managing-heart-failure

# Managing Heart Failure

Guides GDMT optimization for HFrEF and HFpEF with medication titration and monitoring schedules.

## Why This Skill Exists

Heart failure affects over 6 million Americans and is the leading cause of hospitalization in adults over 65. The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure introduced a paradigm shift: simultaneous initiation of all four pillars of GDMT for HFrEF, rather than sequential uptitration. Despite this, real-world data show that fewer than 25% of eligible HFrEF patients are on target doses of all four drug classes. Every month of delay in GDMT optimization is associated with increased mortality risk.

For HFpEF, the 2023 update recognized SGLT2 inhibitors as Class I therapy — the first evidence-based pharmacotherapy for this phenotype. Accurate classification (HFrEF vs. HFmrEF vs. HFpEF), systematic GDMT initiation, and protocol-driven titration are essential to reducing 30-day readmission rates and improving survival.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the current LVEF? (default: "LVEF not provided — classify as [VERIFY]")
2. What is the HF classification — HFrEF (LVEF ≤ 40%), HFmrEF (41–49%), or HFpEF (≥ 50%)? (default: "Classify from LVEF")
3. What is the current NYHA functional class (I–IV)? (default: "NYHA class not specified")
4. List all current cardiac medications with doses (default: "Medication list not provided")
5. What are the most recent labs — BMP (Cr, K+, Na+), BNP/NT-proBNP, CBC? (default: "Labs not available")
6. What is the current blood pressure and heart rate? (default: "Vitals not provided")
7. Is the patient euvolemic, hypervolemic, or hypovolemic? (default: "Volume status not assessed")
8. Are there contraindications to any GDMT pillar — hyperkalemia, renal dysfunction (eGFR), symptomatic hypotension, angioedema history? (default: "No known contraindications")

### Documents to Request

- Most recent echocardiogram report (LVEF, diastolic function, valve disease)
- Current medication list with dosages and timing
- Comprehensive metabolic panel within 2 weeks
- BNP or NT-proBNP (baseline and trend)
- 12-lead ECG (for QRS duration — CRT candidacy)
- Recent discharge summary if hospitalized
- Iron studies (ferritin, TSAT) for IV iron candidacy
- Device interrogation if ICD/CRT present

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## Step 1: Heart Failure Classification and Staging

**LVEF-Based Classification (2022 AHA/ACC/HFSA):**

| Category | LVEF | Primary GDMT Strategy |
|----------|------|----------------------|
| HFrEF | ≤ 40% | Four pillars: ARNi/ACEi/ARB + BB + MRA + SGLT2i |
| HFmrEF | 41–49% | SGLT2i (Class 2a); ARNi, BB, MRA may be considered |
| HFpEF | ≥ 50% | SGLT2i (Class 1); diuretics for congestion; treat comorbidities |

**ACC/AHA Staging:**
- Stage A: At risk (HTN, DM, CAD, cardiotoxin exposure) — no structural disease or symptoms
- Stage B: Pre-HF — structural disease (LVH, reduced LVEF, valve disease) but no symptoms
- Stage C: Symptomatic HF
- Stage D: Advanced HF — refractory symptoms despite optimal GDMT

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## Step 2: GDMT Initiation — The Four Pillars for HFrEF

**Simultaneous Initiation Strategy (2022 Guideline Recommendation):**
Start all four drug classes at low doses simultaneously, then uptitrate each to target over 3–6 months.

| Pillar | Drug Class | Starting Dose Example | Target Dose |
|--------|-----------|----------------------|-------------|
| 1 | ARNi (sacubitril/valsartan) | 24/26 mg BID | 97/103 mg BID |
| 1 alt | ACEi (lisinopril) if ARNi not tolerated | 2.5–5 mg daily | 20–40 mg daily |
| 2 | Beta-blocker (carvedilol) | 3.125 mg BID | 25 mg BID (50 mg BID if > 85 kg) |
| 2 alt | Beta-blocker (metoprolol succinate) | 12.5–25 mg daily | 200 mg daily |
| 3 | MRA (spironolactone) | 12.5–25 mg daily | 25–50 mg daily |
| 4 | SGLT2i (dapagliflozin or empagliflozin) | 10 mg daily | 10 mg daily (no titration) |

**Initiation Guardrails:**
- SBP must be ≥ 100 mmHg for ARNi/ACEi initiation
- HR must be ≥ 60 bpm for beta-blocker initiation
- K+ must be ≤ 5.0 mEq/L and eGFR ≥ 30 for MRA initiation
- eGFR ≥ 20 for SGLT2i (per updated labeling)
- 36-hour washout required between ACEi and ARNi to prevent angioedema

