The Treatment of Heart Failure with Reduced Ejection Fraction

Abstract

Background: Chronic congestive heart failure is a common condition that, if untreated, markedly impairs the quality of life and is associated with a high risk of recurrent hospitalization and death.

Methods: This review is based on articles retrieved by a selective search in PubMed, as well as on relevant guidelines.

Results: Evidence-based treatment options are available only for congestive heart failure with a low ejection fraction. Pharma - cotherapy is based on neurohumoral inhibition of the renin-angiotensin-aldosterone system and the adrenergic system. The prognosis of patients with this condition has been further improved recently through the introduction of combined angiotensin receptor antagonists and neprilysin inhibitors. Modern implantable devices are a further component of treatment. Implantable defibrillators and special pacemakers for cardiac resynchronization are well established; the utility of alternative devices (baroreflex modulation or cardiac contractility modulation) needs to be investigated in further studies. It was recently shown that the catheter-based treatment of secondary mitral regurgitation with a MitraClip improves the outcome of selected patients.

Conclusion: The treatment of chronic systolic heart failure as recommended in the relevant guidelines, with drugs and implanted devices if indicated, can significantly improve the clinical outcome.

Figure 1

Simplified representation of the vicious circle in heart failure ultimately responsible for the disease‘s poor prognosis. The aim of drug therapy as well as device-based therapy is to stop or interrupt this downward spiral.

Figure 2

Overview of drug therapy and possible device-based therapies for heart failure with reduced systolic left ventricular function (HFrEF) (modified from [2, e27]). To treat symptoms, diuretic therapy should be additionally used, as well as implantation of a cardioverter-defibrillator due to the risk of malignant cardiac arrhythmia in persistently reduced left ventricular function (LVEF <35%). In the case of intolerance due to cough, an ACE inhibitor should be swapped for an angiotensin receptor blocker. Color denotes the level of recommendation: green, class I recommendation; yellow, class II recommendation; gray, no clear level of recommendation in the 2016 ESC guidelines *Consider therapy ARB, angiotensin II receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; BAT, baroreflex modulation therapy; CCM, cardiac contractility modulation; CRT, cardiac resynchronization therapy; HF, heart rate; HTx, heart transplantation; LBBB, left bundle branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; non-LBBB, non-left bundle branch block; NYHA, New York Heart Association class