Pharmacologic Support of the Failing Heart

Abstract

Heart failure (HF), the inability of the heart to achieve adequate blood supply to meet the metabolic needs of the organs, is classified based on the left ventricular ejection fraction (LVEF) into HF with reduced LVEF (HFrEF) and HF with preserved LVEF (HFpEF). The pharmacological treatment of HF mainly consists of medications that suppress the maladaptive mechanisms leading to myocardial dysfunction. In HFrEF the treatment mainly focusses on the inhibition of the sympathetic nervous system and renin-angiotensin-aldosterone system, whereas in HFpEF the main goal is to control the comorbidities. The backbone of treatment of HFrEF is neurohormonal consisting of an angiotensin converting enzyme inhibitor, a beta blocker and a mineralocorticoid receptor antagonist. Randomised controlled clinical trials have shown this approach to be effective in improving both mortality and quality of life and these drugs have been included in current guidelines. Relatively newer drugs, such as ivabradine and sacubitril/valsartan are also important in the conservative treatment algorithm of HFrEF. Certain medications, such as diuretics and digoxin, are used regularly in HF because they improve the patients’ symptoms and reduce the number of hospitalizations for HF. The therapeutic approach of HFpEF includes adequate blood pressure control, the treatment of possible underlying myocardial ischemia and the adequate control of the ventricular response in atrial fibrillation. Inotropes can improve HF haemodynamics in the short-term but are associated in the mid-to long-term with arrhythmias, myocardial ischemia and increased mortality. The pharmacological treatment of acute HF mainly consists of intravenous diuretics, intravenous nitrates and, if there are signs of hypoperfusion, short-term inotropes.