Skip to textbook content
Doctor’s PassportTextbook
TopicsAll topics

Loading topic navigation…

Textbook navigation
TopicsAll topics

Loading topic navigation…
Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Chronic heart failure with reduced ejection fraction

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull

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.
  • Never combine ACE inhibitor with ARNI; allow at least a 36-hour washout after the last ACE-inhibitor dose before sacubitril/valsartan.
  • Use loop diuretic for congestion at the lowest dose that maintains euvolaemia; it improves symptoms but is not a substitute for disease-modifying treatment.
  • Check renal function/electrolytes before ACE inhibitor/ARNI/ARB/MRA, then 1–2 weeks after starting and each increment, every 3–6 months once stable and whenever renal function may be compromised.
  • Do not start or up-titrate beta-blocker during acute decompensation; once stable, avoid withholding it solely because of age, COPD, diabetes or peripheral vascular disease.
  • Persistent symptoms, low EF, arrhythmia, worsening end-organ function or repeated admission should trigger specialist review for ICD/CRT, valve/coronary options or advanced therapy.

Key red flags

Urgent decompensation

Rest dyspnoea, pulmonary oedema, hypotension, confusion, oliguria or rapid weight gain needs same-day acute-HF assessment.

Investigation priorities

01
NT-proBNPFirst step

Triage suspected chronic HF for specialist assessment and echocardiography.

Management branches

First-lineConfirm and stabilise

Symptoms/signs with raised NT-proBNP or known LV dysfunction

  1. Use NICE NT-proBNP thresholds for specialist assessment and echocardiography; expedite acute symptoms through the acute-HF pathway.
  2. Define LVEF, aetiology, rhythm, congestion, BP, renal function, potassium, iron status and comorbidity.
  3. Use loop diuretic to achieve euvolaemia and create a written care plan with a named HF coordinator.
  4. Refer to the specialist HF MDT for diagnosis and initial optimisation.
Second-lineIntroduce four classes

Confirmed stable HFrEF

  1. Offer ACE inhibitor, evidence-based beta-blocker, MRA and SGLT2 inhibitor; choose order and starting doses from BP, pulse, renal function, potassium, frailty and preference.
  2. Do not wait to reach the target dose of one class before starting every other class; arrange early monitoring after each change.
  3. If ACE inhibitor causes non-angioedema intolerance, use the NICE ARNI-based alternative with specialist support; after ACE-inhibitor angioedema, avoid ARNI and consider the ARB route.
  4. Keep titrating toward licensed/evidence-based target or maximum tolerated doses while maintaining euvolaemia.

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.BP, creatinine/eGFR and potassium monitoring; pregnancy and prior ACE-inhibitor angioedema contraindicate. Do not combine with ARNI or ARB.
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.Start only when clinically stable; assess ECG, pulse, BP and HF symptoms after increments. Avoid without pacing in second/third-degree block or HR <50 bpm; reduce gradually if stopping rather than withdrawing abruptly.
Open full textbook →Answer 2 questionsCardiology check
Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG106: Chronic heart failure in adultsSeptember 2025 diagnosis, four-class treatment, monitoring, devices and referral.
  • NICE NG106 HFrEF visual summaryCurrent core-treatment combinations.
  • ESC 2021 Guidelines for acute and chronic heart failureAetiology, devices and advanced-HF context.
  • Sacubitril/valsartan SmPCLicensed doses, washout and contraindications.
  • Bisoprolol SmPCLicensed HFrEF titration.
  • MHRA: SGLT2 inhibitors during surgery or acute serious illnessInterruption and blood-ketone safety advice.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom