Management of Heart Failure with Reduced Ejection Fraction

Classification and Diagnosis

• The European Society of Cardiology defines HFrEF as a clinical heart failure syndrome with left ventricular ejection fraction (LVEF) ≤40% 4, 5
• Diagnosis of HFrEF requires typical symptoms, signs, and evidence of structural/functional cardiac abnormality resulting in reduced cardiac output 4, 5

Core Pharmacological Therapy for HFrEF

• The European Journal of Heart Failure recommends a comprehensive quadruple therapy approach with ACEI/ARB/ARNI, beta-blockers, MRAs, and SGLT2 inhibitors as core treatments for all eligible patients with HFrEF to reduce mortality and hospitalizations 1, 2, 3
• Renin-Angiotensin System Inhibitors, such as ACEI/ARB or preferably ARNI, are recommended for patients with HFrEF 2, 6
• Evidence-based Beta-blockers, such as Carvedilol, metoprolol succinate, or bisoprolol, are recommended for patients with HFrEF 2, 6
• Mineralocorticoid Receptor Antagonists (MRAs), such as Spironolactone or eplerenone, are recommended for patients with HFrEF 2, 6
• SGLT2 Inhibitors, such as Dapagliflozin or empagliflozin, are recommended regardless of diabetes status for patients with HFrEF 2, 3

Implementation Strategy

• The European Journal of Heart Failure recommends a simultaneous initiation approach, starting core medications together rather than sequential step-by-step approach 2, 3
• Dose adjustments should be made based on blood pressure, heart rate, congestion, kidney function, and presence of atrial fibrillation 2, 3

Management of Low Blood Pressure

• Asymptomatic low BP should not be a barrier to GDMT initiation or maintenance 8
• For symptomatic low BP, address reversible non-HF causes of hypotension, consider temporary discontinuation of non-HF medications that lower BP, and re-optimize GDMT with careful dose adjustments 8

Device Therapies When Appropriate

• Cardiac Resynchronization Therapy (CRT) is recommended for patients with prolonged QRS duration 4, 6
• Transcatheter Mitral Valve Repair is recommended for selected patients with significant secondary mitral regurgitation 6

Special Considerations for HF with Mildly Reduced EF

• SGLT2 inhibitors are beneficial in decreasing HF hospitalizations and cardiovascular mortality for patients with HFmrEF (LVEF 41-49%) 6
• Evidence-based beta-blockers, ARNI, ACEI/ARB, and MRAs should be considered, particularly for patients with LVEF on the lower end of this spectrum 6