60
Blood Pressure Management
Table 18. GDMT for Patients With Hypertension and Heart
Failure With Reduced Ejection Fraction
Drug Class Notes on Use
BB In patients with HFrEF, even if asymptomatic, use 1 of the 3 BBs
proven to reduce mortality and hospitalizations (bisoprolol, carvedilol,
metoprolol succinate).
MRA In patients with symptomatic HFrEF, spironolactone or eplerenone is
recommended to reduce morbidity and mortality if eGFR is >30 mL/
min/1.73 m
2
and potassium is <5.0 mEq/L.
RAASi
with ACEi
or ARB or
ARNi
In patients with HFrEF and NYHA class II to III symptoms, ARNi is
recommended to reduce morbidity and mortality.
When the use of ARNi is not feasible, ACEi or ARB is recommended
to reduce morbidity and mortality.
SGLT2i SGLT2i are recommended in patients with symptomatic HFrEF to
reduce hospitalization and cardiovascular mortality irrespective of the
presence of type 2 diabetes.
Additional GDMT to be added as indicated
Hydralazine
and
isosorbide
dinitrate
For patients self-identified as Black with NYHA class III to 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.
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.
ACEi indicates angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor
blockers; ARNi, angiotensin receptor-neprilysin inhibitors; BB, beta blocker; eGFR,
estimated glomerular filtration rate; GDMT, guideline-directed medical therapy; HFrEF,
heart failure with reduced ejection fraction; MRA, mineralocorticoid receptor antagonist;
NYHA, New York Heart Association; RAASi, renin-angiotensin-aldosterone system
inhibitors; and SGLT2i, sodium-glucose cotransporter inhibitors
Modified with permission from Heidenreich et al. Copyright © 2022 American Heart
Association, Inc., and American College of Cardiolog y Foundation.
5.3.4.1. Heart Failure With Reduced Ejection Fraction
