A Treatment Approach for Patients With Chronic Systolic Heart Failure

Abstract

The treatment of heart failure with reduced ejection (HFrEF) is changing rapidly. Advances over the past several decades have focused on blocking the adverse effects of neurohormonal activation. This approach has resulted in marked improvement in outcomes in the HFrEF population. Despite these advances, however, mortality and morbidity remain high and HFrEF patients have poor quality of life. New approaches to therapy now offer additional benefits. Combined neprilysin inhibition and angiotensin receptor blockade using sacubitril-valsartan (LCZ696) has been shown to be superior to an angiotensin-converting enzyme inhibitor in HFrEF patients. Compared with enalapril, treatment with LCZ696 was associated with significant reductions in the composite of cardiovascular mortality and heart failure hospitalization, both components of this composite endpoint and all-cause mortality. Another approach that has been shown to be effective is the use of ivabradine, an agent that blocks I_f channels in the sinus node to reduce heart rate. When added to standard therapy (that included a β-blocker in 89% of patients) in symptomatic HFrEF patients who were in sinus rhythm, ivabradine significantly reduced combined cardiovascular mortality and heart failure hospitalizations. Death from heart failure, all-cause hospitalization, and heart failure hospitalization were also significantly reduced when ivabradine was added to the medical regimen. Thus, both LCZ696 and ivabradine represent significant advances in the therapy of HFrEF. Utilization of these drugs in the growing HFrEF population will benefit millions of patients around the world.