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Pharmacologic Treatment of Heart Failure With Reduced Ejection Fraction: An Updated Systematic Review and Network Meta-Analysis

Author/s: 
Bart J. van Essen, Daan C.H. Ceelen, Wouter Ouwerkerk, Tiew-Hwa K. Teng, Ganash N. Tharshana, Fook Ming Hew, Javed Butler, Faiez Zannad, Carolyn S. Lam, Justin Ezekowitz, Adriaan A. Voors, Jasper Tromp

Background: In 2022, a network meta-analysis showed that a combination of β-blockers, angiotensin receptor-neprilysin inhibitors (ARNi), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter 2 inhibitors (SGLT2i) was most effective in reducing all-cause mortality in heart failure with reduced ejection fraction (HFrEF). This study updates the treatment benefit by including additional large randomized controlled trials (RCTs) since 2022, including the VICTOR (Vericiguat Global Study in Participants with Chronic Heart Failure) trial.

Objectives: The goal of this study was to evaluate and compare regimens of pharmacotherapy in patients with HFrEF.

Methods: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for RCTs in patients with HFrEF through April 2025. Using frequentist network meta-analysis, HRs for all-cause mortality (primary outcome), cardiovascular death, and the composite of cardiovascular death or heart failure hospitalization (secondary outcomes) were estimated. Absolute benefits were quantified as life-years gained by using BIOSTAT-CHF (Biology Study to Tailored Treatment in Chronic Heart Failure) and ASIAN-HF (Asian Sudden Cardiac Death in Heart Failure) cohort data.

Results: The analysis included 103,754 patients across 89 randomized controlled trials. Relative to placebo, quintuple therapy with ARNi, β-blockers, MRAs, SGLT2i, and vericiguat most effectively reduced all-cause mortality (HR: 0.35; 95% CI: 0.27-0.45), followed by quadruple therapy with ARNi, β-blockers, MRAs, and SGLT2i (HR: 0.39; 95% CI: 0.32-0.49). For a representative 70-year-old patient, quadruple therapy (ARNi/β-blockers/MRAs/SGLT2i) provided 5.3 additional life-years (95% CI: 2.8-7.7) vs no treatment, while quintuple therapy (ARNi/β-blockers/MRA/SGLT2i/vericiguat) provided 6.0 additional life-years (95% CI: 3.7-8.4).

Conclusions: This analysis reinforces the substantial mortality and morbidity benefit associated with the currently recommended quadruple therapy regimen (ARNi, β-blockers, MRAs, and SGLT2i) in patients with HFrEF. The addition of vericiguat may provide an incremental survival gain of approximately 0.7 year beyond that achieved with quadruple therapy. However, these results should be regarded as exploratory, as they are derived from a secondary endpoint of a single trial.

Keywords: HFrEF; drug therapy; pharmacotherapy.

Keywords 
HFrEF drug therapy pharmacotherapy

Primary Prevention of Sudden Cardiac Death

Author/s: 
Beaser, A.D., Cifu, A.S.

  • In patients with heart failure with reduced ejection fraction (<40%), guideline-directed medical therapy (GDMT) is recommended to reduce sudden cardiac death and all-cause mortality; GDMT includes β-blockers; mineralocorticoid receptor antagonists; and angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor–neprilysin inhibitors (class I, level A recommendation).

  • In patients with left ventricular ejection fraction (LVEF) of 35% or less due to ischemic heart disease at least 40 days after myocardial infarction, at least 90 days after revascularization, and with New York Heart Association (NYHA) class II or III heart failure despite GDMT, an ICD is recommended if expected survival is greater than 1 year (class I, level A recommendation).

  • In patients with LVEF of 30% or less due to ischemic heart disease at least 40 days after myocardial infarction, at least 90 days after revascularization, and with NYHA class I heart failure symptoms despite GDMT, an ICD is recommended if expected survival is greater than 1 year (class I, level A recommendation).

  • In patients with nonischemic cardiomyopathy, NYHA class II to III symptoms, and LVEF of 35% or less despite GDMT, an ICD is recommended if expected survival is greater than 1 year (class I, level A recommendation).

Keywords 
cardiac sudden cardiac death risk reduction risk factors heart failure
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