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cardio.hf.core.v1PRODUCTION
cardio.hf.core.v1

Heart failure (chronic, GDMT titration)

cardiologychronicadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm chronic HF scope — exclude acute decompensation that should route to cardio.acute-hf.core.v1 — ACC/AHA 2022 §3

Inputs
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Actions
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Advance rule
Set
Advance when

patient is hemodynamically stable and not in acute pulmonary edema

Patient inputs (17)

Age cutoffs for ARNi vs ACEi tolerability + dose adjustment — ACC/AHA 2022

GDMT initiation requires SBP ≥ 100 mmHg — ACC/AHA 2022; titration requires monitoring for hypotension

Beta-blocker titration target HR; ivabradine candidacy ≥ 70 bpm sinus — ACC/AHA 2022

eGFR for SGLT2i (≥20 — DAPA-HF 2019), ACEi/ARB initiation, MRA monitoring — ACC/AHA 2022

MRA contraindicated K > 5.0 (RALES, Pitt NEJM 1999); baseline before ACEi/ARB/MRA — ACC/AHA 2022

Branches HFrEF (≤40) / HFmrEF (41–49) / HFpEF (≥50) — ACC/AHA 2022 universal definition; drives 4-pillar regimen choice

Ischemic vs non-ischemic etiology branches workup — ACC/AHA 2022 §4.1

Rate vs rhythm strategy; anticoagulation — ACC/AHA 2022 §7.3.7

CKD stage gates SGLT2i, ACEi/ARB titration, MRA risk — KDIGO 2021 + ACC/AHA 2022

Dual cardiorenal indication — favors SGLT2i (DAPA-HF 2019) + GLP-1 — ADA 2026

Detect existing GDMT components for titration vs initiation; flag NSAIDs/CCB-non-DHP — ACC/AHA 2022 §7.3

Diagnostic confirmation + monitoring; age-adjusted thresholds — ACC/AHA 2022 Class I

Hyper/hypothyroidism as reversible HF cause/aggravator — ACC/AHA 2022 §4.3

IV iron in HFrEF + iron deficiency (FAIR-HF/CONFIRM-HF/AFFIRM-AHF)

Diabetes co-prevalence drives SGLT2i + GLP-1 selection; HFpEF + obesity → semaglutide/tirzepatide (STEP-HFpEF, Kosiborod NEJM 2023)

QRS ≥150ms LBBB → CRT candidacy — ACC/AHA 2022 §7.5; AF rhythm; ischemic Q-waves

NYHA II-IV classification drives device + advanced therapy thresholds — ACC/AHA 2022 §3

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningcardiogenic_shock_route_acute — ACC/AHA 2022
    SBP <90 with signs of hypoperfusion (cool extremities, AMS, oliguria, lactate >2) — ACC/AHA 2022 §10
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehyperkalemia_on_mra — ACC/AHA 2022
    Serum K >5.5 mmol/L on MRA (spironolactone/eplerenone) or finerenone — ACC/AHA 2022 §7.3.3
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaki_on_diuretic_or_RAS_blocker — ACC/AHA 2022
    Creatinine rise ≥0.5 mg/dL (or ≥30%) from baseline on loop diuretic + ACEi/ARNI/ARB — ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereworsening_nyha_class — ACC/AHA 2022
    NYHA class progression (e.g., II → III, III → IV) despite optimised GDMT — ACC/AHA 2022 §8
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprofound_hypotension_on_GDMT — ACC/AHA 2022
    Symptomatic SBP <90 mmHg on ACEi/ARNI/ARB ± beta-blocker ± MRA — ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevolume_overload_outpatient — ACC/AHA 2022
    Home weight gain ≥3 kg in 7 days OR new orthopnea / increased dyspnea — ACC/AHA 2022 §7.3.2
    Trigger could not be auto-evaluated — needs clinician judgement.

