The four pillars of HFrEF treatment, as recommended by The European Society of Cardiology (ESC) and the American College of Cardiology Foundation/American Heart Association/Heart Failure Society of America (ACCF/AHA/HFSA), are guideline-directed medical therapy (GDMT) for symptomatic heart failure with reduced ejection fraction which also apply to midrange EF and include angiotensin receptor-neprilysin inhibitors (ARNI)/angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), evidence-based beta-blockers, mineralocorticoid receptor antagonists (MRAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2) [McDonagh, 2021; McDonagh, 2024; Heidenreich, 2022; Docherty, 2022]. Recent literature is reporting on the addition of a ‘5th pillar’ particularly in frail, older, and multimorbid patients who experience an episode of worsening HF or who cannot have treatment with the other drugs due to poor tolerability and comorbidities. These patients might benefit from a fifth drug, vericiguat, a soluble guanylate cyclase (sGC) stimulator [Beghini, 2025], which is reported to exert beneficial effects in patients with worsening HF, including older subjects, reducing the rate of both hospitalizations and deaths, with limited adverse effects and drug interaction [Spadafora, 2024; Armstrong, 2020].
At the end of the activity, learners should be able to:
Clinicians (including cardiologists, internists, and general practitioners), nurse practitioners and other HCPs who diagnose and manage patients with CVD and hypertension.
English with simultaneous translation into Russian and Chinese
Podcast & Infographic
Four pillars of HFrEF treatment
Martin Savage is Emeritus Professor of Paediatric Endocrinology at William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary, University of London. He was head of the Paediatric Endocrine Unit at Barts and the London School of Medicine from 1982 to 2007. He has interests in growth disorders, specifically those with abnormalities in the GH-IGF-1 axis and in phenotype-genotype relationships of GH-IGF-1 axis defects, notably GH resistance. He published the first human case of an IGF-1 gene defect in the New England Journal of Medicine in 1996. His other interests are Cushing’s syndrome and growth in chronic inflammatory diseases. He was General Secretary of the European Society for Paediatric Endocrinology (ESPE) from 1997 to 2004. He has lectured in 60 countries and has published 482 original articles, reviews, textbook chapters and books. In 2007, he was awarded the ESPE Andrea Prader Prize for contributions to paediatric endocrinology and in 2018 he received a Visionary Award from the American Human Growth Foundation. In 2022, he received a Research Excellence Award from the Dr Sulaiman Al Habib Medical Journal in Riyadh, and the British Society of Paediatric Endocrinology & Diabetes James M. Tanner Lifetime Achievement Award. He continues to lecture nationally and internationally.
Ji-Guang Wang MD, PhD, FAHA, FESC is director of the Shanghai Institute of Hypertension, and director of the Department of Hypertension, director of the Shanghai Key Laboratory of Hypertension, and associate director of the State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. At present, he is coordinating several multicentre randomized clinical trials and population- and patient-cohort studies in China. He has published 676 full-length articles on hypertension in the international literature and 214 articles in the Chinese literature, and has lectured extensively in international and China national conferences. He is a former Executive Council Member of the International Society of Hypertension, past president of the Asian-Pacific Society of Hypertension, past president of the Pulse of Asia Society, current deputy president of the HOPE Asia Network, and current president of the Chinese Hypertension League. He serves on the editorial board of several international and China national journals in the field of hypertension and cardiovascular medicine as Editor-in-Chief (The Journal of Clinical Hypertension), Associate Editor (Hypertension Research, and so on), Section Editor or a Member.
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