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Therapeutics · Cardiovascular

Heart failure with reduced ejection fraction

Therapeutic goals

  • Survival and hospitalization reduction with the four foundational pillars
  • Decongestion and symptom control with the minimum necessary diuretic
  • Every pillar at target dose, or a documented reason why not

Patient factors that steer the choice

  • Blood pressure and heart-rate headroom for titration
  • Renal function and potassium (gates for RAAS and MRA)
  • Congestion status: beta blockers start on dry patients
  • Adherence burden: four pillars is four commitments

Major drug classes

ACE inhibitorsAngiotensin receptor blockersBeta blockersDiabetes agentsLoop diuretics

Treatment approach

  1. 01Four pillars, early

    RAAS blockade (ACEi/ARB/ARNI), evidence-based beta blocker, MRA, and SGLT2 inhibitor: contemporary practice starts all four rapidly rather than sequentially over months.

  2. 02Diuretics for symptoms

    Loops treat congestion, not prognosis; the dose is the lowest that keeps the patient euvolemic, revisited constantly.

  3. 03Titrate to target

    Each pillar climbs toward its trial dose as BP, HR, potassium, and creatinine allow; a plateaued low dose deserves a documented reason.

  4. 04Reassess the whole

    Every decompensation triggers the checklist: adherence, NSAIDs, dietary sodium, interacting drugs, and pillar doses.

Monitoring

  • Daily weights (patient-owned)
  • Potassium and creatinine 1-2 weeks after each RAAS/MRA change
  • Heart rate and BP through beta-blocker titration
  • Reliever-style loop use as a congestion signal

Pearls

  • An SGLT2 inhibitor's early eGFR dip mirrors the ACE inhibitor's: expected, hemodynamic, protective.
  • NSAIDs undo heart-failure therapy from the outside; the counter is part of the care team.

Choose the drug

Heart failure with reduced ejection fraction

66-year-old with HFrEF (EF 30%), now euvolemic on furosemide.

Current: ramipril (target dose), bisoprolol (titrating).

BP 118/72, HR 68, K 4.4, eGFR 58.

What completes the foundational therapy?

Keep going

Heart failure medication review →Empagliflozin →Bisoprolol →

Last reviewed 2026-08-15 · Principle-level content; jurisdiction-specific recommendations live in the cited guidelines: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure · CCS/CHFS Heart Failure Guidelines (current)