Optimizing Medical Care for Patients With HFrEF


Dr Gregg Fonarow explains how best to optimize the medical treatment of HFrEF.

James Januzzi, MD: Let’s circle back to our 4 foundational drug classes. Gregg, I follow you on Twitter. I think you do such a masterful job of taking the complex state of the state, if you will, and put it into terms that clinicians can really understand. Let me ask you, how do you approach initiation and sequencing of therapies? And really, try to think of the ideal state for our clinicians who are viewing.

Gregg C. Fonarow, MD: Yes. I think what’s so important here is the prioritization, and why. These are 4 classes of specific medications that reduce all-cause mortality, along with the benefits in reducing hospitalization. And as alluded to, these work incredibly well together, are additive and incremental to each other, and work incredibly rapidly with regard to their clinical benefits. Taking the approach of starting one and carefully then uptitrating that to target dose, and only then starting that second drug, we’re leaving too much benefit on the table. For most patients who present with new-onset heart failure, they’ve got room on their blood pressure. And so we can actually, at the low recommended initial starting doses, get all 4 either started simultaneously or over a few days; these therapies are complementary to each other. Our focus then is the greatest steep dose-response curve with regard to β-blockers for uptitration. As alluded to, the SGLT2 [sodium-glucose cotransporter-2] inhibitors require no uptitration. Then on the back end we can focus on the sacubitril/valsartan and the MRA [mineralocorticoid receptor antagonist] for fine-tuning and those optimal doses.

But getting those 4 therapies started early sends an important message to our patients that these are the essential foundational lifesaving therapies they need to be on. You’re not adding a later therapy in response to, “Oh, you’re getting worse.” Things like hyperkalemia may be a little less when the SGLT2 inhibitors are on board with that MRA, complementary improvements in ventricular function, more rapid improvements with regard to health status, and patients are far less likely to be hospitalized or have mortality. These therapies added together mean within 30 days we’re seeing tangible improvements in these patients. Thus, it really is a focused way of getting the most essential therapy started in our most vulnerable patients at their highest risk time, and then building upon that.

James Januzzi, MD: Yes, a wonderful answer, and it really speaks to how we’re seeing a shift in the heart failure culture around the guideline-directed medical therapies that are now used, as opposed to starting them sequentially and titrating up slowly. It’s really about all hands on deck, and getting the important therapies on at a low dose and then titrating up to target after establishing therapy. Waiting for a patient to decompensate to intensify therapy is exactly what we’re trying to avoid. Thus, getting these therapies on early is critically important. We’ve talked about this as we put together consensus documents and worked on guidelines. A small amount of each class is better than a large amount of one class. Getting that foundational therapy started is so important. Thank you for that answer, Gregg.

This transcript has been edited for clarity.

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