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1yr
Guideline-directed medical therapy for heart failure

Heart failure (HF) with preserved ejection fraction (HFpEF), which is defined as HF with left ventricular ejection fraction (LVEF) of 50% or more, accounts for more than 50% of HF cases in the United States, and its incidence continues to rise. Historically, treatment for HFpEF was limited to the management of comorbidities, but newer clinical data have established sodium-glucose transport protein 2 (SGLT2) inhibitors as an effective treatment option. The American College of Cardiology (ACC) now recommends initiating SGLT2 inhibitor therapy in all patients with HFpEF.

Inhibitors of SGLT2 also play a key role in treating HF with reduced ejection fraction (HFrEF), in which LVEF is 40% or less. In its 2024 update, the ACC recommends starting treatment for symptomatic HFrEF with the “4 pillars”:

  1. Angiotensin receptor-neprilysin inhibitor
  2. Beta blocker
  3. Mineralocorticoid antagonist
  4. SGLT2 inhibitor

In your patients, how do you manage HF, regardless of ejection fraction?

  • 1yr
    I am still a little old fashioned and like to use inexpensive medications at time of first diagnosis. Patients may rebel if hit with too many medications at once at great cost, and, by far, the worst outcome will be the patient who quits everything (either for cost or side effects). So, for HFpEF, I start with Coreg and an ACE or ARB and titrate as they tolerate. After that I will consider changing the ARB to Entresto and adding SGLT-2 inhibitor; which one first depends on renal function and insulin resistance. Of course if diabetic I will go with SGLT-2 earlier. For HFpEF, I like SGLT-2 due to diuretic effects and data and go to MRA, BB, ACEI/ARB as add on therapy.
  • 1yr
    I tend to use the same medications regardless of Lvef. Which medication I start with depends on how congested they are and what their blood pressure is. I tend to start with ace I ARB ARNI. Add diuretics and b blockers. Then an SGLT2 inhibitor the. A mineralocorticoid. It is important to keep an eye on renal function potassium level and blood pressure
  • 1yr
    Those with HFrEF (LVEF< ), I start with beta blocker if HR allows and ACEI or ARB or ARNI, dose depending on blood pressure. Then I add spironolactone and SGLT2 inhibitor empaglifozin or dapagliflozin if affordable. Diuretic is used as needed for treatment of volume overload with low salt diet. Whole food plant based diet to reduce TMAO levels and promote weight loss. Treat sleep apnea. For HFmEF and HFpEF, I recommend the same measures, but often eliminate beta blocker unless needed for control of ventricular response if afib is present, and ARNI is preferred over ACEI or ARB in HFpEF.
  • 1yr
    Management of HF includes the evaluation of underlying etiology, precipitants and management of reversible causes. In HFrEF, initiation of GDMT and uptitration of medications as BP and electrolytes/renal function allow to highest tolerated doses and use of ARNI/BB/ARB/SGLT2i is standard. For HFpEF, much trickier with lifestyle modification, weight loss, OSA, DM and renal function management important and use of MRA/SGLT2 and ARNI, as tolerated/affordable and as per comorbidities allow
  • 1yr
    I also use quadruple therapy/the four pillars for HFrEF or heart failure with improved ejection fraction. Titration and initiation of quadruple therapy can be limited by hypotension, hyperkalemia, renal insufficiency, and/or prohibitive cost.
  • 1yr
    I routinely use Quad Therapy for all HFrEF and MRA/Entresto/Jardiance for patients with HFpEF. As stated above, SGLT2i is the only drug that occasionally is a problem in terms of affordability. Additionally, i've been using GLP1-RAs increasingly because obesity and insulin resistance is an underlying cause of patients deterioration in regards to sleep apnea, atrial fib, hightened inflammation, poor functional capacity, and lower ability to exercise. I'm interested to hear from others on how much they are focusing on weight loss and use of GLP1-RAs for their obese patients with CHF.
  • 1yr
    I use the 4 pillar agents in HFREF as hemodynamics and renal function allow. In HFPEF I use the SGLT2I with diuretics as needed for symptomatic relief as well as treatment of underlying disorders; in appropriate cases I rule out cardiac amyloid which itself can be treated as well.
  • 1yr
    Generally speaking, I place all of my symptomatic patients with an EF less than 50% on all 4 of the above agents. For patients with preserved ejection fraction, the main goal is to figure out what the etiology is. While sorting that out, SGLT2 inhibitors and sacubitril/valsartan are my starting medications with MRAs added as needed/tolerated.
  • 1yr
