Clinical Commander

Back to dossier
cardio.hfmref.core.v1PRODUCTION
cardio.hfmref.core.v1

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

cardiologychronicadult
Hard-required inputs
0 / 9
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm chronic HFmrEF; if prior LVEF ≤40 → route cardio.hf-improved.core.v1; if decompensated → cardio.acute-hf.core.v1

Inputs
3
Actions
0
Advance rule
Set
Advance when

EF in 41–49 band, no prior ≤40, hemodynamically stable

Patient inputs (19)

Age-adjusted NT-proBNP thresholds + drug tolerability

RAS/ARNi/MRA initiation requires SBP ≥100; monitor for hypotension

BB titration target; AF vs sinus changes BB indication (Cleland IPD 2018)

Weight diary for congestion; loop diuretic titration

eGFR gates SGLT2i (≥20), finerenone (≥25), ACEi/ARNi titration

Finerenone/spironolactone contraindicated K >5.0; baseline before RAS/MRA

HFmrEF gate (LVEF 41–49); migration in/out of band drives re-routing

If LVEF was ever ≤40 → HF-improved (continue HFrEF GDMT), NOT HFmrEF

NYHA II–IV drives visit cadence + advanced-HF thresholds

Ischemic etiology more common in HFmrEF — drives revascularization workup

AF abolishes BB mortality benefit; drives rate/rhythm + AC

CKD stage gates SGLT2i, finerenone, RAS titration

Dual cardiorenal indication — favors SGLT2i + finerenone

Detect existing HF therapy; flag NSAIDs / non-DHP CCB / glitazones

Diagnostic confirmation + monitoring; age-adjusted thresholds

IV iron in symptomatic HF + iron deficiency (AFFIRM-AHF)

Thyroid dysfunction as reversible HF cause/aggravator

DM co-prevalence drives SGLT2i + finerenone selection

AF vs sinus (BB indication), ischemic Q-waves, low-voltage (amyloid)

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

Severity triggers (10)

10 need judgement
  • informationalsevereef_migration_down_to_hfref
    Serial echo LVEF falls ≤40 — phenotype migration to HFrEF — Bozkurt 2021; ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_special_pop
    Pregnancy or planning — STOP ACEi/ARB/ARNi/SGLT2i/finerenone/spironolactone; use BB (metoprolol/bisoprolol/labetalol) + loop diuretic; cardio-obstetric team — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehyperkalemia_on_mra_or_ras
    K ≥5.5 on finerenone/spironolactone/RAS — pause offending agent, treat hyperK, recheck — FINEARTS-HF; ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_special_pop
    eGFR 20–60 — SGLT2i continue to 20, finerenone start at 10 mg if eGFR 25–60, intensify K monitoring — FINEARTS-HF; KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaf_special_pop
    Concurrent AF — beta-blocker mortality benefit is LOST; prioritise rate/rhythm control + anticoagulation by CHA₂DS₂-VASc; consider early rhythm control — Cleland IPD 2018; EAST-AFNET 4
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategeriatric_frailty_special_pop
    Frail elderly — simplify regimen, check orthostatic BP before RAS/BB up-titration, STOPP/START review, accept symptom-guided rather than target-dose titration
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehepatic_special_pop
    Hepatic impairment — sacubitril/valsartan caution Child-Pugh B, contraindicated C; finerenone avoid severe hepatic impairment; spironolactone caution (also used for ascites) — drug labels
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateischemic_etiology_branch
    Ischemic HFmrEF with angina or viable myocardium — Heart-team revascularization decision (STICH CABG benefit at 10 yr; REVIVED-BCIS2 PCI neutral) — individualise
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildef_migration_up_to_hfpef
    Serial echo LVEF rises ≥50 with no prior ≤40 — migration to HFpEF — Bozkurt 2021
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmilddm2_special_pop
    Concurrent T2DM — SGLT2i + finerenone provide dual cardiorenal-metabolic benefit; add GLP-1 RA for obesity/ASCVD — ADA 2026
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
Loading…

Recommended regimen

HFmrEF tiered regimen (2023 ESC Focused Update; 2022 AHA/ACC/HFSA)
axis: hfmref_tieredstep 1 - Tier 1 — SGLT2 inhibitor (Class I ESC 2023 / Class 2a AHA 2022 — first-line in ALL HFmrEF regardless of DM; the ONLY dedicated-RCT-grade therapy in the band)
Selected step "Tier 1 — SGLT2 inhibitor (Class I ESC 2023 / Class 2a AHA 2022 — first-line in ALL HFmrEF regardless of DM; the ONLY dedicated-RCT-grade therapy in the band)" — LVEF 41–49, eGFR ≥20, no active DKA, not pregnant
  • dapagliflozin
    first line
    SGLT2i
    10 mg • PO • once daily
    triggers: LVEF_41_49, eGFR>=20
    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
    rxcui 1488564
  • empagliflozin
    first line
    SGLT2i
    10 mg • PO • once daily
    triggers: LVEF_41_49, eGFR>=20
    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
    rxcui 1545653

outpatient playbook — drug actions (5)

