Cardiology Letters 2023, 32(1):22-31

Drug therapy in chronic heart failure

Lesný P, Luknár M, Gonçalvesová E

Kardiologická klinika Lekárská fakulta Univerzita Komenského a Národný ústav srdcových a cievnych chorôb, a. s., Bratislava, Slovenská republika

Pharmacological therapy for heart failure (HF) shows the strongest evidence in patients with reduced ejection fraction (HFrEF). The four drug pillars with proven mortality benefit in patients with HFrEF are as follows: a renin-angiotensin-aldosterone blocker (angiotensin receptor neprilysin inhibitor should be preferred), a beta-blocker, a mineralocorticoid receptor antagonist, and a sodium-glucose cotransporter-2 inhibitor (SGLT2i). Furthermore, their early prescription reduces mortality more markedly. Optimally, they should be prescribed during hospitalization, after hemodynamic stabilization. The goal is to initialize all four drugs but strategy of drug selection, sequence of application and dosage adjustment should follow the individual patient profile. For the treatment of patients with HF with mildly reduced ejection fraction (EF) the same drugs as for HFrEF can be used, in spite of a weaker evidence of benefit. It has been confirmed recently that SGLT2i reduce mortality and hospitalization for HF in patients with HF with preserved ejection fraction. SGLT2i (dapagliflozin and empagliflozin) are drugs with prognostic benefit in patients with HF regardless of the left ventricular EF. Renin-angiotensin-aldosterone blockers, beta-blockers, and mineralocorticoid antagonists show weak evidence of benefit in patients with HF with preserved EF. Diuretics are indicated in all patients with HF and congestion to alleviate symptoms and to maintain euvolemic state. In patients with improved EF, including asymptomatic patients, as well as patients with normalized EF and chamber geometry, continuation of disease- modifying therapy is recommended to avoid relapse of the disease.

Keywords: heart failure; treatment; mortality; hospitalization

Published: January 1, 2023  Show citation