Latest AHA/ACC approach to HFrEF

The 4 foundational HFrEF medicines

Important practical points

• If changing from an ACE inhibitor to sacubitril-valsartan, allow a 36-hour washout to reduce angioedema risk.
• Monitor blood pressure, creatinine/eGFR, potassium, volume status, heart rate, and symptoms after starting or increasing medication.
• Continue HFrEF therapy even if EF improves above 40%: stopping treatment carries a meaningful relapse risk.
• Address causes and comorbidities: ischemic heart disease, hypertension, valvular disease, atrial fibrillation, diabetes, chronic kidney disease, iron deficiency, sleep apnea, alcohol/toxin exposure, and cardiomyopathy causes.

If symptoms persist despite the four pillars

• Ivabradine: sinus rhythm, LVEF 35% or less, resting HR at least 70/min despite maximally tolerated beta-blocker.
• Hydralazine plus isosorbide dinitrate: especially for self-identified Black patients with persistent NYHA III-IV symptoms on optimal therapy, or when ARNI/ACEi/ARB cannot be used.
• Vericiguat: selected high-risk patients with recent worsening HFrEF despite guideline-directed treatment.
• Digoxin: may reduce HF hospitalizations in selected patients, but requires careful use.
• Assess for ICD and CRT after adequate optimized therapy when EF remains low. CRT is particularly relevant with LBBB and a wide QRS complex.

Hospitalized or acute decompensated HFrEF

1. Assess severity and precipitating factors, such as acute coronary syndrome, arrhythmia, infection, nonadherence, renal failure, anemia, pulmonary embolism, or uncontrolled hypertension.
2. Treat congestion with IV loop diuretics.
3. Use vasodilators only when appropriate blood pressure/perfusion permits.
4. Avoid starting or up-titrating beta-blocker during shock or marked congestion.
5. Before discharge, aim to establish as much of the four-pillar therapy as tolerated, with early follow-up for dose titration. The 2024 pathway specifically stresses in-hospital initiation where possible.