HFmrEF Treatment Recommendations — EECC MCQ

Correct answer: E — The 2023 ESC HF Guidelines recommend SGLT2 inhibitors (Class I) and diuretics (Class I) for HFmrEF; ACEi/ARB/ARNI, beta-blockers, and MRA receive weaker recommendations (Class IIb) based on post-hoc analyses and indirect evidence — HFmrEF likely represents a mixed population with some patients resembling HFrEF

HFmrEF (LVEF 41-49%) is a relatively new category and evidence is growing: (1) SGLT2 inhibitors: Class I for HFmrEF — DELIVER and EMPEROR-Preserved included HFmrEF patients with consistent benefit; (2) diuretics for congestion: Class I; (3) ACEi/ARB/ARNI: Class IIb — CHARM-Preserved subgroup analysis, PARAGON-HF (ARNI showed benefit in LVEF <57% subgroup), and PARADIGM-HF showed consistent benefit down to LVEF 40-49%; (4) beta-blockers: Class IIb — meta-analyses suggest benefit in HFmrEF similar to HFrEF; (5) MRA: Class IIb — TOPCAT subgroup and observational data. The practical implication: many HFmrEF patients have transitional disease (previously HFrEF improving, or early decline toward HFrEF) and may benefit from HFrEF-style GDMT. The 2023 guidelines acknowledge the evidence gap but support a trial of GDMT.

Reference: ESC (2023): HF Guidelines