoxin improves symptoms without a mortality benefit and is particularly useful with coexisting AF.
• Mortality-trial heritage: ACE inhibitors (SAVE, SOLVD, CONSENSUS) · spironolactone (RALES) · beta-blockers (CIBIS) · hydralazine with nitrate (V-HeFT-1).

Decision points in this pathway

• Reduced (HFrEF) or mildly reduced (HFmrEF) ejection fraction?
• ACE inhibitor not tolerated, or still symptomatic on optimal therapy?
• Still symptomatic despite first-line?
• HR > 75/min AND LVEF < 35% despite optimal therapy?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.