How should I initiate and titrate guideline-recommended medications for a patient with heart failure with reduced ejection fraction?

Initiate guideline-recommended medications for heart failure with reduced ejection fraction (HFrEF)

• Start an ACE inhibitor at a low dose and titrate upwards at short intervals (e.g., every 2 weeks) until the target or maximum tolerated dose is reached ¹.
• Measure serum sodium, potassium, and assess renal function before and 1 to 2 weeks after starting an ACE inhibitor, and after each dose increase ¹.
• Measure blood pressure before and after each dose increase, including in people with symptoms of postural hypotension ¹.
• Once the target or maximum tolerated dose of an ACE inhibitor is reached, monitor treatment monthly for 3 months, then at least every 6 months, and at any time the person becomes acutely unwell ².
• If ACE inhibitors are not tolerated, consider an angiotensin-II receptor antagonist (AIIRA), starting at a low dose and titrating similarly, with monitoring of serum electrolytes, renal function, and blood pressure ¹.
• Start a beta-blocker in a 'start low, go slow' manner, assessing heart rate, clinical status, blood pressure, and tolerability after each titration ¹.
• Introduce a mineralocorticoid receptor antagonist (MRA) if symptoms persist despite optimal therapy, with similar monitoring of electrolytes, renal function, and blood pressure ¹.

Seek specialist advice if symptoms persist despite optimized standard care, or if there are contraindications or intolerance to first-line medications ¹.