AttendMe Owl Logo
AttendMe
Sign In
All Pathways
CardiologyManagement

Heart Failure with Reduced EF Management (ESC 2023)

Heart Failure with Reduced EF Management (ESC 2023): HFrEF Diagnosed → Foundational Therapy → 1. ACEi/ARB → ARNI → 4. SGLT2 Inhibitor (Class I) → Reasse...

Pathway Overview

13 steps

Algorithm Steps

13 total

  1. 01Start

    HFrEF Diagnosed

    LVEF ≤40% confirmed

    • Symptoms of heart failure
    • LVEF ≤40% on imaging
    • Consider etiology workup
  2. 02Action

    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
  3. 03Action

    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
  4. 04Action

    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)
  5. 05Decision

    Reassess at 3 Months

    On optimal medical therapy?

    • LVEF still ≤35%?
    • QRS morphology?
    • Persistent symptoms?
  6. 06Action

    ICD Consideration

    Primary prevention if LVEF ≤35%

    • After ≥3 months OMT
    • Life expectancy >1 year
    • NYHA II-III symptoms
  7. 07Outcome

    LVEF Improved

    Continue therapy, reassess annually

  8. 08Action

    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
  9. Path rejoins step 07Shared downstream outcome
  10. 09Action

    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
  11. Path rejoins step 07Shared downstream outcome
  12. 10Warning

    Advanced HF Referral

    Consider LVAD, transplant evaluation

  13. 11Action

    2. Beta-Blocker

    Evidence-based beta-blockers only

    • Bisoprolol
    • Carvedilol
    • Metoprolol succinate (NOT tartrate)
    • Start low, titrate to target dose
  14. Path rejoins step 04Shared downstream outcome
  15. 12Action

    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
  16. Path rejoins step 04Shared downstream outcome
  17. 13Action

    Loop Diuretics

    For congestion (symptom relief)

    • Furosemide, Bumetanide, Torsemide
    • Dose to euvolemia
    • No mortality benefit - symptom control only
  18. Path rejoins step 05Shared downstream outcome

Guideline Source

2021 ESC Guidelines for HF + 2023 Focused Update

DOI: 10.1093/eurheartj/ehab368View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Drug dosing not included - titrate per guidelines
  • Does not address acute decompensated HF
  • ICD/CRT criteria simplified - consult EP for device decisions
  • Assumes stable HFrEF without active congestion

Contraindicated Populations

pediatricpregnancy

Applicable Regions

EUUS

EU: ESC 2023 - SGLT2i Class I regardless of diabetes

US: ACC/AHA 2022 similar - SGLT2i as foundational therapy

Version 1Next review: 2027-08-01

Related Cardiology Pathways

ACLS Bradycardia Algorithm (AHA 2025)

Emergency

ACLS Tachycardia with Pulse Algorithm (AHA 2025)

Emergency

AFib Anticoagulation Decision (ESC 2024)

Management

Aortic Stenosis Management (ESC/EACTS 2025)

Management

Next steps

Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.

Calculator

CHA₂DS₂-VASc Score

Stroke risk stratification in atrial fibrillation

Open page

Compare

AttendMe.ai vs UpToDate

See how this pathway workflow compares against UpToDate.

Open page

Commercial

Start free

Run the pathway in a live AttendMe account with citations and tracked usage.

Start free

Related Resources

All Clinical PathwaysClinical CalculatorsAI Chat with Auto-Detection

Frequently Asked Questions

What is the Heart Failure with Reduced EF Management (ESC 2023)?

The Heart Failure with Reduced EF Management (ESC 2023) is a management clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2021 ESC Guidelines for HF + 2023 Focused Update.

What guideline is the Heart Failure with Reduced EF Management (ESC 2023) based on?

This algorithm is based on 2021 ESC Guidelines for HF + 2023 Focused Update (DOI: 10.1093/eurheartj/ehab368).

What are the limitations of the Heart Failure with Reduced EF Management (ESC 2023)?

Known limitations include: Drug dosing not included - titrate per guidelines; Does not address acute decompensated HF; ICD/CRT criteria simplified - consult EP for device decisions; Assumes stable HFrEF without active congestion. Individual patient factors may require deviation from these recommendations.

Get AI-Powered Analysis Alongside This Algorithm

In AttendMe.ai, the Heart Failure with Reduced EF Management (ESC 2023) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.

Try AttendMe Free