Management of Heart Failure with Reduced Ejection Fraction

Medications to Avoid

The European Society of Cardiology recommends avoiding calcium channel blockers, specifically verapamil, diltiazem, and short-acting dihydropyridines, as they have negative inotropic effects 1, 2
Class I antiarrhythmic agents should be avoided due to their potential to worsen heart failure, as recommended by the European Society of Cardiology 1, 2
The European Society of Cardiology advises against the use of NSAIDs and COX-2 inhibitors, as they cause sodium and water retention 1, 2
Tricyclic antidepressants should be used with caution or avoided due to potential cardiac effects, according to the European Society of Cardiology 1, 2
Corticosteroids should be used with caution due to fluid retention properties, as recommended by the European Society of Cardiology 1, 2
Lithium should be used with caution, according to the European Society of Cardiology 1, 2

The American College of Cardiology guidelines categorize an ejection fraction of 44% as heart failure with mildly reduced ejection fraction (HFmrEF) 3
Patients with HFmrEF may benefit from similar medications as those with more reduced EF, according to the American College of Cardiology 4

Moderate alcohol intake (one beer or 1-2 glasses of wine/day) is generally permitted unless you have alcoholic cardiomyopathy, in which case it is prohibited, as recommended by the European Society of Cardiology 1, 5
Fluid restriction of 1.5-2 L/day is advised for patients with advanced heart failure, according to the European Society of Cardiology 1, 5
Sodium restriction is more important in advanced heart failure than in mild cases, as recommended by the European Society of Cardiology 5
Exercise is beneficial and should be encouraged, but should be tailored to avoid inducing symptoms, according to the European Society of Cardiology 1, 2
Exercise training programs are encouraged for stable patients in NYHA class II-III, as recommended by the European Society of Cardiology 1, 2

ACE inhibitors are recommended for patients with EF <40-45%, according to the European Society of Cardiology 1, 2
Beta-blockers are recommended for patients with left ventricular dysfunction, as recommended by the American Heart Association 6, 7
Regular monitoring of renal function is essential when taking ACE inhibitors, particularly when dose is increased or when other medications affecting renal function are added, according to the European Society of Cardiology 2

The American College of Cardiology defines heart failure with reduced ejection fraction (HFrEF) as a left ventricular ejection fraction (LVEF) ≤ 40 %. 8

ACE inhibitors or ARBs are recommended for all patients with HFrEF (LVEF ≤ 40 %) to improve morbidity and mortality. [8][9]
Beta‑blockers (e.g., carvedilol, metoprolol succinate, bisoprolol) are essential components of therapy for HFrEF, shown to reduce mortality and hospitalizations. 8
Mineralocorticoid receptor antagonists are advised for patients with HFrEF who have a history of myocardial infarction or who have diabetes and heart failure, to further decrease adverse outcomes. 8