Can J Cardiol. 2021 Jan 13:S0828-282X(21)00046-5. doi: 10.1016/j.cjca.2020.12.028. Online ahead of print.
The advent of newly available medical therapies for HFrEF has resulted in many potential therapeutic combinations, increasing treatment complexity. Publication of expert consensus guidelines and initiative aimed to improve treatment implementation have emphasized sequential, stepwise initiation and titration of medical therapy, which is labour intensive. Data taken from heart failure registries shows suboptimal use of medications, prolonged titration time and consequently little change in dose intensity, all of which, indicate therapeutic inertia. Recently published evidence indicates that four medication classes (1. renin-angiotensin-neprilysin inhibitors, 2. beta-blockers, 3. mineralocorticoid antagonists and 4. sodium-glucose cotransporter inhibitors), which we refer to as Foundational Therapy, confer rapid and robust reduction in both morbidity and mortality in most patients with HFrEF, and that they work in additive fashion. Additional morbidity and/or mortality may be observed following addition of several Personalized Therapies in specific subgroups of patients. In this review, we discuss mechanisms of action of these therapies and propose a framework for their implementation based on several principles. These include the critical importance of rapid initiation of all 4 Foundational Therapies followed by their titration to target doses, emphasis on multiple simultaneous drug changes with each patient encounter, attention to patient-specific factors in choice of medication class, leveraging inpatient care, use of the entire health care team and alternative (i.e. virtual visits) modes of care. We have incorporated these principles into a 'Cluster Scheme' designed to facilitate timely and optimal medical treatment for patients with HFrEF.