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2021 ESC Guidelines for Heart Failure

Diagnosis and Treatment of Acute and Chronic Heart Failure — Clinical Quick Reference

Published: European Heart Journal, 2021 (42:3599–3726)
Societies: European Society of Cardiology (ESC)
Updated: 2023 Focused Update (SGLT2i expansion, finerenone for CKD)
DOI: 10.1093/eurheartj/ehab368
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What's New in 2021 & 2023 Update

Key changes from 2016 ESC Guidelines and 2023 Focused Update:

Topic 2016 / Prior 2021 / 2023 Update COR
HFmrEF Classification Grouped with HFpEF Distinct phenotype (LVEF 41–49%) 1
SGLT2i in HFrEF Not recommended Now foundational (dapagliflozin, empagliflozin) alongside ACEi/ARNi, BB, MRA 1
SGLT2i in HFmrEF No recommendation Can be considered (empagliflozin, dapagliflozin) 2a
SGLT2i in HFpEF No recommendation Recommended to reduce CV death, HF hospitalization 1
Finerenone in CKD + HF Not evaluated Recommended (2023 update) to reduce HF hosp & CV death in T2DM with CKD 1
ICD in HFrEF LVEF <35% after GDMT LVEF <35% despite 3 months OMT (optimization phase extended) 1
CRT in HFrEF QRS ≥120 ms QRS 120–149 ms with LBBB morphology OR QRS ≥150 ms; CRT-P vs CRT-D based on ICD indication 1

Heart Failure Classification

HF phenotypes defined by LVEF measurement on echocardiography, with distinct diagnostic and treatment algorithms:

Phenotype LVEF Criteria Diagnostic Findings Typical Presentation
HFrEF
(Reduced)		 LVEF ≤40% Systolic dysfunction; LV dilatation; reduced SV Dyspnea, fatigue, orthopnea, reduced exercise tolerance
HFmrEF
(Mildly Reduced)		 LVEF 41–49% Borderline systolic dysfunction; may have diastolic abnormalities Variable; often similar to HFpEF but with subtle systolic features
HFpEF
(Preserved)		 LVEF ≥50% Diastolic dysfunction ± LV hypertrophy; normal/reduced SV; elevated LV stiffness Dyspnea, orthopnea, pulmonary congestion; often paroxysmal nocturnal dyspnea
HF-improved LVEF >40% (recovered from ≤40%) Recovery from systolic dysfunction; may regress if therapy stopped Improved functional capacity; lower mortality risk if LVEF normalized
Pearl: LVEF ≥50% does NOT exclude HF. In HFpEF, diagnosis requires symptoms + signs + objective evidence of cardiac dysfunction (e.g., diastolic dysfunction, elevated natriuretic peptides, structural abnormalities). Echocardiography is mandatory for phenotyping.

Diagnosis of Heart Failure

Natriuretic Peptide Thresholds for Rule-Out

In suspected HF (symptoms + risk factors), measure BNP or NT-proBNP. Lower limits define HF-unlikely; higher limits define HF-likely:

Biomarker HF Unlikely (Rule Out) Intermediate HF Likely (Rule In)
BNP <35 pg/mL 35–100 pg/mL ≥100 pg/mL
NT-proBNP <125 pg/mL 125–400 pg/mL ≥400 pg/mL
NT-proBNP (age >75) <125 pg/mL 125–900 pg/mL ≥900 pg/mL

Diagnostic Algorithm

Diagnostic Approach to Suspected HF

Step 1 — Clinical Assessment: Symptoms (dyspnea, fatigue, orthopnea, PND) + signs (elevated JVP, peripheral edema, rales, gallop rhythm) + risk factors (prior MI, HTN, CAD, diabetes, obesity). 1
Step 2 — Natriuretic Peptides: If symptoms suspicious, measure BNP/NT-proBNP first. BNP <35 pg/mL or NT-proBNP <125 pg/mL → HF very unlikely; proceed to alternative diagnosis. 1
Step 3 — Echocardiography: All patients with elevated NP or ongoing clinical suspicion. Measure LVEF, assess diastolic function, valve disease, LV hypertrophy, pericardial disease. 1
Step 4 — HFpEF Confirmation: If LVEF ≥50%, confirm diastolic dysfunction (E/e′ >9, LAE, elevated NP, TR velocity >2.8 m/s). Use H2FPEF score to assess HFpEF probability. 2a
Step 5 — Additional Testing: ECG, CXR, labs (troponin if ACS concern), renal function, iron studies; invasive hemodynamics if transplant/MCS consideration. 1

