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HFrEF — Long-Term Management

Registrar quick reference · NHFA/CSANZ · ESC 2026 · evidence-centred update
Updated Aug 2026
Verify doses locally
Four pillars · early · together
Decision support only — use with NHFA/CSANZ guidance, eTG/PBS and your cardiology service. ESC 2026 now labels HF with LVEF <50% as HFrEF; this sheet remains centred on LVEF ≤40%, where Australian pathways and the pivotal four-pillar trials are strongest. Start all four early at tolerable doses rather than maxing one first. Verify doses, renal function and potassium locally.

ESC 2026 update A broader label does not erase the trial thresholds

ESC has retired “HFmrEF” and moved the HFrEF/HFpEF boundary to 50%. Do not automatically extrapolate every ≤40% drug or ≤35% device indication into LVEF 40–49%; use the EF range and phenotype specified for each recommendation. The practical Australian core is unchanged: establish the four pillars promptly, then titrate and retain them.
1 The four pillars — ESC foundational medical therapy
RAAS inhibition I AARNI or ACEi; ARB if intolerant
Evidence: PARADIGM-HF established sacubitril/valsartan superiority to enalapril; PIONEER-HF supports in-hospital initiation after stabilisation.
ESC 2026: ACEi or ARNI are Class I A; switching ACEi/ARB → ARNI is I B. Australian consensus generally prefers ARNI when feasible. Allow 36 h after an ACEi; never use with prior ARNI/ACEi-related angioedema.
Beta-blocker I Aevidence-based agents only
Evidence: CIBIS-II, MERIT-HF and COPERNICUS demonstrated survival benefit across ambulatory and severe HFrEF.
Bisoprolol, carvedilol, metoprolol succinate or nebivolol. Start once haemodynamically stable and adequately decongested. Continue established therapy during an admission unless shock, marked hypoperfusion or another clear contraindication develops.
MRA I Aspironolactone / eplerenone
Evidence: RALES and EMPHASIS-HF reduced death and HF hospitalisation across moderate–severe and mildly symptomatic HFrEF.
Add early. Avoid if K⁺ >5.0 or eGFR <30; recheck K⁺ & creatinine after starting and after dose changes.
SGLT2i I Adapagliflozin / empagliflozin
Evidence: DAPA-HF and EMPEROR-Reduced reduced worsening HF/CV events, with benefit irrespective of diabetes.
Add to all. Minimal titration, fast benefit, mild decongestion. Sick-day rules (euglycaemic DKA).
ESC 2026 Start and up-titrate foundational therapy rapidly. After a HF admission, initiate before discharge when stable and review frequently through the first 6 weeks I B — the STRONG-HF strategy reduced 180-day HF readmission/death. Loop diuretics are not a pillar: they relieve congestion but have not shown a mortality benefit.
2 Getting foundational therapy in — and up to target

The real failure is under-titration

  • TargetsAim for the RCT target, or the highest tolerated dose. A low dose of all four is usually a better start than one maximised agent.
  • CadenceESC I C Assess and up-titrate at least every 1–2 weeks early, guided by symptoms, vitals and labs.
  • Reassess EFUsually after ~3 months of optimised therapy for ICD decisions. With LBBB QRS ≥150 ms, ESC permits CRT planning alongside FMT; recheck EF before implant.

What to hold for

  • BPSymptomatic hypotension → reduce/space doses; asymptomatic low BP is usually fine.
  • K⁺/renalHyperkalaemia or rising creatinine → review volume, interacting drugs and RAASi/MRA dose, then recheck. A K⁺ binder may preserve RAASi/MRA use, but improved HF outcomes are unproven (DIAMOND).
  • HRBradycardia limits beta-blocker — but don't stop reflexively for asymptomatic low-normal HR.

Common trial doses — start low, then aim for target or highest tolerated

  • ARNIsacubitril/valsartan 49/51 mg BD → 97/103 mg BD. Use a lower start where required by BP, renal function, previous RAAS exposure or product information.
  • ACEi / ARBramipril 1.25–2.5 mg BD → 5 mg BD · candesartan 4 mg daily → 32 mg daily.
  • Beta-blockerbisoprolol 1.25 → 10 mg daily · carvedilol 3.125 → 25 mg BD · metoprolol succinate 12.5–25 → 200 mg daily.
  • MRAspironolactone 12.5–25 → 50 mg daily · eplerenone 25 → 50 mg daily.
  • SGLT2idapagliflozin 10 mg daily or empagliflozin 10 mg daily; no HF dose titration.

ESC 2026 change Improved EF is remission, not permission to stop

Continue the highest tolerated foundational therapy even if symptoms settle or LVEF improves I C. In TRED-HF, 44% relapsed within 6 months of phased withdrawal. Gradual withdrawal is only a IIb C option in highly selected, asymptomatic patients with complete structural/biomarker normalisation after a clearly reversible cause, with close clinical, laboratory and imaging surveillance.
3 Devices & add-ons

Devices — phenotype and timing matter

  • ICDLVEF ≤35% after ≥3 months optimal FMT, NYHA II–III and meaningful survival >1 year: ischaemic I B; non-ischaemic IIa B after shared discussion (DANISH). Not within 40 days of MI.
  • CRTLVEF ≤35%, sinus rhythm, symptomatic despite FMT, LBBB QRS ≥150 ms I A. Consider concurrent planning with FMT in this phenotype IIb C; confirm EF before implant.
  • PacingHigh-grade AV block with HFrEF: prefer CRT over isolated RV pacing IIa B.

