The "Four Pillars" of HFrEF Therapy
The gold standard for Heart Failure with Reduced Ejection Fraction (HFrEF) in 2026 is the simultaneous initiation of four drug classes, known as the "Four Pillars." Unlike previous years, where drugs were started one by one, 2026 guidelines recommend starting all four as soon as the patient is stable.
SGLT2 Inhibitors: Dapagliflozin and Empagliflozin are now first-line treatments used to reduce hospitalizations and protect kidney function.
ARNIs (Angiotensin Receptor-Neprilysin Inhibitors): Sacubitril/valsartan (Entresto) is now preferred over traditional ACE inhibitors for many patients.
Beta-blockers: Bisoprolol, Carvedilol, or Nebivolol remain essential for heart rate control and reducing sudden cardiac death.
MRAs (Mineralocorticoid Receptor Antagonists): Spironolactone or Eplerenone are used to prevent heart scarring (fibrosis).