Goldilocks Dilemma of Dose Titration in Heart Failure With Reduced Ejection Fraction
Too Little, Too Much, or Just Right?
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See Article by Khan et al
Medication optimization for heart failure with reduced ejection fraction (HFrEF) is hard work. For a patient recently diagnosed with HFrEF, the number of available therapies has become dizzying. Medications include β-blockers (BB), angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) with added neprilysin inhibitor, mineralocorticoid receptor blockers, hydralazine/isosorbide dinitrate, and ivabradine; this in addition to decongestion with loop diuretics, implantation of devices, referral to cardiac rehabilitation, management of comorbidities, and education of both patients and care providers.1 Recognizing the possible deleterious acute effects of many of these medications, clinical practice guidelines suggest staggered initiation of HFrEF medications, beginning at a low dose for each drug and then slowly increasing to maximum doses targeted in randomized controlled trials. Even with vigilant serial adjustments at 2-week intervals, medication intensification usually takes 3 to 6 months. Meanwhile, frequent monitoring for symptoms, hypotension, and renal dysfunction is needed. Within this context, it is not surprising that up to 80% of patients with HFrEF receive less than recommended doses.2
Although dose maximization is ingrained in chronic ambulatory HFrEF care, the data behind it is surprisingly limited. Do BB improve outcomes in patients with HFrEF? Unequivocally yes. Do higher doses of BB improve outcomes more than lower doses of BB in patients …