Heart Failure
HFrEF, HFpEF, and HFmrEF — diagnosis, GDMT, diuretic titration, monitoring, and decompensation.
Learning Objectives
- 1.Classify heart failure by ejection fraction and assess congestion/perfusion.
- 2.Initiate and titrate guideline-directed medical therapy (GDMT).
- 3.Monitor safely and recognize decompensation.
Overview
Heart failure management is one of the highest-impact things an APP does. The EF classifies the patient, GDMT changes survival in HFrEF, and weight/volume monitoring prevents hospitalizations.
Why this matters
Getting HFrEF patients on all four GDMT pillars — and titrated — meaningfully improves survival and quality of life. Most readmissions are preventable with monitoring and adherence.
Classification
- •HFrEF: EF ≤40%. HFmrEF: EF 41–49%. HFpEF: EF ≥50%.
- •Diagnosis: symptoms/signs + echo (EF, structure) + natriuretic peptides in context.
- •Assess congestion ("wet/dry") and perfusion ("warm/cold").
GDMT for HFrEF — the four pillars
- •ARNI (preferred) or ACE-i/ARB.
- •Evidence-based beta-blocker (carvedilol, metoprolol succinate, bisoprolol).
- •MRA (spironolactone/eplerenone).
- •SGLT2 inhibitor.
- •Goal: start all four early and titrate to target/maximally tolerated doses.
Titration & diuretics
- •Titrate pillars over weeks, watching BP, HR, potassium, and renal function.
- •Loop diuretics treat congestion — titrate to euvolemia using weights/symptoms, not as a survival drug.
- •Don’t stop beta-blockers in stable patients; adjust during decompensation per physician.
HFpEF / HFmrEF
- •HFpEF: SGLT2 inhibitors now have benefit; manage volume with diuretics and treat comorbidities (HTN, AFib, obesity, CAD).
- •HFmrEF: GDMT increasingly applied as in HFrEF.
Monitoring
- •Daily weights with call parameters; BMP (K/Cr) with titration; symptom and volume checks; reassess EF over time for device eligibility.
Advanced therapy / referral
- •Persistent reduced EF despite GDMT → device eligibility (ICD/CRT) assessment; advanced HF referral for refractory disease — physician/cardiology led.
Red flags / escalation
- •Hypotension with hypoperfusion (cold) → cardiogenic shock concern.
- •Severe dyspnea / flash pulmonary edema.
- •Rapid decompensation, syncope, or dangerous arrhythmia.
Escalate
Hypoperfusion/shock or florid pulmonary edema is an emergency — stabilize and escalate, not an outpatient diuretic tweak.
Common beginner mistakes
- •Leaving HFrEF patients on incomplete GDMT (missing pillars).
- •Stopping beta-blockers inappropriately.
- •Over- or under-diuresing without weights/labs.
- •Treating "preserved EF" as a normal heart.
Patient education
- •Daily weights + call parameters (>3 lb in 2 days), salt/fluid guidance, adherence, and warning signs.
Nurse / MA workflow connection
- •Nurse HF protocol (weights, symptoms, escalation) and MA accurate weights are central to your management.
Mini cases
New HFrEF (EF 28%) on an ACE inhibitor and a beta-blocker only, euvolemic, BP 118/72, K 4.2, Cr stable.
Plan?
Show answer
Complete GDMT: add an MRA and an SGLT2 inhibitor (and consider switching the ACE-i to an ARNI), then titrate the pillars as tolerated, monitoring BP, HR, K, and Cr. Two of four pillars is incomplete therapy.
HFrEF patient, BP 84/60, cool extremities, confusion, rising creatinine.
What now?
Show answer
"Cold" hypoperfusion — possible cardiogenic shock. Escalate emergently; this is not a GDMT up-titration moment and over-diuresis could worsen it.