Ejection fraction — the number that decides the whole regimen 40% or below (reduced)
hf-refNo one has reached this rule yetAll four classes: ARNI (or ACEi/ARB), heart-failure beta blocker, MRA, SGLT2 inhibitor; defibrillator question at ≤35%
No clinician has signed off this rule yet. It reflects our reading of the guidelines cited below, which has not been independently checked.
Word for word, as generated for the example person below. Figures in the text are theirs.
Your ejection fraction is 32%. Four drug classes are known to help people in that situation live longer — the question worth taking to your cardiologist is which of them apply to you.
Proven in trialsTrials counted real events, like heart attacks, strokes, or deaths, and this changed them.
The four classes are an ARNI (sacubitril/valsartan) or an ACE inhibitor or ARB; a beta blocker proven in heart failure specifically — carvedilol, metoprolol succinate, or bisoprolol, not just any beta blocker; a mineralocorticoid receptor antagonist such as spironolactone or eplerenone; and an SGLT2 inhibitor — dapagliflozin or empagliflozin — which works here whether or not you have diabetes. Each was tested on top of the others, so the benefits add rather than overlap, and analyses combining the trials estimate that all four adds years of event-free life over the older two-drug standard. What this page cannot tell you is which of them is right for you: that turns on your potassium, your kidney function, your blood pressure, and what has already been tried and stopped. Under-treatment is the common error, but so is hyperkalaemia and symptomatic hypotension — which is why this is a question to ask rather than a list to check.
ACC/AHA (US)
Each of the four classes has its own Class 1, Level A recommendation in the 2022 guideline's HFrEF tables: ARNi for NYHA class II to III (an ACE inhibitor, or an ARB if ACE-intolerant, when ARNi is not feasible), an evidence-based beta blocker, an MRA for NYHA class II to IV when eGFR is above 30 and potassium below 5.0, and an SGLT2 inhibitor irrespective of diabetes. Replacing an ACE inhibitor or ARB with ARNi is Class 1, Level B-R.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Cir… · Recommendation behind this rule · class and level read from the guideline tables on 2026-09-30
Why this is a question. It would need a recent potassium level, everything else you're currently taking. This tool doesn't ask for that, so it stays a question.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Circulation) · Class 1 · Level A
Take one question to your next heart failure appointment: for each of these four classes, is it right for me — and if not, why not?
Framed as a question rather than a checklist on purpose. Only a minority of eligible patients end up on all four classes, so the gap is real and worth raising — but a cardiologist may have deliberately left one out for a reason this page cannot see: your blood pressure, your potassium, your kidney function, or a previous bad reaction. "Why not?" is the useful question. "I should be on all four" is not, and could push you toward a drug that was withheld on purpose.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Circulation)
Once you've had at least three months on optimized medication, ask whether you need a defibrillator.
Proven in trialsTrials counted real events, like heart attacks, strokes, or deaths, and this changed them.
With an ejection fraction at or below 35% after medication has been given a fair trial, an implantable defibrillator reduces the risk of dying from a sudden arrhythmia. If your ECG also shows a wide QRS — particularly a left bundle branch block — a resynchronization device (a special pacemaker) can improve both symptoms and survival on top of that. The three-month wait matters: ejection fraction often improves substantially on the four drug classes, and some people no longer qualify, which is a good outcome rather than a missed one.
ACC/AHA (US)
Once you've had at least three months on optimized medication, ask whether you need a defibrillator.
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Cir… · Recommendation behind this rule · class and level carried over from an earlier review, not yet re-read against the tables
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Circulation) · Class I · Level A
“Heart failure with a weak pump” — an illustrative profile, not a real user.
Asked after: Heart failure
Cited by the recommendations above.
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Runs in lib/engine/heartFailurePathway.ts as hf-ref.