What is considered first-line therapy for heart failure with reduced ejection fraction?

• A. ACE inhibitors or ARBs
• B. Calcium channel blockers
• C. Diuretics only
• D. Beta blockers

Answer: (A)

In heart failure with reduced ejection fraction, the first priority is to block maladaptive neurohormonal activation that drives progression and remodeling. The medication class that best accomplishes this early on is ACE inhibitors or ARBs. They lower afterload, reduce the harmful effects of angiotensin II, improve symptoms over time, and, importantly, reduce mortality and hospitalizations. If a patient cannot tolerate an ACE inhibitor (for example, due to cough or angioedema), an ARB is used instead, preserving the same survival benefits.

Diuretics help with symptoms by relieving volume overload, but they don’t improve survival, so they’re not considered the first-line choice for long-term outcomes. Beta blockers also provide mortality benefits, but they’re typically started after the patient is stabilized and are added to the core regimen rather than used alone as the initial step. Calcium channel blockers, particularly the non-dihydropyridine type, can depress cardiac function and the dihydropyridine type does not improve outcomes in HFrEF, so they aren’t first-line.

So the best initial therapy to improve survival and outcomes in HFrEF is ACE inhibitors or ARBs.