Chronic heart failure in adults

Red Flags

Cardiogenic shock — hypotension, cool peripheries, oliguria, lactic acidosis on top of decompensated heart failure — immediate ICU and inotropic support^[1]
Acute pulmonary oedema with respiratory distress and SpO₂ <90% on supplemental oxygen — IV diuretic, NIV, urgent inpatient cardiology^[1]
New-onset symptoms of heart failure with NT-proBNP ≥2000 ng/L — refer for specialist assessment within 2 weeks; ≥400 within 6 weeks^[1]
Decompensation in established heart failure 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)

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Ramipril^[1]	ACE inhibitor	Start 1.25–2.5 mg PO BD, titrate to 5 mg BD over 2–4 weeks as tolerated	—	Pillar 1 of quadruple therapy in HFrEF. Switch to sacubitril/valsartan if intolerant or symptomatic on optimised dose
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 quadruple therapy. Carvedilol or metoprolol succinate are alternatives
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 quadruple therapy. Eplerenone if gynaecomastia. Monitor K+ and creatinine
Dapagliflozin^[1]	SGLT2 inhibitor	10 mg PO once daily	—	Pillar 4 of quadruple therapy. Empagliflozin is interchangeable. Indicated across all EF phenotypes (HFrEF, HFmrEF, HFpEF) per 2025 update
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	—	First-line in HFrEF if ACE inhibitor intolerant per 2025 update (replaces ARB-as-substitute approach)
Furosemide^[1]	Loop diuretic	20–80 mg PO daily, titrate to symptom control	—	For congestion. Does not improve mortality — use lowest effective dose

Ramipril^[1]

ACE inhibitor

Adult: Start 1.25–2.5 mg PO BD, titrate to 5 mg BD over 2–4 weeks as tolerated
Paediatric: —

Pillar 1 of quadruple therapy in HFrEF. Switch to sacubitril/valsartan if intolerant or symptomatic on optimised dose

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 quadruple therapy. Carvedilol or metoprolol succinate are alternatives

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 quadruple therapy. Eplerenone if gynaecomastia. Monitor K+ and creatinine

Dapagliflozin^[1]

SGLT2 inhibitor

Adult: 10 mg PO once daily
Paediatric: —

Pillar 4 of quadruple therapy. Empagliflozin is interchangeable. Indicated across all EF phenotypes (HFrEF, HFmrEF, HFpEF) per 2025 update

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: —

First-line in HFrEF if ACE inhibitor intolerant per 2025 update (replaces ARB-as-substitute approach)

Furosemide^[1]

Loop diuretic

Adult: 20–80 mg PO daily, titrate to symptom control
Paediatric: —

For congestion. Does not improve mortality — use lowest effective dose

Safety-net

Weigh yourself daily — gain of more than 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 a flare^[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 chronic heart failure across reduced (HFrEF), mildly reduced (HFmrEF), and preserved (HFpEF) ejection fraction phenotypes.

References

1.NICE NG106 Chronic heart failure in adults: diagnosis and management (last updated September 2025) (2025)