Choice of vasodilator in adults with heart failure with reduced ejection fraction*

ARNI therapy is the preferred vasodilating agent in patients with HFrEF. For patients who cannot take an ARNI, reasonable alternatives include ACE inhibitors and single-agent ARB therapy. If none of these agents are feasible for use, isosorbide dinitrate plus hydralazine therapy is a third-line therapy; it can also be used as an additional therapy in patients with residual hypertension or HF symptoms despite other primary therapies for HFrEF.*

HFrEF: heart failure with reduced ejection fraction; eGFR: estimated glomerular filtration rate; ARB: angiotensin II receptor blocker; ACE: angiotensin-converting enzyme; ARNI: angiotensin receptor-neprilysin inhibitor; HF: heart failure.

* Primary pharmacologic therapy for HFrEF typically contains 1 agent from multiple classes of medications. For details on other components of primary pharmacologic therapy for HFrEF, refer to UpToDate topics on pharmacologic therapy for HFrEF.

¶ Kidney function should be assessed when the patient is clinically stable.

Δ In patients who already take an ACE inhibitor, transition to ARNI is the preferred approach. This transition from an ACE inhibitor to sacubtril-valsartan requires additional management to avoid severe complications. For further details, refer to UpToDate topics on pharmacologic therapy for HFrEF.

◊ For patients with eGFR <30 mL/min/1.73 m², start with the lowest doses of ACE inhibitor or ARB and frequently monitor for adverse effects on kidney function and hyperkalemia. If kidney function worsens, a common approach is to discontinue ACE inhibitor or ARB therapy and start hydralazine plus isosorbide dinitrate. For details on dosing and other cautions, refer to UpToDate topics on pharmacologic therapy for HFrEF.

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Choice of vasodilator in adults with heart failure with reduced ejection fraction*