Triple neurohormonal blockade in de novo heart failure with reduced ejection fraction during index hospitalization

Introduction and objectives In de novo heart failure with reduced ejection fraction (HFrEF) current guidelines support, an initial double combination therapy with angiotensin converting enzyme inhibitors/angiotensin-receptor blockers and betablockers, only adding minerocorticoid receptor antagonists if after treatment optimization left ventricular ejection fraction (LVEF) is still under 40%. An initial triple combination therapy could be an attractive initial approach in the stability phase after an acute HF episode in debut HFrEF; which is what we describe in this report and analyze the factors related to the treatment with triple neurohormonal blockade (TNHB). Methods Retrospective study of patients discharged from our centre between January 2009 and January 2016 with de novo HFrEF after an acute HF episode with these criteria: 15–85 year-old, creatinine ≤2.5mg/dL, potassium <5.5mEq/L and no organic severe valvular disease. Results A total of 280 patients fulfilled the criteria, 58% of them were discharged on TNHB. Mean age was 65.4±12.5 years, LVEF 29.8±7.3% and median NT-ProBNP 2917pg/mL. After a mean follow-up of 43.4±26.6 months, 72 patients died (25.7%), with a mean survival of 76 months. Patients treated with TNHB had a better risk profile (they were younger, better creatinine and lower pulmonary pressures) but poorer LVEF (28.7±7.4% vs. 31.4±6.7%; P=.002). Mean survival on TNHB was better (months, 82.1±3.0 vs. 68.6±3.8; P=.007). Multivariate analysis showed that TNHB was an independent predictor of better survival (HR, 1.79; 1.05–3.05; P=.03). Conclusions TNHB is commonly used in debut HFrEF, especially in younger patients with worse LVEF. In our cohort TNHB was an independent factor related to better survival.