Treatment algorithm Stage C and D heart failure with a reduced ejection fraction

Treatment algorithm Stage C and D heart failure with a reduced ejection fraction Heart Failure Heart Failure

«Flowchart»

HFrEF
NYHA class I-IV(Stage C) HFrEF
NYHA class I-IV(Stage C)

<Node Text>

<Go to node 3>

<Go to node 3> Node 3

<Go to node 4>

<Go to node 4> Node 4

<End Node 3>

<End Node 4>

<End Node 4> ACEI or ARB and GDMT beta
blocker; diuretics as needed ACEI or ARB and GDMT beta
blocker; diuretics as needed
Hydral-Nitrates^†‡ Hydral-Nitrates^†‡ ^†‡ Ivabradine Ivabradine ICD^‡ ICD^‡ ^‡ ‡ CRT or CRT-D^‡ CRT or CRT-D^‡ ^‡ ‡ Discontinue ACEI or
ARB; initiate ARNI^* Discontinue ACEI or
ARB; initiate ARNI^*
^* * Aldosterone
antagonist Aldosterone
antagonist

End

Refractory
NYHA class
III-IV (Stage D)

Refractory Symptoms
improved
Symptoms See text for important treatment directions. See text for important treatment directions. NYHA class II-IV, provided
est. CrCI >30 mL/min & K+
<5.0 mEq/L

NYHA class II-IV NYHA class II-III HF
Adequate BP on ACEI or ARB^*
;No C/I to ARB or sacubitril
^* *
NYHA class II-III HF NYHA class III-IV,
in black patients
NYHA class III-IV NYHA class II-III, LVEF
&#lesseq35%; (caveat: >1 year
survival, >40 days post-MI)

NYHA class II-III, LVEF NYHA class II-IV, LVEF
&#lesseq35%, NSR & QRS
&#greteq150ms with LBBB
pattern

NYHA class II-IV, LVEF NYHA class II-III, NSR,
heart rate &#greteq70 bpm on
maximally tolerated
dose beta-blocker

NYHA class II-III, NSR Hydral-Nitrates green box: The combination of ISDN/HYD with ARNI has not been robustly tested. BP response should be carefully monitored. Hydral-Nitrates green box: The combination of ISDN/HYD with ARNI has not been robustly tested. BP response should be carefully monitored. See 2013 ACC/AH heart failure guidelines. See 2013 ACC/AH heart failure guidelines. Participation in investigational studies is also appropriate for stage C, NYHA class II and III HF. Participation in investigational studies is also appropriate for stage C, NYHA class II and III HF. Palliative care^‡ ^‡ ‡ Palliative care‡ Transplant^‡ ^‡ ‡ Transplant‡ LVAD^‡ ^‡ ‡ LVAD‡ Investigational
studies ^§
^§ § Investigational studies §