Heart Failure Management: A Practical Guide to the Four Pillars and Beyond | Medaptly

Heart Failure Management: A Practical Guide to the Four Pillars and Beyond

Clinical Practice Update — Staging, Guideline-Directed Medical Therapy, SGLT2 Inhibitors Across All EF Ranges, Device Therapy, and Advanced Heart Failure

This is an original clinical education article informed by current guidelines and evidence. See References below for source documents.

MDA-HF-2026 · 18 min read

Clinical Focus

Classification, prevention, guideline-directed medical therapy (GDMT) for HFrEF, HFmrEF, and HFpEF, device therapy, management of acute decompensation, and advanced heart failure referral

Target Audience

Internists, cardiologists, primary care physicians, hospitalists, pharmacists, advanced practice providers, residents

Setting

Primary care, cardiology outpatient, heart failure clinics, emergency departments, coronary care units, inpatient wards

Source Evidence

•2022 AHA/ACC/HFSA Guideline for Heart Failure Management (Circulation, 2022)
•2023 Focused Update of the 2021 ESC HF Guidelines (Eur Heart J, 2023)
•DAPA-HF Trial — Dapagliflozin in HFrEF (NEJM, 2019)
•DELIVER Trial — Dapagliflozin in HFmrEF/HFpEF (NEJM, 2022)
•EMPEROR-Preserved Trial — Empagliflozin in HFpEF (NEJM, 2021)
•PARADIGM-HF Trial — Sacubitril/Valsartan in HFrEF (NEJM, 2014)
•STRONG-HF Trial — Rapid Optimisation Post-Discharge (Lancet, 2022)

Key Clinical Takeaways

The most important actionable points from this Practice Update on heart failure management.

Heart failure management practical guide showing the four pillars of guideline-directed medical therapy and SGLT2 inhibitor use across all ejection fraction ranges — Overview of the modern approach to heart failure management across HF stages and EF phenotypes.

1HFrEF management now rests on four foundational drug classes — ARNi (or ACEi/ARB), beta-blocker, MRA, and SGLT2 inhibitor — start all four as early as possible → The Four Pillars
2SGLT2 inhibitors (dapagliflozin or empagliflozin) are now recommended across the entire EF spectrum — HFrEF, HFmrEF, and HFpEF → HFmrEF and HFpEF
3Prefer sacubitril/valsartan (ARNi) over ACEi in HFrEF — it reduces mortality, hospitalisation, and NT-proBNP more effectively → The Four Pillars
4Rapidly initiate and up-titrate GDMT within 6 weeks of a HF hospitalisation — the "high-intensity care" strategy reduces readmissions and death → After a Hospitalisation
5If a patient's EF improves above 40%, continue all four pillars — this is now termed "HF with improved EF" (HFimpEF), and discontinuation risks relapse → HF Classification
6Treat iron deficiency in symptomatic HFrEF and HFmrEF patients with intravenous iron to improve symptoms and reduce hospitalisations → Comorbidities
7CRT is indicated for LVEF ≤35%, sinus rhythm, LBBB with QRS ≥150 ms on optimal medical therapy — it improves EF, symptoms, and survival → Device Therapy
8Refer patients with advanced HF (persistent NYHA III–IV despite optimal therapy, recurrent hospitalisations, declining renal function) to a specialised HF team for evaluation for LVAD or transplant → Advanced HF
9Use diuretics to manage congestion but remember they have no proven mortality benefit — titrate to the lowest dose that maintains euvolaemia → Fluid Management
10Integrate palliative care early for patients with advanced HF — it is not limited to end-of-life care and improves quality of life alongside active treatment → Advanced HF

How Should You Classify Heart Failure?

The 2022 AHA/ACC/HFSA guideline refined heart failure classification by both stage (A through D) and ejection fraction phenotype. The updated EF categories are clinically important because each has a different evidence base for treatment.

