In patients who are on 3 of the 4 pillars of HF therapy for HFrEF, would you add the 4th pillar if they are no longer in symptomatic HF and LVEF normalizes?

This is a great question, and a data-free zone. The way I see it, the LV recovered with 3 pillars, and assuming the EF is normal and patient asymptomatic, I'm not sure what benefit is derived from the fourth pillar. I would not add it as there is no data that in patients with HFimpEF already on 3 pillars that addition of the 4th confers benefit.

Adding a fourth agent offers no proven advantage, and will increase the chance of side effects and drug interactions.

It can always be added later if symptoms develop, or EF falls.

This is a very good question without much data. Certainly, those patients on 4 agents who improved or recovered should be continued based on the TRED-HF trial. Now, I can see the potential lack of benefit in asymptomatic patients (NYHA I) whose LVEF has normalized. In a non-ischemic patient, I probably would not add the 4th agent. In a patient with recovered EF but a known chronic disease such as ischemic cardiomyopathy, I may consider it and would have a low threshold to start if questions abou...

This is an excellent question. I would prefer to have more information.

• NTproBNP
• LV volumes and LVEDD
• Diastolic dysfunction
• Strain imaging details
• If possible, CPET information

Normal LVEF does not necessarily translate into myocardial recovery. Cardiac reverse remodeling is a complex process (whether it is assisted by pharmacologic agents or mechanical circulatory support). Myocardial Recovery and Myocardial Remission are different.

While I agree with what was written already, my take on this matter is that the situation should not occur in current times.

In our practice, we strive to start all 4 pillars within 2-4 weeks and have ARNI/BB doses maximized by week 6 in order to get the full effect and benefit of hospitalization as well as mortality and symptoms.

If the proBNP is elevated, I will certainly add the 4th pillar. I may even consider adding vericiguat if it remains elevated in the presence of all four pillars.