Heart Failure syndrome has a 50% five-year mortality even for patients in stage B, presymptomatic phase. Over the last 35 years, many studies have demonstrated classes of medications that can not only reduce the mortality of heart failure, but also improve quality of life and reduce the risk of hospitalization. Major advances have occurred in the last 10 years with sacubitril/valsartan (Entresto) replacing ACEs and ARBs as a more protective agent. In addition, SGL2 Inhibitors (Empagliflozin, Dapagliflozin) have now become standard care for all heart failure patients, even in those without diabetes. 

The heart failure guidelines in Europe and USA were updated in 2021 and 2022 to reflect these advances. They both have recommended GDMT (Guideline Directed Medical Therapy) for heart failure syndrome to include an evidence-based Beta Blocker (carvedilol, metoprolol succinate, or bisoprolol), an ARNI (ARB/Neprilysin Inhibitor = Entresto), MCRAs (Mineralocorticoid Receptor Antagonists = spironolactone, eplerenone, finerenone), and SGLT-2 inhibitors (e.g., dapagliflozin [Farxiga], canagliflozin [Invokana]). These 4 pillars are recommended for all patients with heart failure with reduced ejection fraction (HFrEF, with EF < 50%). 

SGLT2s and diuretics are now the standard interventions for heart failure with preserved ejection fraction (HFpEF), in addition to optimal management of co-morbidities like HBP, Atrial Fibrillation, Diabetes, Obesity, CAD, CKD, and Sleep Apnea. With the use of GDMT, mortality was reduced by > 60%. This means that heart failure patients with reduced ejection fraction < 40% (HFpEF) and those with heart failure with mildly reduced ejection fraction, EF 40-50% (HFmrEF), may improve by more than 10 points or to > 40% EF. This favorable change is called heart failure with improved ejection fraction (HFimpEF). We now know that these patients still require GDMT to preserve their improvement. Finally, studies now show that rapid introduction of these 4 pillars at lower doses over weeks and than ramping up to maximally tolerated doses, reduces the risks of hospitalization within 1 month, which is a much quicker time to benefit then the former strategy of introducing them one at time to full dose, before adding another pillar.  

These broad-brush strokes are insufficient to bring our readers fully up to speed on these important advances in medicine. In just a brief internet search on this subject, I was able to find multiple guidelines and videos. UCSF posted its grand rounds on this subject from April 2023. I found this 1-hour presentation helpful with multiple implementation details. Here is the link:  https://youtu.be/3mMMDubQtQ4?si=cErafm81X8fLJC0Z

I hope our readers will spend time upgrading their capacity to deliver important heart failure care.