HF Classification by Ejection Fraction: What Each Category Means for Treatment

Category	LVEF Range	Foundation Therapies	Key Practical Point
HFrEF	≤40%	All four pillars: ARNi (or ACEi/ARB) + beta-blocker + MRA + SGLT2i. Add hydralazine/isosorbide dinitrate in self-identified Black patients.	Strongest evidence base. The goal is to get all four classes started and titrated to target doses.
HFimpEF	Previously ≤40%, now >40%	Continue all four pillars indefinitely.	New category. Stopping therapy causes relapse in a large proportion of patients. "Improved" does not mean "cured."
HFmrEF	41–49%	SGLT2i (ESC 2023: Class I; AHA/ACC 2022: Class 2a). Consider ARNi, beta-blocker, MRA based on individual response.	SGLT2i has the strongest recommendation of any drug class in HFmrEF. Other HFrEF drugs are reasonable but less robustly supported.
HFpEF	≥50%	SGLT2i (ESC 2023: Class I; AHA/ACC 2022: Class 2a). Diuretics for congestion. Manage comorbidities aggressively (hypertension, AF, obesity, diabetes, CKD).	SGLT2i is the first drug class with proven benefit in HFpEF. Comorbidity management is central to outcomes.

Staging reminder: Stage A = at risk (no structural disease or symptoms); Stage B = pre-HF (structural disease or elevated biomarkers, no symptoms); Stage C = symptomatic HF; Stage D = advanced HF (refractory symptoms despite optimal therapy).

What Are the Four Pillars of HFrEF Treatment?

Modern heart failure management with reduced EF is built on four foundational drug classes, each of which independently reduces mortality and hospitalisation. The paradigm has shifted from sequential add-on to early, simultaneous initiation of all four whenever possible.

Prescribe sacubitril/valsartan (ARNi) as the preferred renin-angiotensin system inhibitor for patients with HFrEF. If ARNi is not feasible (e.g., cost, hypotension), use an ACEi; if ACEi is not tolerated, use an ARB. Allow a 36-hour washout when switching from ACEi to ARNi.

Strong Rec High Evidence AHA/ACC 2022 ESC 2021 PARADIGM-HF

Prescribe an evidence-based beta-blocker (carvedilol, bisoprolol, or sustained-release metoprolol succinate) for all stable HFrEF patients. Titrate to the maximum tolerated dose. Do not initiate during acute decompensation; wait until the patient is euvolaemic.

Strong Rec High Evidence AHA/ACC 2022 ESC 2021

Prescribe a mineralocorticoid receptor antagonist (MRA) — spironolactone or eplerenone — for HFrEF patients with NYHA II–IV who have adequate renal function and potassium ≤5.0 mEq/L. Monitor potassium and creatinine within 1–2 weeks of initiation.

Strong Rec High Evidence AHA/ACC 2022 ESC 2021

Prescribe an SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg) for all patients with symptomatic HFrEF, regardless of diabetes status. SGLT2 inhibitors reduce heart failure hospitalisations and cardiovascular death independently and additively to the other three pillars.

Strong Rec High Evidence AHA/ACC 2022 ESC 2023 Update DAPA-HF

Clinical Pearl: The traditional approach of starting one drug, titrating to target, then adding the next is being replaced by a "start low, start all" strategy. Getting all four classes on board at low doses within the first 1–4 weeks provides greater cumulative mortality benefit than maximising one class at a time. SGLT2 inhibitors are the easiest to initiate — single dose, no titration, and they can be started even during a HF hospitalisation before discharge.

The Four Pillars: A Drug-by-Drug Guide for HFrEF

Drug Class	Preferred Agent(s)	Target Dose	Key Caution	Practical Tips
ARNi	Sacubitril/valsartan	97/103 mg BID	Hypotension; angioedema (rare). 36h washout from ACEi.	Start at 24/26 mg BID if ACEi-naive or SBP 100–110. Can start de novo without prior ACEi in new HFrEF.
Beta-blocker	Carvedilol, bisoprolol, metoprolol succinate	Carvedilol 25 mg BID (50 mg BID if >85 kg); bisoprolol 10 mg; metoprolol succinate 200 mg	Bradycardia; hypotension; bronchospasm. Do not start in acute decompensation.	Only these three agents have mortality data. Metoprolol tartrate is NOT interchangeable with succinate.
MRA	Spironolactone 25–50 mg; eplerenone 25–50 mg	Spironolactone 25–50 mg daily; eplerenone 50 mg daily	Hyperkalaemia; renal impairment. Avoid if K >5.0 or eGFR <30.	Eplerenone has fewer anti-androgenic effects (gynaecomastia). Check K+ and Cr at 1–2 weeks and after dose changes.
SGLT2i	Dapagliflozin 10 mg; empagliflozin 10 mg	10 mg daily (single dose, no titration)	Genital mycotic infections; euglycaemic ketoacidosis (rare, mainly T1DM). Not for eGFR <20.	Easiest pillar to start: single fixed dose, no titration. Can safely initiate during HF hospitalisation. Benefits seen regardless of diabetes status.

