Heart Failure Pharmacological Management: Gaps and Current Perspectives

Abstract

Proper therapeutic management of patients with heart failure (HF) is a major challenge for cardiologists. Current guidelines indicate to start therapy with angiotensin converting enzyme inhibitors/ angiotensin receptor neprilysin inhibitors (ACEi/ARNI), beta blockers (BB), mineralocorticoid receptor antagonists and sodium glucose cotransporter 2 inhibitors (SGLT2i) to reduce the risk of death and hospitalization due to HF. However, certain aspects still need to be defined. Current guidelines propose therapeutic algorithms based on left ventricular ejection fraction values and clinical presentations. However, these last do not always reflect the precise hemodynamic status of patients and pathophysiologic mechanisms involved, particularly in the acute setting. Even in the field of chronic management there are still some critical points to discuss. The guidelines do not specify which of the four pillar drugs to start first, nor at what dosage. Some authors suggest starting with SGLT2i and BB, others with ACEi or ARNI, while one of the most recent approach proposes to start with all four drugs together at low doses. The aim of this review is to revise current gaps and perspectives regarding pharmacological therapy management in HF patients, in both the acute and chronic phase.

Heart failure ‘the cancer of the heart’: the prognostic role of the HLM score

“…The complexity of the HF syndrome requires a global, multiparametric, and objective approach to patients, going beyond the cardiocentric view based on LVEF and HF symptoms, addressing the pathophysiological mechanisms underlying heart abnormalities 25,26,30,31 . We propose the HLM score as a new, multivariable, user‐friendly, and pragmatic classification model in the HF population.…”

“…The complexity of the HF syndrome requires a global, multiparametric, and objective approach to patients, going beyond the cardiocentric view based on LVEF and HF symptoms, addressing the pathophysiological mechanisms underlying heart abnormalities. 25 , 26 , 30 , 31 We propose the HLM score as a new, multivariable, user‐friendly, and pragmatic classification model in the HF population. Although developed in a relatively small study population, HLM demonstrated the best overall accuracy in predicting the composite of all‐cause death and rehospitalization due to HF, at 12 months, compared with currently used prognostic models, representing a promising tool to guide HF staging and management.…”

Telemedicine: an Effective and Low-Cost Lesson From the COVID-19 Pandemic for the Management of Heart Failure Patients

“…On the other hand, the pathophysiology and the treatment available for HF with mildly reduced ejection fraction (HFmrEF) and HF with preserved ejection fraction (HFpEF) patients remain unclear. In these populations, TM may play an additive role, being a tool to prevent hospitalizations, thus improving the prognosis [ 47 , 48 ]. A subanalysis of the recent ICOR study aimed to evaluate the efficacy of TM in these patients, in terms of risk of non-fatal acute HF and risk of hospitalization after 6 months of follow-up [ 49 ].…”

Clinical Usefulness of Speckle-Tracking Echocardiography in Patients with Heart Failure with Preserved Ejection Fraction

“…However, LVEF has high variability and low repeatability. In various guidelines, the critical values of LVEF in different HF subtypes are different, and there is still a lack of definition of the normal range [ 7 , 8 ]. According to both European and American guidelines, HF is divided into three subtypes: heart failure with preserved ejection fraction (HFpEF, LVEF ≥ 50%), heart failure with mid-range ejection fraction (HFmrEF, LVEF ≥ 40 and < 50%), and heart failure with reduced ejection fraction (HFrEF, LVEF < 40%) [ 6 , 9 , 10 ].…”