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TREATMENTrequiredDrives dose adjustment
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Recommended regimen

GDMT 4-pillar — HFrEF (LVEF ≤40) — rapid simultaneous initiation (2024 ACC Consensus + STRONG-HF)
axis: gdmt_4_pillar_hfrefstep 1 - Step 1 — Initiate ALL four pillars at low dose within 1–2 weeks (2024 ACC HFrEF Consensus PMID 38466244; STRONG-HF PMID 36356631) — do not serialise pillar-by-pillar over months
Selected step "Step 1 — Initiate ALL four pillars at low dose within 1–2 weeks (2024 ACC HFrEF Consensus PMID 38466244; STRONG-HF PMID 36356631) — do not serialise pillar-by-pillar over months" — HFrEF (LVEF ≤40), SBP ≥100, K <5.0, eGFR ≥20, no active decompensation per 2022 AHA/ACC/HFSA Class I
  • sacubitril/valsartan
    first line
    ARNi
    24/26 mg (49/51 if ACEi/ARB-tolerant) • PO • BID
    triggers: LVEF<=40, no_ACEi_within_36h, SBP>=100
    Pillar 1 — PARADIGM-HF CV death/HHF HR 0.80 (0.73–0.87), all-cause death HR 0.84 (0.76–0.93); ARNi preferred de novo. 2022 AHA/ACC/HFSA Class I (PMID 25176015)
    rxcui 1656339
  • carvedilol
    first line
    beta_blocker
    3.125 mg • PO • BID
    triggers: LVEF<=40, no_active_decompensation
    Pillar 2 — COPERNICUS all-cause death 35% RRR (95% CI 19–48%); reverse remodelling over 3–6 mo. Class I (PMID 11386263)
    rxcui 20352
  • metoprolol succinate
    first line
    beta_blocker
    12.5–25 mg • PO • once daily
    triggers: LVEF<=40, no_active_decompensation
    Pillar 2 alt — MERIT-HF all-cause death RR 0.66 (0.53–0.81); CR/XL long-acting only (PMID 10376614)
    rxcui 221124
  • bisoprolol
    first line
    beta_blocker
    1.25 mg • PO • once daily
    triggers: LVEF<=40, no_active_decompensation
    Pillar 2 alt — CIBIS-II all-cause death HR 0.66 (0.54–0.81) (PMID 10023943)
    rxcui 19484
  • spironolactone
    first line
    MRA
    12.5–25 mg • PO • once daily
    triggers: LVEF<=40, K<5.0, eGFR>30
    Pillar 3 — RALES all-cause death RR 0.70 (0.60–0.82); HHF RR 0.65 (0.54–0.77). Class I (PMID 10471456)
    rxcui 9997
  • eplerenone
    first line
    MRA
    25 mg • PO • once daily
    triggers: gynecomastia_on_spironolactone, LVEF<=40, K<5.0, eGFR>30
    Pillar 3 alt — EMPHASIS-HF CV death/HHF HR 0.63 (0.54–0.74); endocrine-ADR sparing (PMID 21073363)
    rxcui 298869
  • dapagliflozin
    first line
    SGLT2i
    10 mg • PO • once daily
    triggers: LVEF<=40, eGFR>=20
    Pillar 4 — DAPA-HF worsening HF/CV death HR 0.74 (0.65–0.85); benefit DM-independent; curve separation by ~28 d. Class I (PMID 31535829)
    rxcui 1488564
  • empagliflozin
    first line
    SGLT2i
    10 mg • PO • once daily
    triggers: LVEF<=40, eGFR>=20
    Pillar 4 alt — EMPEROR-Reduced CV death/HHF HR 0.75 (0.65–0.86) (PMID 32865377)
    rxcui 1545653

outpatient playbook — drug actions (7)

