Pharmacotherapy of Heart Failure

Introduction

• Definition — Heart failure (HF) is a clinical syndrome — the heart cannot pump blood to meet tissue metabolic demand, or only at elevated filling pressure; modern definitions anchor it to raised natriuretic peptides + objective congestion.
• Final common pathway — of ischaemic heart disease (commonest cause of HFrEF, ~75%), chronic hypertension, valvular disease, cardiomyopathies, myocarditis and cardiotoxins (alcohol, doxorubicin, trastuzumab, checkpoint inhibitors).
• Two haemodynamic syndromes — forward (low-output) failure → fatigue, exertional dyspnoea; backward (congestive) failure → pulmonary/peripheral oedema, hepatic congestion.
• Grim prognosis — ~50% 5-year mortality (~42% survival), ~40% of deaths sudden; survival has improved tracking the rising use of ACEI/ARB, β blockers & MRAs — drug therapy drives survival.
• Therapeutic split — symptomatic / no mortality benefit (diuretics, digoxin, inotropes) vs disease-modifying / prolongs survival (ACEI/ARB, β blocker, MRA, ARNI, SGLT2i) — the four-pillar GDMT lives in the latter.