The following are key points to remember from a 2024 ACC Expert Consensus Decision Pathway for treatment of heart failure with reduced ejection fraction (HFrEF), an update to the 2021 document:

1. In line with recent evidence and guidelines, the recommended core guideline-directed medical therapy (GDMT) for chronic heart failure (HF) includes an angiotensin II receptor/neprilysin inhibitor (ARNI), evidence-based beta-blocker, sodium-glucose cotransporter (SGLT) inhibitor, and mineralocorticoid antagonist (MRA). When feasible, early and rapid initiation of these therapies and titration to maximally tolerated doses within 3 months is recommended.
2. While no specific order of initiation or titration of GDMT is mandated, the following is some useful guidance: a) initiating low doses of all core therapies is likely more beneficial than being on one or two maximally titrated therapies, b) beta-blocker initiation and titration should be deferred until HF is compensated, c) ARNIs and SGLT inhibitors may lead to lower diuretic requirements, d) MRA and SGLT inhibitor use often has less blood pressure lowering effects, and e) mild declines in estimated glomerular filtration rate should not necessarily lead to medication stoppage.
3. A referral to an HF specialist should be considered for chronic HF with high-risk features to assess need for advanced HF therapies. A referral can also be considered for new-onset HF for initial evaluation and management, second opinion on potential HF etiologies, ongoing evaluation of known advanced HF or specific cardiomyopathies, and potential enrollment in clinical trials.
4. Management of HF is complex and requires a high degree of care coordination. A multidisciplinary, team-based approach should be used, with an emphasis on patient-centered care, shared decision making, and effective communication.
5. Difficulties with adherence to recommended HF therapies can be multifactorial. Effective strategies to improve adherence should be targeted to individual patient needs. Strategies include patient education, simplification of overall medication regimen, reduction of cost and access barriers, medication reminders, utilization of clinical pharmacist, and cognitive behavioral therapies.
6. For specific patient cohorts (self-identified African American patients, older patients, and patients with frailty), it is important to consider additional therapies, modified approaches to titration, and additional support systems that can improve overall outcomes.
7. Focusing on reducing patient costs for and increasing access to HF medications is important. Strategies to achieve this include using generic medications when possible and working with the multidisciplinary team to identify patient assistance programs, request pharmacy price matching, and complete necessary prior authorizations.
8. Assessing and addressing social determinants of health for patients is important in the context of the increasing complexity of HF care.
9. In addition to managing cardiovascular (CV) comorbidities, attention should be paid to addressing non-CV comorbidities that impact HF outcomes such as diabetes, chronic kidney disease, sleep-disordered breathing, iron deficiency, and viral infections (prevention with vaccination).
10. Palliative care is an integral part of HF care. All clinicians can contribute to palliative care support through routinely identifying goals of care, emphasizing quality of life, managing congestive symptoms throughout the HF course (including end-of-life), utilizing decision support tools, and engaging in preparedness planning.

Clinical Topics: Heart Failure and Cardiomyopathies

Keywords: Heart Failure, Reduced Ejection Fraction, Decision Support Systems, Clinical

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