Abstract
As given in previous chapters, the pathophysiology of heart failure (HF) indicates that behavioral factors predisposing HF are not duly treated before the initiation of drug therapy. For treatment of HF, pharmacotherapy and lifestyle recommendations have been suggested by all the agencies concerned with health and diseases. These guidelines have been updated in light of recent developments across the spectrum of left ventricular ejection fraction. The most interesting areas across these guidelines include recommendations on quadruple therapy for patients with HF with reduced ejection fraction (HFrEF). It seems that there is no guideline proposed for the ideal sequence of initiation of therapy, such as treatment of anemia via intravenous iron among patients with HFrEF and simultaneous deficiency of iron. The guidelines are unanimous in recommending the combination of four standard therapy options for the treatment of HFrEF. These are angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), or angiotensin receptor-neprilysin inhibitors (ARNI); beta-blockers; mineralocorticoid receptor antagonists (MRA); and sodium-glucose cotransporter-2 inhibitors (SGLT2i). The Canadian guidelines do, however, recommend that ACEI/ARB be switched to ARNI prior to discharge in patients hospitalized with acute decompensated HF and that ARNI be started in patients admitted with a new HFrEF diagnosis. These guidelines also advise that starting with an ARNI rather than an ACEI/ARB may lead to more rapid optimization of therapy. Meanwhile, the ESC advises that ARNI “may be considered as a first-line therapy instead of [ACEI]” without further specification of which conditions may warrant de novo initiation. In view of the lower-quality evidence, there are disagreements regarding the management of HF with preserved ejection fraction (HFpEF) and uncertainty regarding the management of HF with mildly reduced ejection fraction (HFmrEF). Such uncertainty may be due to the etiology of HF because HF in patients with coronary artery diseases (CAD), in particular acute myocardial infarction (AMI), may have different strategies. Novel mechanisms have been proposed to explain the benefits of drug therapy, including improved cardiomyocyte calcium handling, enhanced myocardial energetics, induced autophagy, and reduced epicardial fat, which can occur via lifestyle modification and SGLT2 inhibitors. In addition, there are opportunities for improvement in guidelines and harmonization. It seems that there is broad agreement across these guidelines, although some areas of controversy remain and need new trials.
Original language | English (US) |
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Title of host publication | Pathophysiology, Risk Factors, and Management of Chronic Heart Failure |
Publisher | Elsevier |
Pages | 325-341 |
Number of pages | 17 |
ISBN (Electronic) | 9780128229729 |
ISBN (Print) | 9780128231111 |
DOIs | |
State | Published - Jan 1 2024 |
Bibliographical note
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Keywords
- Acute heart failure
- cardiac failure
- cardiomyocyte damage
- drug therapy