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explain in detail the pharmacologic therapies for heart failure with reduced ejection fraction

Answer

The pharmacologic therapies for heart failure with reduced ejection fraction (HFrEF) include several classes of medications, each with specific indications and guidelines for use:

Renin-angiotensin system (RAS) inhibitors

Beta-blockers

Mineralocorticoid receptor antagonists (MRAs)

Sodium-glucose cotransporter-2 inhibitors (SGLT-2 inhibitors)

  • Sodium-glucose cotransporter-2 inhibitors (SGLT-2 inhibitors): SGLT-2 inhibitors should reduce the risk of heart failure hospitalization and death in patients with NYHA class II-IV HFrEF (LVEF ≤ 40%)

Other therapies

  • Ivabradine: Ivabradine is recommended to reduce the risk of heart failure hospitalization and cardiovascular death in symptomatic patients with LVEF ≤ 35%, in sinus rhythm, and a resting heart rate ≥ 70 bpm despite treatment with a β-blocker, ACEI or angiotensin receptor-neprilysin inhibitor, and a mineralocorticoid receptor antagonist
  • Hydralazine and isosorbide dinitrate: This combination is recommended for self-identified Black patients with LVEF ≤ 35% or with an LVEF < 45% combined with a dilated left ventricle in NYHA class III-IV despite treatment with an ACEI (or angiotensin receptor-neprilysin inhibitor), a β-blocker, and a mineralocorticoid receptor antagonist

In summary, the pharmacologic management of heart failure with reduced ejection fraction involves a combination of medications that target different pathways to improve patient outcomes. Core therapies include RAS inhibitors (ACEIs, ARBs, ARNi), beta-blockers, MRAs, and SGLT-2 inhibitors. Additional therapies like ivabradine and the combination of hydralazine and isosorbide dinitrate are utilized in specific patient populations to further reduce morbidity and mortality.

References

1

Heart failure

Medical management

Guidelines

RAS inhibitors

Pathway
ACC/.../HRS 2018