nursing
,COMPREHENSIVE HEART FAILURE PHARMACOLOGY GUIDE
Compiled from NHS Greater Glasgow & Clyde, NHS England (North West), and
2026 Evidence Update
Version 1.0 | July 2026
TABLE OF CONTENTS
1. Heart Failure Classification & Overview
2. The Four Pillars of GDMT (HFrEF)
3. Drug Class 1: RAAS Inhibitors (ARNi / ACEi / ARB)
4. Drug Class 2: Beta-Blockers
5. Drug Class 3: Mineralocorticoid Receptor Antagonists (MRA)
6. Drug Class 4: SGLT2 Inhibitors
7. Loop Diuretics
8. Additional Therapies
9. HFmrEF & HFpEF Management
10. Acute Heart Failure
11. Monitoring & Annual Care
12. Medicines to Avoid
13. 2026 Emerging Therapies
14. Practical Algorithms
1. HEART FAILURE CLASSIFICATION & OVERVIEW
Ejection Fraction-Based Classification
Type LVEF Core Therapy
HFrEF <40% ARNi/ACEi/ARB + BB + MRA + SGLT2i
(Reduced)
HFmrEF 41-49% ACEi/ARB + BB + SGLT2i; consider
(Mildly Reduced) MRA
HFpEF >=50% SGLT2i; manage comorbidities; diuretics
nursing
, Type LVEF Core Therapy
(Preserved) for congestion
HFimpEF >=50% (was Continue HFrEF therapy
(Improved) <=40%)
Key Principle: Concurrent Initiation
• Move away from sequential initiation (ACEi -> BB -> MRA ->
SGLT2i)
• Preferred approach: Initiate all four core therapies as soon as
practically possible, then up-titrate to target doses
• Concurrent initiation reduces hospitalizations and improves prognosis
faster than sequential approaches
• Aim to establish all four disease-modifying therapies within 4 weeks of
diagnosis
Five-Year Mortality
• HFrEF: >50% without optimal therapy
• Prompt GDMT initiation and up-titration significantly improves outcomes
2. THE FOUR PILLARS OF GDMT (HFrEF)
Optimal GDMT = All Four Classes at Target/Max Tolerated Doses
1. ARNi/ACEi/ARB (Renin-Angiotensin-Aldosterone System Inhibitors)
2. Beta-Blocker (BB)
3. Mineralocorticoid Receptor Antagonist (MRA)
4. SGLT2 Inhibitor (SGLT2i)
Once diagnosis established:
• Continue up-titration of ALL four drug classes to target dose, even if
symptoms improve
• Loop diuretics for symptomatic relief only — they do not modify disease
progression
nursing
,COMPREHENSIVE HEART FAILURE PHARMACOLOGY GUIDE
Compiled from NHS Greater Glasgow & Clyde, NHS England (North West), and
2026 Evidence Update
Version 1.0 | July 2026
TABLE OF CONTENTS
1. Heart Failure Classification & Overview
2. The Four Pillars of GDMT (HFrEF)
3. Drug Class 1: RAAS Inhibitors (ARNi / ACEi / ARB)
4. Drug Class 2: Beta-Blockers
5. Drug Class 3: Mineralocorticoid Receptor Antagonists (MRA)
6. Drug Class 4: SGLT2 Inhibitors
7. Loop Diuretics
8. Additional Therapies
9. HFmrEF & HFpEF Management
10. Acute Heart Failure
11. Monitoring & Annual Care
12. Medicines to Avoid
13. 2026 Emerging Therapies
14. Practical Algorithms
1. HEART FAILURE CLASSIFICATION & OVERVIEW
Ejection Fraction-Based Classification
Type LVEF Core Therapy
HFrEF <40% ARNi/ACEi/ARB + BB + MRA + SGLT2i
(Reduced)
HFmrEF 41-49% ACEi/ARB + BB + SGLT2i; consider
(Mildly Reduced) MRA
HFpEF >=50% SGLT2i; manage comorbidities; diuretics
nursing
, Type LVEF Core Therapy
(Preserved) for congestion
HFimpEF >=50% (was Continue HFrEF therapy
(Improved) <=40%)
Key Principle: Concurrent Initiation
• Move away from sequential initiation (ACEi -> BB -> MRA ->
SGLT2i)
• Preferred approach: Initiate all four core therapies as soon as
practically possible, then up-titrate to target doses
• Concurrent initiation reduces hospitalizations and improves prognosis
faster than sequential approaches
• Aim to establish all four disease-modifying therapies within 4 weeks of
diagnosis
Five-Year Mortality
• HFrEF: >50% without optimal therapy
• Prompt GDMT initiation and up-titration significantly improves outcomes
2. THE FOUR PILLARS OF GDMT (HFrEF)
Optimal GDMT = All Four Classes at Target/Max Tolerated Doses
1. ARNi/ACEi/ARB (Renin-Angiotensin-Aldosterone System Inhibitors)
2. Beta-Blocker (BB)
3. Mineralocorticoid Receptor Antagonist (MRA)
4. SGLT2 Inhibitor (SGLT2i)
Once diagnosis established:
• Continue up-titration of ALL four drug classes to target dose, even if
symptoms improve
• Loop diuretics for symptomatic relief only — they do not modify disease
progression
nursing
