Notes · Cardiovascular · 8 min read

Heart failure with reduced ejection fraction: the four pillars

Four drug classes, each reducing mortality, started early and titrated.

Key points

  1. HFrEF is heart failure with a left ventricular ejection fraction of 40% or less.
  2. Pillar 1: ACE inhibitor, ARB or ARNI (sacubitril–valsartan).
  3. Pillar 2: an evidence-based beta-blocker (bisoprolol, carvedilol, metoprolol succinate).
  4. Pillar 3: a mineralocorticoid receptor antagonist (spironolactone or eplerenone).
  5. Pillar 4: an SGLT2 inhibitor (dapagliflozin or empagliflozin).

Based on the ESC heart failure guidelines (2021, focused update 2023) and the AHA/ACC/HFSA guideline (2022). A study aid, not a substitute for the current guideline or local protocols.

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