scholarly journals Contemporary Pillars of Heart Failure with Reduced Ejection Fraction Medical Therapy

2021 ◽  
Vol 10 (19) ◽  
pp. 4409
Author(s):  
Eldad Rahamim ◽  
Dean Nachman ◽  
Oren Yagel ◽  
Merav Yarkoni ◽  
Gabby Elbaz ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Standard Of Care ◽  
Left Ventricular ◽  
Pharmacological Therapy ◽  
Public Health Issue ◽  
High Morbidity ◽  
Remarkable Change ◽  
Reduced Ejection Fraction

Heart failure with reduced ejection fraction (HFrEF) is a clinical condition associated with cardiac contractility impairment. HFrEF is a significant public health issue with a high morbidity and mortality burden. Pathological left ventricular (LV) remodeling and progressive dilatation are hallmarks of HFrEF pathogenesis, ultimately leading to adverse clinical outcomes. Therefore, cardiac remodeling attenuation has become a treatment goal and a standard of care over the last three decades. Guideline-directed medical therapy mainly targeting the sympathetic nervous system and the renin–angiotensin–aldosterone system (RAAS) has led to improved survival and a reduction in HF hospitalization in this population. More recently, novel pharmacological therapies targeting other pathways implicated in the pathophysiology of HFrEF have emerged at an exciting rate, with landmark clinical trials demonstrating additive clinical benefits in patients with HFrEF. Among these novel therapies, angiotensin receptor–neprilysin inhibitors (ARNI), sodium–glucose cotransporter-2 inhibitors (SGLT2i), vericiguat (a novel oral guanylate cyclase stimulator), and omecamtiv mecarbil (a selective cardiac myosin activator) have shown improved clinical benefit when added to the traditional standard-of-care medical therapy in HFrEF. These new comprehensive data have led to a remarkable change in the medical therapy paradigm in the setting of HFrEF. This article will review the pivotal studies involving these novel agents and present a suggestive paradigm of pharmacological therapy representing the 2021 European Society of Cardiology (ESC) guidelines for the treatment of chronic HFrEF.

scholarly journals Contemporary Pharmacologic Management of Heart Failure with Reduced Ejection Fraction: A Review

2020 ◽  
Vol 16 (1) ◽  
pp. 55-64 ◽  
Author(s):  
Obiora Egbuche ◽  
Bishoy Hanna ◽  
Ifeoma Onuorah ◽  
Emmanuela Uko ◽  
Yasir Taha ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Cochrane Library ◽  
Ventricular Ejection Fraction ◽  
Reduced Ejection Fraction ◽  
Advanced Therapy ◽  
Pharmacologic Management

Heart failure with reduced ejection fraction (HFrEF) is defined as the presence of typical symptoms of heart failure (HF) and a left ventricular ejection fraction ≤ 40%. HFrEF patients constitute approximately 50% of all patients with clinical HF. Despite breakthrough discoveries and advances in the pharmacologic management of HF, HFrEF patients continue to pose a significant economic burden due to a progressive disease characterized by recurrent hospitalizations and need for advanced therapy. Although there are effective, guideline-directed medical therapies for patients with HFrEF, a significant proportion of these patients are either not on appropriate medications’ combination or on optimal tolerable medications’ doses. Since the morbidity and mortality benefits of some of the pharmacologic therapies are dose-dependent, optimal medical therapy is required to impact the burden of disease, quality of life, prognosis, and to curb health care expenditure. In this review, we summarize landmark trials that have impacted the management of HF and we review contemporary pharmacologic management of patients with HFrEF. We also provide insight on general considerations in the management of HFrEF in specific populations. We searched PubMed, Scopus, Medline and Cochrane library for relevant articles published until April 2019 using the following key words “heart failure”, “management”, “treatment”, “device therapy”, “reduced ejection fraction”, “guidelines”, “guideline directed medical therapy”, “trials” either by itself or in combination. We also utilized the cardiology trials portal to identify trials related to heart failure. We reviewed guidelines, full articles, review articles and clinical trials and focused on the pharmacologic management of HFrEF.

