Heart Failure Treatment Guidelines

HFrEF Treatment

The American College of Cardiology recommends ACE inhibitors or ARBs as Class I for HFrEF patients, providing high economic value with proven mortality reduction 1, 4
The American College of Cardiology suggests ARNi (sacubitril/valsartan) as preferred over ACEi/ARB, providing superior mortality benefit for HFrEF patients 1, 2, 4
Beta-blockers are recommended for HFrEF patients, with proven mortality reduction 1, 2, 4
Mineralocorticoid receptor antagonists (MRAs) are recommended for HFrEF patients with NYHA class II-IV symptoms 1, 2, 4
SGLT2 inhibitors reduce cardiovascular death and HF hospitalizations in HFrEF patients 1, 2
Hydralazine plus isosorbide dinitrate is specifically recommended for self-identified African American HFrEF patients with NYHA class III-IV on optimal therapy 2, 4
Implantable cardioverter-defibrillators (ICDs) are recommended for primary prevention in HFrEF patients with LVEF ≤35% 2, 4
Cardiac resynchronization therapy (CRT) is recommended for HFrEF patients with LVEF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms, NYHA class II-IV 2, 4

The American College of Cardiology recommends SGLT2 inhibitors as Class 2a for HFpEF patients, reducing HF hospitalizations and cardiovascular death composite endpoint 1, 2
Diuretics are recommended as needed for congestion management and symptom relief in HFpEF patients 1, 2, 5
ARNi (sacubitril/valsartan) may reduce hospitalizations in HFpEF patients, particularly those with LVEF closer to 50% 2
MRAs may have greater benefit in HFpEF patients with LVEF closer to 50% 2
ARBs may decrease hospitalizations in HFpEF patients, particularly those with lower-end LVEF in the preserved range 2

The American College of Cardiology recommends elevated natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL ambulatory) as diagnostic evidence for HFpEF 1, 5
Evidence of increased LV filling pressures (E/e' ≥15, invasive hemodynamics) is recommended as diagnostic evidence for HFpEF 1, 3
Structural heart disease (increased LA volume index, increased LV mass index) is recommended as diagnostic evidence for HFpEF 1, 3
The H2FPEF score may aid in diagnosing HFpEF, considering factors such as obesity, AF, age >60, ≥2 antihypertensives, E/e' >9, PA systolic pressure >35 mmHg 1

Transthoracic echocardiography is usually appropriate for EF classification in both HFrEF and HFpEF patients 1, 6
Coronary CTA, stress testing, or cardiac MRI is recommended to distinguish ischemic vs non-ischemic etiology and guide revascularization decisions in HFrEF patients 6
Exercise stress echocardiography with diastolic parameter assessment is recommended if HFpEF diagnosis is uncertain 1

Patients with HFrEF who improve LVEF to >40% are classified as HFimpEF and must continue HFrEF GDMT to prevent relapse, even if asymptomatic, according to the American College of Cardiology - Class I recommendation 1, 2, 4
The American College of Cardiology recommends recognizing HFmrEF (LVEF 41-49%) as a distinct intermediate category, often representing dynamic trajectory between HFrEF and HFpEF 1, 3, 7