Sequencing Quadruple Therapy for Heart Failure with Reduced Ejection Fraction: Does It Really Matter?
Jiun-Ruey Hu1, Alexandra N Schwann2, Jia Wei Tan3
1Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. Electronic address: https://twitter.com/ruey_hu.
Heart Failure Clinics
|August 31, 2024
Summary
Flexible sequencing of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) is crucial. Achieving partial doses of all four pillars of HFrEF treatment is more effective than maximizing only a few.
Area of Science:
- Cardiology
- Pharmacology
- Internal Medicine
Background:
- Current guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) follows a conventional initiation sequence.
- This sequence is often based on the historical order of drug discovery, not necessarily on optimal patient outcomes or tolerability.
Purpose of the Study:
- To review and advocate for flexible sequencing of GDMT in HFrEF.
- To highlight the importance of individualized treatment strategies for special patient populations.
Main Methods:
- Literature review and synthesis of current evidence on GDMT for HFrEF.
- Discussion of challenges and benefits of alternative GDMT initiation sequences.
Main Results:
- The effectiveness and tolerability of GDMT agents do not correlate with their order of discovery.
- Flexible GDMT sequencing can improve tolerability and adherence in patients with comorbidities like bradycardia, chronic kidney disease, or atrial fibrillation.
- Initiating certain GDMT medications can enhance tolerance for others.
Conclusions:
- Achieving at least partial doses of all four pillars of GDMT is superior to maximizing doses of only a few.
- Individualized GDMT sequencing is essential for optimizing outcomes in HFrEF patients.
- Flexible GDMT strategies should be considered for special populations.
Keywords:
Beta blockersGuideline-directed medical therapyHeart failure with reduced ejection fractionMineralocorticoid receptor antagonistsRenin–angiotensin aldosterone system inhibitorsSequenceSodium–glucose cotransporter 2 inhibitorsTolerabilityMore Related Videos
08:42Cox-Maze IV Procedure Concomitant with Valvular Surgery In Situs Inversus Dextrocardia: A Single-Center Experience in China
Published on: February 11, 2022
3.4K
09:11Cell-based Therapy for Heart Failure in Rat: Double Thoracotomy for Myocardial Infarction and Epicardial Implantation of Cells and Biomatrix
Published on: September 22, 2014
11.9K
Related Concept Videos
01:26Heart Failure Drugs: Inhibitors of Renin-Angiotensin System
404
The activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) contributes to cardiac remodeling, and inhibiting the RAAS is a pharmacological target in heart failure management. As a result, neurohumoral modulation is a crucial treatment principle for managing heart failure. This approach involves using medications like ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β-blockers, mineralocorticoid receptor antagonists (MRAs), and neutral...
404
01:22Heart Failure Drugs: Diuretics
352
Heart failure and kidney perfusion are interconnected in a complex way. Reduced renal perfusion and venous congestion are two significant factors that contribute to renal dysfunction in heart failure. The kidneys, primarily responsible for fluid balance in the body, are adversely affected due to compromised cardiac output and increased venous pressure. In response to reduced renal perfusion, the kidneys activate neurohumoral mechanisms to restore balance. However, these mechanisms can be...
352
01:22Heart Failure Drugs: β-Blockers
322
β-adrenergic antagonists, commonly known as β-blockers, block the effects of sympathetic neurotransmitters such as noradrenaline (NA) and adrenaline (ADR). They have several beneficial effects in heart failure treatment. They reduce heart rate, the force of contraction, and cardiac muscle relaxation. They also slow the atrial-ventricular conduction rate and raise the threshold for arrhythmias. The concentration of β-blockers determines their effects on bronchodilation,...
322
01:17Pathophysiology of Heart Failure
1.5K
Heart failure (HF) is a progressive syndrome involving ventricles that leads to inadequate cardiac output. It can be classified based on location and output or ejection fraction. Ejection fraction (EF) is an essential measurement in the diagnosis and surveillance of HF. Reduced EF corresponds to systolic heart failure (HFrEF). However, HF with preserved ejection fraction (HFpEF) is becoming increasingly prevalent. Also known as diastolic HF, this form of HF is related to aging. The...
1.5K
01:17Imaging Studies for Cardiovascular System I:Echocardiography
303
Cardiac imaging studies encompass a wide range of noninvasive and minimally invasive techniques designed to visualize the heart's structure and function in detail. One such technique is echocardiography, which uses high-frequency ultrasound waves to produce detailed images of the heart, known as echocardiograms.
Indications: Echocardiography is utilized to diagnose heart failure, valve disorders, and myocardial infarction. It also assesses cardiac structures' size, shape, and motion,...
Indications: Echocardiography is utilized to diagnose heart failure, valve disorders, and myocardial infarction. It also assesses cardiac structures' size, shape, and motion,...
303
01:26Heart Failure Drugs: Inotropic Agents
545
Positive inotropic agents are commonly used as the first line of treatment for heart failure. One such agent is digoxin, derived from the genus Digitalis, which has been known for centuries but effectively utilized since 1785. However, these cardiac glycosides can have potentially toxic effects due to their mechanism of action, which involves inhibiting Na+/K+-ATPase and increasing contractility. Digoxin is absorbed orally and distributed in various tissues, including the CNS. It has a long...
545