26
Treatment
7.3.3. Mineralocorticoid Receptor Antagonists (MRAs)
COR LOE
Recommendations
1 A 1. In patients with HFrEF and NYHA class II-IV symptoms,
an MRA (spironolactone or eplerenone) is recommended to
reduce morbidity and mortality, if eGFR is >30 mL/min/
1.73 m
2
and serum potassium is <5.0 mEq/L. Careful
monitoring of potassium, renal function, and diuretic dosing
should be performed at initiation and closely monitored
thereafter to minimize risk of hyperkalemia and renal
insufficiency.
Value Statement:
High Value (A)
2. In patients with HFrEF and NYHA class II-IV symptoms,
MRA therapy provides high economic value.
3: Harm B-NR 3. In patients taking MRA whose serum potassium cannot be
maintained at <5.5 mEq/L, MRA should be discontinued to
avoid life-threatening hyperkalemia.
7.3.4. Sodium-Glucose Cotransporter 2 Inhibitors
COR LOE
Recommendations
1 A 1. In patients with symptomatic chronic HFrEF, SGLT2i
are recommended to reduce hospitalization for HF and
cardiovascular mortality, irrespective of the presence of type
2 diabetes.
Value Statement:
Intermediate Value
(A)
2. In patients with symptomatic chronic HFrEF, SGLT2i
therapy provides intermediate economic value.
7.3.5. Hydralazine and Isosorbide Dinitrate
COR LOE
Recommendations
1 A 1. For patients self-identified as African American with NYHA
class III-IV HFrEF who are receiving optimal medical therapy,
the combination of hydralazine and isosorbide dinitrate is
recommended to improve symptoms and reduce morbidity
and mortality.
Value Statement:
High Value
(B-NR)
2. For patients self-identified as African American with NYHA
class III-IV HFrEF who are receiving optimal medical
therapy with ACEi or ARB, beta blockers, and MRA, the
combination of hydralazine and isosorbide dinitrate provides
high economic value .
2b C-LD 3. In patients with current or previous symptomatic HFrEF
who cannot be given first-line agents, such as ARNi, ACEi,
or ARB, because of drug intolerance or renal insufficiency, a
combination of hydralazine and isosorbide dinitrate might be
considered to reduce morbidity and mortality.
