Treatment options for systolic heart failure: An overview of viable medications
In the management of Heart Failure with Reduced Ejection Fraction (HFrEF), after initial treatment with Angiotensin-Converting Enzyme (ACE) inhibitors, Angiotensin Receptor Blockers (ARBs), or Angiotensin Receptor Neprilysin Inhibitors (ARNIs), several pharmacological options are typically considered as second-line treatments.
One such option is the use of Beta-blockers. These medications reduce sympathetic nervous system activity, improving mortality and morbidity in HFrEF patients. By preventing the kidneys from producing angiotensin II, beta-blockers play a crucial role in slowing the progression of the condition and easing symptoms.
Another group of medications includes Mineralocorticoid Receptor Antagonists (MRAs) such as spironolactone or eplerenone. These drugs reduce aldosterone effects, improve symptoms, and reduce hospitalizations in HFrEF patients.
Recently, Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors have become foundational therapies for HFrEF due to their benefits on heart failure outcomes. Examples of SGLT2 inhibitors include dapagliflozin and empagliflozin.
In cases of iron deficiency, Intravenous Iron supplementation has been found to reduce hospitalizations and improve symptoms in HFrEF patients. The European Society of Cardiology (ESC) has upgraded intravenous iron supplementation to a class IA recommendation to improve symptoms/quality of life and class IIA to reduce HF hospitalizations in iron-deficient HFrEF patients.
For patients with persistent symptoms despite standard therapy, Vericiguat, a soluble guanylate cyclase stimulator, may be considered.
Diuretic therapy intensification, including multi-nephron segment diuretic therapy, is also used to manage congestion in HFrEF patients.
It is important to note that ARNIs, such as Sacubitril/valsartan (Entresto), are not interchangeable with ACE inhibitors or ARBs. Entresto does not have a generic form, making it potentially more expensive than ACE inhibitors or ARBs.
ARNIs, like Sacubitril/valsartan, relax blood vessels to decrease heart rate and blood pressure. However, they may cause side effects such as allergic reactions, nausea, headache, diarrhea, vomiting, itching, and skin rash.
ARBs, which come in tablet form in varying dosages, such as candesartan, losartan, and valsartan, widen blood vessels to allow easier blood flow and reduce the risk of death from a cardiac issue, stroke, and heart attack. However, side effects of ARBs are rare and include cough, rash, anaphylaxis, blood vessel inflammation, low white blood cells, and abnormal liver tests.
ACE inhibitors, which come in oral and intravenous forms with varying dosages, such as captopril, enalapril, fosinopril, lisinopril, quinapril, perindopril, trandolapril, and ramipril, reduce the workload on the heart muscle and make it easier for the heart to pump blood, also decreasing blood pressure. However, side effects of ACE inhibitors include dry cough, low blood pressure, dizziness, fainting, high potassium levels, increased creatinine and blood urea nitrogen, and angioedema (rare).
In conclusion, after initial treatment with ACE inhibitors, ARBs, or ARNIs, the typical second-line pharmacological treatments for HFrEF include beta-blockers, MRAs, SGLT2 inhibitors, intravenous iron (if deficient), and newer agents like vericiguat, plus tailored diuretic strategies. It is essential to consult with a healthcare professional to determine the most suitable treatment plan for each individual case.
- The use of Beta-blockers, which reduce sympathetic nervous system activity, is a second-line treatment option in the management of Heart Failure with Reduced Ejection Fraction (HFrEF).
- Mineralocorticoid Receptor Antagonists (MRAs) such as spironolactone or eplerenone, that reduce aldosterone effects, also serve as a viable pharmacological choice in the treatment of HFrEF.
- Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors, like dapagliflozin and empagliflozin, have become a significant component of clinical approaches for HFrEF due to their benefits on heart failure outcomes.
- In the realm of medical-conditions related to heart failure and cardiovascular-health, Iron deficiency can be managed with Intravenous Iron supplementation, which has been found to reduce hospitalizations and improve symptoms in HFrEF patients.