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## Step 3: Uptitration Protocol and Monitoring

**Uptitration Schedule:**
- Double the dose of one pillar every 1–2 weeks as tolerated
- Recheck BMP (Cr, K+) within 1–2 weeks of any dose change for ARNi/ACEi/MRA
- Monitor symptoms, BP, and HR at each visit

**When to Hold or Reduce:**
- SBP < 90 mmHg with symptoms → reduce ARNi/ACEi first, then BB
- K+ > 5.5 mEq/L → hold MRA; recheck in 3 days
- Cr rise > 30% from baseline → hold ARNi/ACEi; evaluate volume status
- HR < 55 bpm with symptoms → reduce BB dose

**Adjunctive Therapies:**
- Hydralazine/Isosorbide dinitrate: add for African American patients with NYHA III–IV on optimal GDMT (A-HeFT trial)
- Ivabradine: consider when HR ≥ 70 bpm on maximally tolerated BB
- IV iron (ferric carboxymaltose): if ferritin < 100 or ferritin 100–300 with TSAT < 20%
- Loop diuretics: for volume management (not mortality benefit) — titrate to euvolemia

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## Step 4: Device Therapy Evaluation

**ICD Eligibility (Primary Prevention):**
- LVEF ≤ 35% despite ≥ 3 months of optimal GDMT
- NYHA II–III
- Life expectancy > 1 year
- Ischemic etiology: ≥ 40 days post-MI
- Non-ischemic etiology: ≥ 3 months on GDMT

**CRT Eligibility:**
- LVEF ≤ 35%, NYHA II–IV (ambulatory), LBBB with QRS ≥ 150 ms → Class I
- LBBB with QRS 120–149 ms → Class IIa
- Non-LBBB with QRS ≥ 150 ms → Class IIa
- Non-LBBB with QRS 120–149 ms → Class IIb

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## Step 5: Monitoring and Follow-Up Schedule

| Timepoint | Actions |
|-----------|---------|
| 1–2 weeks post-initiation | Recheck BMP, BP, HR; assess tolerability |
| Monthly (during titration) | Uptitrate one pillar per visit; recheck labs |
| 3 months | Reassess LVEF if newly diagnosed; evaluate device candidacy |
| 6 months | Target GDMT doses achieved; repeat echo |
| Annually | Full reassessment: echo, labs, functional status, device check |

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the HF classification correct based on the documented LVEF?
2. Are all four pillars of GDMT addressed — initiated, dose documented, or contraindication noted?
3. Is the uptitration plan documented with specific next-dose targets and lab monitoring?
4. Has device therapy candidacy been evaluated or scheduled for reassessment?
5. Are volume status management and diuretic dosing addressed?

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## Quality Audit

- [ ] HF classified as HFrEF, HFmrEF, or HFpEF with LVEF documented
- [ ] ACC/AHA stage (A–D) assigned
- [ ] NYHA functional class documented
- [ ] All four GDMT pillars addressed with current doses
- [ ] Contraindications to each pillar explicitly documented
- [ ] Uptitration targets and timeline established
- [ ] Lab monitoring schedule defined (BMP, BNP trend)
- [ ] ICD/CRT eligibility assessed or assessment scheduled
- [ ] Volume status documented with diuretic plan
- [ ] Iron studies checked and IV iron considered
- [ ] Hydralazine/isosorbide dinitrate considered for eligible patients
- [ ] 30-day readmission risk factors addressed
- [ ] Follow-up visit scheduled with specific titration goals

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## Guidelines

1. Never delay GDMT initiation for sequential uptitration — start all four pillars simultaneously at low doses per 2022 guidelines.
2. ARNi is preferred over ACEi/ARB in all HFrEF patients who tolerate it — switching from ACEi to ARNi improves outcomes (PARADIGM-HF).
3. SGLT2 inhibitors benefit HFrEF, HFmrEF, and HFpEF — do not withhold based on diabetes status.
4. An initial eGFR dip of up to 30% with ARNi or SGLT2i may be acceptable and often stabilizes — do not reflexively discontinue.
5. Beta-blockers should not be initiated during acute decompensation — stabilize volume status first, then start in the euvolemic state.
6. MRA-related hyperkalemia risk increases with eGFR < 30 and concurrent ACEi/ARB — monitor K+ closely.
7. Document the reason for every GDMT pillar that is not at target dose — "patient intolerant" requires documentation of the specific adverse effect and dose attempted.
8. Refer to advanced HF specialist for Stage D: persistent NYHA IV, recurrent hospitalizations, need for inotropes, or consideration of LVAD/transplant.