HFrEF — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 64-year-old man has 3 weeks of exertional breathlessness, orthopnoea and ankle oedema. Echocardiography shows a dilated left ventricle with an LVEF of 28%. ECG: sinus rhythm, left bundle branch block, QRS 158 ms. Blood pressure 118/72 mmHg, potassium 4.4 mmol/L, eGFR 58 mL/min/1.73 m². CT coronary angiography shows no obstructive coronary disease. He takes no cardiac drugs and has never taken an ACE-I or ARB.^[1]

1. Classify his heart failure under the 2026 ESC guideline, and state how AHA/ACC/HFSA 2022 would classify an LVEF of 45% differently. (2)^[1][2]
2. Name the four classes of foundational medical therapy (FMT) for HFrEF with their ESC 2026 class and level, and give one agent with its Table 11 starting and target dose for each class. (4)^[1]
3. How fast should these drugs be uptitrated, and which landmark trials support the ARNI and SGLT2 inhibitor? (2)^[1][4][5]
4. Outline the device plan, with class and level. (2)^[1]

Model answers

1. (2 marks) HFrEF, stage C: current or prior symptoms and/or signs of HF with an LVEF below 50%.^[1] AHA/ACC/HFSA 2022 defines HFrEF as LVEF 40% or less; an LVEF of 45% would be HFmrEF (41–49%) provided there is evidence of spontaneous or provokable raised LV filling pressures, such as elevated natriuretic peptide; ESC 2026 has removed HFmrEF and would call it HFrEF.^[2][1]
2. (4 marks) ESC 2026 Recommendation Table 5 (each for symptomatic HFrEF; the beta-blocker in stable patients) and Table 11 doses:^[1]
   • Beta-blocker (Class I, level A): bisoprolol 1.25 mg o.d. to 10 mg o.d.^[1]
   • ACE-I or ARNI (Class I, level A): sacubitril–valsartan 49/51 mg b.i.d. to 97/103 mg b.i.d. He is ACE-I-naive with eGFR 58, so the optional 24/26 mg b.i.d. start is available (it is offered for a history of symptomatic hypotension, ACE-I-naive patients or eGFR 30–60 mL/min/1.73 m²).^[1]
   • MRA (Class I, level A, steroidal MRA for HFrEF): eplerenone 25 mg o.d. to 50 mg o.d.^[1]
   • SGLT2 inhibitor (Class I, level A): dapagliflozin 10 mg o.d., or empagliflozin 10 mg o.d.^[1]
3. (2 marks) No sequence is favoured, so by consensus FMT can be commenced together, with individual variations based on clinical assessment, as soon as HFrEF is diagnosed; uptitrate at least every 1–2 weeks towards trial target doses, guided by symptoms, vital signs and laboratory findings (Class I, level C).^[1] PARADIGM-HF: sacubitril–valsartan versus enalapril, primary outcome HR 0.80.^[4][2] DAPA-HF: dapagliflozin versus placebo, primary outcome HR 0.74, with benefit regardless of the presence or absence of diabetes.^[5]
4. (2 marks) He has symptomatic HFrEF with LBBB, QRS 150 ms or more and LVEF 35% or less. ESC 2026 says FMT initiation and CRT planning may be considered simultaneously (Class IIb, level C), reassessing LVEF before implant.^[1] If he stays symptomatic in sinus rhythm with LVEF 35% or less despite optimal FMT, CRT is Class I, level A.^[1] CT coronary angiography showed no obstructive coronary disease, so his aetiology is non-ischaemic. A primary prevention ICD should be considered (Class IIa, level B1) if, after 3 months or more of optimal FMT, he is symptomatic in NYHA II/III with LVEF 35% or less and is expected to survive more than 1 year with good functional status.^[1]

SAQ 2 (10 marks)

Practice scenario. A different patient, a 66-year-old man with known HFrEF (LVEF 30%), is admitted with decompensated HF. He takes enalapril and bisoprolol only. After IV diuresis he is haemodynamically stable, with no signs of hypoperfusion.^[1]

1. What happens to his bisoprolol and enalapril on admission, and which drug class should be started in hospital, with class and level? (3)^[1]
2. How do you convert enalapril to sacubitril–valsartan, and which trial supports in-hospital initiation? (2)^[1][20]
3. Describe the discharge strategy ESC 2026 recommends and the trial behind it. (3)^[1][22]
4. At the first visit his creatinine is 30% above baseline, eGFR 42 mL/min/1.73 m², potassium 4.9 mmol/L, and he feels well. What do you do? (2)^[1]

Model answers

1. (3 marks) Continue FMT or reintroduce it rapidly; discontinue only for clear hypoperfusion or a specific indication.^[1] In-hospital initiation of an SGLT2 inhibitor after initial stabilisation is recommended (Class I, level B1).^[1] IV loop diuretics for fluid overload are 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.^[1]
2. (2 marks) Stop enalapril and wait at least 36 h before the first ARNI dose to minimise angio-oedema.^[1][2] PIONEER-HF randomised stabilised inpatients: 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.^[20]
3. (3 marks) Exclude persistent congestion before discharge 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] STRONG-HF, in patients admitted with acute HF who were not on full doses of guideline-directed therapy, uptitrated to 100% of recommended doses within 2 weeks of discharge, with four visits over 2 months: 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] Blood pressure, heart rate, creatinine, potassium and NT-proBNP help guide uptitration.^[1]
4. (2 marks) Continue all drugs. A creatinine rise of less than 50% with eGFR above 15 mL/min/1.73 m² is considered acceptable, and a transient fall after starting RAS blockers, MRAs or SGLT2 inhibitors should not prompt interruption.^[1]