  1. 1. sacubitril/valsartan
    rxcui 1656339
    24/26 mg PO BID start (49/51 if prior ACEi/ARB-tolerant); titrate to 97/103 mg BID over 2–4 weeks • PO • BID
    trigger: HFrEF (LVEF ≤40), SBP ≥100, no ACEi within 36 h, no angioedema history
    PARADIGM-HF CV death/HHF HR 0.80 (0.73–0.87) — first pillar; ARNi preferred over ACEi/ARB de novo. Start all four pillars within 1–2 wk (2024 ACC Consensus PMID 38466244)
  2. 2. carvedilol OR metoprolol succinate OR bisoprolol
    rxcui 20352
    Carvedilol 3.125 mg PO BID → up-titrate q2 weeks to 25 mg BID; metoprolol succinate 12.5–25 mg PO daily → 200 mg daily; bisoprolol 1.25 mg → 10 mg daily • PO • daily-BID
    trigger: HFrEF, no active decompensation, HR adequate
    Beta-blocker pillar — only these 3 agents have HF mortality benefit (COPERNICUS / MERIT-HF / CIBIS-II)
  3. 3. spironolactone (or eplerenone)
    rxcui 9997
    Spironolactone 12.5–25 mg PO daily → 25–50 mg; switch to eplerenone 25–50 mg if gynecomastia • PO • daily
    trigger: LVEF ≤40, K <5.0, eGFR >30
    MRA pillar (RALES / EMPHASIS-HF)
  4. 4. dapagliflozin OR empagliflozin
    rxcui 1488564
    Dapagliflozin 10 mg PO daily OR empagliflozin 10 mg PO daily • PO • daily
    trigger: LVEF ≤40 (HFrEF) OR LVEF ≥50 (HFpEF DELIVER/EMPEROR-Preserved); eGFR ≥20
    SGLT2i pillar — benefit independent of DM (DAPA-HF / EMPEROR-Reduced / DELIVER / EMPEROR-Preserved)
  5. 5. finerenone
    rxcui 2562811
    10–20 mg PO daily (titrate by eGFR + K) • PO • daily
    trigger: LVEF ≥40 (HFmrEF/HFpEF), eGFR ≥25, K <5.0
    FINEARTS-HF total worsening-HF events + CV death RR 0.84 (0.74–0.95) — non-steroidal MRA add-on for HFpEF/HFmrEF (PMID 39225278)
  6. 6. furosemide (volume control adjunct)
    rxcui 4603
    20–40 mg PO daily, titrate to euvolemia; switch to torsemide if poor absorption • PO • daily-BID
    trigger: Volume overload / pulmonary congestion / weight gain ≥3 kg in 7 days
    Loop diuretic for symptom control; not disease-modifying — ACC/AHA 2022 §7.3.2
  7. 7. semaglutide OR tirzepatide (HFpEF + obesity)
    rxcui 1991302
    Semaglutide titrate to 2.4 mg SC weekly OR tirzepatide titrate to 10–15 mg SC weekly • SC • weekly
    trigger: HFpEF (LVEF ≥50) + BMI ≥30
    STEP-HFpEF / SUMMIT — HFpEF-specific weight + symptom benefit

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Dyspnea on exertion / orthopnea / PND; Lower-extremity edema; NT-proBNP elevated.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Heart failure (chronic, GDMT titration)** (cardio.hf.core.v1).
Phenotype framing: Phenotype as HFrEF (≤40) / HFmrEF (41–49) / HFpEF (≥50) / HF-improved — ACC/AHA 2022 universal definition
Scope: Confirm chronic HF scope — exclude acute decompensation that should route to cardio.acute-hf.core.v1 — ACC/AHA 2022 §3

No severity triggers fired against current inputs.

