Ask the expert: what are the four pillars of heart failure therapy?

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This month’s expert: Dr Jim Moore, GP with a special interest in cardiology, and director of the Primary Care Cardiovascular Society.

Heart failure (HF) is typically classified by the ejection fraction (which is the percentage of blood pumped out of the left ventricle during the cardiac cycle) as usually measured during an echocardiogram:

• HF with reduced ejection fraction (HFrEF): ejection fraction ≤ 40%
• HF with mildly reduced ejection fraction (HFmrEF): ejection fraction 41-49%
• HF with preserved ejection fraction (HFpEF): ejection fraction ≥ 50%

Treatment is based around the underlying phenotype and the four pillars of heart failure therapy relate to the four drug groups recommended for people classified as having HFrEF alone.

NICE recommends people with HFrEF should be offered a medication from each of the following four pharmacological groups:¹

ACE inhibitors, ARBs and ARNIs – the ACE inhibitors enalapril, lisinopril and ramipril are licensed for treating HFrEF but can cause a troublesome cough and hyperkalaemia. ARBs (candesartan, losartan and valsartan) can be considered as alternatives where ACE inhibitors are contraindicated or not tolerated.

Sacubitril/valsartan is a combination of an ARB and a neprilysin inhibitor (ARNI). It is frequently used as a first-line option for HFrEF in the UK although NICE recommends it as an option in symptomatic patients when ACE inhibitors are contraindicated or not tolerated.¹

This drug group requires close monitoring of renal function, electrolytes and blood pressure during the introduction and optimisation of therapy.

Beta-blockers are recommended for people with HFrEF. People presenting with HFrEF are frequently taking a beta-blocker for another condition such as atrial fibrillation and where necessary this should be changed to an evidence-based beta-blocker licensed for HFrEF (e.g. bisoprolol, carvedilol, nebivolol). Heart rate and blood pressure should be monitored closely.

Mineralocorticoid receptor antagonists (MRAs) – namely spironolactone or eplerenone – are recommended for the treatment of HFrEF and also require close monitoring of renal function, electrolytes and blood pressure during the introduction and optimisation of therapy.

There is an increased risk of hyperkalaemia, particularly in combination with an ACE inhibitor/ARB/ARNI, and potassium binders may be used to address this.²

SGLT2 inhibitors are well-established treatments for type 2 diabetes, but studies in people with or without type 2 diabetes and HFrEF have shown beneficial outcomes. Patients with HFrEF should be offered dapagliflozin or empagliflozin.³

SGLT2s are generally very well tolerated although there can be an increased risk of genital candidal infection. Pharmacists should make patients aware of rare side-effects, which include diabetic ketoacidosis.

The choice of individual drugs and the order in which they are introduced and then optimised depends on the person’s medical history, clinical status and personal preferences.

If you have a clinical question you would like answered, get in touch via pm@1530.com