Medical Treatment in Heart Failure with Reduced Ejection Fraction: A Proposed Algorithm Based on the Patient's
Ioannis Paraskevaidis1, Andrew Xanthopoulos2, Nikolaos Karamichalakis1
16th Department of Cardiology, Hygeia Hospital, 15123 Athens, Greece.
Insights
This study identifies heart failure with reduced ejection fraction (HFrEF) phenotypes based on sodium and potassium levels. It proposes a personalized drug initiation and titration strategy for HFrEF management.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Four drug classes (beta-blockers, ACEi/ARNI, MRA, SGLT2i) are pillars in heart failure with reduced ejection fraction (HFrEF) treatment.
- Randomized controlled trials (RCTs) comparing these drugs are limited due to differing methodologies and patient populations.
- Electrolyte disturbances, particularly sodium and potassium imbalances, are prevalent in HFrEF patients.
Purpose of the Study:
- To identify distinct HFrEF phenotypes based on real-world sodium and potassium levels.
- To propose a practical algorithm for drug initiation and titration in HFrEF, considering patient electrolytes and congestion status.
Main Methods:
- Phenotyping HFrEF patients based on serum sodium (Na+) and potassium (K+) levels in a real-world setting.
- Developing a treatment algorithm for HFrEF management tailored to electrolyte status and congestion.
Main Results:
- Identification of several HFrEF phenotypes characterized by specific sodium and potassium profiles.
- A proposed algorithm for introducing and titrating HFrEF medications based on identified phenotypes.
Conclusions:
- Personalized treatment strategies considering electrolyte balance are crucial for optimizing HFrEF management.
- The proposed algorithm aims to guide clinicians in selecting and adjusting HFrEF therapies for improved patient outcomes.
Abstract:
In heart failure (HF) with reduced ejection fraction (HFrEF), four classes of drugs (β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and the most recent Sodium-Glucose Co-Transporters 2 Inhibitors) have demonstrated positive results in randomized controlled trials (RCTs). Nevertheless, the latest RCTs are not proper for comparison since they were carried out at various times with dissimilar background therapies and the patients enrolled did not have the same characteristics. The difficulty of extrapolating from these trials and proposing a common framework appropriate for all cases is thus obvious. Despite the fact that these four agents are now the fundamental pillars of HFrEF treatment, the built-up algorithm of initiation and titration is a matter of debate. Electrolyte disturbances are common in HFrEF patients and can be attributed to several factors, such as the use of diuretics, renal impairment, and neurohormonal activation. We have identified several HFrEF phenotypes according to their sodium (Na+) and potassium (K+) status in a "real world" setting and suggest an algorithm on how to introduce the most appropriate drug and set up therapy based on the patients' electrolytes and the existence of congestion.
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