heart failure with reduced ejection fraction (HFrEF)

see also:

• cardiology
• cor pulmonale
• acute pulmonary oedema (APO)
• Mx of the wheezy elderly patient - acute pulmonary oedema versus asthma
• AFTB lectures - APO
• heart failure with preserved EF (HFpEF)
• congestive cardiac failure
• NB. age > 65 with primary Dx of CCF are admitted to cardio-geriatric unit at Western Hospital if present to Western Health

• the following applies to patients with LVEF < 41%
  • NB. “mildly reduced LVEF” (HFmrEF) are those with LVEV of 41-49%
  • NB. those with heart failure but normal LVEF > 49% are classified as heart failure with preserved EF (HFpEF)
• SGLT2 inhibitors and MRAs can prevent or delay the development of heart failure in patients with diabetic kidney disease
• in all patients with established HFrEF, there is now strong evidence to support combining either an ARNI or ACE inhibitor with a beta blocker, MRA and SGLT2 inhibitor
• diuretics are used to reduce congestion - avoid beta blockers if congested
• patients should be referred to a multidisciplinary heart failure service and undergo exercise training

• see:
  • Guideline Directed Medical Therapy (GDMT)
  • 2022: MJA Consensus statement on the current pharmacological prevention and management of heart failure (pdf)
    • use of sodium– glucose cotransporter 2 (SGLT2) inhibitors to prevent hospitalisation for heart failure in type 2 diabetes mellitus can be extended to patients with multiple cardiovascular risk factors, albuminuric chronic kidney disease, or atherosclerotic cardiovascular disease.
      • a SGLT2 inhibitor (empagliflozin) should be considered in patients with heart failure with preserved LVEF (≥ 50%) (HFpEF).
    • new evidence supports the use of a mineralocorticoid receptor antagonist (finerenone) to prevent heart failure in type 2 diabetes mellitus associated with albuminuric chronic kidney disease.
    • in addition to renin-angiotensin system inhibitors (RAS) (angiotensin receptor–neprilysin inhibitors (ARNIs) preferred), beta blockers and mineralocorticoid receptor antagonists, an SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in all patients with heart failure with reduced left ventricular ejection fraction (LVEF ≤ 40%) (HFrEF). Lower quality evidence supports these therapies in patients with heart failure with mildly reduced LVEF (41-49%) (HFmrEF).
    • a soluble guanylate cyclase stimulator (vericiguat), selective cardiac myosin activator (omecamtiv mecarbil) and, if iron deficient, intravenous iron (ferric carboxymaltose) provide additional benefits in persistent HFrEF.
    • if euvolaemic
      • start with angiotensin receptor–neprilysin inhibitors (ARNIs) plus beta adrenergic blockers then if needed add mineralocorticoid receptor antagonists and SGLT2 inhibitor
    • if congested
      • start with angiotensin receptor–neprilysin inhibitors (ARNIs) plus SGLT2 inhibitor then if needed add mineralocorticoid receptor antagonists and once euvolemic, consider adding beta adrenergic blockers
    • if ferritin < 100 or ferritin 100-299 and transferrin saturation < 20% then consider iron infusion (ferric carboxymaltose)
    • after 3 months if LVEF < 35%:
      • consider implantable cardioverter defibrillator &/or cardiac resynchronisation therapy (CRT)
      • if SR > 70bpm, add hyperpolarization-activated cyclic nucleotide-gated (HCN) channel blockers
    • if unable to use renin-angiotensin system inhibitors (RAS), then consider nitrates plus hydralazine
    • if refractory symptoms, consider nitrates +/- hydralazine +/- digoxin
    • if recent hospitalisation and high risk readmission, consider a soluble guanylate cyclase stimulator eg. vericiguat
    • if LVEF still < 35%, consider a selective cardiac myosin activator eg. omecamtiv mecarbil
  • ScienceOpen Dec 2023: Heart Failure Guideline Directed Medical Therapy: Which One and When?
  • 2025: Consensus Statement on Optimisation of Patient Management Following Hospitalisation for Acute Heart Failure—Cautions and Caveats
• hyperkalaemia considerations¹⁾
  • K+ above 6mmol/L
    • temporarily withhold renin-angiotensin system inhibitors (RAS), MRAs and cautiously re-start when K below 5.5mmol/L
  • K+ between 5.5-6mmol/L
    • reduce dose of renin-angiotensin system inhibitors (RAS), MRAs
  • K+ 5.0-5.5mmol/L
    • cautiously uptitrate renin-angiotensin system inhibitors (RAS), MRAs if systolic BP < 95mmHg or eGFR < 20
  • consider potassium binders (patiromer and sodium zirconium cyclosilicate) if recurrent hyperkalaemia
• renal impairment considerations²⁾
  • if eGFR < 20 then consider reducing dose of diuretic if there is little evidence of congestion
  • when titrating, an increase in CRN of 25-30% from start of titration should be tolerated
  • if CRN rises more than 25-30% then down-titrate or discontinue renin-angiotensin system inhibitors (RAS), MRAs, treat causes of AKI such as sepsis, dehydration, anaemia, blood loss, etc then re-challenge with renin-angiotensin system inhibitors (RAS), MRAs
• beta blockers
  • cautiously uptitrate if HR < 55 &/or systolic BP < 95mmHg