HFrEF therapy reference (2026)
Reference snapshot of HFrEF therapy across the four-pillar standard, additional approved options, and emerging mechanism classes.
HFrEF therapy in 2026 organises around four-pillar foundational therapy plus add-on options.
Four-pillar standard: angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) or ACE inhibitor or ARB; evidence-based beta-blocker (carvedilol, metoprolol succinate, bisoprolol); mineralocorticoid receptor antagonist (spironolactone or eplerenone); SGLT2 inhibitor (dapagliflozin or empagliflozin). Modern guidelines favour starting all four foundational classes early at low dose with up-titration.
Add-on therapy: vericiguat (sGC stimulator) for high-risk patients despite optimised foundational therapy. Hydralazine plus isosorbide dinitrate in selected populations including African American patients. Ivabradine for sinus rhythm with elevated heart rate despite beta-blocker. Digoxin in selected patients for symptom control or rate control.
Device therapy: implantable cardioverter-defibrillator and cardiac resynchronisation therapy in eligible patients per guidelines. Mitral transcatheter edge-to-edge repair (MitraClip) for selected secondary mitral regurgitation. Cardiac contractility modulation (Optimizer) in selected populations.
Emerging tier: cardiac myosin activators (mavacamten and aficamten, primarily for hypertrophic cardiomyopathy but with evolving roles), gene therapy for inherited cardiomyopathy, additional mechanism-targeted programs in late-stage trials.
The genetic-testing pathway is increasingly relevant. Inherited dilated cardiomyopathy (titin, lamin, MYH7, others), inherited hypertrophic cardiomyopathy (MYBPC3, MYH7, others), and inherited arrhythmogenic cardiomyopathy define a growing fraction of HFrEF and HFpEF practice that has historically gone untyped.
Continue reading
Full intelligence on PanaceaIntel
PatientSpotlight publishes the headline framing. The full brief, the editorial takeaway, and the source list sit on PanaceaIntel for entitled clients.
New to PanaceaIntel? Request access and the team will reply within one working day.