Red Flags
- Cardiogenic shock — hypotension, cool peripheries, oliguria, elevated lactate on top of decompensated heart failure — immediate ICU and inotropic/MCS support[1]
- Acute pulmonary oedema with respiratory distress and SpO₂ <90% on supplemental oxygen — IV diuretic, NIV, urgent inpatient cardiology[1]
- New-onset symptoms with NT-proBNP ≥ 2000 ng/L — refer for specialist assessment within 2 weeks; ≥ 400 within 6 weeks[1]
- Decompensation in established HF with weight gain >2 kg in 3 days, worsening orthopnoea, or NYHA class deterioration[1]
First-line treatment
Interventions
- Cardiac rehabilitation and lifestyle[1]Structured supervised exercise programme, sodium and fluid moderation, smoking cessation, alcohol limitation, vaccination (influenza, pneumococcal, COVID-19)
- Rapid in-hospital optimisation[1]Initiate or up-titrate the four pillars of HF therapy during the index admission rather than after discharge — the 'STRONG-HF' protocol; reduces 6-month death and rehospitalisation
First-line drug therapy
| 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 |
Ramipril or perindopril[1]
ACE inhibitor
- Adult
- Ramipril 1.25–10 mg PO daily; perindopril 2–8 mg daily; titrate over 2–4 weeks
- Paediatric
- —
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
- Adult
- 49/51 mg PO BD, titrate to 97/103 mg BD; allow 36-hour washout from prior ACE inhibitor
- Paediatric
- —
Class I for HFrEF in place of ACE-i. Cornerstone of foundation therapy
Bisoprolol[1]
Beta-blocker (cardioselective)
- Adult
- Start 1.25 mg PO once daily, titrate to 10 mg once daily over 4–8 weeks
- Paediatric
- —
Pillar 2 of HFrEF foundation therapy. Carvedilol or metoprolol succinate are interchangeable
Spironolactone[1]
Mineralocorticoid receptor antagonist (MRA)
- Adult
- 12.5–25 mg PO once daily, up-titrate to 50 mg if tolerated and K+ <5.5
- Paediatric
- —
Pillar 3 of HFrEF foundation therapy. Eplerenone if gynaecomastia. Monitor K+ and creatinine
Dapagliflozin or empagliflozin[1]
SGLT2 inhibitor
- Adult
- 10 mg PO once daily
- Paediatric
- —
Pillar 4 of foundation therapy. 2023 update extends Class I to HFmrEF AND HFpEF — full LVEF spectrum
Furosemide[1]
Loop diuretic
- Adult
- 20–80 mg PO daily; titrate to symptom and weight control
- Paediatric
- —
For congestion. Does not improve mortality — use lowest effective dose
Ferric carboxymaltose or ferric derisomaltose[1]
IV iron
- Adult
- Per package weight-based regimen, single or split infusions
- Paediatric
- —
Symptomatic HFrEF or HFmrEF with iron deficiency (ferritin <100 µg/L OR ferritin 100–299 with transferrin saturation <20%); reduces HF hospitalisation
Safety-net
- Weigh yourself daily — gain of >2 kg in 3 days means more fluid is building up; contact your clinician same day[1]
- Worsening breathlessness, leg swelling, sleeping propped up on more pillows, or new dizziness — call your clinician same day; severe distress means emergency services[1]
- Continue all four heart-failure medications even when feeling well — stopping any one increases the risk of decompensation[1]
Referral criteria
- Cardiogenic shock or acute pulmonary oedema with SpO₂ <90% on oxygenEmergency department for IV diuretic, NIV, and ICU consideration[1]
- Suspected heart failure with NT-proBNP ≥2000 ng/LCardiology and specialist heart-failure team within 2 weeks[1]
- Suspected heart failure with NT-proBNP 400–2000 ng/LCardiology and echocardiography within 6 weeks[1]
- HFrEF symptomatic on optimised quadruple therapy with QRS ≥130 ms or LVEF ≤35%Cardiology for cardiac resynchronisation or ICD evaluation[1]
Clinical summary
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.