Neurohormonal Blockade

Blockade of the neurohormonal system has been the focus of intense research in the treatment of chronic heart failure (HF) due to the deleterious effects of the activated system on myocardial function, disease progression, and mortality. Deleterious effects of the activated renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS) with counteractive beneficial effects of natriuretic peptide signaling have been targets of therapeutic interventions. Current evidence supports the use of angiotensin converting enzyme (ACE) inhibitors, β-blockers, and aldosterone antagonists in HF patients with a reduced ejection fraction (HFrEF). The angiotensin receptor blocker-neprilysin inhibitors (ARNIs) have recently shown even further benefit with reduction of mortality and morbidity in this group of patients, with possible promise in patients with HF with preserved ejection fraction (HFpEF). However, evidence does not support the routine use of ACE inhibitors and β-blockers to reduce mortality or morbidity in patients with HFpEF. There may be a limited role of aldosterone antagonists in selected patients with HFpEF.