Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Seyedmahdi Pahlavani, M.D. [3]
Abbreviations: ACE-I: Angiotensin-converting enzyme inhibitor; ARNI: Angiotensin receptor-neprilysin inhibitor; CRT-D: cardiac resynchronization therapy with defibrillator ; CRT-P: cardiac resynchronization therapy with pacemaker; ICD: Implantable cardioverter-defibrillator; HFrEF: Heart failure with reduced ejection fractio;
Management of HFrEF | |||||||||||||||||||||||||||||||||||||||||||
(Class I) | |||||||||||||||||||||||||||||||||||||||||||
LVEF ≤35% and QRS <130 ms | LVEF >35% or device
therapy not indicated or inappropriate | Sinus rhythm and LVEF ≤35% and QRS ≥130 ms | |||||||||||||||||||||||||||||||||||||||||
ICD implantation
| If symptoms persist, consider therapies (class II) | CRT-D/-P
| |||||||||||||||||||||||||||||||||||||||||
The above table adopted from 2021 ESC Guideline |
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Pathophysiology | Treatment |
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Renin-angiotensin-aldosterone system | ARNIs/ACEIs/ARBs, aldosterone antagonist |
Sympathetic nervous system | Beta-blockers |
Natriuretic and other vasodilator peptides | Neprilysin inhibitor (ARNI) |
Sodium-glucose cotransporter-2 | SGLT2 inhibitors |
Balanced vasodilation and oxidative stress modulation | Hydralazine/Isosorbide dinitrate |
Elevated heart rate | Betablocker, Ivabradine |
Guanylyl cyclase | Soluble guanylyl cyclase stimulator |
Relief of congestion | Diuretic |
Ventricul;ar arrhythmia | Implantable cardioverter defibrilator |
Ventricular dyssynchrony due to conduction abnormalities | Cardiac resynchronization therapy |
Mitral regurgitation | Surgical or percutaneous Mitral repair |
Reduced aerobic capacity | Aerobic exercise training |
The above table adopted from 2021 AHA/ACC Guideline |
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Heart failure reduced EF, stage C, treatment | |||||||||||||||||||||||||||||||||||||||||||||
ARNI, ACEI, ARB | |||||||||||||||||||||||||||||||||||||||||||||
For patients with eGFR≥ 30 mL/min/1.73m² or creatinine≤ 2.5 mg/dL in males or ≤2 mg/dL in females or K≤ 5 mEq/L, NYHA 2-4 | For patients with eGFR criteria, NYHA 2-4 | For patients with persistent volume overload, NYHA 2-4 | For symptomatic black patients despite receiving ARNI, betablocker,aldosterone antagonist, SGLT2 inhibitor, NYHA 3-4 | For patients with resting HR>70/min despite maximum tolerated betablocker dose, sinus rhythm, NYHA 2-3 | |||||||||||||||||||||||||||||||||||||||||
Add | Add | Titrate | Add | Add | |||||||||||||||||||||||||||||||||||||||||
Aldosterone antagonist | SGLT2 inhibitor | Diuretic agents | Hydralazine + Isosorbide dinitrate | Ivabradine | |||||||||||||||||||||||||||||||||||||||||
The above algorithm adopted from 2021 AHA/ACC Guideline |
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ACEI, ARB | |||||||||||||||||||
Starting in patient if ARNI is not accessible | |||||||||||||||||||
Dosage initiation based on indication | |||||||||||||||||||
Increasing dose every 2 weeks until achieving target dose or maximum tolerance and monitoring of blood pressure, renal function, potassium after initiation and during titration | |||||||||||||||||||
ARNI | |||||||||||||||||||
Initiation after 36 hours of discontinuing ACEI, if the patient is on ACEI | |||||||||||||||||||
Dosage initiation based on indication | |||||||||||||||||||
24/26 mg twice daily if the patient is taking enalapril≤ 10 mg/day or valsartan≤ 160 mg/day | 49/51 mg twice daily if the patient is taking enalapril> 10 mg/day or valsartan > 160 mg/day | ||||||||||||||||||
In 2 weeks assessment about tolerance, blood pressure, electrolytes, renal function and dosage titration to target of 97/103 mg twice daily | |||||||||||||||||||
Diuretics | |||||||||||||||||||
Initiation loop diuretic dose based on renal function, previous use of diuretics | |||||||||||||||||||
Titration dose until recovery of congestion, reducing dose in concomitant administration of ACEI, ARB, ARNI, monitoring blood pressure, renal function, electrolytes after initiation and during titration dose | |||||||||||||||||||
In high dose of loop diuterics (80 mg furosemide twice daily), Considering other type of loop diuretics or adding thiazide to loop diuretic by monitoring of blood pressure, renal function, electrolytes after initiation dose or during titration | |||||||||||||||||||
SGLT2 inhibitor | |||||||||||||||||||
Dosage initiation based on indication | |||||||||||||||||||
Initiation dapaglifelozin in eGFR≥ 30 mL/min/1.73 m², and empagliflozin in eGFR≥ 20 mL/ min/1.73 m² | |||||||||||||||||||
Betablocker | |||||||||||||||||||
Dosage initiation based on indication | |||||||||||||||||||
Dosage titration every two weeks until achieving target dose or maximum tolerance, monitoring heart rate , blood pressure after initiation and during titration | |||||||||||||||||||
Aldosterone antagonist | |||||||||||||||||||
Dosage initiation based on indication | |||||||||||||||||||
Increase dose every 2 weeks up to maximum dose or achieving tolerated dose, monitoring electrolytes and renal function at 2-3 days following initiation then 7 days after initiation or titration, then monthly for 3 months and every 3 months afterward, clinical status monitoring | |||||||||||||||||||
Hydralazine, isosorbide dinitrate | |||||||||||||||||||
Increase dose every 2 weeks until target dose or achieving tolerated dose with monitoring of blood pressure | |||||||||||||||||||
Sacubitril/Valsartan | Ivabradine | SGLT2 Inhibitors |
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Contraindications | Contraindications
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Contraindications
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Causions
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Causions
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Causions
For prevention of ketoacidosis in patients with diabetes:
erythema, or swelling in the genital or perineal area, along with fever or malaise |
The above table adopted from 2021 AHA/ACC Guideline[2] |
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Ivabradine | |||||||||||||||||||||||||
Given Betablocker by maximum tolerable dose, sinus rhythm on ECG | |||||||||||||||||||||||||
Starting dose | |||||||||||||||||||||||||
Age ≥ 75 years, 2.5 mg twice daily with food | Age <75 years, 5 mg twice daily with food | ||||||||||||||||||||||||
Evaluation of heart rate in 2-4 weeks | |||||||||||||||||||||||||
Heart rate < 50 beats /min or symptoms of bradycardia | Heart rate 50-60 beats/ min | Heart rate>60 beats /min | |||||||||||||||||||||||
Reduced dose 2.5 mg twice daily with food, or discontinued if already on 2.5 mg twice daily | Maintaing current dose with monitoring heart rate | Increased dose by 2.5 mg twice daily until maximum dose of 7.5 mg twice daily, monitoring heart rate | |||||||||||||||||||||||
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