24th April 2024

Management

Non pharmacological treatment includes reduced dietary salt intake, exercise-based rehabilitation programmes, smoking cessation and moderating alcohol intake. 

ACE inhibitors (ramipril, enalapril), beta blockers (bisoprolol, metoprolol), SGLT-2 inhibitors (dapagliflozin, empagliflozin) and MRA (spironolactone, eplerenone) are indicated in HFrEF as these medications have been shown to reduced morbidity and mortality. 

When starting ACE inhibitors, blood pressure and renal function should be measured at baseline, 1-2 weeks after initiation and after any dose adjustments. A dry cough is reported in 4-35% of patients taking ACE inhibitors and may occur any time after starting treatment. It can be managed by switching to an angiotensin-II receptor antagonist (ARB) such as losartan. Other side effects of ACE inhibitors include first dose hypotension and angioedema.  

In HFrEF with NYHA class II, III or IV symptoms, ACE-i/ARB can be replaced with an angiotensin receptor/neprilysin inhibitor (ARNI) such as sacubitril/valsartan. This should be initiated after a wash-out period where ACE inhibitor or ARB is stopped. 

Other adjunct therapies include loop diuretics (furosemide, bumetanide) and ivabradine in those in sinus rhythm with a heart rate over 75 bpm and an ejection fraction less than 35%. Digoxin may provide symptomatic relief through positive inotropic and negative chronotropic effects but it has no effect on mortality. Medications such as hydralazine in combination with ISDN can be beneficial in people of African-Caribbean descent.

Vericiguat is a novel oral agent used in symptomatic chronic HFrEF. It does not prolong survival but reduces HF related rehospitalisation and the need for outpatient intravenous diuretics. 

Patients may also benefit from an antiplatelet and statin therapy based on their cardiovascular risk assessment and should be offered an annual influenza vaccine. 

Device therapy with an implantable cardioverter-defibrillator (ICD) or cardiac resynchronisation therapy (CRT) may be considered in selected patients who remain symptomatic despite optimal medical management with LVEF ≤35%, LBBB and/or prolonged QRS.

Management in HFmrEF and HFpEF is aimed at managing modifiable cardiovascular risk factors; improving functional status, reducing symptoms and hospitalizations related to HF. This includes the use of diuretics to improve congestion and the use of sequential nephron blockade using thiazide/thiazide like diuretics and MRAs in diuretic resistance. 

Although RCTs involving ACE-i, ARB, MRA and ARNI have not shown mortality benefit in HFmrEF, selected patients may still be prescribed such medications to reduce rehospitalization particularly those with LVEF toward the lower end of the range. 

An SGLT-2 inhibitor is recommended by the European Society of Cardiology, to reduce HF related hospitalisations and cardiovascular death.