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)

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ACEI or ARB and GDMT beta
blocker; diuretics as needed

Hydral-Nitrates^†‡

^†‡

Ivabradine

ICD^‡

^‡ ‡

CRT or CRT-D^‡

^‡ ‡

Discontinue ACEI or
ARB; initiate ARNI^*

^* *

Aldosterone
antagonist

End

Refractory
NYHA class
III-IV (Stage D)

Refractory

Symptoms
improved

Symptoms

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
≤ 35%; (caveat: >1 year
survival, >40 days post-MI)

≤
NYHA class II-III, LVEF

NYHA class II-IV, LVEF
≤ 35%, NSR & QRS
≥ 150ms with LBBB
pattern

≤
≥
NYHA class II-IV, LVEF

NYHA class II-III, NSR,
heart rate ≥ 70 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.

See 2013 ACC/AH heart failure guidelines.

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 §