[Update on the pharmacotherapy of chronic heart failure with reduced ejection fraction: from four to six pillars?]

Contemporary pharmacotherapy of chronic heart failure with reduced ejection fraction (HFrEF) consists of angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium glucose cotransporter 2 inhibitors. In this year two more agents were added to the existing armamentarium: (1) digitoxin as inhibitor of sodium-potassium-ATPase and (2) vericiguat as stimulator of soluble guanylate cyclase. Vericiguat has already been shown to reduce cardiovascular death and heart failure hospitalization in patients with recent decompensation. This year it was tested in stable heart failure without prior recent decompensation; however, in this case there was no reduction for the combined endpoint of cardiovascular mortality and hospitalization. In the secondary endpoint analysis mortality was significantly reduced. In addition, a meta-analysis including combined data from patients with unstable and also stable heart failure confirmed the positive effects of vericiguat on cardiovascular death and heart failure hospitalization. In the DIGIT-HF study low-dose digitoxin (serum level 8-18 ng/l) significantly reduced death and heart failure hospitalization. Both studies provide evidence that digitoxin and vericiguat added significant benefits to the established 4‑pillar pharmacotherapy and the treatment of HFrEF will be expanded by two more pillars.