The EMPEROR-Reduced trial demonstrated that empagliflozin reduced the primary composite of CV death or HF hospitalisation in HFrEF. Which class of drugs now forms part of the 'fantastic four' (or foundational quadruple therapy) for HFrEF per ESC 2021 guidelines?

• A ACE inhibitor/ARB + beta-blocker + MRA + digoxin
• B ACE inhibitor/ARB/ARNI + beta-blocker + MRA (aldosterone antagonist) + SGLT2 inhibitor ✓
• C ACE inhibitor + beta-blocker + loop diuretic + ivabradine
• D ARNI + beta-blocker + SGLT2 inhibitor + hydralazine/nitrate

Explanation

ESC 2021 and ACC/AHA 2022 HF guidelines establish four drug classes with Class I evidence for mortality benefit in HFrEF (LVEF ≤40%): (1) ACE inhibitor (or ARB if ACE intolerant) or preferably sacubitril/valsartan (ARNI — PARADIGM-HF trial), (2) beta-blocker, (3) mineralocorticoid receptor antagonist (spironolactone/eplerenone), and (4) SGLT2 inhibitor (dapagliflozin — DAPA-HF; empagliflozin — EMPEROR-Reduced). Each reduces CV death and/or HF hospitalisation independently. This quadruple therapy is recommended in all eligible HFrEF patients, introduced simultaneously or in rapid sequential uptitration.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.