Recommended Diagnostic Tests

Test Recommendation COR LOE
BNP / NT-proBNP All suspected HF; initial diagnostic test 1 B
Transthoracic Echocardiography All suspected HF; assess LVEF, structure, function 1 C
12-lead ECG All patients; assess rhythm, ischemia, LVH, conduction disease 1 C
Chest X-ray Evaluate pulmonary congestion, cardiomegaly, alternative diagnosis 1 C
Labs (FBC, U&E, Cr, eGFR, TFTs, glucose, iron studies) All patients; guide therapy, identify comorbidities 1 C
Cardiac MRI Assess infiltrative disease, iron overload, myocarditis if ECG/echo abnormal 1 C
Right Heart Catheterization Severe HF, MCS/transplant consideration, hemodynamic-guided therapy 1 C

HFrEF Pharmacotherapy — The "Big 4"

All four drug classes (ACEi/ARNi, beta-blockers, MRA, SGLT2i) are foundational. Start early, titrate to target doses, use sequentially if needed. Use the GDMT Optimizer calculator to sequence therapy and track titration.

1. ACE Inhibitors / Angiotensin Receptor-Neprilysin Inhibitors (ACEi / ARNi)

Drug Class / Agent Starting Dose Target Dose Evidence / Comments COR
ACE Inhibitors
(e.g., lisinopril, enalapril, ramipril)		 2.5–5 mg daily 10–40 mg daily (usually 20 mg BID) First-line HFrEF; reduces mortality, HF hospitalizations. Monitor K+, Cr. Contraindicated in pregnancy, angioedema history. 1
ARNi (Sacubitril/Valsartan)
(PARADIGM-HF trial)		 49/26 mg BID 97/103 mg BID Preferred over ACEi (superior mortality/HF hosp reduction). Dual neprilysin + AT1 inhibition. Monitor for hypotension, hyperkalemia, cough (less than ACEi). 1
ARB (if ACEi intolerant)
(e.g., valsartan, candesartan)		 40–80 mg daily 160 mg daily (split or single) Second-line if ACEi/ARNi not tolerated. Reduces HF hospitalizations; less proven mortality benefit than ACEi/ARNi. 1

2. Beta-Blockers

Agent Starting Dose Target Dose Key Points COR
Bisoprolol 1.25 mg daily 10 mg daily Beta-1 selective; excellent HFrEF evidence (CIBIS-III). Gradual up-titration over weeks. 1
Carvedilol 3.125 mg BID 25 mg BID Non-selective (alpha + beta blocking); alpha property may improve symptoms. US-favored agent. 1
Metoprolol succinate (XL) 12.5–25 mg daily 190 mg daily Extended-release form; proven mortality benefit (MERIT-HF). Standard-release metoprolol NOT recommended. 1
Nebivolol 1.25 mg daily 10 mg daily Vasodilatory beta-blocker; endorsed in some European guidelines; less US data than bisoprolol/carvedilol. 1

3. Mineralocorticoid Receptor Antagonists (MRA)

Agent Starting Dose Target Dose Key Points COR
Spironolactone 12.5–25 mg daily 25–50 mg daily Non-selective MRA; potassium-sparing. Monitor K+ (target <5.0 mmol/L), eGFR >30. Gynecomastia in ~10%. RALES trial foundation. 1
Eplerenone 25 mg daily 50 mg daily Selective MRA; less gynecomastia/sexual dysfunction than spironolactone. More expensive. Similar K+ concerns. 1
Finerenone (NEW 2023) 10 mg daily 20 mg daily Non-steroidal MRA; 2023 update recommends for T2DM + CKD + HF to reduce HF hosp & CV death. Renal protection. 1

