Traitement de l'insuffisance cardiaque avec fraction d'éjection réduite
L'insuffisance cardiaque avec fraction d'éjection réduite (ICFEr) est prise en charge par une approche pharmacologique structurée et fondée sur les preuves, visant à réduire la morbidité, les hospitalisations et la mortalité cardiovasculaire.
Approche thérapeutique
Les recommandations actuelles préconisent d'initier une thérapie médicale guidée par les recommandations en prescrivant simultanément plusieurs classes médicamenteuses à faibles doses — l'inhibition du système rénine-angiotensine en étant l'un des piliers fondamentaux — avec titration vers les doses cibles selon la tolérance. Les critères de sélection des classes, l'algorithme décisionnel et les objectifs de titration sont détaillés dans le protocole complet.
Objectif clinique
Élimination des signes cliniques de rétention hydrique et maintien de l'euvolémie.
References
DOI: 10.1161/CIR.0000000000001063
- Inhibition of the renin-angiotensin system is recommended to reduce morbidity and mortality for patients with HFrEF, and ARNi, ACEi, or ARB are recommended as first-line therapy.
- In patients with HFrEF and NYHA class II to III symptoms, the use of ARNi is recommended to reduce morbidity and mortality.
- In patients with previous or current symptoms of chronic HFrEF, the use of ACEi is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible.
- In patients with previous or current symptoms of chronic HFrEF who are intolerant to ACEi because of cough or angioedema and when the use of ARNi is not feasible, the use of ARB is recommended to reduce morbidity and mortality.
- In patients with HFrEF, with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality (eg, bisoprolol, carvedilol, sustained-release metoprolol succinate) is recommended to reduce mortality and hospitalizations.
- In patients with HFrEF and NYHA class II to IV symptoms, an MRA (spironolactone or eplerenone) is recommended to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m² and serum potassium is <5.0 mEq/L.
- In patients with symptomatic chronic HFrEF, SGLT2i are recommended to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes.
- In patients with HF who have fluid retention, diuretics are recommended to relieve congestion, improve symptoms, and prevent worsening HF.
- The treatment goal of diuretic use is to eliminate clinical evidence of fluid retention, using the lowest dose possible to maintain euvolemia.
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