Treatment of heart failure with reduced ejection fraction

Background: Heart failure with reduced ejection fraction (HFrEF) is a syndrome consisting of typical symptoms and/or signs of heart failure (HF) due to left ventricular systolic dysfunction (ejection fraction <= 40%) caused by various underlying cardiac diseases. We report conventional and recently established pharmacologic and non-pharmacologic treatments of HFrEF in this review article. Current Concepts: So far, various pharmacologic treatments have been proven beneficial in reducing HF-associated hospitalization or cardiac death. The mainstay of the treatments is renin-angiotensin-aldosterone system inhibitors, which are sympathetic nervous system blockers on top of the diuretics to relieve symptoms of systemic or pulmonary congestion. Recently, new treatment targets for natriuretic peptide and sodium-glucose cotransporter have emerged in HFrEF, allowing the use of these novel drugs in addition to the optimal conventional medications. Device therapies, such as implantable cardioverter-defibrillator and cardiac resynchronization therapy, can improve the outcome in a special population. Heart transplantation is the final treatment for patients with advanced HF. However, due to the limitation of the donor pool, mechanical circulatory support is necessary. Discussion and Conclusion: Current guidelines recommend using the four pillars of medications in HFrEF, including angiotensin-converting enzyme inhibitors (angiotensin-neprilysin inhibitors or angiotensin receptor blockers), beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter inhibitors. Appropriate device therapy, mechanical circulatory support, and heart transplantation can enhance survival in advanced HF patients. Balanced treatment, including conventional and newer therapies, is necessary.