Dr. Avishek Bagchi,

MBBS, MD (Medicine), DM (Cardiology),

Consultant – Cardiology

Evidence based management of patients with heart failure with reduced ejection fraction consists of a combination of four group of drugs- traditionally called the “four pillars” of heart failure therapy. These drugs include the beta blockers, angiotensin receptor-neprilysin inhibitors (ARNIs), mineralocorticoid receptor antagonists (MRAs) and sodium-glucose co-transporter 2 Inhibitors (SGLT2i). The older concept was that patients should be started on these drugs one after one; however recent evidences show that patients with heart failure should be put on these four group drugs all at once and then the doses should be gradually up-titrated. The first pillar – the beta blockers – have been around for more than three decades now, but there is still only 60 percent penetrance with heart failure when it should be around 90 percent, the second pillar (ARNI) is a combination of sacubitril, a neprilysin inhibitor, and valsartan, an angiotensin II receptor blocker (ARB) and is now considered first choice for initiation. The current recommendation is to titrate both the beta blocker and ARNI to maximum tolerated dosage. The one limitation to this recommendation is cost. The third pillar of heart failure therapy are MRAs. Discovered in the 1990s, these drugs are aldosterone antagonists that reduce excess fluid in the body while preventing the loss of potassium. Yet the primary efficacy is from neurohormonal blockage. SGLT2 inhibitors – the fourth pillar – are the newest drug class shown to be effective against heart failure. They are being incorporated into practice faster than the other drug classes were when they were first introduced. These drugs are well tolerated by patients. We advocate rapid titration of all four medication classes. This can be done weekly or simultaneously. Of course, not every patient will tolerate speed, so physicians have to make the appropriate patient assessment. The goal is to go as fast as possible to mitigate disease progression.