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cardio.hfref.core.v1PRODUCTION
cardio.hfref.core.v1

Heart failure with reduced EF (HFrEF, LVEF ≤40)

cardiologychronicadult
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Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm chronic HFrEF — exclude acute decompensation that should route to cardio.acute-hf.core.v1

Inputs
2
Actions
0
Advance rule
Set
Advance when

patient is hemodynamically stable and not in acute pulmonary edema

Patient inputs (18)

Age cutoffs for ARNi vs ACEi tolerability + dose adjustment

GDMT initiation requires SBP ≥100 mmHg; titration requires monitoring for hypotension

BB titration target HR; ivabradine candidacy ≥70 bpm sinus on max BB

Weight diary for congestion; carvedilol dose threshold (>85 kg)

eGFR for SGLT2i (≥20), ACEi/ARNi titration, MRA monitoring

MRA contraindicated K >5.0; baseline before ACEi/ARNi/MRA

HFrEF gate (LVEF ≤40); drives 4-pillar regimen

NYHA II–IV drives device + advanced therapy thresholds

Ischemic vs non-ischemic etiology branches workup

Rate vs rhythm strategy; anticoagulation

CKD stage gates SGLT2i, ACEi/ARNi titration, MRA risk

Dual cardiorenal indication — favors SGLT2i + GLP-1

Detect existing GDMT components for titration vs initiation; flag NSAIDs/non-DHP CCB

Diagnostic confirmation + monitoring; age-adjusted thresholds

IV iron for symptomatic iron deficiency in HFrEF (AFFIRM-AHF PMID 33197395; IRONMAN PMID 36347265)

Hyper/hypothyroidism as reversible HF cause/aggravator

DM co-prevalence drives SGLT2i + GLP-1 selection

QRS ≥150 ms LBBB → CRT candidacy; AF rhythm; ischemic Q-waves

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

Severity triggers (7)

7 need judgement
  • informationallife_threateningsbp_under_90_with_hypoperfusion
    SBP <90 + cool extremities, oliguria, AMS, or rising lactate — ACC/AHA 2022; ESC 2021
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverek_above_5_5_on_mra_or_arni
    K ≥5.5 on MRA / ACEi / ARNi — ACC/AHA 2022; RALES Pitt NEJM 1999
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaki_on_gdmt
    Cr rise >0.3 mg/dL or >50% from baseline on ACEi / ARNi / MRA / SGLT2i — ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateorthopnea_or_pnd
    New orthopnea (≥1 extra pillow) OR PND — ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecent_worsening_hf
    Recent HF hospitalisation OR outpatient IV diuretic in last 6 months — VICTORIA NEJM 2020; ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildweight_gain_2kg_3d
    Home weight gain ≥2 kg in 3 days OR ≥2.5 kg in 1 week — ACC/AHA 2022; STRONG-HF Mebazaa Lancet 2022
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildhr_ge_70_on_max_BB
    Resting HR ≥70 in sinus rhythm despite maximally tolerated BB, LVEF ≤35, NYHA II–III — SHIFT Lancet 2010; ACC/AHA 2022
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

GDMT 4-pillar — HFrEF (LVEF ≤40) (ACC/AHA 2022 HF; 2024 ACC ECDP HFrEF)
axis: gdmt_4_pillar_hfrefstep 1 - Pillar 1 — RAS inhibition (ARNi preferred; ACEi or ARB if intolerant/cost)
Selected step "Pillar 1 — RAS inhibition (ARNi preferred; ACEi or ARB if intolerant/cost)" — LVEF ≤40, SBP ≥100, eGFR ≥30, K <5.0, no angioedema history
  • sacubitril/valsartan
    first line
    ARNi
    24/26 mg • PO • BID (max: 97/103 mg BID (target))
    triggers: LVEF<=40, no_ACEi_within_36h, SBP>=100
    PARADIGM-HF (PMID 25176015) — CV death/HHF HR 0.80 (0.73–0.87), all-cause death HR 0.84 (0.76–0.93), p<0.001, stopped early at 27 mo; titrate q2–4 wk to 97/103 BID; 2022 AHA/ACC/HFSA Class I (PMID 35363499)
    rxcui 1656339
  • lisinopril
    contraindication substitute
    ACEi
    2.5–5 mg • PO • once daily (max: 40 mg/day (target))
    triggers: ARNi_intolerant, cost_barrier
    Foundational ACEi mortality benefit (SOLVD/CONSENSUS class); switch to ARNi when feasible — 2022 AHA/ACC/HFSA Class I (PMID 35363499)
    rxcui 29046
  • losartan
    contraindication substitute
    ARB
    25–50 mg • PO • once daily (max: 150 mg/day (target))
    triggers: ACEi_cough_or_angioedema, ARNi_unavailable
    HEAAL — high-dose 150 mg preferred when ACEi/ARNi unavailable; 2022 AHA/ACC/HFSA Class I (PMID 35363499)
    rxcui 52175

outpatient playbook — drug actions (7)

