New HFrEF after emergency admission — case discussion

Objectives

1. Classify the heart failure and stage the patient under the 2026 ESC guideline.^[1]
2. Decongest and keep or start foundational therapy during the admission.^[1]
3. Start foundational medical therapy (FMT) before discharge, including the SGLT2 inhibitor and ARNI decisions.^[1][20][2]
4. Build the discharge plan around rapid uptitration and early review.^[1][22]
5. Plan device reassessment.^[1]

Candidate brief

You are the admitting cardiology consultant. Present management from door to discharge in twenty minutes, grounded in the 2026 ESC heart failure guideline and the trials below.^[1]

Expected actions

• Classify: decompensated HF with LVEF below 50%, so HFrEF, stage C.^[1] Complete the Class I laboratory screen including UACR and iron status (TSAT and ferritin); the 12-lead ECG and chest X-ray (both Class I) have been done.^[1] Look for the cause: CAD is the commonest cause of HFrEF, and contrast-enhanced CMR is Class I, level C when aetiology is uncertain and further characterisation is likely to add value to care.^[1]
• Decongest: IV loop diuretic (Class I, level A; the Task Force assigns level A for clear clinical benefit, and no adequately powered RCT has been or is likely to be done, for ethical reasons). A diuretic-naive patient usually responds to 40 mg IV furosemide.^[1]
• Start FMT in hospital: SGLT2 inhibitor after initial stabilisation (Class I, level B1).^[1] Beta-blocker cautiously once haemodynamically stable.^[1] The patient is ACE-I-naive. ESC notes that pre- and post-discharge initiation of ARNIs in HFrEF have shown similar efficacy and safety, with larger NT-proBNP reductions than ACE-I in ACE-I/ARB-naive patients; Table 11 gives an optional 24/26 mg twice-daily start for ACE-I-naive patients. In PIONEER-HF, the time-averaged NT-proBNP reduction (weeks 4 and 8 versus baseline) was 46.7% with sacubitril–valsartan versus 25.3% with enalapril, with no significant difference in worsening renal function, hyperkalaemia, symptomatic hypotension or angioedema.^[1][20] AHA/ACC/HFSA 2022 recommends ARNi de novo before discharge in hospitalised acute HF.^[2] Add an MRA given potassium 4.2 and preserved creatinine.^[1]
• Discharge: before discharge, exclude persistent congestion using clinical evaluation, natriuretic peptides, kidney function and electrolytes, and imaging (Class I, level C). Then use an intensive strategy of rapid initiation and uptitration of FMT before discharge and at frequent follow-up visits in the first 6 weeks after an HFH (Class I, level B2).^[1] In STRONG-HF (patients admitted with acute HF, not on full doses of guideline-directed therapy), HF readmission or all-cause death by day 180 occurred in 15.2% with high-intensity care versus 23.3% with usual care (RR 0.66).^[22]
• Devices: QRS 132 ms with LBBB lies in the 130–149 ms band. CRT should be considered (Class IIa, level C) if the patient remains symptomatic in sinus rhythm with LVEF 35% or less despite optimal FMT.^[1] Reassess the ICD after 3 months or more of optimal FMT: it applies with symptomatic NYHA II/III, LVEF 35% or less and expected survival above 1 year with good functional status (Class I, level B1 if ischaemic outside 40 days of MI; IIa, B1 if non-ischaemic). SCD-HeFT (NYHA II–III, LVEF 35% or less) showed a 23% mortality reduction with ICD versus placebo.^[1][14][2]

Marking

Pass:

• correct 2026 classification and stage.
• prompt IV diuresis with a stated dose.
• SGLT2 inhibitor started in hospital; FMT started before discharge.
• washout of at least 36 hours known for any ACE-I to ARNI switch.
• discharge plan with early, frequent uptitration visits.
• device decision deferred to reassessment on optimal FMT.

Fail:

• uses the retired HFmrEF label or a 40% HFrEF cut-off as the ESC definition.
• discharges on one or two classes with no titration plan.
• overlaps an ACE inhibitor with an ARNI.
• stops FMT for a small creatinine rise.
• implants CRT now on a QRS of 132 ms without reassessing LVEF on optimal FMT, when no work-up has shown abnormal conduction to be the only cause with a low likelihood of LVEF improvement (the setting in which ESC allows early CRT planning).