Classification and Management of Heart Failure with Reduced Ejection Fraction (LVEF 35‑40%)

Definition and Classification

• An LVEF of 35‑40 % meets the definition of heart failure with reduced ejection fraction (HFrEF), which is classified as LVEF < 40 % in major international guidelines. 1, 2, 3, 4
• The 2022 AHA/ACC/HFSA guideline defines HFrEF as LVEF ≤ 40 %; LVEF 41‑49 % as HFmrEF, and LVEF ≥ 50 % as HFpEF. 3, 4

Chronic vs. Acute Presentation

• “Chronic” heart failure refers to a disease course lasting weeks to months rather than an acute decompensation, independent of severity. 1, 5
• Chronic HFrEF requires optimization of guideline‑directed medical therapy (GDMT) with neurohormonal antagonists. 6, 3
• Acute decompensated heart failure requires immediate hemodynamic stabilization before long‑term GDMT optimization. 2

Guideline‑Directed Medical Therapy (Class I Recommendation)

• ACE inhibitor, ARB, or preferably ARNI for all patients with HFrEF (LVEF ≤ 40 %) unless contraindicated. 6, 3, 4
• Beta‑blockers (bisoprolol, metoprolol succinate, carvedilol, or nebivolol) for all HFrEF patients. 6, 7, 3
• Mineralocorticoid receptor antagonists for patients with NYHA class II‑IV symptoms. 6, 3
• SGLT2 inhibitors (dapagliflozin or empagliflozin) as an additional Class I therapy for HFrEF. 3

Device Therapy Considerations (Class I Recommendation)

Patients with an LVEF at the upper end of the range (≈ 40 %) do *not* meet current device criteria, whereas those at the lower end (≈ 35 %) do. 7, 8

Clinical Pitfalls to Avoid

• Do not delay therapy in asymptomatic left‑ventricular systolic dysfunction (Stage B HF); ACE inhibitor and beta‑blocker therapy are indicated early. 6, 3
• Avoid the term “diastolic heart failure” for patients with reduced LVEF, as it creates confusion; most systolic HF patients also have diastolic abnormalities. 1, 5
• Do not discontinue GDMT when LVEF improves (HFimpEF); continuation prevents relapse and recurrent dysfunction. 3, 4