  1. 1. sacubitril/valsartan
    24/26 → 49/51 → 97/103 mg • PO • BID
    trigger: LVEF ≤40, SBP ≥100, no ACEi within 36 h, no angioedema history (ACC/AHA 2022 HF)
    PARADIGM-HF McMurray NEJM 2014; ACC/AHA 2022 HF Class I
  2. 2. carvedilol OR metoprolol succinate OR bisoprolol
    carvedilol 3.125 → 25 BID; metoprolol succ 12.5 → 200 daily; bisoprolol 1.25 → 10 daily • PO • BID/daily
    trigger: No active decompensation (ACC/AHA 2022 HF)
    COPERNICUS NEJM 2001 / MERIT-HF Lancet 1999 / CIBIS-II Lancet 1999; ACC/AHA 2022 HF Class I
  3. 3. spironolactone OR eplerenone
    spironolactone 12.5 → 50 daily; eplerenone 25 → 50 daily • PO • daily
    trigger: K <5.0, eGFR ≥30 (ACC/AHA 2022 HF)
    RALES Pitt NEJM 1999 / EMPHASIS-HF Zannad NEJM 2011; ACC/AHA 2022 HF Class I
  4. 4. dapagliflozin OR empagliflozin
    10 mg • PO • daily
    trigger: eGFR ≥20, no active DKA (ACC/AHA 2022 HF)
    DAPA-HF McMurray NEJM 2019 / EMPEROR-Reduced Packer NEJM 2020; ACC/AHA 2022 HF Class I
  5. 5. ivabradine
    5 → 7.5 mg • PO • BID
    trigger: HR ≥70 sinus on max BB, LVEF ≤35, NYHA II–III (ACC/AHA 2022 HF)
    SHIFT Lancet 2010; ACC/AHA 2022 HF Class IIa
  6. 6. vericiguat
    2.5 → 10 mg • PO • daily
    trigger: Recent worsening HF / IV diuretic / hospitalisation, SBP ≥100 (ACC/AHA 2022 HF)
    VICTORIA NEJM 2020; ACC/AHA 2022 HF Class IIb
  7. 7. furosemide / torsemide
    furosemide 20–40 mg or torsemide 10–20 mg • PO • daily–BID
    trigger: Volume overload / weight gain >2 kg in 3 days (ACC/AHA 2022 HF)
    Symptom + congestion control (ACC/AHA 2022 HF)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Echo LVEF ≤40 — HFrEF phenotype; Dyspnea on exertion / orthopnea / PND; Lower-extremity edema.

Objective

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

Assessment

**Heart failure with reduced EF (HFrEF, LVEF ≤40)** (cardio.hfref.core.v1).
Phenotype framing: Confirm HFrEF (LVEF ≤40) vs HFmrEF (41–49) vs HFpEF (≥50) vs HF-improved (ACC/AHA 2022 HF §3; ESC 2021)
Scope: Confirm chronic HFrEF — exclude acute decompensation that should route to cardio.acute-hf.core.v1

No severity triggers fired against current inputs.

Plan

Regimen axis: **GDMT 4-pillar — HFrEF (LVEF ≤40) (ACC/AHA 2022 HF; 2024 ACC ECDP HFrEF)** — step "Pillar 1 — RAS inhibition (ARNi preferred; ACEi or ARB if intolerant/cost)".
1. sacubitril/valsartan 24/26 mg PO BID (ARNi, first line) — PARADIGM-HF (PMID 25176015) — CV death/HHF HR 0.80 (0.73–0.87), all-cause death HR 0.84 (0.76–0.93), p<0.001, stopped early at 27 mo; titrate q2–4 wk to 97/103 BID; 2022 AHA/ACC/HFSA Class I (PMID 35363499)
2. lisinopril 2.5–5 mg PO once daily (ACEi, contraindication substitute) — Foundational ACEi mortality benefit (SOLVD/CONSENSUS class); switch to ARNi when feasible — 2022 AHA/ACC/HFSA Class I (PMID 35363499)
3. losartan 25–50 mg PO once daily (ARB, contraindication substitute) — HEAAL — high-dose 150 mg preferred when ACEi/ARNi unavailable; 2022 AHA/ACC/HFSA Class I (PMID 35363499)

