The 2021 ESC Guidelines represent a paradigm shift in heart failure management by recommending the early and simultaneous use of ARNI and SGLT2 inhibitors alongside traditional foundational therapies.
Medical, primarily drug therapy directed by the New ESC Guide or Guidelines for Patients with Heart Failure (HF) brings significant innovations and changes in the treatment paradigm, from the gradual introduction of drugs to the simultaneous introduction of 5 main classes of drugs. Treatment of heart failure with reduced left ventricular ejection fraction (HFrEF) and symptoms of class II-New York Heart Association (NYHA) -dispnea at higher exertion and higher NYHA classes, now includes angiotensin receptor inhibitor neprilysin (ARNI) as a substitute for angiotenzin convertase enzyme inhibitor( ACEI). Another significant innovation is the addition of SGLT-2 inhibitors (SGLT2i = sodium-glucose channel cotransporter-2 inhibitors). SGLT2i: dapagliflozin or empagliflozin are now in the first line of therapy for heart failure, along with the introduction of beta-blockers (BB), ACEI or ARNI, mineralocorticotide receptor inhibitors (MRAs) and Henle's loop diuretics in fluid retention as recommended in Class I. Sacubitril-valsartan, a combined neprilysin and angiotensin inhibitor (ARNI), was introduced in the reduced left ventricular ejection fraction (HFrEF) and showed an additional reduction in CV mortality and hospitalization due to HFrEF compared to the ACE inhibitor enalapril. Dapagliflozin and empagliflozin reduce the risk of cardiovascular mortality or hospitalization due to HF in patients with HF and reduced left ventricular ejection fraction <40% (HFrEF), but empagliflozin has recently shown an effect in HFpEF with an ejection fraction of 65% of 40%.
Bastać et al. (Sat,) studied this question.