Four pillars of heart failure: contemporary pharmacological therapy for heart failure with reduced ejection fraction

The past two decades have heralded dramatic improvements in outcomes for people living with heart failure with reduced ejection fraction (HFrEF).1 The more widespread implementation of disease modifying pharmacological therapies,2 supported by landmark trials of renin-angiotensin system inhibitors3 and beta-blockers4 have improved longevity despite a background of an ageing and increasingly multimorbid population. Although the benefits of comprehensive pharmacological therapies are clear, the real-world attainment of target doses5 6 and utilisation of novel agents such as angiotensin receptor-neprilysin inhibitors (ARNI)7 remain low. Furthermore, HFrEF remains a disease associated with significant morbidity and reduced survival relative to those without HFrEF, even after taking into account comorbidities.8 Recently, trials have demonstrated improved outcomes in people with HFrEF receiving sodium-glucose co-transporter 2 inhibitors (SGLT2i).9 10 However, it is currently unclear how these agents will be used alongside established therapies. Now is therefore an opportune moment to pause and reflect on our current practice, barriers to further progress and how future guidelines might work better for our patients. In this viewpoint we summarise how our current linear approach, on a background of increasingly complex pharmacotherapy has the potential to cause confusion and consequent delays which could lead to even worse attainment of optimal therapies. On the other hand, a more parallel approach to the initiation and optimisation of the Four Pillars of Heart Failure would simplify our approach, yielding benefits for our patients and healthcare systems.