Decision support only — not a substitute for the NHFA/CSANZ guidelines, ESC/ACC guidance, eTG, or your cardiology team. HFrEF = LVEF ≤40% with symptoms/signs. The shift since 2018: start all four pillars early and together at low dose, then up-titrate — don't max one before adding the next. Verify all doses, renal function and potassium.
1 The four pillars — all Class I, all started early
ARNI Ior ACEi / ARB
Sacubitril/valsartan preferred over ACEi/ARB (PARADIGM-HF).
ARNI first-line. ACEi or ARB if ARNI not feasible (cost/tolerance). 36h washout from an ACEi (angioedema); none from an ARB.
Beta-blocker Ievidence-based agents
Bisoprolol, carvedilol, metoprolol succinate, nebivolol (CIBIS-II, MERIT-HF, COPERNICUS).
Start when euvolaemic. Not in acute decompensation / "wet." Low dose → up-titrate to target HR/dose.
MRA Ispironolactone / eplerenone
RALES, EMPHASIS-HF.
Add early. Avoid if K⁺ >5.0 or eGFR <30; recheck K⁺ & creatinine after starting and after dose changes.
SGLT2i Idapagliflozin / empagliflozin
DAPA-HF, EMPEROR-Reduced — benefit regardless of diabetes.
Add to all. Minimal titration, fast benefit, mild decongestion. Sick-day rules (euglycaemic DKA).
Benefits of ARNI and SGLT2i appear within weeks, so start them upfront rather than after maxing the older agents (STRONG-HF: rapid up-titration + close follow-up improves outcomes). All four can be commenced before discharge after an admission, once stabilising. Loop diuretics are not a pillar — they relieve congestion but give no mortality benefit.
2 Getting GDMT in — and up to target
The real failure is under-titration
- TargetsMost patients sit on sub-target doses. Chase target (or max tolerated) doses — that's where the survival benefit lives.
- CadenceReview & up-titrate at short intervals (~1–2 weekly early), with bloods each step.
- Reassess EFAfter ~3 months optimal GDMT — many recover, which changes device decisions.
What to hold for
- BPSymptomatic hypotension → reduce/space doses; asymptomatic low BP is usually fine.
- K⁺/renalHyperkalaemia or rising creatinine → adjust RAASi/MRA, recheck. Consider K⁺ binder rather than abandoning GDMT.
- HRBradycardia limits beta-blocker — but don't stop reflexively for asymptomatic low-normal HR.
3 Devices & add-ons
Devices — after optimal GDMT
- ICDPrimary prevention: LVEF ≤35% despite ≥3 mo GDMT, good function, >1 yr survival. (Weaker in non-ischaemic — DANISH.)
- CRTLVEF ≤35%, LBBB QRS ≥150 ms, sinus rhythm — strongest benefit. Weaker 130–149 / non-LBBB.
Selected add-ons
- IV ironIron deficiency (ferritin <100, or 100–300 + TSAT <20%) even without anaemia — symptoms/HFH (AFFIRM-AHF, IRONMAN).
- IvabradineSinus rhythm, HR ≥70 despite max beta-blocker, LVEF ≤35% (SHIFT).
- VericiguatWorsening HF despite GDMT (VICTORIA).
- Hyd/nitrateSelf-identified Black patients (A-HeFT) or RAASi-intolerant.
Symptom control
- LoopFurosemide for congestion — lowest effective dose. No mortality benefit.
- DigoxinSymptom/HFH reduction; rate control in AF.
- Self-careDaily weights, fluid/salt awareness, adherence.
4 What to avoid — and the congestion trap
Drugs that worsen HFrEF
- NSAIDsAvoid — fluid retention, renal, blunt diuretics/RAASi.
- CCBsNon-dihydropyridine (verapamil, diltiazem) — negative inotropes, avoid. Amlodipine/felodipine are safe if a CCB is needed.
- TZDsPioglitazone — fluid retention, worsens HF.
- AntiarrhythmicsMost class I agents are pro-arrhythmic in HF; amiodarone is the usual safe choice.
Don't confuse the two jobs
- DiureticDecongests, relieves symptoms — does not modify disease. Down-titrate as the pillars and SGLT2i take effect.
- PillarsModify disease, cut mortality. A dry, comfortable patient still needs all four at target.
- EF spectrumSGLT2i now benefits HFmrEF/HFpEF too (DELIVER, EMPEROR-Preserved) — but this sheet is HFrEF.
5 The whole patient & when to escalate
Comorbidities & supports
- Look forAF (rate/rhythm + anticoagulation), iron deficiency, CKD, sleep apnoea, diabetes.
- ProgramRefer to a HF disease-management program / specialist HF nurse — cuts readmission.
- RehabExercise-based cardiac rehab; vaccinate (flu, pneumococcal, COVID).
When to escalate
- AdvancedRecurrent admissions, escalating diuretics, low BP limiting GDMT, end-organ hypoperfusion → refer for transplant/LVAD assessment.
- PalliativeRefractory symptoms despite optimal therapy → palliative care alongside, not instead of, HF care.
- ACPAdvance care planning + device deactivation discussions before crisis.
Sources.
NHFA/CSANZ — Guidelines for the Prevention, Detection and Management of Heart Failure in Australia (2018) & MJA consensus statement on pharmacological management of HF (2022, four-pillar / upfront initiation). ESC 2021 HF guideline + 2023 focused update. ACC/AHA/HFSA 2022 + ACC 2025 HFrEF decision pathway. eTG; PBS for subsidy criteria.
Key trials: PARADIGM-HF & PIONEER-HF (ARNI); CIBIS-II/MERIT-HF/COPERNICUS (beta-blockers); RALES/EMPHASIS-HF (MRA); DAPA-HF/EMPEROR-Reduced (SGLT2i); STRONG-HF (rapid up-titration); SHIFT (ivabradine); VICTORIA (vericiguat); A-HeFT (hydralazine/nitrate); AFFIRM-AHF/IRONMAN (IV iron); DANISH (ICD in non-ischaemic).
Caveats: target doses and agent choice are individualised — verify against eTG/product information; PBS governs ARNI, SGLT2i, ivabradine and IV iron access. Reassess LVEF after GDMT optimisation before committing to a device. Companion to the chronic-disease set.