Introduction to Heart Failure
Heart failure is a chronic condition where the heart cannot pump blood effectively enough to meet metabolic demands.
Symptoms include:
Breathlessness
Fatigue
Fluid retention
Correct classification of heart failure is essential for appropriate medicine selection and counselling.
Classification of Heart Failure (UPDATED NICE)
Heart failure is classified based on left ventricular ejection fraction (LVEF).
Heart Failure with Reduced Ejection Fraction (HFrEF)
Definition
LVEF ≤40%
Impaired ventricular contraction (systolic dysfunction)
Common Causes
Ischaemic heart disease
Previous myocardial infarction
Hypertension
Dilated cardiomyopathy
Pharmacological Management
Core disease-modifying therapy
ACE inhibitor or ARB (or ARNI where appropriate)
Beta-blocker
Mineralocorticoid receptor antagonist
SGLT2 inhibitor
Diuretics
For symptom relief of congestion (not prognostic)
Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF) (NEW NICE EMPHASIS)
Definition
LVEF 41–49%
Management
Offer an SGLT2 inhibitor (dapagliflozin)
Continue or consider:
ACE inhibitors or ARBs
Beta-blockers
MRAs
Diuretics for fluid overload
Heart Failure with Preserved Ejection Fraction (HFpEF) (UPDATED)
Definition
LVEF ≥50%
Impaired ventricular relaxation and filling (diastolic dysfunction)
Common Causes
Hypertension
Diabetes
Obesity
Atrial fibrillation
Pharmacological Management (UPDATED)
Offer an SGLT2 inhibitor (dapagliflozin)
Diuretics for congestion
Optimise treatment of comorbidities:
Blood pressure control
Rate/rhythm control in AF
Diabetes management
Comparison of Heart Failure Types
| Feature | HFrEF | HFmrEF | HFpEF |
|---|---|---|---|
| LVEF | ≤40% | 41–49% | ≥50% |
| Main problem | Poor contraction | Mixed systolic/diastolic | Poor relaxation |
| Disease-modifying therapy | Strong evidence | Emerging evidence | Limited but improving |
| SGLT2 inhibitors | Recommended | Recommended | Recommended |
Conclusion
HF classification directly determines treatment strategy
SGLT2 inhibitors are now recommended across HFrEF, HFmrEF, and HFpEF
Pharmacists are essential in:
Medicine optimisation
Monitoring renal function and electrolytes
Supporting long-term adherence
References
NICE, “Chronic heart failure in adults: diagnosis and management”
British National Formulary, “Heart failure”
NHS, “Heart failure”
British Heart Foundation, “Types of heart failure”