Verify all doses against current formulary. Titrate ARNi, beta-blockers, and MRA to target; SGLT2i is fixed-dose.
For self-identified Black patients with NYHA III–IV symptoms on optimal triple therapy, add hydralazine 75 mg TID + isosorbide dinitrate 40 mg TID.

What Can You Offer Patients With HFmrEF and HFpEF?

Prescribe an SGLT2 inhibitor (dapagliflozin or empagliflozin) for patients with HFmrEF and HFpEF to reduce heart failure hospitalisations and cardiovascular death. The 2023 ESC Focused Update gives this a Class I recommendation across the entire EF spectrum (Level A), based on the EMPEROR-Preserved and DELIVER trials. The AHA/ACC 2022 guideline classifies SGLT2i as Class 2a for HFmrEF and HFpEF.

Strong Rec High Evidence ESC 2023 Update AHA/ACC 2022 DELIVER

Prescribe diuretics for congestion management in HFpEF. Use the lowest effective dose to maintain euvolaemia. Diuretics do not alter disease progression but are essential for symptom relief.

Strong Rec Low Evidence AHA/ACC 2022

Ensure aggressive comorbidity management in HFpEF: blood pressure control (<130/80 mmHg), AF management (rhythm control where appropriate), weight loss in obesity, treatment of sleep apnoea, and glycaemic optimisation with agents that have cardiovascular benefit (SGLT2i, GLP-1 RA).

Strong Rec Moderate Evidence AHA/ACC 2022 ESC 2023 Update

Clinical Decision Pathway

Managing a New Heart Failure Diagnosis: 5 Sequential Questions

Question 1: What is the ejection fraction?

LVEF ≤40% → HFrEF. Start all four pillars (ARNi + beta-blocker + MRA + SGLT2i) simultaneously at low doses. Titrate over weeks.

LVEF 41–49% → HFmrEF. Start SGLT2i (ESC 2023: Class I; AHA/ACC: Class 2a). Consider adding ARNi, beta-blocker, MRA based on individual features.

LVEF ≥50% → HFpEF. Start SGLT2i (ESC 2023: Class I; AHA/ACC: Class 2a). Manage congestion with diuretics. Aggressively treat comorbidities.

Question 2: Is the patient congested?

If YES → Start loop diuretic (furosemide or bumetanide). Target euvolaemia. Consider adding a thiazide (metolazone) for diuretic resistance.

If NO → Hold or reduce diuretics. Focus on GDMT optimisation.

Question 3: Is there an indication for a device?

LVEF ≤35% + LBBB + QRS ≥150 ms + NYHA II–IV on optimal GDMT → CRT (Class I).

LVEF ≤35% + NYHA II–III on optimal GDMT ≥3 months (or ≥40 days post-MI) with reasonable life expectancy >1 year → Consider ICD for primary prevention.

Question 4: Is the patient improving or deteriorating?

If LVEF has improved above 40% → HFimpEF. Continue all medications. Do not de-escalate.

If persistent NYHA III–IV despite optimal GDMT, recurrent hospitalisations, or declining renal function → Consider referral to advanced HF centre for LVAD or transplant evaluation.

Question 5: Are comorbidities and iron deficiency addressed?

Check ferritin and TSAT. If ferritin <100 ng/mL (or 100–299 with TSAT <20%) → IV iron supplementation in symptomatic HFrEF/HFmrEF.

Screen for and treat AF, diabetes, CKD, sleep apnoea, and depression. Refer to cardiac rehabilitation.

What Should You Do After a Heart Failure Hospitalisation?

Initiate and rapidly up-titrate GDMT before discharge and during the first 6 weeks post-hospitalisation. The STRONG-HF trial demonstrated that this "high-intensity care" strategy — with frequent visits, lab checks, and dose adjustments — reduces the composite of death and HF rehospitalisation at 180 days.

Strong Rec Moderate Evidence ESC 2023 Update STRONG-HF

Arrange a follow-up visit within 7 days of discharge. Check weight, fluid status, renal function, potassium, NT-proBNP, blood pressure, and heart rate. Adjust diuretics and titrate GDMT at each encounter during the first 6 weeks.

