Heart Failure Treatment — Modern Medications and Management (2026)
- Modern heart failure treatment has 4 pharmacological pillars — all four together reduce mortality by ~73%
- SGLT2 inhibitors are now a core pillar of HFrEF AND HFpEF treatment
- NT-proBNP is the key blood test for diagnosing and monitoring heart failure
- Cardiac resynchronisation therapy (CRT) improves ejection fraction by 5–10% in eligible patients
- A low-sodium diet (under 2g/day) and fluid restriction are cornerstones of self-management
Understanding Heart Failure Types
Heart failure is not a single condition — treatment depends on the type of ejection fraction impairment:
- HFrEF (Heart Failure with Reduced Ejection Fraction): EF below 40% — the most studied form with the most treatment options
- HFmrEF (Mildly Reduced EF): EF 40–49% — emerging evidence supports similar treatment
- HFpEF (Preserved EF): EF ≥50% — historically undertreated; SGLT2 inhibitors are the first drug class proven to improve outcomes
The Four Pillars of HFrEF Treatment
1. ACE Inhibitor or ARNi (Sacubitril/Valsartan)
ACE inhibitors (ramipril, lisinopril) or ARBs reduce mortality by ~17%. The newer ARNi sacubitril/valsartan (Entresto) is superior to ACE inhibitors — 20% further reduction in mortality and HF hospitalisation. Now first-line preferred over ACE inhibitors in guidelines when affordable.
2. Beta-Blockers
Bisoprolol, carvedilol, or nebivolol — reduce mortality by ~34% in HFrEF. Counterintuitively, they improve heart function over time by blocking the harmful effects of chronic sympathetic activation. Start low, go slow — they temporarily worsen function before improving it.
3. MRA — Mineralocorticoid Receptor Antagonists
Spironolactone or eplerenone — reduce mortality by ~25%. Essential add-on for EF ≤35%. Monitor potassium carefully — hyperkalaemia risk, especially with ACE inhibitors/ARBs and CKD.
4. SGLT2 Inhibitors (Empagliflozin or Dapagliflozin)
The newest pillar — reduce HF hospitalisation and cardiovascular death by 25–35%. Uniquely, they work in HFpEF as well as HFrEF — the first drugs to improve outcomes in preserved EF heart failure (EMPEROR-Preserved, DELIVER trials).
Lifestyle Management
- Salt restriction: Under 2g sodium (5g salt) per day — reduces fluid retention and hospitalisation
- Fluid management: Typically 1.5–2 litres/day in stable HF — varies by severity
- Daily weight monitoring: Weight gain of 2 kg in 2 days = fluid retention = contact healthcare team
- Exercise: Supervised cardiac rehabilitation reduces hospitalisation by 25% and improves quality of life — exercise is no longer contraindicated in stable HF