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  • Writer's pictureThe Review Course in Family Medicine

A NEW Key to Your Heart (failure)

The Canadian Cardiovascular Society has teamed up with the Canadian Heart Failure Society to

provide us with updated 2021 guidelines on how to best manage heart failure with reduced ejection

fraction (HFrEF). New evidence has shown that we need to consider the addition of other pharmacological therapies to the original players.


  • Angiotensin receptor-neprilysin inhibitors (ARNI) - e.g. ACEi

  • Sinus node inhibitors - e.g. Ivabradine - approved by Health Canada if heart rate ≥ 77

  • Sodium glucose transport 2 inhibitors (SGLT2 inhibitor) - e.g. empagliflozin

  • Soluble guanylate cyclase stimulators - e.g. Vericiguat (not yet approved in Canada)


Treatment for patients with HFrEF now to include FOUR drug classes

  1. ARNI (now first line), or an ARB (sacubitril-valsartan = only ARNI in Canada)

  2. beta-blocker (e.g. carvedilol, bisoprolol, metoprolol)

  3. Mineralocorticoid receptor antagonist (spironolactone, eplerenone)

  4. SGLT2 inhibitor (dapagliflozin, canagliflozin)

These four classes of medications function uniquely and complementary to each other – a

recipe for decreased mortality and hospitalization.


Treatment initiation can be done by non-specialists. The new guidelines provide

simplified treatment algorithms suitable for most patients, including initial and optimal dosing


Guidelines stress there is no proven right way to initiate treatment and suggest that the “in parallel” approach may be preferable to the “strict sequential” approach.


Aim for target dose OR maximally tolerated dose ASAP.

CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction

Canadian Journal of Cardiology 37 (2021) 531-546; DOI:



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