Why Pillar Directed Therapy Do Not Provide Absolute Protection in Heart Failure? The Five Pillars of the Management of Heart Failure


Authors: Ehab Hamdy, Galal Elkilany, Osama Elmarghi, and Jan Fedacko
Page Range: 193-208
Published in: World Heart Journal, 15#3 (2023)
ISSN: 1556-4002

Table of Contents


There is evidence that cardiac toxicity may be induced by tobacco and alcohol intake as well as due to western diet, sedentary behavior and obesity, and by sleep disorders and emotional stress. Therefore, primary risk factors are the basic causes of heart failure (HF), which should be treated urgently. This review aims to highlight the role of “four pillars” of HF therapy, including beta blockers, angiotensin receptor-neprilysin inhibitors (ARNIs)/angiotensin receptor blockers (ARBs), mineral-corticoid receptor antagonists (MRAs), and sodium-glucose co-trans-porter 2 Inhibitors (SGLT2i), used in the management of HF. The fifth pillar appears to be vericiguat, which is the most recent agent for the management of HF. However, nutritional factors may also be considered as 1st Pillar in the management of HF. HF has been classified based on clinical trial inclusion criteria into patients with a reduced or preserved left ventricular ejection fraction (LVEF), using a cut-off of above or below 40%. It seems that the benefits of disease-modifying drug therapy has been in patients with HFrEF. Although, the time has come to treat HF regardless of ejection fraction, provided nutritional factors are also treated simultaneously. In HFpEF, management of comorb-idities: hypertension, obesity, diabetes, AF, and sleep apnea is done as priority. Hypertension should be optimally controlled to systolic blood pressure <130 mmHg. Agents of choice include diuretics, ARNIs, ARBs, and MRAs, ACE inhibitors and beta-blockers. They suppress the renin-angiotensin and sympathetic nerve systems, respectively. These two systems are fundamental processes behind the pathophysiology of HFrEF. Patients who remain symptomatic, after maximum tolerated dosages of ACEi and beta-blockers and consistently with reduced left ventricular function, are encouraged to seek further treatments, according to both European and American recomm-endations. While there is some subtle variation in the recommendations, they all agree that MRA should be the last line of treatment. Keywords: Diet, sleep, physical training, beta blockers, ACE-inhibitors, ARNI, SGLT2i.

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