SCIENTIFIC JOURNAL of the Hungarian Society of Cardiology

The new slogen in the baseline pharmacological therapy of heart failure with reduced ejection fraction: ASAP!

DOI: 10.26430/CHUNGARICA.2023.53.5.502

Kovács Árpád
Debreceni Egyetem, Általános Orvostudományi Kar, Kardiológiai Intézet,
Kardiológia Tanszék, Debrecen


Pharmacological management of heart failure with reduced ejection fraction (HFrEF) has reached a turning point. Guideline-directed medical therapy involves renin-angiotensin system (RAS) inhibitor, sodium-glucose co-transporter 2 (SGLT2) inhibitor, mineralocorticoid receptor antagonist (MRA) and beta-blocker (BB) therapy. Although angiotensin-converting enzyme inhibitor (ACEi) or – if not tolerated – angiotensin receptor blocker (ARBs) is recommended as RAS inhibitors in the first place, evidence suggests that sacubitril/valsartan (ARNi) is the increasingly preferred choice. However, the greatest therapeutic benefit is achieved when the 4 agents are given together. Of note, there is no hierarchy or preference between the drugs. It is important to emphasise the prognostic importance of optimal medical therapy initiated and adjusted during hospitalisation. In this regard, patient’s clinical profile is the determining factor, but starting with an SGLT2 inhibitor is ideal for all phenotypes. The timing of therapy is also a key issue, as significant clinical benefit can be achieved in as little as 2-4 weeks with ARNi and SGLT2 inhibitor treatment. It is therefore unacceptable to titrate the baseline therapy for months. The keyword is „ASAP” that means the initiation and uptitration of the combination of ACEi/ARB/ARNi, SGLT2 inhibitor, aldosterone antagonist (i.e. MRA) and pulse reduction (BB) as soon as possible (graphical abstract).


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