CardiologyTier 1Disease (DEADMAN)

Heart failure - reduced ejection fraction

Description

Syndrome: breathlessness + fatigue + fluid retention
- From structural/functional cardiac impairment

Phenotypes - 2026 Second Universal Definition

Moves away from rigid EF cutoffs. HFmrEF retired as a category.**


HFrEF	Reduced EF. Full evidence base
HFimpEF	Previously reduced, now increased/normalised. Improvement is NOT resolution - remain at risk, continue therapy
HFpEF	Preserved EF

EF ~<=40% still the practical threshold for "reduced" and for trial entry
- But the 2026 document deliberately avoids fixed cutoffs - measurement varies by modality

Stages

A - risk factors, no structural disease
B - pre-HF: structural/functional abnormality or raised NP, no symptoms
- Emphasised in 2026 as the critical window for intervention
C - symptomatic (may remit or progress)
D - advanced

Syndrome, not a diagnosis - always establish aetiology

Epidemiology

1-2% adults; >10% if age >70
~480,000 Australians
M>F in HFrEF (F>M in HFpEF)
Incidence falling (better IHD care), prevalence rising (better survival)
Aboriginal and Torres Strait Islander: earlier onset, higher rates
- RHD, IHD, CKD burden

Aetiopathogenesis

Causes

IHD ~2/3
Pressure/volume overload - HTN, AS, regurgitant lesions, shunts
Toxic - EtOH, anthracyclines, trastuzumab, checkpoint inhibitors, methamphetamine
Inflammatory - viral/giant cell myocarditis, sarcoid, CTD
Infiltrative - amyloid, haemochromatosis
Genetic - DCM (titin, lamin A/C)
Arrhythmic - tachycardia-mediated (reversible if rate controlled)
Other - peripartum, thyroid

Mechanism

dec cardiac output -> neurohormonal activation
- Adaptive acutely, destructive chronically
SNS
- inc HR, inc contractility
- -> inc O2 demand, arrhythmia
RAAS
- Vasoconstriction, Na retention
- -> fibrosis, adverse remodelling
Natriuretic peptides oppose -> progressively overwhelmed
Remodelling: dilatation, wall thinning, spherical LV, functional MR
- -> self-reinforcing
Every mortality-benefit drug interrupts neurohormonal activation
- Inotropes improve haemodynamics without it -> better symptoms, shorter life

Diagnosis

Clinical

Exertional dyspnoea, orthopnoea, PND, fatigue
Congestion: inc JVP, S3, bibasal creps, oedema, hepatomegaly
- Specific but insensitive
Displaced apex = dilatation
Cool peripheries + narrow pulse pressure = low output

A. Natriuretic peptides

First-line rule-out
HF unlikely if:
- NT-proBNP <125 ng/L (non-acute)
- NT-proBNP <300 ng/L (acute)
inc by: age, AF, renal impairment
dec by obesity - normal level does not exclude

B. TTE

EF, chamber size, wall motion, valves, filling pressures, RV

C. ECG - in everyone

Ischaemia, prior infarct, LBBB, arrhythmia
Completely normal ECG makes HFrEF unlikely

Bloods

FBE, UEC, LFT, TSH, iron studies, HbA1c, lipids

Establish aetiology

Ischaemic assessment in most
CMR if cause unclear - sarcoid, myocarditis, amyloid, infiltrative
Bone scintigraphy + paraprotein if ATTR amyloid suspected
Genetics if family history or phenotype suggestive

Management

Foundational medical therapy - all patients

The four pillars. Start early and together, then up-titrate.

Rapid up-titration is now validated (STRONG-HF) - not the old slow sequential approach
- Aim for full doses within ~2 weeks of discharge, with close follow-up
- Also has a decongestive, diuretic-sparing effect

	Agent	Note
1	ARNI (sacubitril/valsartan)	Preferred if symptoms persist on ACEi; else ACEi, or ARB if intolerant. 36h washout from ACEi - angioedema
2	Beta blocker	Only bisoprolol, carvedilol, metoprolol succinate, nebivolol. Start low, go slow, not in decompensation
3	MRA	Spironolactone or eplerenone. Monitor K+, renal function. ESC 2026: MRA now Class I across the EF spectrum; finerenone (non-steroidal) has evidence in HFpEF/HFmrEF
4	SGLT2i	Dapagliflozin or empagliflozin. Benefit independent of diabetes

Titrate to trial target dose, or highest tolerated
- Falling BP or modest creatinine rise usually tolerable - not automatic stop

Additional medical therapy

Loop diuretic - for congestion
- Symptomatic only, no mortality benefit, minimum effective dose
Ivabradine - if sinus rate >=70 despite maximal beta blockade
Hydralazine + nitrate - if RAAS inhibition not tolerated; added in African ancestry
IV iron - if iron deficient, improves symptoms regardless of anaemia
Digoxin - recommendation upgraded in ESC 2026 for selected chronic HF
In HFpEF with obesity: semaglutide or tirzepatide now Class IIa (STEP-HFpEF, SUMMIT) - not HFrEF

Non-pharmacological and interventional

ICD if:
- EF <=35% after >=3 months optimal therapy, AND
- NYHA II-III, AND
- Survival >1yr expected
CRT added if QRS >=150 ms with LBBB
- Greatest benefit
Transplant or durable MCS if refractory
- Refer before irreversible end-organ damage
Fluid/weight self-monitoring + escalation plan
HF MDT follow-up
Vaccination

Avoid

NSAIDs, thiazolidinediones, CCBs other than amlodipine, class I antiarrhythmics

Associations

AF - shared risk factors, each worsens the other
- Rhythm control incl. ablation benefits selected patients
Iron deficiency - ~50%, with or without anaemia
CKD - cardiorenal syndrome, limits drug titration
T2DM - drives risk, shifts choice toward SGLT2i
Sleep-disordered breathing - obstructive and central (Cheyne-Stokes)
Depression + cognitive impairment - common, under-recognised, worse adherence
Cardiac cachexia - advanced disease, ominous

Natural history & complications

Progressive, punctuated by decompensations
- Each leaves a lower functional baseline
~50% dead within 5 years (worse than many common cancers)
HF admission = clear inflection in trajectory

Poor prognostic markers

NYHA class, low EF, high NP
Renal impairment, hyponatraemia
Persistent congestion, cachexia, frequent admission

Decompensation triggers

Ask at every presentation

Non-adherence - drugs or fluid
Dietary salt
Arrhythmia (esp. new AF), ischaemia, infection
Anaemia, thyroid dysfunction
NSAIDs, uncontrolled HTN

Complications

Arrhythmia + SCD
Progressive pump failure
Functional MR
Thromboembolism
Cardiorenal / cardiohepatic syndrome

Trajectory uncertain rather than steadily downward - begin advance care planning early

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