Heart Failure with Reduced EF Management (ESC 2023)

Algorithm Steps

1. ▶

   Start

   HFrEF Diagnosed

   LVEF ≤40% confirmed

   • Symptoms of heart failure
   • LVEF ≤40% on imaging
   • Consider etiology workup
   1. ●

      Action

      Foundational Therapy

      The 'Fantastic Four' - Start all 4 drug classes

      • Can initiate simultaneously or sequentially
      • Rapid optimization within 4 weeks (Class I)
      • All reduce mortality
      1. ●

         Action

         1. ACEi/ARB → ARNI

         RAAS inhibition

         • ARNI (sacubitril/valsartan) preferred
         • Can start ARNI directly (no ACEi trial needed)
         • ACEi if ARNI not tolerated/available
         • 36h washout if switching from ACEi
         1. ●

            Action

            4. SGLT2 Inhibitor (Class I)

            Regardless of diabetes status - 2023 Update

            • Dapagliflozin 10mg daily
            • Empagliflozin 10mg daily
            • Evidence: DAPA-HF, EMPEROR-Reduced
            • Hold perioperatively (DKA risk)
            1. ◆

               Decision

               Reassess at 3 Months

               On optimal medical therapy?

               • LVEF still ≤35%?
               • QRS morphology?
               • Persistent symptoms?
               1. ●

                  Action

                  ICD Consideration

                  Primary prevention if LVEF ≤35%

                  • After ≥3 months OMT
                  • Life expectancy >1 year
                  • NYHA II-III symptoms
                  1. ✓

                     Outcome

                     LVEF Improved

                     Continue therapy, reassess annually

               2. ●

                  Action

                  CRT Consideration

                  If QRS ≥130ms with LBBB

                  • LBBB + QRS ≥150ms: Class I
                  • LBBB + QRS 130-149ms: Class I
                  • Non-LBBB ≥150ms: Class IIa
                  • Sinus rhythm preferred
               3. ●

                  Action

                  Additional Therapies

                  Selected patients

                  • Ivabradine: HR ≥70 despite max BB
                  • Hydralazine/nitrate: If RAAS not tolerated
                  • Digoxin: Symptom control in AF
                  • IV iron: If iron deficient
                  1. ⚠

                     Warning

                     Advanced HF Referral

                     Consider LVAD, transplant evaluation

      2. ●

         Action

         2. Beta-Blocker

         Evidence-based beta-blockers only

         • Bisoprolol
         • Carvedilol
         • Metoprolol succinate (NOT tartrate)
         • Start low, titrate to target dose
      3. ●

         Action

         3. MRA

         Mineralocorticoid receptor antagonist

         • Spironolactone 25-50mg
         • Eplerenone 25-50mg (less gynecomastia)
         • Monitor K+ and renal function
         • Avoid if K+ >5.0 or eGFR <30
         1. ●

            Action

            Loop Diuretics

            For congestion (symptom relief)

            • Furosemide, Bumetanide, Torsemide
            • Dose to euvolemia
            • No mortality benefit - symptom control only