Selected add-ons

  • IV ironSymptomatic HFrEF with iron deficiency: improves symptoms/QoL I B; consider to reduce HFH IIa B. FAIR-HF, CONFIRM-HF, AFFIRM-AHF, IRONMAN/HEART-FID.
  • IvabradineSinus rhythm, resting HR >70, LVEF ≤35% despite maximal tolerated beta-blocker and other FMT IIa B (SHIFT).
  • VericiguatSelected symptomatic LVEF <45% after recent worsening despite optimal FMT IIb B (VICTORIA).
  • Hyd/nitrateSelected Black patients despite FMT (A-HeFT), or when RAAS inhibition cannot be used.

Persistent symptoms / structural disease

  • LoopFurosemide for congestion — lowest effective dose. No mortality benefit.
  • GlycosideUpgraded Persistent symptoms, LVEF ≤40% despite optimal FMT: consider a cardiac glycoside to reduce HFH IIa B. DIGIT-HF tested digitoxin, not digoxin; ESC extrapolates to either. Australian practice generally means digoxin: check renal function, K⁺, interactions and drug level/toxicity. Do not promise mortality benefit.
  • Severe SMRDespite FMT/CRT: Heart Team review for mitral TEER in a stable, suitable COAPT/RESHAPE-HF2 phenotype I B.
  • AFSelected symptomatic AF/HFrEF: consider catheter ablation; benefit is most credible where sinus rhythm is achievable (CASTLE-AF).
4 What to avoid — and the congestion trap

Drugs that worsen HFrEF

  • NSAIDsAvoid — fluid retention, renal, blunt diuretics/RAASi.
  • CCBsNon-dihydropyridine (verapamil, diltiazem) — negative inotropes, avoid. Amlodipine/felodipine are safe if a CCB is needed.
  • TZDsPioglitazone — fluid retention, worsens HF.
  • AntiarrhythmicsMost class I agents are pro-arrhythmic in HF; amiodarone is the usual safe choice.
  • ASVDo not use adaptive servo-ventilation for predominant central sleep apnoea in HFrEF (SERVE-HF) III A.

Don't confuse the two jobs

  • DiureticDecongests, relieves symptoms — does not modify disease. Down-titrate as the pillars and SGLT2i take effect.
  • PillarsModify disease, cut mortality. A dry, comfortable patient still needs all four at target.
  • EF labelNew ESC 2026 calls LVEF <50% HFrEF and ≥50% HFpEF. The drug/device evidence still follows each trial's EF and phenotype thresholds.
5 The whole patient & when to escalate

Cause, comorbidity & supports

  • AetiologyDefine ischaemic burden. Use CMR when cardiomyopathy is suspected or cause remains uncertain ESC I C; review RV pacing burden if function worsens.
  • Selected testsGenetic assessment for qualifying cardiomyopathy. Suspected amyloidosis: serum + urine immunofixation and serum free light chains, alongside DPD/PYP/HMDP scintigraphy. An abnormal monoclonal screen prevents a scan-only ATTR diagnosis.
  • Look forAF, iron deficiency, CKD, sleep-disordered breathing, diabetes, frailty and depression.
  • ProgramMultidisciplinary HF program I B, self-management education I A and personalised exercise/rehab I B.

When to escalate

  • AdvancedRefer early I A: recurrent HF admissions/inotropes, escalating diuretics, intolerable FMT, NYHA III–IV, low BP, end-organ dysfunction, EF <20%, RV failure or recurrent ICD shocks (“I NEED HELP”).
  • PalliativeRefractory symptoms despite optimal therapy → palliative care alongside, not instead of, HF care.
  • ACPAdvance care planning + device deactivation discussions before crisis.
Sources. Primary source: 2026 ESC Guidelines for the management of heart failure (Eur Heart J, 28 Aug 2026; doi:10.1093/eurheartj/ehag100). Mapped to NHFA/CSANZ 2018 and the Australian four-pillar pharmacotherapy consensus (MJA 2022), eTG/PBS, ACC/AHA/HFSA 2022 and ACC 2025 HFrEF pathway.   Seminal and update trials: PARADIGM-HF/PIONEER-HF (ARNI); CIBIS-II, MERIT-HF, COPERNICUS (beta-blockers); RALES/EMPHASIS-HF (MRA); DAPA-HF/EMPEROR-Reduced (SGLT2i); STRONG-HF (rapid optimisation); TRED-HF (withdrawal after recovery); DIG and DIGIT-HF (glycosides); DIAMOND (patiromer/RAASi enablement); SHIFT (ivabradine); VICTORIA (vericiguat); A-HeFT (hydralazine/nitrate); AFFIRM-AHF/IRONMAN/HEART-FID (IV iron); DANISH (non-ischaemic ICD); COAPT/RESHAPE-HF2 (mitral TEER); CASTLE-AF (AF ablation); SERVE-HF (ASV harm).   Caveats: ESC 2026 nomenclature and several recommendations await incorporation into Australian guidance. Apply local PBS criteria, product information and service protocols. Evidence at LVEF 40–49% is intervention-specific; do not infer an indication from the new label alone. Reassess LVEF after optimisation before most device decisions.