Medscape InDiscussion: Heart Failure S1 Episode 2: Nuanced Management of Heart Failure With Reduced Ejection Fraction (HFrEF): Select Patients
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Jan 10, 2023 Gregg Fonarow, cardiologist and UCLA heart failure expert, discusses nuanced selection of adjunct HFrEF therapies. He covers ivabradine use and prescribing rules. He reviews hydralazine‑nitrate benefits in select populations. He outlines vericiguat's role after worsening heart failure and the evidence for transcatheter mitral repair. Practical tips on multidisciplinary care and medication optimization are highlighted.
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When To Add Ivabradine
- Use ivabradine only after you have maximized beta blocker therapy and the patient remains in sinus rhythm with resting heart rate ≥70–77 bpm.
- SHIFT trial showed ~20% RRR in CV death/HF hospitalization, strongest benefit for HR ≥77 and in those who couldn't tolerate beta blockers.
Race Specific Benefit Of Hydralazine Nitrates
- Isosorbide dinitrate–hydralazine benefits are most clearly shown in self-identified Black patients already on guideline therapy.
- A-HeFT showed substantial mortality and QoL gains in Black patients, but evidence in others is limited and controversial.
Selective Use Of Vericiguat
- Consider vericiguat for select patients recently hospitalized for worsening HFrEF despite background therapy, not as foundational therapy.
- VICTORIA showed ~10% RRR, modest benefit, uncertain additive effect with SGLT2 inhibitors and limited QoL gains.