  1. 1. dapagliflozin OR empagliflozin
    10 mg • PO • daily
    trigger: LVEF 41–49, eGFR ≥20, no DKA (2023 ESC Class I)
    DELIVER NEJM 2022 / EMPEROR-Preserved NEJM 2021
  2. 2. finerenone
    10–40 mg • PO • daily
    trigger: K ≤5.0, eGFR ≥25 (FINEARTS-HF)
    FINEARTS-HF NEJM 2024 — RR 0.84 total worsening HF + CV death
  3. 3. sacubitril/valsartan OR ARB OR ACEi
    ARNi 24/26→97/103 BID • PO • BID/daily
    trigger: SBP ≥100, residual symptoms (2022 ACC/AHA Class 2b)
    PARAGON-HF / CHARM-Preserved / PEP-CHF — stronger at lower EF
  4. 4. carvedilol OR metoprolol succinate OR bisoprolol
    titrate to max tolerated • PO • BID/daily
    trigger: Sinus rhythm OR angina/AF rate (Cleland IPD 2018)
    Mortality benefit only in sinus rhythm; neutral in AF
  5. 5. furosemide / torsemide
    furosemide 20–40 mg or torsemide 10–20 mg • PO • daily–BID
    trigger: Volume overload / weight gain >2 kg in 3 days
    Congestion control (ACC/AHA 2022 HF)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Echo LVEF 41–49 — HFmrEF phenotype; Dyspnea on exertion / orthopnea / PND; Lower-extremity edema.

Objective

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

Assessment

**Heart failure with mildly reduced EF (HFmrEF, LVEF 41–49)** (cardio.hfmref.core.v1).
Phenotype framing: HFmrEF vs HFpEF (EF ±5% band) vs HFrEF vs HF-improved vs high-output vs valvular vs infiltrative vs tachycardia-mediated
Scope: Confirm chronic HFmrEF; if prior LVEF ≤40 → route cardio.hf-improved.core.v1; if decompensated → cardio.acute-hf.core.v1

No severity triggers fired against current inputs.

Plan

Regimen axis: **HFmrEF tiered regimen (2023 ESC Focused Update; 2022 AHA/ACC/HFSA)** — step "Tier 1 — SGLT2 inhibitor (Class I ESC 2023 / Class 2a AHA 2022 — first-line in ALL HFmrEF regardless of DM; the ONLY dedicated-RCT-grade therapy in the band)".
1. dapagliflozin 10 mg PO once daily (SGLT2i, first line) — 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
2. empagliflozin 10 mg PO once daily (SGLT2i, first line) — 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

Setting playbook (outpatient) — Start SGLT2i, layer finerenone/RAS/BB by EF-band evidence weight, treat comorbidities, and serially re-phenotype (2023 ESC Focused Update; 2022 AHA/ACC/HFSA)
3. dapagliflozin OR empagliflozin 10 mg PO daily — LVEF 41–49, eGFR ≥20, no DKA (2023 ESC Class I) (DELIVER NEJM 2022 / EMPEROR-Preserved NEJM 2021)
4. finerenone 10–40 mg PO daily — K ≤5.0, eGFR ≥25 (FINEARTS-HF) (FINEARTS-HF NEJM 2024 — RR 0.84 total worsening HF + CV death)
5. sacubitril/valsartan OR ARB OR ACEi ARNi 24/26→97/103 BID PO BID/daily — SBP ≥100, residual symptoms (2022 ACC/AHA Class 2b) (PARAGON-HF / CHARM-Preserved / PEP-CHF — stronger at lower EF)
6. carvedilol OR metoprolol succinate OR bisoprolol titrate to max tolerated PO BID/daily — Sinus rhythm OR angina/AF rate (Cleland IPD 2018) (Mortality benefit only in sinus rhythm; neutral in AF)
7. furosemide / torsemide furosemide 20–40 mg or torsemide 10–20 mg PO daily–BID — Volume overload / weight gain >2 kg in 3 days (Congestion control (ACC/AHA 2022 HF))

Non-pharmacologic actions:
- Sodium <2 g/day; fluid restriction if hyponatraemia/congestion — ACC/AHA 2022
- Cardiac rehab referral — ACC/AHA 2022
- Revascularization decision in ischemic HFmrEF (Heart-team; STICH vs REVIVED context)
- Vaccinations (flu, pneumococcal, COVID, RSV) — ACC/AHA 2022
- AF rhythm-control / catheter ablation discussion (EAST-AFNET 4 early rhythm control)

