Four-Drug Therapy for Heart Failure With Reduced LV Ejection Fraction: Here and Now

The goals of therapy for patients hospitalized with acute heart failure (HF) and reduced ejection fraction (HFrEF) are both immediate, through the relief of congestion, and long term, through the application of chronic medical therapies that provide improved survival, freedom from subsequent hospitalization and improved quality of life. Robust evidence guides therapy for chronic HFrEF; contemporary practice is now rooted in 4-drug therapy, including angiotensin receptor‐neprilysin inhibitors, angiotensin converting enzyme inhibitors, angiotensin receptor blockers (ACEI/ARB/ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 (SGLT-2) inhibitors 2 Committee Writing Maddox TM Januzzi JL Allen LA Breathett K Butler J et al. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2021; 77: 772-810https://doi.org/10.1016/j.jacc.2020.11.022 Crossref PubMed Scopus (297) Google Scholar ; there is scant evidence to guide appropriate decongestive therapy for acute HF. Use of chronic HFrEF therapies in the setting of acute or postacute HF has been the subject of numerous observational studies but fewer randomized controlled trials. 3 Bhagat AA Greene SJ Vaduganathan M Fonarow GC Butler J. Initiation, continuation, switching, and withdrawal of heart failure medical therapies during hospitalization. JACC Heart Fail. 2019; 7: 1-12https://doi.org/10.1016/j.jchf.2018.06.011 Crossref PubMed Scopus (66) Google Scholar Overall, available data support the safety of continuation or initiation of chronic HFrEF therapies during hospitalization due to acute HF. Discontinuation or nonuse of these therapies is associated with worse near-term and intermediate-term outcomes. The clearest example from a randomized controlled trial of the beneficial initiation of more intensive medical therapy for chronic HFrEF during the acute phase comes from the PIONEER-HF study (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on NT-pro BNP in Patients Stabilized From an Acute Heart Failure Episode), in which in-hospital initiation of sacubitril/valsartan was superior to valsartan for reducing natriuretic peptide levels and a composite of serious clinical events. 4 Velazquez EJ Morrow DA DeVore AD Duffy CI Ambrosy AP McCague K et al. Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med. 2019; 380: 539-548https://doi.org/10.1056/NEJMoa1812851 Crossref PubMed Scopus (510) Google Scholar However, we lack such high-quality randomized controlled trial data for every permutation of escalating or initiating chronic HFrEF therapies in hospitalized patients. In the absence of randomized trial data for the use of chronic HF therapies in acute HF, what decisions should we make for our patients? Projected Clinical Benefits of Implementation of SGLT-2 Inhibitors Among Medicare Beneficiaries Hospitalized for Heart FailureJournal of Cardiac FailureVol. 28Issue 4PreviewThe sodium-glucose cotransporter-2 (SGLT-2) inhibitors form the latest pillar in the management of heart failure with reduced ejection fraction (HFrEF) and appear to be effective across a range of patient profiles. There is increasing interest in initiating SGLT-2 inhibitors during hospitalization, yet little is known about the putative benefits of this implementation strategy. Full-Text PDF