4. SGLT2 Inhibitors (NEW — Foundational in HFrEF)

Agent Dose Key Trial Benefits / Cautions COR
Dapagliflozin 10 mg daily DAPA-HF Reduces CV death + HF hosp by ~26% HFrEF. Safe in T2DM, non-diabetic HF. Avoid if eGFR <30. DKA risk (rare). 1
Empagliflozin 10 mg daily EMPEROR-Reduced Similar CV death + HF hosp reduction. HFrEF, HFpEF, HFmrEF benefit. eGFR <20 caution. 1

Sequencing & Titration Schedule

HFrEF Optimal Treatment Sequence

Baseline (All eligible patients): Start ACEi/ARNi + beta-blocker + MRA (usually all 3 simultaneously if tolerated, or sequentially if hypotension/renal concerns). Add SGLT2i independently. 1
Week 1–2: ACEi/ARNi at low dose (1/4 target); BB at 1/4 target; MRA at starting dose. SGLT2i started as tolerated. Monitor BP, K+, Cr.
Week 2–4: Uptitrate to 1/2 target doses if tolerated. Assess for hypotension (SBP >90 mmHg acceptable if symptomatic); K+ <5.5 mmol/L; Cr increase <30% baseline.
Week 4–12 (Optimization Phase): Continue gradual up-titration toward full target doses. Typical window 8–12 weeks. May slow if persistent symptoms, renal deterioration, or hyperkalemia.
3–4 Month Assessment: At target or maximum tolerated doses. Reassess LVEF, symptoms, BNP/NT-proBNP. Consider CRT/ICD if LVEF still ≤35% and QRS ≥120 ms.
Pitfall: Delaying or under-dosing GDMT due to modest initial hypotension or creatinine rise (up to 30% acceptable). Doses should be titrated to target despite these changes if patient remains stable. Abrupt ACEi/ARNi withdrawal may unmask decompensation.

Additional Agents to Consider

Agent / Class Indication / Evidence COR
Ivabradine Sinus rhythm HFrEF, HR >70 bpm despite BB/BB max tolerated, to reduce HF hosp (SHIFT trial). Symptomatic improvement. 2a
Hydralazine + Nitrate Add-on for HFrEF HFpEF if ongoing congestion despite GDMT, or AA ethnicity with reduced LVEF (CHET trial benefit). 2b
Digoxin Symptomatic HFrEF with AF + RVR (rate control); reduces hospitalizations but NOT mortality. Consider if congestion despite therapy. 2b

HFmrEF Management

HFmrEF (LVEF 41–49%) is a distinct phenotype between HFrEF and HFpEF. Evidence base is growing but less robust than HFrEF. Use GDMT Optimizer for medication guidance.

Pharmacotherapy Recommendations

Drug Class Recommendation Rationale / Evidence COR
ACEi / ARNi Should be considered Extrapolation from HFrEF; no large RCT specifically in HFmrEF. Symptom improvement expected. 2a
Beta-Blockers Should be considered Rate control, symptom benefit, limited mortality data. No strong HFmrEF-specific trial. 2a
MRA May be considered Extrapolation from HFrEF; weak HFmrEF-specific evidence. Use if congestion or hyperkalemia controlled. 2b
SGLT2i (empagliflozin, dapagliflozin) Can be considered EMPEROR-Preserved, DELIVER trials show benefit in HFmrEF. Reduces HF hosp & CV death. 2a
Diuretics For fluid retention Symptom relief in congestion; no mortality benefit. Adjust based on fluid status. 1
Pearl: HFmrEF outcomes are intermediate between HFrEF and HFpEF. Response to GDMT may be better than HFpEF but less dramatic than HFrEF. Monitor for progression to HFrEF (adverse prognostic indicator) or regression to HFpEF (favorable).