AVOID / contraindication checks:
- Finerenone block if K gt 5.0 or eGFR lt 25 — FINEARTS HF Solomon NEJM 2024
- Spironolactone block if K gt 5.0 — TOPCAT Pitt NEJM 2014
- Sglt2i block if egfr lt 20 or active DKA — DELIVER Solomon NEJM 2022
- Arni acei arb block in pregnancy — fetotoxic RAS blockade
- Sglt2i finerenone spironolactone block in pregnancy — inadequate safety data
- Bb no mortality benefit in AF — Cleland IPD Eur Heart J 2018
- Angioedema arni history block — PARAGON HF Solomon NEJM 2019
- Aki rasi pause if Cr rise gt 30pct — ACC/AHA 2022 HF

Monitoring

Regimen monitoring:
- BMP 1-2wk after RAS or MRA change — ACC/AHA 2022
- K within 4w of finerenone start and after each titration — FINEARTS-HF Solomon NEJM 2024
- serial echo 3-6mo for phenotype migration — Universal Definition Bozkurt 2021
- NT-proBNP q3-6m or after decompensation — ACC/AHA 2022
- weight daily at home — ACC/AHA 2022
- iron panel q6m until repleted — AFFIRM-AHF Ponikowski Lancet 2020
- BP HR rhythm at each visit BB indication depends on sinus vs AF — Cleland IPD 2018

Setting (outpatient) monitoring:
- BMP 1–2 wk after RAS/MRA change, then q3m steady state — ACC/AHA 2022
- Serial echo at 3–6 mo — re-phenotype to HFrEF (≤40) or HFpEF (≥50) — Bozkurt 2021
- NT-proBNP q3–6 mo — ACC/AHA 2022
- Daily home weight; alert if >2 kg in 3 days — ACC/AHA 2022

Follow-up plan: Cardiac rehab, vaccinations, re-phenotype: re-route to HFrEF if EF ≤40 or HFpEF if EF ≥50
- Close-out criterion: follow-up scheduled with re-phenotype trigger documented

Monitoring phase: BMP within 1–2 wk of RAS/MRA change; weight diary; serial echo 3–6 mo for phenotype migration; NT-proBNP q3–6 mo

Disposition

Current setting: outpatient — Start SGLT2i, layer finerenone/RAS/BB by EF-band evidence weight, treat comorbidities, and serially re-phenotype (2023 ESC Focused Update; 2022 AHA/ACC/HFSA)

Disposition criteria:
- Stable NYHA I–II on tolerated regimen → q6–12 mo visits with annual echo
- Symptomatic / recently titrated → q1–3 mo visits
- Phenotype migration out of 41–49 band → re-route dossier

Escalation triggers (move to higher acuity):
- Echo LVEF falls ≤40 → route cardio.hfref.core.v1 + start 4-pillar GDMT — ACC/AHA 2022
- NYHA IV / refractory congestion → advanced HF referral — ACC/AHA 2022
- SBP <90 + hypoperfusion → ED + cardio.cardiogenic-shock.core.v1 — ACC/AHA 2022

Patient Action Plan

**HFmrEF action plan (weight + dyspnea zones) — ACC/AHA 2022**
Personalised values: dry_weight_kg, home_diuretic, home_diuretic_rescue_dose, NYHA_baseline.

**All clear — at dry weight, baseline activity — ACC/AHA 2022** (green):
Triggers:
- 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
Actions:
- 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

**Caution — early congestion or symptom drift — ACC/AHA 2022** (yellow):
Triggers:
- 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
Actions:
- 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
Contact provider when:
- No return to dry-weight range after 48 h rescue diuretic — ACC/AHA 2022
- Any worsening symptoms despite rescue diuretic — ACC/AHA 2022

**Medical alert — severe decompensation — ACC/AHA 2022** (red):
Triggers:
- 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
Actions:
- 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
Contact provider when:
- Any red-zone symptom — go to ED now — ACC/AHA 2022

Earlier-Return Triggers

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

Citations

- 2022 AHA/ACC/HFSA HF Guideline + 2023 ESC Focused Update on HF + 2021 Universal Definition of HF (Bozkurt) [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 37622666) [PMID:37622666](https://pubmed.ncbi.nlm.nih.gov/37622666/)
- Cited evidence (PMID 33605000) [PMID:33605000](https://pubmed.ncbi.nlm.nih.gov/33605000/)
- Cited evidence (PMID 36027570) [PMID:36027570](https://pubmed.ncbi.nlm.nih.gov/36027570/)

Last reconciled with current guidelines: 2026-05-26.
References