Heart Failure Treatment at a Glance
Full update May 2022
The chart below delineates the role of medications and other interventions for heart failure with reduced (≤40%) ejection fraction (HFrEF). For more information on dosing and titration, see our chart, Target Doses of Meds for Heart Failure. Our toolbox, Improving Heart Failure Care, provides practical tips and resources to help improve care in your heart failure patients and prevent readmissions.
**Chart information may differ from product labeling. Canadian HF guideline recommendations included if significantly different from US.**
Drug, Drug Class, or Intervention |
Use for… |
First-Line |
|
ARNI (sacubitril/valsartan [Entresto]) |
Comments:
|
ACEI |
Comments:
|
ARB |
Comments:
|
Beta-Blocker |
Comments:
|
Aldosterone Antagonist (eplerenone or spironolactone) |
Comments:
|
SGLT2 inhibitor |
Comments:
|
Diuretics |
Comments:
|
Education to facilitate HF self-care |
|
Avoidance of excessive sodium |
Comments:
|
Exercise (regular physical activity or cardiac rehab) |
|
First-Line Alternatives or Add-ons for Select Patients |
|
Hydralazine and Isosorbide Dinitrate |
Comments:
|
Ivabradine (Corlanor[US], Lancora [Canada]) |
Comments:
|
Last-Line Add-ons |
|
Digoxin |
Comments:
|
Vericiguat (Verquvo)(US) (guanylate cyclase stimulator) |
Comments:
|
Abbreviations: ACEI=angiotensin-converting enzyme inhibitor, ACS = acute coronary syndrome, ARB=angiotensin receptor blocker, ARNI=angiotensin receptor-neprilysin inhibitor, BNP=B-type natriuretic peptide, CV = cardiovascular, EF = ejection fraction, HF=heart failure, IV = intravenous, MI=myocardial infarction, SBP = systolic blood pressure; SGLT2 = sodium glucose cotransporter 2
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
|
B |
Inconsistent or limited-quality patient-oriented evidence.* |
|
C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/afp/2004/0201/p548.pdf.]
References
- Writing Committee Members, Heidenreich PA, Bozkurt B, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022 Mar 24:S0735-1097(21)08395-9. doi: 10.1016/j.jacc.2021.12.012.
- McDonald M, Virani S, Chan M, et al. CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction. Can J Cardiol. 2021 Apr;37(4):531-546.
- Armstrong PW, Pieske B, Anstrom KJ, et al. Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2020 May 14;382(20):1883-1893.
- Product information for Entresto. Novartis. East Hanover, NJ 07936. February 2021.
- Product monograph for Entresto. Novartis Canada. Dorval, QC H9S 1A9. July 2021.
- McMurray JJ, Packer M, Desai AS, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014 Sep 11;371(11):993-1004.
- Product information for Corlanor. Amgen, Inc. Thousand Oaks, CA 91320. August 2021.
- Product monograph for Lancora. Servier Canada. Laval, QC H7V 4A7. May 2018.
- Swedberg K, Komajda M, Böhm M, et al. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet. 2010 Sep 11;376(9744):875-85. [Erratum in: Lancet. 2010 Dec 11;376(9757):1988.]
- Product information for Verquvo. Merck & Co. Whitehouse Station, NJ 08889. June 2021.
- Packer M, Anker SD, Butler J, et al. Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure. N Engl J Med. 2020 Oct 8;383(15):1413-1424.
- McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019 Nov 21;381(21):1995-2008.
- Shore S. 2021 Expert Decision Pathway for HFrEF Treatment Optimization. January 11, 2021. https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2021/01/2021/21/56/2021-Update-Expert-Consensus-for-HFrEF. (Accessed April 9, 2022).
- Canadian Cardiovascular Society. Is it heart failure and what should I do? 2021 update. https://ccs.ca/app/uploads/2021/04/2021-HF-Gui-PG-FINAL-WEB.pdf. (Accessed April 8, 2022).
Cite this document as follows: Clinical Resource, Heart Failure Treatment at a Glance. Pharmacist’s Letter/Prescriber’s Letter. May 2022.[380501]