9 8
NYHA class II–IV, provided est.
CrCl >30 mL/min & K+ <5.0 mEq/L
ACEI or ARB AND
GDMT beta
blocker; diuretics
as needed
(COR I)
HFrEF
NYHA class I–IV
(Stage C)
Step 1:
Establish Dx of HFrEF;
assess volume;
initiate GDMT
Step 2:
Consider the following patient
scenarios
Step 3:
Implement indicated GDMT.
Choices are not mutually
exclusive, and no order is
inferred
Step 4:
Reassess
symptoms
Step 5:
Consider additional
therapy
NYHA class II–III HF
Adequate BP on ACEI or ARB
*
;
No C/I to ARB or sacubitril
NYHA class III–IV,
in black patients
NYHA class II–III, LVEF ≤35%;
(caveat: >1 y survival, >40 d post MI)
NYHA class II–IV, LVEF ≤35%,
NSR & QRS ≥150 ms with
LBBB pattern
NYHA class II–III, NSR,
heart rate ≥70 bpm on maximally
tolerated dose beta blocker
Aldosterone antagonist
(COR I)
Discontinue ACEI or
ARB; initiate ARNI
*
(COR I)
Hydral-Nitrates
†,‡
(COR I)
ICD
‡
(COR I)
CRT or CRT-D
‡
(COR I)
Ivabradine
(COR IIa)
Treatment
Colors correspond to COR/LOE Table. For all medical therapies, dosing should be optimized and
serial assessment exercised.
*
See text for important treatment directions.
†
Hydral-Nitrates green box: e combination of ISDN/HYD with ARNI has not been robustly
tested. BP response should be carefully monitored.
‡
See 2013 HF guideline.
§
Participation in investigational studies is also appropriate for stage C, NYHA class II and III HF.
ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor-blocker; ARNI,
angiotensin receptor-neprilysin inhibitor; BP, blood pressure; bpm, beats per minute; C/I,
contraindication; COR, Class of Recommendation; CrCl, creatinine clearance; CRT-D, cardiac
resynchronization therapy–device; Dx, diagnosis; GDMT, guideline-directed management and
therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable
cardioverter-defibrillator; ISDN/HYD, isosorbide dinitrate hydral-nitrates; K+, potassium; LBBB,
le bundle-branch block; LVAD, le ventricular assist device; LVEF, le ventricular ejection fraction;
MI, myocardial infarction; NSR, normal sinus rhythm; NYHA, New York Heart Association.
Continue GDMT with serial reassessment & optimized dosing/adherence
Refractory
NYHA class III-IV
(Stage D)
Symptoms
improved
Palliative care
‡
(COR I)
Transplant
‡
(COR I)
LVAD
‡
(COR IIa)
Investigational
studies
§
Figure 2. Treatment of HFr EF Stage C and D (2017)
