Ambulatory: exertional dyspnea, orthopnea, PND, S4, apical murmur→axilla, edema; long-standing HTN
Initial orders: ECG, CXR, transthoracic echo (only way to tell systolic vs diastolic; EF low = systolic)
Start — 4 pillars (mortality benefit): ARNI (sacubitril-valsartan) or ACE-inhibitor/ARB + β-blocker (metoprolol succinate/carvedilol/bisoprolol) + SGLT2 inhibitor (dapagliflozin/empagliflozin) + MRA (spironolactone/eplerenone)
Congestion / fluid overload → loop diuretic (furosemide) titrated to symptoms
Still symptomatic → add Digoxin — ↓ symptoms & hospitalizations, does NOT ↓ mortality
Still symptomatic + wide QRS → Biventricular pacemaker (CRT). EF <35% → ICD (↓ mortality, not symptoms) — despite ≥3 months of optimal GDMT (and >40 days post-MI)
Order set
- ECG
- CXR
- Echo (EF)
- U&E, BNP
- Ferritin/TSAT, TFT, HbA1c
Criteria
AdmitDecompensation, hypotension, or worsening renal function
ICUCardiogenic shock / needing inotropes
VasopressorsLow-output shock despite optimisation
DischargeEuvolaemic, stable renal function/K⁺, on optimised oral therapy, weights + follow-up arranged
Never
- Combine ACE inhibitor with ARB (no benefit, ↑ harm)
- Order a cardiology consult on a single-answer CHF question
Key
- Mortality ↓: ACEi/ARB, β-blocker, spironolactone/eplerenone (SGLT2i now added).
- HFpEF (preserved EF): SGLT2 inhibitor is Class 2a to reduce HF hospitalizations (empagliflozin 10 mg OD — EMPEROR-Preserved; dapagliflozin — DELIVER); manage congestion with diuretics and treat comorbidities (HTN, AF). Non-DHP CCB: avoid in HFrEF.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Rest dyspnea
- Hypotension
- Worsening renal function on up-titration
Differentials
- COPD
- Renal/hepatic edema
- Constrictive pericarditis
- Anemia
Common mistakes
- Under-dosing the 4 pillars
- Stopping ACEi for mild Cr rise
- NSAIDs
Disposition & follow-up
Optimise 4 pillars; HF clinic follow-up 1–2 wk; daily weights.
Discharge package
MedicationsOptimised 4 pillars + diuretic for symptoms
Follow-upHF nurse/clinic; repeat U&E after titration
VaccinationInfluenza + pneumococcal
LifestyleSalt/fluid limits, daily weights, exercise as tolerated
Warning symptomsIncreasing SOB, oedema, weight gain, dizziness, palpitations
💊 Treatment detail — doses & preparation
Sacubitril/valsartan (ARNI)HF pillar
DoseStart 24/26 mg BD (49/51 if tolerated), double q2–4 wk to 97/103 mg BD
PreparationFixed-combination tablets 24/26, 49/51, 97/103 mg
Monitor36-h ACEi washout before starting (angioedema); BP, K⁺, creatinine
Bisoprololβ-blocker (HF)
DoseStart 1.25 mg OD, double every 2 wk to target 10 mg OD
Preparation1.25/2.5/5/10 mg tablets; take same time daily
MonitorHR, BP, HF symptoms — titrate slowly
SpironolactoneMRA
Dose25–50 mg OD (HF); 100–400 mg/day (hyperaldosteronism)
Preparation25/50/100 mg tablets
MonitorK⁺, creatinine at 3 d + 1 wk; gynaecomastia (eplerenone alternative)
DapagliflozinSGLT2 inhibitor
Dose10 mg OD (HF ± diabetes)
Preparation10 mg tablets
MonitorSick-day rules (hold when fasting/surgery), euglycaemic DKA, genital infections, eGFR
Furosemide POloop diuretic
Dose20–80 mg OD/BD, titrate to dry weight
Preparation20/40/500 mg tablets; take morning/midday
MonitorDaily weight, K⁺, renal function
📖 ESC / ACC-AHA Heart FailureReviewed July 2026