Synopsis
Diagnose HFrEF, introduce the NICE 2025 four-class treatment package safely and know when to move to ARNI, devices or advanced-heart-failure referral.
- NICE defines HFrEF as symptomatic heart failure with LVEF 40% or less.
- For HFrEF, offer an ACE inhibitor, evidence-based beta-blocker, MRA and SGLT2 inhibitor; individualise order and timing rather than fully titrating one before introducing the next.
- If symptoms persist on the maximum tolerated four classes, consider replacing the ACE inhibitor with an ARNI; primary-care prescribers should consider specialist advice before starting ARNI.
Key red flags
Rest dyspnoea, pulmonary oedema, hypotension, confusion, oliguria or rapid weight gain needs same-day acute-HF assessment.
Investigation priorities
Triage suspected chronic HF for specialist assessment and echocardiography.
Management branches
Symptoms/signs with raised NT-proBNP or known LV dysfunction
- Use NICE NT-proBNP thresholds for specialist assessment and echocardiography; expedite acute symptoms through the acute-HF pathway.
- Define LVEF, aetiology, rhythm, congestion, BP, renal function, potassium, iron status and comorbidity.
Confirmed stable HFrEF
Key medicines
RamiprilFor stable chronic HF, a typical licensed start is 1.25 mg orally once daily, doubling every 1–2 weeks toward 10 mg/day (once daily or divided) as tolerated; lower or slower dosing may be required.
BisoprololStart 1.25 mg orally once daily for 1 week, then 2.5 mg once daily for 1 week, 3.75 mg once daily for 1 week, 5 mg once daily for 4 weeks, 7.5 mg once daily for 4 weeks, then 10 mg once daily as maintenance if each stage is tolerated.