Key result
Rapid initiation of four foundational therapies improves early survival and prevents hospitalization in HFrEF.
Why the study?
Should the four foundational therapies for HFrEF be rapidly initiated together rather than utilizing historical stepwise sequencing and uptitration?
Should the four foundational therapies for HFrEF be rapidly initiated together rather than utilizing historical stepwise sequencing and uptitration?
A paradigm shift toward the rapid initiation of all four foundational HFrEF therapies, prioritizing early start over dose uptitration, maximizes life-saving benefits.
May support rapid foundational HFrEF therapy initiation; leaves open optimal sequencing pending prospective trials.
In this review, we discuss what is meant by "foundational" therapy for patients with heart failure and reduced ejection fraction (HFrEF) and the evidence supporting the use of the five agents that comprise this group of drugs i.e., sacubitril/valsartan, a beta-blocker, an aldosterone or mineralocorticoid receptor antagonist (MRA) and a sodium-glucose cotransporter 2 (SGLT2) inhibitor. We review the conventional approach to sequencing these therapies in HFrEF and proposed new rapid sequencing strategies. We review a recent modelling study suggesting the optimal sequence of treatment includes a sodium-glucose cotransporter 2 inhibition and an MRA as the first two therapies. Finally, we review the important opportunity offered by hospitalization for worsening heart failure to initiate and optimize foundational therapies in patients at high risk of early adverse outcomes.
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McMurray et al. (2022) conducted a review in Heart failure with reduced ejection fraction (HFrEF). Foundational therapies (sacubitril/valsartan, beta-blocker, MRA, SGLT2 inhibitor) vs. Conventional stepwise sequencing was evaluated. Rapid initiation of the four foundational therapies (sacubitril/valsartan, beta-blocker, MRA, SGLT2 inhibitor) for HFrEF is newly recommended to maximize early survival and prevent hospitalization.
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