HFpEF Management

HFpEF (LVEF ≥50%) accounts for ~50% of symptomatic HF. Diagnosis requires symptoms + diastolic dysfunction + elevated natriuretic peptides. Use H2FPEF Score to aid diagnosis.

Diagnosis of HFpEF

Three-Criterion Approach:

Criterion Definition / Markers
1. Symptoms & Signs Dyspnea (exertional, paroxysmal nocturnal), orthopnea, fatigue, reduced exercise tolerance; ± edema, JVD, rales
2. Natriuretic Peptides (Elevated) BNP ≥35 pg/mL OR NT-proBNP ≥125 pg/mL (or higher thresholds with age ≥75)
3. Diastolic Dysfunction ± Structural Findings E/e′ >9, LAE (indexed LA volume >34 mL/m²), elevated TR velocity (>2.8 m/s), LVH (LVMI >115 ♂; >95 ♀), prolonged DT, reduced S′, or CMR evidence

Pharmacotherapy in HFpEF

Agent / Class Trial Evidence Recommendation COR
SGLT2i (Dapagliflozin) DELIVER trial: 18% reduction HF hosp + CV death Recommended to reduce HF hosp & CV death 1
SGLT2i (Empagliflozin) EMPEROR-Preserved: 21% reduction CV death + HF hosp Recommended for HFpEF 1
ACEi / ARNi / ARB I-PRESERVE, CHARM-Preserved limited benefits Can be considered for HTN control, AF management, renal protection 2a
Beta-Blockers Limited HFpEF-specific benefit; symptomatic relief Use for rate control (esp. AF), HTN, or IHD 2b
Diuretics (Loop / Thiazide) Symptom relief; no mortality benefit For fluid retention, dyspnea control 1

HFpEF-Specific Strategies

DO:

  • Optimize HTN control (target SBP 130–139 mmHg if tolerated)
  • Aggressive AF management (rate control, consider ablation if AF-induced, anticoagulation per CHA₂DS₂-VASc)
  • Manage comorbidities: obesity weight loss, diabetes glycemic control, CKD (slow progression)
  • Exercise rehabilitation & education; self-management programs reduce admissions
  • Start SGLT2i early (dapagliflozin, empagliflozin) — foundational therapy
  • Consider diuretics for congestion; avoid over-diuresis (decompensation risk)

DON'T:

  • Rely on ACEi/ARNi/ARB alone; insufficient HFpEF evidence
  • Use MRA unless specific indication (AF + CKD, post-MI); less data in pure HFpEF
  • Restrict fluids unless severe hyponatremia; may worsen renal perfusion
  • Over-diurese (excessive hypotension, worsening renal function)

Device Therapy in HF

Implantable Cardioverter-Defibrillator (ICD) — Indications in HFrEF

Indication Criteria COR
Primary Prevention ICD LVEF ≤35% despite ≥3 months optimal medical therapy; NYHA II–III; expected survival >1 year; sinus rhythm 1
Secondary Prevention ICD Sustained VT/VF despite antiarrhythmic therapy, or previous cardiac arrest (primary prevention failed) 1
Bridge to Transplant / MCS Hemodynamically unstable VT/VF; awaiting definitive therapy 2a

Cardiac Resynchronization Therapy (CRT) — Pacing ± Defibrillator

Phenotype Criteria Device (CRT-P vs CRT-D) COR
CRT-eligible HFrEF LVEF ≤35%, NYHA II–IV, QRS ≥120 ms, sinus rhythm CRT-D if also ICD-eligible; CRT-P if no ICD indication 1
LBBB (120–149 ms) Specific LBBB morphology (strict ESC criteria: >40 ms R-peak notch mid-QRS) CRT likely to benefit; strong recommendation 1
Non-LBBB (120–149 ms) Right bundle branch block (RBBB) or atypical morphology; less data CRT can be considered; weaker evidence 2a
QRS ≥150 ms Any morphology; higher likelihood of response CRT-D if ICD-eligible 1
AF + Advanced HFrEF LVEF ≤35%, AF with rapid ventricular rate refractory to medical therapy AV node ablation + CRT-D; restores BiV pacing 2a
Pearl: CRT response rates are ~60–70%, with superior outcomes in LBBB morphology and narrower QRS. Optimization of device settings (AV delay, VV delay) post-implant may improve response. Consider echocardiogram or strain imaging 3–6 months post-implant to confirm response.

