HFrEF: Guideline Directed Medical Therapy



"Must Be On"

 • ACEI, ARB, or ARNI AND select Beta Blockers (bisoprolol, carvedilol, metoprolol XL)



"Can Be On"

 • Diuretics*

 • Aldosterone antagonist

 • Hydralazine + Isosorbide dinitrate**

 • Ivabradine

 • Digoxin



Optimize BB to target dose first before increasing ACEI or ARB dose for higher mortality benefit.



Mortality Reducing:

 • ACEI or ARB

 • ARNI

 • Select BBs

 • Aldosterone antagonist

 • Hydralazine + Isosorbide dinitrate**



Morbidity Reducing:

 • Diuretics*

 • Ivabradine

 • Digoxin



*Loop diuretics preferred (add metolazone in diuretic resistance)

**For African American patients



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