Therapeutic appraisal in protracted heart failure

Area of Science:

• Cardiology
• Pharmacology

Background:

• Guideline-directed medical therapy (GDMT) comprises four pillars for heart failure with reduced ejection fraction (HFrEF).
• Pivotal trials established GDMT efficacy in stable HFrEF patients (NYHA class II-III) with low event rates.
• The benefit of GDMT in advanced HFrEF stages with worsening symptoms and decreased life expectancy is understudied.

Purpose of the Study:

• To review observational data on the therapeutic value of GDMT pillars in advanced HFrEF.
• To explore the fading benefits of neurohormonal modulation and cardiac afterload reduction in late-stage cardiovascular or renal diseases.
• To propose a pragmatic approach for collecting evidence on sequential withdrawal of GDMT in advanced HFrEF.

Main Methods:

• Review of observational studies investigating GDMT efficacy in advanced HFrEF.
• Analysis of evidence on neurohormonal modulation and cardiac afterload reduction in late-stage disease.
• Proposal of a pragmatic framework for data collection on GDMT withdrawal.

Main Results:

• Observational studies suggest diminishing benefits of neurohormonal modulation and cardiac afterload reduction in late-stage cardiovascular or renal diseases.
• Limited data exists on the efficacy of GDMT in patients with advanced HFrEF.
• A need for evidence-based strategies for managing GDMT in advanced HFrEF is identified.

Conclusions:

• The therapeutic value of GDMT pillars may decrease in advanced HFrEF.
• Further research is needed to guide the sequential withdrawal of GDMT in this population.
• A pragmatic approach to evidence collection is proposed for optimizing care in advanced HFrEF.