Gestion de la médication pour l’insuffisance cardiaque avec fraction d’éjection réduite: Perles cliniques pour optimiser la thérapie fondée sur des données probantes

There have been numerous developments in the management of heart failure (HF) over the past several years. Terminology has evolved, with systolic dysfunction now referred to as HF with reduced ejection fraction (HFrEF) (ie, a left ventricular ejection fraction [LVEF] of < 40%) (Table 1). Medications, such as sacubitril-valsartan and sodium-glucose cotransporter-2 inhibitors (SGLT2ls), have been added to the list of agents that provide mortality and morbidity benefits in this patient population. Recommended pharmacotherapy for individuals with HFrEF has subsequently expanded to include 4 types of foundational medications, also referred to as HFrEF quadruple therapy (Table 2).3,4 Furthermore, the 2021 Canadian Cardiovascular Society (CCS) HF guidelines suggest initiating HFrEF quadruple therapy and completing titration to maximally tolerated doses within 3 to 6 months of diagnosis. This may seem ambitious but. despite the evidence for and advances in medication management, the mortality and morbidity rates in HF remain high. The mortality rate of individuals with HF is approximately 50% within 5 years of diagnosis. These patients also have a high risk of being hospitalized for HF, which is associated with a subsequent increased risk of death.3 Underuseand underdosing of HFrEF medications are thought to be key contributors to the continued high rates of mortality and HF hospitalizations. Notably, loop diuretics (eg, furosemide) are crucial to managing fluid retention, but do not reduce the risk of mortality and may even limit the titration of other mortality-reducing HF medications. Thus, diuretics should be reassessed at every visit and tapered to the minimum effective dose to maintain euvolemia.