Patient handout

Heart failure with mildly reduced EF (HFmrEF, LVEF 41–49)

PRODUCTION

1. Your condition

This handout is for heart failure with mildly reduced ef (hfmref, lvef 41–49). Your care team identified this based on: echo lvef 41–49 — hfmref phenotype.

Other reasons your team may use this plan: dyspnea on exertion / orthopnea / pnd; lower-extremity edema; nt-probnp elevated with mildly reduced lvef.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
dapagliflozin	10 mg	PO	once daily	DELIVER NEJM 2022 (PMID 36027570) — worsening-HF/CV-death HR 0.82 (95% CI 0.73–0.92, p<0.001) across LVEF >40 incl. mid-range; consistent <60 vs ≥60% EF; benefit DM-independent; event-curve separation ~13–28 d. DEDICATED evidence. 2023 ESC Class I LOE A / 2022 AHA Class 2a
empagliflozin	10 mg	PO	once daily	EMPEROR-Preserved NEJM 2021 (PMID 34449189) — CV-death/HHF HR 0.79 (0.69–0.90, p<0.001) in LVEF >40; total HHF HR 0.73 (0.61–0.88); DM-independent. DEDICATED evidence. 2023 ESC Class I LOE A / 2022 AHA Class 2a

Plan: HFmrEF tiered regimen (2023 ESC Focused Update; 2022 AHA/ACC/HFSA)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — All clear — at dry weight, baseline activity — ACC/AHA 2022

If you have:

Weight within 1 kg of dry weight — ACC/AHA 2022
No new dyspnea, orthopnea, PND, or edema — ACC/AHA 2022
Usual activity tolerance — ACC/AHA 2022

Do this:

Take all HF meds (SGLT2i, finerenone/MRA, RAS, BB) every day — ACC/AHA 2022
Sodium <2 g/day; daily weight same time after voiding — ACC/AHA 2022
Keep clinic + lab + echo appointments (re-phenotype echo) — Bozkurt 2021

YELLOW — Caution — early congestion or symptom drift — ACC/AHA 2022

If you have:

Weight up 2 kg in 3 days OR 2.5 kg in a week — ACC/AHA 2022
New ankle/leg swelling — ACC/AHA 2022
Extra pillow to sleep or waking short of breath — ACC/AHA 2022
Reduced exercise tolerance — ACC/AHA 2022

Do this:

Take prescribed rescue diuretic dose per action plan — ACC/AHA 2022
Recheck weight + symptoms in 24 h — ACC/AHA 2022
Tighten sodium and fluid intake — ACC/AHA 2022
Call HF clinic / PCP within 24–48 h — ACC/AHA 2022

Call your provider if:

No return to dry-weight range after 48 h rescue diuretic — ACC/AHA 2022
Any worsening symptoms despite rescue diuretic — ACC/AHA 2022

RED — Medical alert — severe decompensation — ACC/AHA 2022

If you have:

Severe shortness of breath at rest — ACC/AHA 2022
Cannot lie flat / cannot sleep due to breathlessness — ACC/AHA 2022
New chest pain or pressure — ACC/AHA 2022
Confusion, fainting, or near-fainting — ACC/AHA 2022

Do this:

Call 911 / emergency services immediately — ACC/AHA 2022
Sit upright; do not drive yourself — ACC/AHA 2022
Bring medication list + weight diary — ACC/AHA 2022

Call your provider if:

Any red-zone symptom — go to ED now — ACC/AHA 2022

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Serial echo heart pumping strength (LVEF) falls ≤40 — phenotype migration to HFrEF — Bozkurt 2021; ACC/AHA 2022
Pregnancy or planning — STOP ACEi/ARB/ARNi/SGLT2i/finerenone/spironolactone; use BB (metoprolol/bisoprolol/labetalol) + loop diuretic; cardio-obstetric team — ESC 2018 Pregnancy
K ≥5.5 on finerenone/spironolactone/RAS — pause offending agent, treat hyperK, recheck — FINEARTS-HF; ACC/AHA 2022

5. Follow-up

Cardiac rehab, vaccinations, re-phenotype: re-route to HFrEF if EF ≤40 or HFpEF if EF ≥50

6. Sources

Guideline: 2022 AHA/ACC/HFSA HF Guideline + 2023 ESC Focused Update on HF + 2021 Universal Definition of HF (Bozkurt)