scholarly journals Anti-Hypertensive Medication in Geriatric Population with HFpEF

2020 ◽  
Vol 1 (1) ◽  
pp. 9-13
Author(s):  
Singh Jaspal ◽  
◽  
Wibawanti Retno ◽  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Meta Analysis ◽  
Left Ventricular ◽  
High Morbidity ◽  
Geriatric Population ◽  
Ongoing Research ◽  
Reduced Ejection Fraction ◽  
Patients With Heart Failure ◽  
Method Evidence

INTRODUCTION Heart failure with preserved ejection fraction (HFpEF) is a condition where the left ventricular function is ≥50%. This population has a high morbidity and mortality compared to its counter-part heart failure with reduced ejection fraction (HFrEF). However treatment in this group remain spares. Hypertension medications are widely used in practice for patients with heart failure with reduced ejection fraction, however its efficacy in HFpEF is still an ongoing research. METHOD Evidence based research from various different search engines such as Medline® , Cochrane ® , and Proquest® with inclusion of high quality evidence such as meta-analysis, systematic review, RCT, and cohort studies. The selected papers were screened for validity, importance and applicability to the case in question. RESULT The two different RCTs studies showed that ACE-I had no effects in HFpEF. Research by Kitzman et al. showed that ACE-I did not show any improvement of left ventricular mass, neuro-hormonal profile, and 6 minutes walking test. This was also confirmed by Zi et al., which in addition showed that ACE-I did not increase the quality of life in the geriatric subjects. CONCLUSION All in all, ACE-I as a type of anti-hypertensive medication does not benefit geriatric population of HFpEF

scholarly journals The independent reduction in mortality associated with guideline-directed medical therapy in patients with coronary artery disease and heart failure with reduced ejection fraction

2020 ◽  
Author(s):  
Natasha K Wolfe ◽  
Joshua D Mitchell ◽  
David L Brown
Keyword(s):  
Heart Failure ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Antiplatelet Drug ◽  
Reduced Ejection Fraction ◽  
Artery Disease

Abstract Aims Guideline-directed medical therapy (GDMT) is underutilized in patients with coronary artery disease (CAD). However, there are no studies evaluating the impact of GDMT adherence on mortality among patients with CAD and heart failure with reduced ejection fraction (HFrEF). We sought to investigate the association of GDMT adherence with long-term mortality in patients with CAD and HFrEF. Methods and results Surgical Treatment for Ischaemic Heart Failure (STICH) was a trial of patients with an left ventricular ejection fraction ≤35% and CAD amenable to coronary artery bypass graft surgery (CABG) who were randomized to CABG plus medical therapy (N = 610) or medical therapy alone (N = 602). Median follow-up time was 9.8 years. We defined GDMT for the treatment of CAD and HFrEF as the combination of at least one antiplatelet drug, a statin, a beta-blocker, and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. The primary outcome was all-cause mortality. Assessment of the independent association between GDMT and mortality was performed using multivariable Cox regression with GDMT as a time-dependent covariate. In the CABG arm, 63.6% of patients were on GDMT throughout the study period compared to 66.5% of patients in the medical therapy arm (P = 0.3). GDMT was independently associated with a significant reduction in mortality (hazard ratio 0.65, 95% confidence interval 0.56–0.76; P < 0.001). Conclusion GDMT is associated with reduced mortality in patients with CAD and HFrEF independent of revascularization with CABG. Strategies to improve GDMT adherence in this population are needed to maximize survival.

scholarly journals Validation of a novel framework defining the acceptable standard of care for heart failure with reduced ejection fraction

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
P Lopes ◽  
F Albuquerque ◽  
P Freitas ◽  
J Presume ◽  
B Rocha ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Real World ◽  
Standard Of Care ◽  
Left Ventricular Ejection ◽  
World Population ◽  
Reduced Ejection Fraction ◽  
Acceptable Standard ◽  
All Cause Mortality

