Red Flags
- Cardiogenic shock — hypotension with hypoperfusion on top of decompensated HF — emergent ICU and inotropic/MCS support[1]
- Acute pulmonary oedema with SpO₂ <90% on supplemental oxygen — IV diuretic, NIV, urgent inpatient cardiology[1]
- New-onset HF symptoms with NT-proBNP markedly elevated — refer for specialist assessment[1]
- Decompensation with weight gain >2 kg in 3 days, worsening orthopnoea, NYHA class deterioration[1]
First-line treatment
Interventions
- Cardiac rehabilitation[1]Structured supervised exercise; reduces death and rehospitalisation
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Sacubitril/valsartan (ARNI)[1] | Angiotensin receptor-neprilysin inhibitor | 49/51 mg PO BD, titrate to 97/103 mg BD; 36-h washout from prior ACE-i | — | Pillar 1 in HFrEF (replaces ACE-i where tolerated) |
| Bisoprolol or carvedilol or metoprolol succinate[1] | Evidence-based beta-blocker | Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD; metoprolol succ 25–200 mg daily | — | Pillar 2 of foundation therapy |
| Spironolactone or eplerenone[1] | Mineralocorticoid receptor antagonist | Spironolactone 12.5–50 mg daily; eplerenone 25–50 mg daily | — | Pillar 3; monitor K+ and creatinine |
| Dapagliflozin or empagliflozin[1] | SGLT2 inhibitor | 10 mg PO once daily | — | Pillar 4 across HFrEF, HFmrEF, HFpEF (full LVEF spectrum per 2023 update) |
| Furosemide[1] | Loop diuretic | 20–80 mg PO daily; titrate to volume status | — | Symptom control only |
Sacubitril/valsartan (ARNI)[1]
Angiotensin receptor-neprilysin inhibitor
- Adult
- 49/51 mg PO BD, titrate to 97/103 mg BD; 36-h washout from prior ACE-i
- Paediatric
- —
Pillar 1 in HFrEF (replaces ACE-i where tolerated)
Bisoprolol or carvedilol or metoprolol succinate[1]
Evidence-based beta-blocker
- Adult
- Bisoprolol 1.25–10 mg daily; carvedilol 3.125–25 mg BD; metoprolol succ 25–200 mg daily
- Paediatric
- —
Pillar 2 of foundation therapy
Spironolactone or eplerenone[1]
Mineralocorticoid receptor antagonist
- Adult
- Spironolactone 12.5–50 mg daily; eplerenone 25–50 mg daily
- Paediatric
- —
Pillar 3; monitor K+ and creatinine
Dapagliflozin or empagliflozin[1]
SGLT2 inhibitor
- Adult
- 10 mg PO once daily
- Paediatric
- —
Pillar 4 across HFrEF, HFmrEF, HFpEF (full LVEF spectrum per 2023 update)
Furosemide[1]
Loop diuretic
- Adult
- 20–80 mg PO daily; titrate to volume status
- Paediatric
- —
Symptom control only
Safety-net
Referral criteria
- Cardiogenic shock or acute pulmonary oedema with SpO₂ <90%Emergency department; ICU consideration[1]
- Suspected new HF with markedly elevated natriuretic peptideCardiology / heart failure team within 2 weeks[1]
- HFrEF symptomatic on optimised quadruple therapy with QRS ≥130 ms or LVEF ≤35%Cardiology for CRT or ICD evaluation[1]
Clinical summary
Diagnosis and management of heart failure across HFrEF, HFmrEF, and HFpEF with quadruple-pillar foundation therapy.