Medications with proven benefit in patients with heart failure with reduced ejection fraction are recommended, according to prospective large clinical trials, in the stable patient after careful up-titration in a strict sequential order. Although the relevance of careful clinical up-titration is unproven, there is evidence that after recompensation and shortly after hospital discharge, the rate of cardiovascular death and hospitalization is high. Clinical studies provided evidence that the onset of treatment effects is rapid, occurring within 28 days with most of these drugs used, and in some trials, early treatment after discharge or already started in the hospital has provided benefits. Therefore, early treatment without deferring it to the stable outpatient may be useful to reduce cardiac-related events further. This expert opinion proposes treatment layering according to individual patient phenotypes involving heart rate, blood pressure, impaired renal function, and electrolyte disturbances, as well as dedicated subgroups of patients with specific requirements for treatment initiation. This complements other approaches that suggest starting sequential treatment according to the size of treatment effects of drugs, specific cardiac diseases, and patient wishes. Patient phenotyping may guide personalized drug layering in heart failure with reduced ejection fraction that provides the best outcomes, whereas pragmatic clinical trials are warranted to scrutinize the effectiveness of these approaches.

根据前瞻性大型临床试验，推荐在按严格顺序仔细滴定后病情稳定的患者中使用经证实对射血分数降低的心力衰竭患者有益的药物。尽管谨慎的临床递增滴定的相关性尚未得到证实，但有证据表明，在补偿后和出院后不久，心血管死亡率和住院率很高。临床研究提供的证据表明，使用大多数这些药物后，治疗效果起效迅速，在 28 天内发生，在一些试验中，出院后或已经在医院开始的早期治疗提供了益处。因此，早期治疗而不将其推迟到稳定的门诊患者可能有助于进一步减少心脏相关事件。该专家意见建议根据个体患者的表型（包括心率、血压、肾功能受损和电解质紊乱）以及对开始治疗有特定要求的特定患者亚组进行治疗分层。这补充了其他建议根据药物治疗效果的大小、特定心脏疾病和患者意愿开始序贯治疗的方法。患者表型可以指导射血分数降低的心力衰竭患者的个性化药物分层，从而提供最佳结果，而务实的临床试验需要仔细审查这些方法的有效性。以及对开始治疗有特殊要求的患者的专用亚组。这补充了其他建议根据药物治疗效果的大小、特定心脏疾病和患者意愿开始序贯治疗的方法。患者表型可以指导射血分数降低的心力衰竭患者的个性化药物分层，从而提供最佳结果，而务实的临床试验需要仔细审查这些方法的有效性。以及对开始治疗有特殊要求的患者专用亚组。这补充了其他建议根据药物治疗效果的大小、特定心脏疾病和患者意愿开始序贯治疗的方法。患者表型可以指导射血分数降低的心力衰竭患者的个性化药物分层，从而提供最佳结果，而务实的临床试验需要仔细审查这些方法的有效性。