The HFrEF Standard of Care

An expert in the management of heart failure discusses the standard of care for patients with reduced ejection fraction.

John McMurray, MBChB: In patients with heart failure and reduced ejection fraction, we have what some people have recently been calling the 5 alive: the 5 pharmacological approaches that improve survival. These can be given in 4 pills. First is a renal angiotensin system blocker. Today we would couple that with a neprilysin inhibitor, and those 2 treatments can be prescribed in 1 pill: sacubitril-valsartan. Next is a beta-blocker with a mineral corticoid receptor antagonist or aldosterone antagonist. Most recently, the fifth of those pharmacological approaches is an SGLT2 inhibitor. In addition, we have other drugs that improve symptoms and reduce the risk of heart failure hospitalization, but they don’t reduce mortality. Good examples of that would be ivabradine, digoxin, and most recently, a treatment called vericiguat. We may see also new ideas about intravenous iron very shortly, so that may also be added to that list. We also have devices that we use selectively in certain patients that improve survival, and these are implantable cardioverter variation defibrillators and cardiac resynchronization therapy. We’ve got a wealth of life-saving treatments, and a wealth of treatments that improve symptoms and reduce hospital admission.

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