Chronic heart failure in adults

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]

Cardiac rehabilitation^[1]
Structured supervised exercise; reduces death and rehospitalisation

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

Pillar 3; monitor K+ and creatinine

Dapagliflozin or empagliflozin^[1]

SGLT2 inhibitor

Pillar 4 across HFrEF, HFmrEF, HFpEF (full LVEF spectrum per 2023 update)

Furosemide^[1]

Loop diuretic

Symptom control only

Weigh yourself daily; gain >2 kg in 3 days — call same day^[1]
Worsening breathlessness, swelling, or new dizziness — same-day medical review^[1]
Continue all four pillars even when feeling well — stopping any one increases decompensation risk^[1]

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]

Diagnosis and management of heart failure across HFrEF, HFmrEF, and HFpEF with quadruple-pillar foundation therapy.

1.2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (with 2023 focused update) (2022)