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7.3.1. Renin-Angiotensin System Inhibition With ACEi or
ARB or ARNi
COR LOE
Recommendations
1 A 1. In patients with HFrEF and NYHA class II to III symptoms,
the use of ARNi is recommended to reduce morbidity and
mortality.
1 A 2. In patients with previous or current symptoms of chronic
HFrEF, the use of ACEi is beneficial to reduce morbidity and
mortality when the use of ARNi is not feasible.
1 A 3. In patients with previous or current symptoms of chronic
HFrEF who are intolerant to ACEi because of cough or
angioedema and when the use of ARNi is not feasible, the use
of ARB is recommended to reduce morbidity and mortality.
Value Statement:
High Value (A)
4. In patients with previous or current symptoms of chronic
HFrEF, in whom ARNi is not feasible, treatment with an
ACEi or ARB provides high economic value.
1 B-R 5. In patients with chronic symptomatic HFrEF NYHA class II
or III who tolerate an ACEi or ARB, replacement by an ARNi
is recommended to further reduce morbidity and mortality.
Value Statement:
High Value (A)
6. In patients with chronic symptomatic HFrEF, treatment with
an ARNi instead of an ACEi provides high economic value.
3: Harm B-R 7. ARNi should not be administered concomitantly with ACEi
or within 36 hours of the last dose of an ACEi.
3: Harm C-LD 8. ARNi should not be administered to patients with any history
of angioedema.
3: Harm C-LD 9. ACEi should not be administered to patients with any history
of angioedema.
7.3. Pharmacological Treatment* for HFrEF
* See Section 7.2, "Diuretics and Decongestion Strategies in Patients with HF," for diuretic
recommendations.
7.3.2. Beta Blockers
COR LOE
Recommendations
1 A 1. In patients with HFrEF, with current or previous symptoms,
use of 1 of the 3 beta blockers proven to reduce mortality (e.g.,
bisoprolol, carvedilol, sustained-release metoprolol succinate)
is recommended to reduce mortality and hospitalizations.
Value Statement:
High Value (A)
2. In patients with HFrEF, with current or previous symptoms,
beta-blocker therapy provides high economic value (4-8).
