| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Ramipril or perindopril[1] | ACE inhibitor | Ramipril 1.25–10 mg PO daily; perindopril 2–8 mg daily; titrate over 2–4 weeks | — | Pillar 1 of HFrEF foundation therapy. Switch to sacubitril/valsartan if intolerant or symptomatic on optimised dose |
| Sacubitril/valsartan (ARNI)[1] | Angiotensin receptor-neprilysin inhibitor | 49/51 mg PO BD, titrate to 97/103 mg BD; allow 36-hour washout from prior ACE inhibitor | — | Class I for HFrEF in place of ACE-i. Cornerstone of foundation therapy |
| Bisoprolol[1] | Beta-blocker (cardioselective) | Start 1.25 mg PO once daily, titrate to 10 mg once daily over 4–8 weeks | — | Pillar 2 of HFrEF foundation therapy. Carvedilol or metoprolol succinate are interchangeable |
| Spironolactone[1] | Mineralocorticoid receptor antagonist (MRA) | 12.5–25 mg PO once daily, up-titrate to 50 mg if tolerated and K+ <5.5 | — | Pillar 3 of HFrEF foundation therapy. Eplerenone if gynaecomastia. Monitor K+ and creatinine |
| Dapagliflozin or empagliflozin[1] | SGLT2 inhibitor | 10 mg PO once daily | — | Pillar 4 of foundation therapy. 2023 update extends Class I to HFmrEF AND HFpEF — full LVEF spectrum |
| Furosemide[1] | Loop diuretic | 20–80 mg PO daily; titrate to symptom and weight control | — | For congestion. Does not improve mortality — use lowest effective dose |
| Ferric carboxymaltose or ferric derisomaltose[1] | IV iron | Per package weight-based regimen, single or split infusions | — | Symptomatic HFrEF or HFmrEF with iron deficiency (ferritin <100 µg/L OR ferritin 100–299 with transferrin saturation <20%); reduces HF hospitalisation |
Diagnosis and management of acute and chronic heart failure across HFrEF, HFmrEF, and HFpEF, with foundational quadruple therapy and SGLT2 inhibitors across the LVEF spectrum.