Evidence map›Paper›PMID 33704874›Full record

ReviewEuropean journal of heart failure2021

Rapid evidence-based sequencing of foundational drugs for heart failure and a reduced ejection fraction.

Milton Packer, John J V McMurray

Open access · hybridAbstract readReview
PubMed Full text at PMC Publisher
In one paragraph

Review in European journal of heart failure, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 70 papers.

0numbers the graph read from it
0cells of the map it votes in
70citing papers in PubMed
19.0field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

70 citing papers in PubMed, 154 citations in OpenAlex.

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  5. Unexpected therapeutic scenarios: initiating SGLT2 inhibitors in de novo heart failure without echocardiography.European heart journal supplements : journal of the European Society of Cardiology · 2026
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10 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

  • Commented on by
    2021
5 · Who and what money

Authors and funding

2 authors at 2 institutions in 2 countries.

Milton PackerBaylor University Medical Center, Dallas, TX, USA.
John J V McMurrayBritish Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
Baylor University Medical Center · USBritish Heart Foundation · GB

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Foundational therapy for heart failure and a reduced ejection fraction consists of a combination of an angiotensin receptor-neprilysin inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist and a sodium-glucose co-transporter 2 (SGLT2) inhibitor. However, the conventional approach to the implementation is based on a historically-driven sequence that is not strongly evidence-based, typically requires ≥6 months, and frequently leads to major gaps in treatment. We propose a rapid sequencing strategy that is based on four principles. First, since drugs act rapidly to reduce morbidity and mortality, patients should be started on all four foundational treatments within 2-4 weeks. Second, since the efficacy of each foundational therapy is independent of treatment with the other drugs, priority can be determined by considerations of relative efficacy, safety and ease-of-use. Third, low starting doses of foundational drugs have substantial therapeutic benefits, and achievement of low doses of all four classes of drugs should take precedence over up-titration to target doses. Fourth, since drugs can influence the tolerability of other foundational agents, sequencing can be based on whether agents started earlier can enhance the safety of agents started simultaneously or later in the sequence. We propose an accelerated three-step approach, which consists of the simultaneous initiation of a beta-blocker and an SGLT2 inhibitor, followed 1-2 weeks later by the initiation of sacubitril/valsartan, and 1-2 weeks later by a mineralocorticoid receptor antagonist. The latter two steps can be re-ordered or compressed depending on patient circumstances. Rapid sequencing is a novel evidence-based strategy that has the potential to dramatically improve the implementation of treatments that reduce the morbidity and mortality of patients with heart failure and a reduced ejection fraction.

Indexed as

Heart FailureVentricular Dysfunction, LeftAminobutyratesAngiotensin Receptor AntagonistsDrug CombinationsHumansNeprilysinStroke VolumeTetrazolesTreatment OutcomeAminobutyratesAngiotensin Receptor AntagonistsDrug CombinationsNeprilysinTetrazolesAngiotensin receptor-neprilysin inhibitorBeta-blockerMineralocorticoid receptor antagonistRapid sequencingSodium-glucose co-transporter 2 inhibitor

Identifiers

PMID33704874
PMCPMC8360176
OpenAlexW3135263240

What OpenQuestion holds

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LicenceCC BY-NC
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.