Cardiology

Heart Failure with Reduced Ejection Fraction (HFrEF)

Systolic heart failure with LVEF <=40% due to ischaemic or non-ischaemic cardiomyopathy; four-pillar guideline-directed medical therapy dramatically improves outcomes.

Last reviewed 2 Jul 2026 - MedicoMedics editorial team

Reduced ejection fraction cardiac remodelling

Pathophysiology

Loss of contractile function activates RAAS and sympathetic systems; adverse remodelling. Ischaemia, hypertension, valvular disease, viral, toxic (alcohol, chemo), genetic aetiologies.

Sources: AHA/ACC HF 2022 (Circulation 2022;145:e895); DAPA-HF (NEJM 2019;381:1995)

Presentation

Dyspnoea on exertion, orthopnoea, PND, fatigue, oedema, elevated JVP, S3, bibasilar crackles, cool extremities.

Diagnosis

BNP/NT-proBNP elevated; echocardiogram (LVEF <=40%); ECG; CMR or angiography for aetiology.

Management

Four pillars simultaneously: ARNI (sacubitril/valsartan) or ACEi/ARB, beta-blocker (carvedilol, metoprolol succinate, bisoprolol), MRA (spironolactone/eplerenone), SGLT2 inhibitor (dapagliflozin/empagliflozin). Diuretics for congestion. ICD if LVEF <=35% despite GDMT. CRT if LBBB QRS >=150.

Sample USMLE-style MCQs

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Question 1

A 58-year-old post-MI has LVEF 30%, NYHA III on lisinopril and metoprolol. Which change reduces mortality most?

Question 2

Which SGLT2 inhibitor is approved for HFrEF regardless of diabetes?

Question 3

Which beta-blocker is preferred in HFrEF?

Question 4

ICD primary prevention criterion?

Question 5

Which agent stimulates soluble guanylate cyclase in worsening HFrEF?

References

Primary guidelines and peer-reviewed sources used for this entry. Reviewed 2 Jul 2026 by MedicoMedics editorial team.

Frequently asked

Why SGLT2 in HFrEF?

30% reduction in HF hospitalisation regardless of diabetes (DAPA-HF, EMPEROR-Reduced).

ARNI vs ACEi?

ARNI reduces CV death and HF hospitalisation vs enalapril (PARADIGM-HF).

Vericiguat role?

sGC stimulator for worsening HF despite GDMT.

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