Optimization of heart failure with reduced ejection fraction prognosis-modifying drugs: A 2021 heart failure expert consensus paper

Heart failure (HF) with reduced ejection fraction (HFrEF) is associated with high rates of hospitalization and death. It also has a negative impact on patients' functional capacity and quality of life, as well as on healthcare costs. In recent years, new HFrEF prognosis-modifying drugs have emerged, leading to intense debate within the international scientific community toward a paradigm shift for the management of HFrEF. In this article, we report the contribution of a Portuguese HF expert panel to the ongoing debate. Based on the most recently published clinical evidence, and the panel members' clinical judgment, three key principles are highlighted: (i) sacubitril/valsartan should be preferred as first-line therapy for HFrEF, instead of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker; (ii) the four foundation HFrEF drugs are the angiotensin receptor/neprilysin inhibitor, beta-adrenergic blocking agents, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors, regardless of the presence of type-2 diabetes mellitus; (iii) these four HFrEF drug classes should be introduced over a short-term period of four to six weeks, guided by a safety protocol, followed by a dose up-titration period of 8 weeks. (C) 2021 Sociedade Portuguesa de Cardiologia. Published by Elsevier Espana, S.L.U.

Automated summary

The Portuguese HF expert panel contributed to the ongoing debate regarding HFrEF management by highlighting three key principles: the preference for sacubitril/valsartan as first-line therapy, the importance of four foundation HFrEF drugs regardless of diabetes status, and the introduction and dose up-titration of these drugs over specific timeframes guided by a safety protocol.