Strong Rec Moderate Evidence AHA/ACC 2022

Clinical Pearl: The vulnerable period after a HF hospitalisation is the highest-risk window for re-admission and death. Every day that GDMT remains sub-optimally dosed is a missed opportunity. The STRONG-HF approach — starting GDMT pre-discharge, scheduling weekly visits, and rapidly titrating — cut the primary endpoint by approximately one-third (34% relative risk reduction) compared to usual care. This is arguably the single most impactful change in HF care delivery.

Evidence in Context

Where AHA/ACC 2022 and ESC 2021/2023 Agree

Both frameworks agree on the four-pillar approach to HFrEF (ARNi, beta-blocker, MRA, SGLT2i), SGLT2 inhibitors across all EF phenotypes (following the 2023 ESC update), the central role of diuretics for congestion without mortality benefit, the importance of CRT for LBBB with QRS ≥150 ms and reduced EF, early follow-up post-discharge, the classification of HFimpEF as a distinct category requiring ongoing therapy, and IV iron for symptomatic iron deficiency in HFrEF/HFmrEF.

Where AHA/ACC 2022 and ESC 2021/2023 Differ

Hydralazine/isosorbide dinitrate: The AHA/ACC specifically recommends this combination for self-identified Black patients with NYHA III–IV HFrEF on triple therapy (based on A-HeFT trial). The ESC does not make a race-specific recommendation, instead endorsing it as an alternative when ACEi/ARB/ARNi are contraindicated.

Rapid up-titration post-discharge: The 2023 ESC update explicitly incorporated the STRONG-HF strategy as a Class I recommendation. The AHA/ACC 2022 guideline emphasises early follow-up and GDMT optimisation but was published before the STRONG-HF results were available.

ICD for primary prevention in non-ischaemic cardiomyopathy: The ESC gives a weaker recommendation (Class IIa) for ICD in non-ischaemic HFrEF, citing the DANISH trial. The AHA/ACC maintains a Class I recommendation for ICD regardless of aetiology when LVEF is ≤35% and NYHA II–III on optimal GDMT.

SGLT2 Inhibitors: From Diabetes Drug to Universal HF Therapy

The DAPA-HF and EMPEROR-Reduced trials established SGLT2 inhibitors (dapagliflozin and empagliflozin) as foundational therapy in HFrEF regardless of diabetes status. Both showed approximately 25% reductions in the composite of cardiovascular death or HF hospitalisation. The EMPEROR-Preserved and DELIVER trials then extended this benefit to patients with EF above 40%, making SGLT2 inhibitors the first and only drug class with proven benefit across the entire EF spectrum. A pooled analysis of DELIVER and EMPEROR-Preserved showed a 20% reduction in the composite endpoint, driven primarily by fewer HF hospitalisations. The 2023 ESC focused update now gives SGLT2 inhibitors a Class I (Level A) recommendation for HFmrEF and HFpEF. The AHA/ACC 2022 guideline recommends SGLT2 inhibitors at Class 2a for both populations.

STRONG-HF: Why Early Optimisation Saves Lives

The STRONG-HF trial randomised patients hospitalised for acute HF to high-intensity care (rapid initiation and up-titration of GDMT with frequent clinic visits in the first 6 weeks) versus usual care. The high-intensity group achieved higher proportions of patients on optimal drug doses and experienced a roughly 34% relative reduction in the composite of HF readmission or all-cause death at 180 days. The trial was stopped early for efficacy. This evidence formed the basis of the 2023 ESC focused update recommendation for rapid, intensive GDMT optimisation in the peri-discharge period.

What We Still Don't Know

Optimal treatment beyond SGLT2i for HFpEF: While SGLT2 inhibitors are now established, the role of ARNi, MRA, and other agents in HFpEF remains uncertain. The PARAGON-HF trial with sacubitril/valsartan in HFpEF was formally neutral, though subgroup analyses suggest benefit in women and those with EF at the lower end.

Can GLP-1 receptor agonists benefit HFpEF in obese patients? Early data from the STEP-HFpEF trial with semaglutide showed improvements in symptoms and exercise capacity in obese HFpEF patients. Whether this translates to hard outcomes (mortality, hospitalisation) is under investigation.

