19
Step 3:
Implement indicated GDMT.
Choices are not mutually
exclusive, and no order is
inferred
Step 4:
Reassess
symptoms
Step 5:
Consider additional
therapy
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)
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.
Refractory
NYHA class III-IV
(Stage D)
Symptoms
improved
Palliative care
‡
(COR I)
Transplant
‡
(COR I)
LVAD
‡
(COR IIa)
Investigational
studies
§
