Expansion
ACE inhibitor, beta blocker, mineralocorticoid antagonist and SGLT2 inhibitor
Expansion
Four pillars improving mortality in heart failure with reduced ejection fraction:
- ACE inhibitor or angiotensin receptor blocker, or sacubitril-valsartan (an angiotensin receptor-neprilysin inhibitor, superior to ACE inhibition alone)
- Beta blocker: bisoprolol, carvedilol or nebivolol
- Mineralocorticoid receptor antagonist: spironolactone or eplerenone
- SGLT2 inhibitor: dapagliflozin or empagliflozin, effective regardless of diabetes
All work by blocking the maladaptive neurohormonal compensation described in the pathophysiology, which is why they improve survival while positive inotropes, which support it, worsen it.
Symptomatic only
- Loop diuretics for congestion: essential for symptoms, no mortality benefit
- Digoxin: reduces hospitalisation, no mortality benefit; useful with atrial fibrillation
- Ivabradine if the heart rate remains above 75 in sinus rhythm
Avoid: NSAIDs, most calcium channel blockers (verapamil and diltiazem are negatively inotropic), pioglitazone and high-dose steroids, all of which cause fluid retention or depress contractility.
In heart failure with preserved ejection fraction, only SGLT2 inhibitors have clear evidence, with diuretics for symptoms.