Fast Five Quiz: Heart Failure With Reduced Ejection Fraction (HFrEF) Treatment Optimization

Alanna Morris, MD; Michael Weber, MD; Jeffrey J. Hsu, MD


March 13, 2023

Figure 1. Heart failure. X-rays of a patient before (left) and after (right) treatment for heart failure. The heart (white) is greatly enlarged at the left, obscuring much of the lung (black) on the right of the X-ray plate.

According to the 2022 AHA/ACC/HFSA guidelines for the management of heart failure, guideline-directed medical therapy consists of four core medication classes: renin-angiotensin system (RAS) inhibitors, sodium-glucose cotransporter-2 (SGLT2) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. ARNI/ACEI/ARBs inhibit the RAS and are recommended for all patients with new-onset stage C HFrEF to reduce morbidity and mortality.

Following clinical trials, the ARNI sacubitril-valsartan became the preferred agent. In patients with chronic HFrEF, sacubitril-valsartan was shown to significantly reduce cardiovascular death and heart failure hospitalizations by 21% compared with enalapril. In hospitalized patients with acute decompensated heart failure, sacubitril-valsartan led to a greater reduction in N-terminal pro-brain natriuretic peptide concentration than enalapril did.

Nondihydropiridine calcium-channel blockers may be harmful to patients with HFrEF owing to their negative ionotropic effects.

Digoxin may be considered in patients who remain symptomatic despite optimal treatment for fluid control or rate control in the presence of atrial fibrillation.

Combination therapy with hydralazine and isosorbide dinitrate is recommended for symptomatic patients receiving optimal therapy and those unable to tolerate ARNI/ACEI/ARB.

Learn more about the treatment of HFrEF.


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