Heart Failure with Reduced Ejection Fraction (HFrEF) 

The following guidance applies to patients with heart failure with reduced ejection fraction (HFrEF) with a left ventricular ejection fraction (LVEF) <40%.

Drug therapy and treatment options

Sequencing of medicines should be tailored to the individual patient.
Disease modifying therapy to reduce mortality (all patients)
ACE-I/ARNI BB MRA SGLT2i
To reduce hospitalisation and alleviate symptoms (selected patients)
Diuretics
Abbreviations: ACE inhibitor (ACE-I), angiotensin receptor-neprilysin inhibitor (ARNI), beta blocker (BB), mineralocorticoid receptor antagonist (MRA), sodium-glucose co-transporter-2 inhibitor (SGLT2i).
Notes
  1. For patients with fluid overload consider a loop diuretic.
  2. Consider BB. Delay if pulmonary oedema, ascites or marked oedema.
  3. Consider ACE-I or ARNI. Angiotensin receptor blocker (ARB) can be used as an alternative to ACE-I or ARNI. ARNI can be considered in symptomatic patients hospitalised with heart failure as first line therapy, especially in non-ischaemic cardiomyopathy. See Entresto® (sacubitril/valsartan) initiation guidelines.
  4. Consider SGLT2i in both non-diabetics and in type 2 diabetics. See SGLT2i initiation guidelines.
  5. Consider MRA if ejection fraction (EF) ≤35% (or EF ≤40% and post MI) and eGFR >30ml/min and K+ <5.0mmol/L.
  6. If symptoms persist despite stable first line treatment seek specialist advice and consider second line treatment (see below).
  7. Certain medications may not be suitable for patients with hypertrophic cardiomyopathy (particularly with left ventricular outflow tract obstruction). Please contact inherited cardiac conditions team for advice.
Second line treatments (selected patients)
Ivabradine Only for patients in sinus rhythm (SR), heart rate >75bpm and EF <35% in combination with standard therapy, or where beta blockers are contraindicated or not tolerated.
Digoxin For rate control in patients with atrial fibrillation. Or for symptomatic non-ischaemic heart failure in patients in SR and EF <40%.
Hydralazine + Isosorbide Mononitrate For patients intolerant of ACE-I/ARB due to renal dysfunction and/or hyperkalaemia.
Thiazide Diuretics Bendroflumethiazide or metolazone may be useful in patients with resistance to large doses of loop diuretic. Should be initiated by cardiologist or specialist HF nurse with close supervision and monitoring.
To reduce HF hospitalisation and improve quality of life (all patients)
Exercise Rehabilitation Patients should keep as active as possible. NYHA I-II encourage regular aerobic exercise. NHYA III-IV do not avoid gentle exercise - start with small amounts.
Multi-Professional Disease Management Lifestyle advice (smoking cessation, diet, exercise, alcohol reduction, pneumococcal vaccine and annual influenza vaccine). Provide patient education and information leaflets.

Monitoring

  • Review frequently with assessment of heart rate/rhythm, blood pressure, U&Es, fluid balance and weight.
  • Goal is to establish patient on disease modifying drug therapy at target or highest tolerated doses (ACE-I/BB/MRA/SGLT2i) alongside loop diuretic.
  • Reassess by ECHO after completing titration, particularly in device candidates (review by cardiologist)
    • In patients with EF <35% with LBBB and QRS ≥130ms consider CRT
    • In patients with EF <35% and QRS <130ms consider risk/benefit of ICD therapy.
  • Focus on symptoms and quality of life for the advanced heart failure patient who does not improve with aggressive therapy where palliation is more appropriate.
Guideline reviewed October 2022
Page updated September 2023



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