    SGLT-2 inhibitors have become the standard of care for HF irrespective of the EF status. For those with HFrEF I tend to use all the 4 pillars as recommended by ACC . HFpEF treatment is more challenging until recently, however SGLT-2 inhibitors are now being widely used and recommended. The only issue is affordability especially for those on Medicare and Medicare HMOs.
  • 1yr
    In all patients with CHF regardless of EF, I try to start an SGLT2 inhibitor due to mortality benefit. Unfortunately a fair number of patients cannot afford these medications. For patients with HFrEF, I try to start patients on all 4 pillars including ARNi, beta-blockers, MRA, and SGLT2 inhibitors. However, patients who are borderline hypotensive or with renal dysfunction may not tolerate ARNi or MRA.
  • 1yr
    I agree with the other comments regarding the broad use of sglt2 inhibitors in heart failure either systolic or diastolic. For hospitalized patients I feel that the sooner introduction will lead to a better clinical outcome. if I'm not mistaken, there have been several publications validating an early use. Moreover there appears to be a class effect regarding renal protection. the main limitation to their use is related to insurance coverage.
  • 1yr
    SGLT2 inhibitors are now utilized in treatment of CHF with both preserved and reduced EF. Additional meds for CHF with reduced EF will still consist of entresto, beta-blockers, and mineralocorticoid antagonists along with diuretics as needed. It is important to monitor renal function, blood pressure, weight, and volume status in all patients with CHF.
  • 1yr
    As difficult as it is, we can't rest on our laurels and SGLT2 inhibitors are first-line therapy nowadays regardless of the EF. One nice thing about them is that they don't impact BP too much. Unfortunately they are still difficult to afford for many people. It can be pretty daunting for patients to go home with prescriptions for 2-3 expensive medications all at once so usually I start with the SGLT2 and (if EF is down) Entresto next but will 'cover' them with an ARB until we get insurance coverage worked out. Beta blockers still a cornerstone. MRA are certainly more helpful than loop diuretics but sometimes the very sickest patients are more delicate with their volume status.
  • 1yr
    In patients with HFPEF SGLT2 inhibitors are first medication to use in addition to diureics. Would start with SGLT2 inhibitor and BB as well as diuretic then consider addition of mineralocorticoid and possibly RAAS inhibitor
  • 1yr
    It is so interesting that reduced and preserved EF HF patients can be treated in a similar way. Certainly GDMT is the goal in reference to treating these patients. Sometimes there are roadblocks to that in terms of patient acceptance or cost issues, but when possible, patients should be on the four components of GDMTin reference to treating CHF. SGLT inhibitors are a very important component of this.
  • 1yr
    Or Hfref I start with ace/arb or arni and quickly add beta blocker and sglt2 blocker
    I find using mra limited by BP or hyperkalemia
    For hfpef I first normalize volume with diuretic, control BP and then add sglt2 agent
    Unfortunately coverage for sglt2 agents are poor and cost prohibitive for many patients
  • 1yr
    After the acute episode is managed for symptoms (PO/IV diuretics, O2, inotropes etc.), I would introduce ACEI/ARB/ARNI and SGLT2 inhibitors (Sotagliflozin for dual SGLT 1-2 action if payer plan permits). MRA to be introduced next day if renal function/serum potassium is WNL. Low dose betablocker (for example, Metoprolol succinate) for euvolemic patients. Follow up in a few weeks to titrate the doses. Repeat echo in 3 months to assess the need for device therapy (ICD//CRT) as per criteria.
  • 1yr
    Most patients need diuresis first so they are started on a loop diuretic.
    Assuming normal renal fx, will start spironolactone at the same time to facilitate diuresis and treat/prevent hypokalemia. I will usually start SGLT2 inhibitor at the same time since they also facilitate diuresis.
    In systolic failure, I will usually start Entresto directly the following day. In diastolic failure I will prob use an ACE/ARB primarily for risk factors.
    Beta blockers once euvolemic
  • 1yr
    When it comes to HFpEF, SGLT2 inhibitors are my first choice and I will branch off my treatment plan off of SGLT2 inhibitors, which are considered primary therapy. When in comes to HFrEF, I will start ACEI/ARB/ARNI and beta blockers first but will quickly add on SGLT2 inhibitors and MRAs as soon as I can. In HFmrEF, I will tend to use SGLT2 inhibitors first and build on GDMT from there.
  • 1yr
    SGLT2 inhibitors are my first choice with heart failure of any type. They are cost prohibitive for some patients but many are eligible for prescription assistance programs. In new HFrEF patients, I start with SGLT2i and beta blocker, and possibly ACEi/ARB/ARNI, see back in a couple weeks and then add MRA if possible. Usually, GDMT is limited by either hypotension or renal function.

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