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Published on: February 13, 2021
Chronic Heart Failure Clinical Practice Guidelines' Class 1-A Pharmacologic Recommendations: Start-to-End Synergistic
Ramon F Abarquez1, Paul Ferdinand M Reganit1, Carmen N Chungunco1
1Section of Cardiology, Department of Medicine, University of the Philippines, College of Medicine and Philippine General Hospital, 6/F, PGH Compound, Taft Avenue, 1000 Manila, Philippines.
Insights
Chronic heart failure (HF) drug therapy involves a synergistic effect between baseline (BDT) and add-on (ADT) treatments. This combination significantly improves survival and reduces hospitalizations compared to initial recommendations.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- Chronic heart failure (HF) presents a significant global health challenge with substantial economic and psychosocial burdens.
- Despite evidence-based guidelines, HF management faces challenges in reducing hospitalization, readmission, morbidity, and mortality rates.
Purpose of the Study:
- To evaluate the synergistic effect of baseline HF drug therapy (BDT) and add-on HF drug therapy (ADT) on survival and hospitalization-free event rates.
- To analyze the contribution of BDT and initial HF drug therapy (IDT) within current chronic HF clinical practice guidelines.
Main Methods:
- A comprehensive review of references from major chronic HF clinical practice guidelines (AHA/ACC, HFSA, ESC) published between 2005 and 2013.
- Comparison of cited recommendations and outcomes with respective guidelines and international standards.
Main Results:
- Baseline HF drug therapy (BDT) demonstrated survival rates of 46%-89% and hospitalization-free rates of 47.1%-85.3%.
- Initial HF drug therapy (IDT) showed survival rates of 61%-92.8% and hospitalization-free rates of 61.8%-90%.
- Add-on HF drug therapy (ADT) contributed an additional 0.4%-15% to survival and 4.6%-14.7% to hospitalization-free rates, indicating a synergistic effect.
Conclusions:
- Baseline HF drug therapy (BDT) significantly contributes to improved survival and reduced hospitalizations in chronic heart failure.
- The initial HF drug therapy (IDT) recommended in guidelines appears to have synergistic effects when combined with BDT, essentially functioning as add-on therapy (ADT).
- Polypharmacy in HF treatment, combining BDT and ADT, results in a significant synergistic benefit.
Background:
Chronic heart failure (HF) disease as an emerging epidemic has a high economic-psycho-social burden, hospitalization, readmission, morbidity and mortality rates despite many clinical practice guidelines' evidenced-based and consensus driven recommendations that include trials' initial-baseline data.
Objective:
To show that the survival and hospitalization-free event rates in the reviewed chronic HF clinical practice guidelines' class I-A recommendations as initial HF drug therapy (IDT) is possibly a combination and 'start-to-end' synergistic effect of the add-on ('end') HF drug therapy (ADT) to the baseline ('start') HF drug therapy (BDT).
Methodology:
The references cited in the chronic HF clinical practice guidelines of the 2005, 2009, and 2013 American Heart Association/American College of Cardiology (AHA/ACC), the 2006 Heart Failure Society of America (HFSA), and the 2005, 2008, and 2012 European Society of Cardiology (ESC) were reviewed and compared with the respective guidelines' and other countries' recommendations.
Results:
The BDT using glycosides and diuretics is 79%-100% in the cited HF trials. The survival rates attributed to the BDT ('start') is 46%-89% and IDT ('end') 61%-92.8%, respectively. The hospitalization-free event rate of the BDT group: 47.1% to 85.3% and IDT group 61.8%-90%, respectively. Thus, the survival and hospitalization-free event rates of the ADT is 0.4%-15% and 4.6% to 14.7%, respectively. The extrapolated BDT survival is 8%-51% based on a 38% estimated natural HF survival rate for the time period109.
Conclusion:
The contribution of baseline HF drug therapy (BDT) is relevant in terms of survival and hospitalization-free event rates compared to the HF class 1-A guidelines initial drug therapy recommendations (IDT). Further, the proposed initial HF drug ('end') therapy (IDT) has possible synergistic effects with the baseline HF drug ('start') therapy (BDT) and is essentially the add on HF drug therapy (ADT) in our analysis. The polypharmacy HF treatment is a synergistic effect due to BDT and ADT.
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