Heart failure with reduced ejection fraction (GDMT)

ACC/AHA/HFSA2022

HFrEF (LVEF <=40%): start all four pillars. ARNI (sacubitril-valsartan) preferred over ACEi/ARB, Class 1 (LOE A); use ACEi (Class 1, LOE A) or ARB (Class 1, LOE A) if ARNI not feasible. Beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), Class 1, LOE A. MRA (spironolactone or eplerenone) if eGFR >30 and K+ <5.0, Class 1, LOE A. SGLT2i (dapagliflozin or empagliflozin) regardless of diabetes, Class 1, LOE A. Titrate to target or max tolerated doses.

ACC/AHA/HFSA2022Grade Class 1

Asymptomatic LVEF ≤40% (stage B, pre-HF): start an ACEi (LOE A) and an evidence-based beta-blocker (C-LD) to prevent symptomatic HF; ARB after a recent MI if ACEi-intolerant. ICD for primary prevention if at least 40 days post-MI with LVEF ≤30% and NYHA I on GDMT, with survival expected beyond 1 year (B-R). HF with improved EF (prior LVEF ≤40%, now >40%): continue GDMT even if asymptomatic, to prevent relapse (B-R).

ACC/AHA/HFSA2022Grade Class 1 / 3: Harm

Beyond the four pillars: add hydralazine plus isosorbide dinitrate for patients who self-identify as African American with NYHA III to IV symptoms on optimal GDMT (Class 1). Refer for cardiac resynchronization when LVEF ≤35% with sinus rhythm, LBBB, QRS ≥150 ms, and NYHA II to ambulatory IV symptoms on GDMT (Class 1). Avoid thiazolidinediones and nondihydropyridine calcium channel blockers when LVEF is reduced, under 50% (Class 3: Harm).