鉴于心力衰竭和射血分数(HFrEF)降低的患者出现不良后果的风险较高,迫切需要可以降低发病率和死亡率风险的指南指导药物治疗(GDMT)的启动和滴定.临床实践指南现在强调需要早期和快速启动具有心血管益处的疗法。认识到GDMT启动和优化存在许多障碍,卫生保健提供者应旨在介绍目前大多数临床实践指南推荐的四联疗法的四大支柱:血管紧张素受体-脑啡肽抑制剂,β受体阻滞剂,盐皮质激素受体拮抗剂,和钠-葡萄糖协同转运蛋白2抑制剂。大部分HFrEF患者没有GDMT的临床禁忌症,但未接受这些疗法的治疗。大多数患者应耐受早期开始低剂量联合治疗。然而,患者相关因素,如血液动力学,脆弱,和实验室值将需要考虑最大耐受GDMT。在急性心力衰竭住院中启动GDMT代表了改善GDMT使用的另一个重要途径。最后,应考虑取消对心血管无明显益处的治疗,以降低多药疗法并降低不良副作用的风险.未来的前瞻性研究旨在指导最佳实施四联疗法,以降低HFrEF患者的发病率和死亡率。
Given the high risk of adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF), there is an urgent need for the initiation and titration of guideline-directed medical therapy (GDMT) that can reduce the risk of morbidity and mortality. Clinical practice guidelines are now emphasizing the need for early and rapid initiation of therapies that have cardiovascular benefit. Recognizing that there are many barriers to GDMT initiation and optimization, health care providers should aim to introduce the 4 pillars of quadruple therapy now recommended by most clinical practice guidelines: angiotensin receptor-neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors. A large proportion of patients with HFrEF do not have clinical contraindications to GDMT but are not treated with these therapies. Early initiation of low-dose combination therapy should be tolerated by most patients. However, patient-related factors such as hemodynamics, frailty, and laboratory values will need consideration for maximum tolerated GDMT. GDMT initiation in acute heart failure hospitalization represents another important avenue to improve use of GDMT. Finally, removal of therapies that do not have clear cardiovascular benefit should be considered to lower polypharmacy and reduce the risk of adverse side effects. Future prospective studies aimed at guiding optimal implementation of quadruple therapy are warranted to reduce morbidity and mortality in patients with HFrEF.