Plan

Regimen axis: **GDMT 4-pillar — HFrEF (LVEF ≤40) — rapid simultaneous initiation (2024 ACC Consensus + STRONG-HF)** — step "Step 1 — Initiate ALL four pillars at low dose within 1–2 weeks (2024 ACC HFrEF Consensus PMID 38466244; STRONG-HF PMID 36356631) — do not serialise pillar-by-pillar over months".
1. sacubitril/valsartan 24/26 mg (49/51 if ACEi/ARB-tolerant) PO BID (ARNi, first line) — Pillar 1 — PARADIGM-HF CV death/HHF HR 0.80 (0.73–0.87), all-cause death HR 0.84 (0.76–0.93); ARNi preferred de novo. 2022 AHA/ACC/HFSA Class I (PMID 25176015)
2. carvedilol 3.125 mg PO BID (beta_blocker, first line) — Pillar 2 — COPERNICUS all-cause death 35% RRR (95% CI 19–48%); reverse remodelling over 3–6 mo. Class I (PMID 11386263)
3. metoprolol succinate 12.5–25 mg PO once daily (beta_blocker, first line) — Pillar 2 alt — MERIT-HF all-cause death RR 0.66 (0.53–0.81); CR/XL long-acting only (PMID 10376614)
4. bisoprolol 1.25 mg PO once daily (beta_blocker, first line) — Pillar 2 alt — CIBIS-II all-cause death HR 0.66 (0.54–0.81) (PMID 10023943)
5. spironolactone 12.5–25 mg PO once daily (MRA, first line) — Pillar 3 — RALES all-cause death RR 0.70 (0.60–0.82); HHF RR 0.65 (0.54–0.77). Class I (PMID 10471456)
6. eplerenone 25 mg PO once daily (MRA, first line) — Pillar 3 alt — EMPHASIS-HF CV death/HHF HR 0.63 (0.54–0.74); endocrine-ADR sparing (PMID 21073363)
7. dapagliflozin 10 mg PO once daily (SGLT2i, first line) — Pillar 4 — DAPA-HF worsening HF/CV death HR 0.74 (0.65–0.85); benefit DM-independent; curve separation by ~28 d. Class I (PMID 31535829)
8. empagliflozin 10 mg PO once daily (SGLT2i, first line) — Pillar 4 alt — EMPEROR-Reduced CV death/HHF HR 0.75 (0.65–0.86) (PMID 32865377)

Setting playbook (outpatient) — Rapidly initiate ALL applicable GDMT pillars within 1–2 weeks then up-titrate on the STRONG-HF cadence (HFrEF 4-pillar — 2022 AHA/ACC/HFSA + 2024 ACC Consensus PMID 38466244; HFmrEF/HFpEF SGLT2i Class I/IIa + finerenone — DELIVER PMID 36027570 / FINEARTS-HF PMID 39225278) to lowest tolerated maximal dose; treat reversible drivers; reduce HF hospitalisation risk.
9. sacubitril/valsartan 24/26 mg PO BID start (49/51 if prior ACEi/ARB-tolerant); titrate to 97/103 mg BID over 2–4 weeks PO BID — HFrEF (LVEF ≤40), SBP ≥100, no ACEi within 36 h, no angioedema history (PARADIGM-HF CV death/HHF HR 0.80 (0.73–0.87) — first pillar; ARNi preferred over ACEi/ARB de novo. Start all four pillars within 1–2 wk (2024 ACC Consensus PMID 38466244))
10. carvedilol OR metoprolol succinate OR bisoprolol Carvedilol 3.125 mg PO BID → up-titrate q2 weeks to 25 mg BID; metoprolol succinate 12.5–25 mg PO daily → 200 mg daily; bisoprolol 1.25 mg → 10 mg daily PO daily-BID — HFrEF, no active decompensation, HR adequate (Beta-blocker pillar — only these 3 agents have HF mortality benefit (COPERNICUS / MERIT-HF / CIBIS-II))
11. spironolactone (or eplerenone) Spironolactone 12.5–25 mg PO daily → 25–50 mg; switch to eplerenone 25–50 mg if gynecomastia PO daily — LVEF ≤40, K <5.0, eGFR >30 (MRA pillar (RALES / EMPHASIS-HF))
12. dapagliflozin OR empagliflozin Dapagliflozin 10 mg PO daily OR empagliflozin 10 mg PO daily PO daily — LVEF ≤40 (HFrEF) OR LVEF ≥50 (HFpEF DELIVER/EMPEROR-Preserved); eGFR ≥20 (SGLT2i pillar — benefit independent of DM (DAPA-HF / EMPEROR-Reduced / DELIVER / EMPEROR-Preserved))
13. finerenone 10–20 mg PO daily (titrate by eGFR + K) PO daily — LVEF ≥40 (HFmrEF/HFpEF), eGFR ≥25, K <5.0 (FINEARTS-HF total worsening-HF events + CV death RR 0.84 (0.74–0.95) — non-steroidal MRA add-on for HFpEF/HFmrEF (PMID 39225278))
14. furosemide (volume control adjunct) 20–40 mg PO daily, titrate to euvolemia; switch to torsemide if poor absorption PO daily-BID — Volume overload / pulmonary congestion / weight gain ≥3 kg in 7 days (Loop diuretic for symptom control; not disease-modifying — ACC/AHA 2022 §7.3.2)
15. semaglutide OR tirzepatide (HFpEF + obesity) Semaglutide titrate to 2.4 mg SC weekly OR tirzepatide titrate to 10–15 mg SC weekly SC weekly — HFpEF (LVEF ≥50) + BMI ≥30 (STEP-HFpEF / SUMMIT — HFpEF-specific weight + symptom benefit)

