What is the most appropriate drug to initiate in an asymptomatic patient newly diagnosed with HFrEF?

In an asymptomatic patient newly diagnosed with Heart Failure with Reduced Ejection Fraction (HFrEF), initiating treatment with an ACE inhibitor, such as lisinopril, is the most appropriate choice. ACE inhibitors have been shown to reduce morbidity and mortality in patients with HFrEF by decreasing afterload and preload, leading to improved cardiac output and symptoms over time. They help in remodeling the heart, protecting renal function, and controlling blood pressure, which can be particularly beneficial in a patient who has just received a diagnosis and is not currently experiencing symptoms.

Other agents typically used in managing HFrEF have different roles and indications. Dobutamine is primarily used as a short-term treatment for patients in acute heart failure or those who are decompensated, not as a first-line therapy for asymptomatic patients. Furosemide, a diuretic, is important for managing fluid overload but is indicated for symptomatic relief rather than initiation in asymptomatic patients. Sacubitril/valsartan, while effective in reducing morbidity and mortality, is generally used in patients who may not tolerate ACE inhibitors or have advanced heart failure, thus not suitable for someone who is asymptomatic at diagnosis.

Thus, starting with lisinopril aligns well with established