Setting playbook (outpatient) — Initiate and rapidly titrate all 4 GDMT pillars to target or maximally tolerated dose (ACC/AHA 2022 HF; 2024 ACC ECDP HFrEF)
4. sacubitril/valsartan 24/26 → 49/51 → 97/103 mg PO BID — LVEF ≤40, SBP ≥100, no ACEi within 36 h, no angioedema history (ACC/AHA 2022 HF) (PARADIGM-HF McMurray NEJM 2014; ACC/AHA 2022 HF Class I)
5. carvedilol OR metoprolol succinate OR bisoprolol carvedilol 3.125 → 25 BID; metoprolol succ 12.5 → 200 daily; bisoprolol 1.25 → 10 daily PO BID/daily — No active decompensation (ACC/AHA 2022 HF) (COPERNICUS NEJM 2001 / MERIT-HF Lancet 1999 / CIBIS-II Lancet 1999; ACC/AHA 2022 HF Class I)
6. spironolactone OR eplerenone spironolactone 12.5 → 50 daily; eplerenone 25 → 50 daily PO daily — K <5.0, eGFR ≥30 (ACC/AHA 2022 HF) (RALES Pitt NEJM 1999 / EMPHASIS-HF Zannad NEJM 2011; ACC/AHA 2022 HF Class I)
7. dapagliflozin OR empagliflozin 10 mg PO daily — eGFR ≥20, no active DKA (ACC/AHA 2022 HF) (DAPA-HF McMurray NEJM 2019 / EMPEROR-Reduced Packer NEJM 2020; ACC/AHA 2022 HF Class I)
8. ivabradine 5 → 7.5 mg PO BID — HR ≥70 sinus on max BB, LVEF ≤35, NYHA II–III (ACC/AHA 2022 HF) (SHIFT Lancet 2010; ACC/AHA 2022 HF Class IIa)
9. vericiguat 2.5 → 10 mg PO daily — Recent worsening HF / IV diuretic / hospitalisation, SBP ≥100 (ACC/AHA 2022 HF) (VICTORIA NEJM 2020; ACC/AHA 2022 HF Class IIb)
10. furosemide / torsemide furosemide 20–40 mg or torsemide 10–20 mg PO daily–BID — Volume overload / weight gain >2 kg in 3 days (ACC/AHA 2022 HF) (Symptom + congestion control (ACC/AHA 2022 HF))

Non-pharmacologic actions:
- Sodium <2 g/day, fluid <1.5–2 L/day if hyponatraemia or congestion — ACC/AHA 2022
- Cardiac rehab referral (HF-ACTION) — ACC/AHA 2022
- CRT eligibility check at LVEF ≤35 + LBBB ≥150 ms despite ≥3 mo GDMT — ACC/AHA 2022; ESC 2021
- ICD eligibility check at LVEF ≤35 + NYHA II–III despite ≥3 mo GDMT — ACC/AHA 2022
- Vaccinations (flu annually; pneumococcal; COVID; RSV in eligible) — ACC/AHA 2022
- AF rhythm control / catheter ablation per CASTLE-AF if AF + HFrEF — ESC 2021; CASTLE-AF

AVOID / contraindication checks:
- Hyperkalemia mra block if K gt 5.0 — ACC/AHA 2022; RALES Pitt NEJM 1999
- Aki acei arni pause if AKI — ACC/AHA 2022
- Angioedema arni history block — PARADIGM HF McMurray NEJM 2014
- Bb block if acute decompensation or hr lt 50 — ACC/AHA 2022; ESC 2021
- Sglt2i block if egfr lt 20 or active DKA — DAPA HF McMurray NEJM 2019; EMPEROR Reduced Packer NEJM 2020
- Ivabradine block if AF or HR lt 70 — SHIFT Lancet 2010
- Vericiguat block if SBP lt 100 — VICTORIA NEJM 2020