Is it safe to withdraw GDMT after EF recovery (HFimpEF)? The TRED-HF study showed high relapse rates after therapy withdrawal, but the ideal long-term strategy — full-dose lifelong therapy versus carefully monitored dose reduction — is still being defined.

Role of cardiac amyloidosis screening in HFpEF: Transthyretin cardiac amyloidosis (ATTR-CM) is increasingly recognised as an underdiagnosed cause of HFpEF, particularly in elderly patients. Tafamidis has shown mortality benefit, but optimal screening strategies for ATTR-CM in the broader HFpEF population are still evolving.

References

1.Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation. 2022;145(18):e895–e1032. doi:10.1161/CIR.0000000000001063
2.McDonagh TA, Metra M, Adamo M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure. Eur Heart J. 2023;44(37):3627–3639. doi:10.1093/eurheartj/ehad195
3.McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction (DAPA-HF). N Engl J Med. 2019;381(21):1995–2008. doi:10.1056/NEJMoa1911303
4.Solomon SD, McMurray JJV, Claggett B, et al. Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER). N Engl J Med. 2022;387(12):1089–1098. doi:10.1056/NEJMoa2206286
5.McMurray JJV, Packer M, Desai AS, et al. Angiotensin-Neprilysin Inhibition versus Enalapril in Heart Failure (PARADIGM-HF). N Engl J Med. 2014;371(11):993–1004. doi:10.1056/NEJMoa1409077
6.Mebazaa A, Davison B, Chioncel O, et al. Safety, Tolerability, and Efficacy of Up-Titration of Guideline-Directed Medical Therapies for Acute Heart Failure (STRONG-HF). Lancet. 2022;400(10367):1938–1952. doi:10.1016/S0140-6736(22)02076-1
7.Anker SD, Butler J, Filippatos G, et al. Empagliflozin in Heart Failure with a Preserved Ejection Fraction (EMPEROR-Preserved). N Engl J Med. 2021;385(16):1451–1461. doi:10.1056/NEJMoa2107038
8.Solomon SD, McMurray JJV, Anand IS, et al. Angiotensin–Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction (PARAGON-HF). N Engl J Med. 2019;381(17):1609–1620. doi:10.1056/NEJMoa1908655
9.Kosiborod MN, Abildstrøm SZ, Borlaug BA, et al. Semaglutide in Patients with Heart Failure with Preserved Ejection Fraction and Obesity (STEP-HFpEF). N Engl J Med. 2023;389(12):1069–1084. doi:10.1056/NEJMoa2306963
10.Halliday BP, Wassall R, Lota AS, et al. Withdrawal of Pharmacological Treatment for Heart Failure in Patients with Recovered Dilated Cardiomyopathy (TRED-HF). Lancet. 2019;393(10166):61–73. doi:10.1016/S0140-6736(18)32484-X
11.Maurer MS, Schwartz JH, Gundapaneni B, et al. Tafamidis Treatment for Patients with Transthyretin Amyloid Cardiomyopathy (ATTR-ACT). N Engl J Med. 2018;379(11):1007–1016. doi:10.1056/NEJMoa1805689

How to Read the Evidence Tags

Every recommendation carries two tags. These are Medaptly's own simplified interpretations for educational clarity.

Recommendation Strength

Tag	What It Means	In Practice
Strong Rec	Benefits clearly outweigh risks for most patients.	Standard practice.
Moderate Rec	Evidence favours benefit; some uncertainty remains.	Most patients should receive this.
Conditional Rec	Benefit less certain; individualise.	Shared decision-making.
Against	Risks outweigh benefits.	Avoid.

Evidence Quality

Tag	What It Means	Confidence
High Evidence	Multiple RCTs or meta-analyses.	Very confident.
Moderate Evidence	Single RCT or large observational.	Reasonably confident.
Low Evidence	Expert consensus or small studies.	Less certain.

These are Medaptly's simplified interpretations. Consult the original documents in References for full classification systems.

Article Information

For Educational Purposes Only. This is original clinical education content informed by current published guidelines and clinical evidence. It does not constitute medical advice, is not endorsed by any guideline body (AHA, ACC, HFSA, ESC, or any other organisation), and does not replace individualised clinical judgement, institutional protocols, or local formulary guidance. Drug dosages should always be verified against current prescribing information before prescribing. Readers are encouraged to consult the original source guidelines listed in the References section for the full evidence review and complete recommendation sets.