Heart Failure Medications: The Four Pillars of GDMT

Treating heart failure with a reduced ejection fraction now rests on four classes of medicine that each lower mortality. Here's what they are, how they work together, and where diuretics and the older drugs fit.

How heart failure medications work

Modern heart-failure treatment for a reduced ejection fraction is built on four drug classes — the "four pillars" of guideline-directed medical therapy (GDMT) — that each independently improve survival. The goal is to block the harmful neurohormonal systems (the renin-angiotensin and sympathetic systems) that drive the disease, while easing the heart's workload.

The four pillars (HFrEF)

Diuretics — for symptoms, not survival

Loop diuretics such as furosemide relieve the congestion of heart failure — the breathlessness and swelling — by removing excess fluid. They are essential for symptom control but, unlike the four pillars, they don't by themselves improve survival. Doses are adjusted to the patient's fluid status.

Other heart-failure drugs

• Hydralazine + nitrate — added benefit, particularly in self-identified Black patients or when ARNI/ACE-I aren't tolerated.
• Ivabradine — slows the sinus rate in selected patients already on a beta-blocker.
• Digoxin — can reduce hospitalisations; a narrow therapeutic window.
• Vericiguat — an option in worsening heart failure.

What about preserved ejection fraction (HFpEF)?

For heart failure with a preserved ejection fraction, SGLT2 inhibitors are now recommended, alongside diuretics for congestion and aggressive treatment of the underlying conditions (hypertension, atrial fibrillation, obesity). The evidence base here has grown quickly.

Key takeaways

• Four pillars treat HFrEF: ARNI/ACE-I, beta-blocker, MRA, and SGLT2 inhibitor.
• Each pillar independently improves survival; start them early.
• Diuretics relieve congestion but don't improve survival on their own.
• SGLT2 inhibitors are now recommended in HFpEF too.

Educational summary of current heart-failure guidance; treatment is individualised by a clinician.

Frequently asked questions

What are the four pillars of heart failure treatment?

ARNI (or an ACE inhibitor/ARB), a beta-blocker, a mineralocorticoid receptor antagonist (MRA), and an SGLT2 inhibitor — four drug classes that each improve survival in heart failure with reduced ejection fraction.

What is the best medication for heart failure?

There's no single best drug; the four pillars are used together. Which to prioritise depends on the individual, but all four are started and titrated for reduced-ejection-fraction heart failure.

Do diuretics treat heart failure?

Diuretics relieve congestion — breathlessness and swelling — but, unlike the four pillars, they don't by themselves improve survival.

Are ACE inhibitors used for heart failure?

Yes. An ACE inhibitor (or an ARB, or the newer ARNI sacubitril-valsartan) is one of the core pillars, blocking the renin-angiotensin system.

Do SGLT2 inhibitors help heart failure without diabetes?

Yes — SGLT2 inhibitors reduce hospitalisation and death in heart failure even in people without diabetes, and are recommended in both reduced and preserved ejection fraction.