What is the correct order of initiating therapies in heart failure according to the material?

What is the correct order of initiating therapies in heart failure according to the material?

• A. ACE inhibitors or ARBs first, then beta-blocker, then spironolactone
• B. Beta-blocker first, then ACE inhibitors, then spironolone
• C. Spironolactone first, then ACE inhibitors, then beta-blocker
• D. ACE inhibitors or ARBs only; no beta-blocker or spironolactone

Answer: (A)

In heart failure with reduced ejection fraction, the patient is started on disease-modifying therapies in a stepwise sequence that targets neurohormonal systems. Begin with an ACE inhibitor or an ARB to blunt the renin–angiotensin–aldosterone system, reduce afterload, improve remodeling, and lower mortality. Once the patient tolerates that therapy and blood pressure and kidney function are acceptable, add a beta-blocker carefully and titrate up. Beta-blockers counteract the harmful effects of chronic sympathetic activation and also improve survival, but they can cause initial symptoms to worsen, so they’re introduced after the ACE inhibitor/ARB is well tolerated. After stable entries on both, introduce spironolactone to inhibit aldosterone’s profibrotic effects, providing additional mortality benefits, with ongoing monitoring of renal function and potassium. Diuretics may be used for symptom relief, but they do not alter long-term outcomes, so the disease-modifying sequence remains ACE inhibitor/ARB, then beta-blocker, then spironolactone.

In heart failure with reduced ejection fraction, the patient is started on disease-modifying therapies in a stepwise sequence that targets neurohormonal systems. Begin with an ACE inhibitor or an ARB to blunt the renin–angiotensin–aldosterone system, reduce afterload, improve remodeling, and lower mortality. Once the patient tolerates that therapy and blood pressure and kidney function are acceptable, add a beta-blocker carefully and titrate up. Beta-blockers counteract the harmful effects of chronic sympathetic activation and also improve survival, but they can cause initial symptoms to worsen, so they’re introduced after the ACE inhibitor/ARB is well tolerated. After stable entries on both, introduce spironolactone to inhibit aldosterone’s profibrotic effects, providing additional mortality benefits, with ongoing monitoring of renal function and potassium. Diuretics may be used for symptom relief, but they do not alter long-term outcomes, so the disease-modifying sequence remains ACE inhibitor/ARB, then beta-blocker, then spironolactone.