Monitoring

Regimen monitoring:
- BMP q1w x2 after GDMT change — ACC/AHA 2022; 2024 ACC ECDP HFrEF
- BMP q1m during titration — ACC/AHA 2022
- BMP q3m at steady state — ACC/AHA 2022
- BP HR at each visit — ACC/AHA 2022
- weight daily at home — ACC/AHA 2022; STRONG-HF Mebazaa Lancet 2022
- NT-proBNP q3-6m or after decompensation — ESC 2021; ACC/AHA 2022
- iron panel q6m until repleted — AFFIRM-AHF (PMID 33197395) total HHF RR 0.74 (0.58–0.94); IRONMAN (PMID 36347265); ESC 2023 FU Class IIa (PMID 37622666)

Setting (outpatient) monitoring:
- BMP at 1–2 wks after each GDMT change, then q1m during titration, q3m steady state — ACC/AHA 2022; 2024 ACC ECDP HFrEF
- Daily home weight; alert if >2 kg gain in 3 days — ACC/AHA 2022; STRONG-HF Mebazaa Lancet 2022
- NT-proBNP q3–6 mo or after decompensation — ESC 2021; ACC/AHA 2022
- Echo at 6–12 mo to assess LVEF recovery — ACC/AHA 2022

Follow-up plan: Visit cadence by NYHA + recent titration; cardiac rehab; vaccinations (flu, pneumococcal, COVID, RSV)
- Close-out criterion: follow-up scheduled and patient given return precautions

Monitoring phase: BMP within 1–2 wks of GDMT change, then at each titration; weight + symptom diary; iron repletion check

Disposition

Current setting: outpatient — Initiate and rapidly titrate all 4 GDMT pillars to target or maximally tolerated dose (ACC/AHA 2022 HF; 2024 ACC ECDP HFrEF)

Disposition criteria:
- Continue titration if asymptomatic + at goal dose — 2024 ACC ECDP HFrEF
- Refer advanced HF clinic if Stage D criteria — ACC/AHA 2022
- Discharge to PCP follow-up only after all 4 pillars at maximum tolerated dose — ACC/AHA 2022; STRONG-HF Mebazaa Lancet 2022

Escalation triggers (move to higher acuity):
- Weight gain >2 kg in 3 days + worsening symptoms → outpatient diuretic up-titration or admit — ACC/AHA 2022
- NYHA IV / inotrope-dependence / refractory volume overload → advanced HF referral (VAD/transplant) — ACC/AHA 2022; ESC 2021
- SBP <90 + signs of hypoperfusion → ED + cardio.cardiogenic-shock.core.v1 — ACC/AHA 2022

Patient Action Plan

**HFrEF 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 at or 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
- No new lightheadedness or palpitations — ACC/AHA 2022
Actions:
- Take all GDMT meds as prescribed every day — ACC/AHA 2022
- Sodium <2 g/day; fluids per plan — ACC/AHA 2022
- Daily weight at the same time, after voiding, in same clothing — ACC/AHA 2022
- Keep all clinic + lab appointments — ACC/AHA 2022

**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; STRONG-HF Mebazaa Lancet 2022
- New ankle / leg swelling — ACC/AHA 2022
- Need extra pillow to sleep, or waking up short of breath — ACC/AHA 2022
- Increased fatigue or reduced exercise tolerance — ACC/AHA 2022
- New persistent cough — ACC/AHA 2022
Actions:
- Take prescribed rescue diuretic dose (e.g., extra furosemide 40 mg) per action plan — ACC/AHA 2022
- Recheck weight in 24 h; recheck symptoms — 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:
- Weight not back to dry-weight range after 48 h of 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
- Cold/clammy skin, very low BP, or HR <50 / >130 — ACC/AHA 2022; ESC 2021
Actions:
- Call 911 / emergency services immediately — ACC/AHA 2022
- Sit upright; loosen tight clothing — ACC/AHA 2022
- Do not drive yourself — call EMS — ACC/AHA 2022
- Bring medication list + weight diary — ACC/AHA 2022
Contact provider when:
- Any red zone symptom — go to ED now, do not wait — ACC/AHA 2022

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90 + cool extremities, oliguria, AMS, or rising lactate — ACC/AHA 2022; ESC 2021
- [SEVERE] K ≥5.5 on MRA / ACEi / ARNi — ACC/AHA 2022; RALES Pitt NEJM 1999
- [SEVERE] Cr rise >0.3 mg/dL or >50% from baseline on ACEi / ARNi / MRA / SGLT2i — ACC/AHA 2022

Citations

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

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