Pharmacologic Therapy for Heart Failure With Reduced Ejection Fraction: Closing the Gap Between Clinical Guidelines and Practice

Despite the great progress made in the management of heart failure (HF) with reduced ejection fraction (HFrEF), its prevalence continues to rise owing to an aging population and an epidemic of hypertension, obesity and coronary artery disease. For decades, angiotensin converting enzyme inhibitors and beta blockers have been the mainstay of HFrEF therapy. The recent addition of sacubitril/valsartan and ivabradine to the HF armamentarium has the potential to transform our therapeutic approach to HFrEF, while simultaneously raising some questions and uncertainties on their applicability. In this paper, we review the pathophysiology of HFrEF, discuss already established and novel evidenced-based pharmacologic therapies available for these patients. We also share some therapeutic strategies aimed to optimize HF therapy in specific undertreated patient populations including the elderly and patients with chronic kidney disease, while offering insight on how to tailor therapy in the “real-world.”