Non-pharmacologic actions:
- Sodium/fluid education + daily weight diary — ACC/AHA 2022 §7.1
- Cardiac rehab referral — ACC/AHA 2022 Class IIa
- Vaccinations (influenza, pneumococcal, COVID-19, RSV ≥60) — ACC/AHA 2022 §7.3.8
- IV iron in HFrEF + iron deficiency (FAIR-HF / CONFIRM-HF / AFFIRM-AHF)
- CRT/ICD evaluation when indicated (QRS ≥150 ms LBBB; LVEF ≤35 despite GDMT) — ACC/AHA 2022 §7.5
- Advance-care planning + advanced HF referral if NYHA IV / inotrope-dep / VAD candidate — ACC/AHA 2022 §8

AVOID / contraindication checks:
- Hyperkalemia mra block if K gt 5.0 — RALES (PMID 10471456) exclusion
- Aki acei arni pause if AKI — 2022 AHA/ACC/HFSA §7.3
- Angioedema arni history block — 2022 AHA/ACC/HFSA Class III
- Arni acei 36h washout — PARADIGM HF (PMID 25176015)
- Bb block if acute decompensation or hr lt 50 — 2022 AHA/ACC/HFSA
- Sglt2i block if egfr lt 20 or active DKA — DAPA HF (PMID 31535829) eGFR floor
- Hydral isdn avoid with PDE5i — 2022 AHA/ACC/HFSA

Monitoring

Regimen monitoring:
- BMP at 1–2 weeks after every GDMT initiation/change — 2022 AHA/ACC/HFSA
- STRONG-HF cadence: 1-week safety visit then q2-week × 6 weeks; target dose by ~wk 6 — PMID 36356631
- BMP monthly during titration; q3 months at steady state — 2022 AHA/ACC/HFSA
- BP + HR at each visit (BB titration target) — 2022 AHA/ACC/HFSA
- Daily home weight + symptom diary (return precautions ≥3 kg in 7 days) — 2022 AHA/ACC/HFSA
- NT-proBNP trend at major titration steps — 2022 AHA/ACC/HFSA Class IIa
- LVEF reassessment at 3–6 mo on full GDMT (device re-eligibility) — 2022 AHA/ACC/HFSA §7.5

Setting (outpatient) monitoring:
- BMP at 1–2 weeks after every GDMT change — ACC/AHA 2022
- BMP monthly during titration; q3 months at steady state — ACC/AHA 2022
- BP + HR at every visit — ACC/AHA 2022
- Daily home weight + symptom diary (return precautions: ≥3 kg in 7 days, increasing dyspnea/orthopnea) — ACC/AHA 2022
- NT-proBNP trend at major titration steps — ACC/AHA 2022 Class IIa
- LFTs + LVEF reassessment at 6–12 months on full GDMT — ACC/AHA 2022

Follow-up plan: Visit cadence by NYHA + recent titration; cardiac rehab referral; vaccination check (flu, pneumococcal, COVID) — ACC/AHA 2022 §7.3.8
- Close-out criterion: follow-up scheduled and patient given return precautions