Abstract Background In heart failure with reduced ejection fraction (HFrEF), uptitration of neurohormonal antagonists to trial-proven doses shown to reduce mortality is challenging and seldomly achieved in clinical practice. A major reason for underdosing of these agents is the lack of a clear description of what constitutes an acceptable standard of care in HFrEF. To address this limitation, a novel framework for describing the physician adherence to evidence-based treatment was recently proposed. The aim of our study was to evaluate and validate the proposed framework in a real-world population of patients with HFrEF. Methods A cohort of patients with HFrEF, defined as left ventricular ejection fraction (LVEF) <40%, under treatment with neurohormonal antagonists for at least 3 months were retrospectively identified at a tertiary hospital's Heart Failure Clinic. Demographic, clinical, echocardiographic and treatment data were assessed. Patients were divided in three strata for each neurohormonal antagonist, according to the proposed framework: Status I – patients receiving target doses or the highest tolerated dose; Status II – use of subtarget doses for reasons unrelated to clinically important intolerance; and Status III – not receiving the drug at any dose. The prognostic value of each strata was assessed for all-cause mortality. Results A total of 408 patients (mean age 68±12 years, 78% male, 63% ischemic etiology) were included. The median LVEF was 31% (IQR 25–36) and most patients were in NYHA class II or III [210 (51.5%) and 163 (40%), respectively]. Medical therapy is described in Table 1. During a median follow-up of 3.3 years (IQR 1.4–5.6), 210 patients died. On univariable analysis, achieving Status I of beta-blocker (BB) therapy (HR: 0.50; 95% CI: 0.32–0.81; P=0.004) or ACEi/ARB (HR: 0.56; 95% CI: 0.36–0.86; P=0.012) was associated with reduced all-cause mortality. The mortality of patients in Status II of BB or ACEi/ARB was similar to the mortality of those not receiving the drug (HR for BB: 0.90; 95% CI: 0.53–1.52; P=0.69 and HR for ACEi/ARB: 0.71; 95% CI: 0.42–1.18; P=0.182) – figure 1. Achieving Status I of BB remained independently associated with reduced mortality after adjustment for several clinical and echocardiographic confounders (n=13) (adjusted HR: 0.59; 95% CI: 0.35–0.98; P=0.041). Conclusions In this real-world population of patients with HFrEF, the vast majority of patients were in Status I of BB and ACEi/ARB therapy. Achieving Status I of BB therapy seems to be associated with reduced mortality, even after adjustment for several markers of disease severity, highlighting the need for uptitration of medical therapy to maximal tolerated doses according to trial-proven regimens. FUNDunding Acknowledgement Type of funding sources: None.

Heart Failure with Preserved Ejection Fraction – A Review

2012 ◽  
Vol 9 (1) ◽  
pp. 90-95 ◽  
Author(s):  
Otto A Smiseth ◽  
Anders Opdahl ◽  
Espen Boe ◽  
Helge Skulstad
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Diastolic Heart Failure ◽  
The Elderly ◽  
Left Ventricular ◽  
Filling Pressure ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Reduced Ejection Fraction ◽  
Objective Evidence

Heart failure with preserved left ventricular ejection fraction (HF-PEF), sometimes named diastolic heart failure, is a common condition most frequently seen in the elderly and is associated with arterial hypertension and left ventricular (LV) hypertrophy. Symptoms are attributed to a stiff left ventricle with compensatory elevation of filling pressure and reduced ability to increase stroke volume by the Frank-Starling mechanism. LV interaction with stiff arteries aggravates these problems. Prognosis is almost as severe as for heart failure with reduced ejection fraction (HF-REF), in part reflecting co-morbidities. Before the diagnosis of HF-PEF is made, non-cardiac etiologies must be excluded. Due to the non-specific nature of heart failure symptoms, it is essential to search for objective evidence of diastolic dysfunction which, in the absence of invasive data, is done by echocardiography and demonstration of signs of elevated LV filling pressure, impaired LV relaxation, or increased LV diastolic stiffness. Antihypertensive treatment can effectively prevent HF-PEF. Treatment of HF-PEF is symptomatic, with similar drugs as in HF-REF.

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