At what stage should ACE/ARB, BB, and ICD be introduced in heart failure patients?

The introduction of ACE inhibitors (ACEI), angiotensin receptor blockers (ARB), beta-blockers (BB), and implantable cardioverter-defibrillators (ICD) is most appropriate at Stage B of heart failure. At this stage, patients have structural heart disease but do not exhibit any current symptoms of heart failure.

Initiating these therapies at Stage B is crucial because they are aimed at preventing the progression of heart failure and reducing the risk of developing symptoms. Evidence-based guidelines support the use of these medications in patients with structural heart changes, such as left ventricular hypertrophy or prior myocardial infarction, to improve outcomes. This preventative approach is essential because it targets the underlying pathophysiology of heart failure, potentially delaying or preventing the onset of symptoms associated with more advanced stages of heart failure.

In earlier stages, such as Stage A, patients are at risk for heart failure but do not have any structural heart disease, hence these medications would not be indicated as they are not yet necessary for symptom prevention or treatment. In Stage C, patients have current symptoms of heart failure and are typically already initiated on these medications as part of their treatment regimen. Stage D is characterized by refractory heart failure requiring specialized interventions, generally indicating that the patient is beyond