The 2024 ACC Expert Consensus Decision Pathway for the treatment of HFrEF recommends ARNi as the only first-line RASi1†
First-line RASi therapy: ARNi is preferred for all appropriate HFrEF patients1
ARNi is the only recommended first-line RASi* along with beta blocker, mineralocorticoid antagonist, and SGLT inhibitor for all appropriate HFrEF patients
*In PARAGON-HF, defined as LVEF ≥45% with structural heart disease (LAE or LVH); median LVEF was 57%. LVEF is a variable measure and the normal range can vary.2
†The 2024 ACC ECDP HFrEF treatment algorithm no longer includes ACE inhibitors/ARBs as a primary first-line treatment. ACE inhibitors/ARBs should be considered in patients with contraindications, intolerance, or inaccessibility to ARNi.
In the ECDP, ENTRESTO®, a fixed combination of an angiotensin receptor blocker and a neprilysin inhibitor, is referred to as an ARNi.1
A de novo ARNi approach is preferred to ACEi or ARB pretreatment, with close follow-up, serial assessments (blood pressure, electrolytes, and kidney function), and consideration of risk of angioedema or hypotension.1
When making the transition from an ACEi to an ARNi, a 36-hour washout period should be strictly observed to avoid angioedema. This delay is not required when switching from an ARB to an ARNi.1
The ACC ECDP recommends that regardless of the sequencing of agents, careful initiation and titration of GDMT should be early and as rapid as possible with the goal to use the 4 key medication classes (ARNi, beta blocker, mineralocorticoid antagonist, and SGLT inhibitor) in each patient.1
The 2024 ACC ECDP for HFrEF reinforces the 2022 AHA/ACC/HFSA HF Guideline recommendation to replace well-tolerated ACEi/ARB with ARNi for NYHA Class II–III HFrEF patients. ACEi/ARB should be considered in patients with contraindications, intolerance, or inaccessibility to ARNi.1,3
Please see the 2024 ACC ECDP for full guidance on GDMT optimization.
2024 ECDP for HFrEF: Treatment Algorithm for GDMT
Colors correspond to ACC/AHA Class of Recommendation. Green = Class 1 (strong); Yellow = Class 2a (moderate); Orange = Class 2b (weak).
*ACE inhibitors/ARBs should only be considered in patients with contraindications, intolerance, or inaccessibility to ARNi.
†Carvedilol, metoprolol succinate, or bisoprolol.
Adapted from the Journal of the American College of Cardiology; 2024; Maddox TM, Januzzi JL Jr, Allen LA, et al. 2024 ACC Expert Consensus Decision Pathway for treatment of heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee; with permission from Elsevier.
