Niewydolność serca: od obniżonej do zachowanej frakcji wyrzutowej — jak optymalnie leczyć pacjenta?

Abstract

The 2016 ESC/PTK guidelines specify the recommendations for the treatment of heart failure with a reduced ejection fraction (HFrEF). However, there is still much confusion about the treatment of patients with a mid-range and preserved EF. The classification of HF based on the EF into specific phenotypes is rather formal and should take into account a practical approach to each patient, as patients often change the category to which they were initially assigned based on the EF. Here we can talk about the so-called “transitions” between particular groups of patients with HF. The guidelines recommend the use of a blockade of the renin–angiotensin–aldosterone system and heart rate control in all patients with a reduced EF. However, they do not specify the pharmacotherapy of patients with a mid-range and preserved EF. Diuretics are recommended in all types of patients with symptoms of congestion. In both groups of patients, it is recommended to assess the presence of comorbidities and apply appropriate therapy. Clinical trials indicate indirectly that the treatment of patients with an intermediate EF should be similar to the treatment of patients with a reduced EF. However, there are no unequivocally convincing clinical trials on a larger and diverse group of patients. The 2019 ESC consensus recommends cautious use of beta-blockers, candesartan and spironolactone in the group of patients with a mid-range EF, which was based on the results of clinical trials. Treatment of patients with preserved E remains unspecified. From a practical point of view, however, it seems that a one-off qualification of the patient to the HF group is not justified. We should remember that patients who achieved an improvement in left ventricular ejection fraction during treatment and changed the HF class, e.g. from HFrEF to HFpEF, constantly require optimal pharmacological therapy. Its discontinuation or reduction may lead to deterioration of the left ventricular function and a long-term prognosis