Emerging concepts in heart failure management and treatment: focus on current guideline-directed medical therapy for heart failure with reduced ejection fraction

Figures

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  Figure 1. ESC diagnostic algorithm for heart failure BNP, B-type natriuretic peptide; ECG, electrocardiogram; HF, heart failure; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro-B type natriuretic peptide. Adapted from ESC guidelines 2021.1

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  Figure 2. ESC therapeutic algorithms evolution for HFrEF (2016 versus 2021) ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker, ARNI, angiotensin receptor neprilysin inhibitor; CRT, cardiac resynchronization therapy; HFrEF, heart failure with reduced ejection fraction; H-ISDN, hydralazine and isosorbide dinitrate; HR, heart rate; ICD, implantable cardioverter defibrillator; LBBB, left bundle branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist, SGLT2I, sodium-glucose cotransporter 2 inhibitor. Adapted from ESC guidelines.1,2

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  Figure 3. Sacubitril/valsartan mode of action Sacubitril/valsartan lead to a simultaneous neprylisin inhibition (LBQ657) and AT1 receptor blockade (valsartan) Neprylisin substrates may have biological opposing actions so the benefits of increasing the natriuretic peptides system may be lost by increasing Angiotension-II, so a simultaneous suppression of the RAAS is necessary. Figure only shows effects on BNP but other metabolites are affected.23,24 AT1-receptor, Angiotensin II receptor type 1; BNP, brain type natriuretic peptide; NT-proBNP, N-terminal pro-brain natriuretic peptide; Pro-BNP, pro-brain natriuretic peptide; RAAS, renin–angiotensin–aldosterone system.

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  Figure 4. Proposed cardioprotective direct and indirect effects of SGLT2 inhibitors Possible mechanisms of action of SGLT2 inhibitors in heart failure.7,8