Monitoring phase: BMP within 1–2 weeks of GDMT change, then at each titration — ACC/AHA 2022; weight + symptom diary; iron repletion check (FAIR-HF 2009)

Disposition

Current setting: outpatient — Rapidly initiate ALL applicable GDMT pillars within 1–2 weeks then up-titrate on the STRONG-HF cadence (HFrEF 4-pillar — 2022 AHA/ACC/HFSA + 2024 ACC Consensus PMID 38466244; HFmrEF/HFpEF SGLT2i Class I/IIa + finerenone — DELIVER PMID 36027570 / FINEARTS-HF PMID 39225278) to lowest tolerated maximal dose; treat reversible drivers; reduce HF hospitalisation risk.

Disposition criteria:
- Continue current titration cadence if symptoms stable and labs in range — ACC/AHA 2022
- Step up GDMT pillars sequentially until target dose or intolerance — ACC/AHA 2022; STRONG-HF (Mebazaa Lancet 2022) supports rapid up-titration
- Step down only if symptomatic hypotension, hyperkalemia, AKI — not for asymptomatic stability — ACC/AHA 2022
- Refer for advanced HF if NYHA IV / Stage D / inotrope-dependent / VAD candidate — ACC/AHA 2022 §8

Escalation triggers (move to higher acuity):
- Acute decompensation (rest dyspnea, pulmonary edema) → ED + route to cardio.acute-hf.core.v1 — ACC/AHA 2022
- SBP <90 + signs of hypoperfusion → ED + cardiogenic shock workup — ACC/AHA 2022 §10
- NYHA IV despite optimised GDMT, recurrent HF hospitalisations, escalating diuretic need, persistent VT/VF, worsening renal function with diuresis → advanced HF referral (LVAD / transplant / palliative) — ACC/AHA 2022 §8
- New AF with rapid ventricular response → rate/rhythm strategy + anticoagulation — ACC/AHA 2022 §7.3.7

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 with signs of hypoperfusion (cool extremities, AMS, oliguria, lactate >2) — ACC/AHA 2022 §10
- [SEVERE] Serum K >5.5 mmol/L on MRA (spironolactone/eplerenone) or finerenone — ACC/AHA 2022 §7.3.3
- [SEVERE] Creatinine rise ≥0.5 mg/dL (or ≥30%) from baseline on loop diuretic + ACEi/ARNI/ARB — ACC/AHA 2022

Citations

- 2022 AHA/ACC/HFSA HF Guideline (Circulation 35363499 / JACC 35379503) + 2024 ACC HFrEF Expert Consensus (38466244) + ESC 2021 HF (34447992) + 2023 ESC Focused Update (37622666) + FINEARTS-HF (2024) [PMID:35363499](https://pubmed.ncbi.nlm.nih.gov/35363499/)
- Cited evidence (PMID 35379503) [PMID:35379503](https://pubmed.ncbi.nlm.nih.gov/35379503/)
- Cited evidence (PMID 38466244) [PMID:38466244](https://pubmed.ncbi.nlm.nih.gov/38466244/)
- Cited evidence (PMID 34447992) [PMID:34447992](https://pubmed.ncbi.nlm.nih.gov/34447992/)
- Cited evidence (PMID 37622666) [PMID:37622666](https://pubmed.ncbi.nlm.nih.gov/37622666/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2022 AHA/ACC/HFSA HF Guideline (Circulation 35363499 / JACC 35379503) + 2024 ACC HFrEF Expert Consensus (38466244) + ESC 2021 HF (34447992) + 2023 ESC Focused Update (37622666) + FINEARTS-HF (2024) — PMID:35363499
  • Cited evidence (PMID 35379503) — PMID:35379503
  • Cited evidence (PMID 38466244) — PMID:38466244
  • Cited evidence (PMID 34447992) — PMID:34447992
  • Cited evidence (PMID 37622666) — PMID:37622666