Medical Therapy for HFrEF - Early Benefit from Synergies and a Personalised Approach

The current guidelines for the pharmacotherapy of heart failure with reduced ejection fraction recommend the early and, if possible, simultaneous start of a beta-blocker (BB), SGLT2-inhibitor (SGLT2i), mineralocorticoid receptor antagonist (MRA) and ACE inhibitor (ACEi) or, alternatively, angiotensin receptor neprilysin inhibitor (ARNI). The choice of these drug classes used at the beginning and their expansion and dose increase over the course of time is deliberately left to the treating physician, taking into account the individual patient characteristics and comorbidities. This means that the previous recommendations for a sequential initiation of the various drug classes are abandoned, as these are primarily based on the history of the underlying clinical endpoint trials and do not do justice to the early and synergistic prognosis-improving effects of the drug classes. However, the recommendation to increase the dose of BB, SGLT2i, MRA and ACEi/ARNI to the target doses used in clinical trials remains in place. The inclusion of other drug groups should depend on comorbidities, clinical parameters, progression of heart failure and evidence from clinical studies.