Acute Heart Failure Management

Classification by congestion (wet/dry) and perfusion (warm/cold) guides initial therapy. Rapid stabilization and transition to optimal OMT essential.

Acute HF Classification & Initial Approach

Status Signs Initial Management Priority
Warm & Dry
(Compensated)		 Normal perfusion, no congestion Maintain OMT; outpatient optimization
Warm & Wet
(Congested)		 Normal perfusion, edema/orthopnea/PND, elevated JVP, rales Diuretics (IV loop); vasodilators if HTN; target euvolemia over 48–72 h
Cold & Dry
(Low output)		 Reduced perfusion (confusion, cold extremities, ↓ urine output), no congestion IV inotropes (dobutamine, milrinone); invasive monitoring; consider MCS
Cold & Wet
(Cardiogenic shock)		 Hypotension, organ hypoperfusion, pulmonary/systemic congestion Aggressive diuretics + vasopressor/inotrope support; consider mechanical circulatory support (IABP, Impella, ECMO)

Diuretic Strategy in Acute Decompensated HF

IV Diuretic Approach

Initial Assessment: Determine volume status, kidney function, electrolytes. IV loop diuretic preferred in AHF with congestion. 1
Dosing Strategy: Diuretic-naïve: Start 40 mg IV furosemide (or equivalent). Prior chronic furosemide dose: 1–2× daily home dose. Bolus vs infusion: Low-dose continuous infusion may be safer (less hyperkalemia, renal injury)
Escalation: Double dose if inadequate diuresis at 2–4 h. Add second diuretic class (thiazide IV or PO) if diuretic-resistant. 2a
Target: Euvolemia (loss JVD, orthopnea, rales); avoid over-diuresis (azotemia, hypotension). Monitoring urine output, Cr, K+, Na+ critical.
Transition: Once euvolemic, resume oral diuretics (same or higher home dose to prevent re-decompensation). 2a

Vasodilators & Inotropes in Acute HF

Agent Indication Dose / Route Key Caution COR
Nitrates (IV)
(e.g., isosorbide dinitrate)		 AHF + congestion + SBP >100 mmHg; acute pulmonary edema Start 10–20 μg/min; titrate to dyspnea relief, ↓ PCWP Hypotension, reflex tachycardia, tolerance with prolonged use. Contraindicated in RV infarction. 2a
Hydralazine (IV) AHF + HTN + pulmonary edema; preload/afterload reduction 10–20 mg IV Q4–6h; oral 25–50 mg TID chronic Reflex tachycardia, lupus-like syndrome (chronic). Less common in modern HF. 2b
Dobutamine Low-output AHF (cold/dry or cold/wet); cardiogenic shock 2.5–5 μg/kg/min IV infusion; titrate to CI >2.2, PCWP <18 Tachycardia, arrhythmia risk, increased myocardial O₂ demand. Not mortality-protective (may worsen). 2a
Milrinone Low-output HF refractory to dobutamine; inotrope-vasodilator; bridge to MCS 0.25–0.75 μg/kg/min; titrate for hemodynamics Systemic hypotension, arrhythmia. Reserved for ICU/hemodynamic monitoring. 2b

Mechanical Circulatory Support Indications

Device / Strategy Criteria Duration COR
Intra-Aortic Balloon Pump (IABP) Cardiogenic shock refractory to inotropes; mechanical mitral regurgitation; VSD post-MI; bridge to MCS/transplant Days to weeks 2b
Impella Cardiogenic shock; LV unloading; bridge to decision/transplant; ARDS Days to weeks 2a
ECMO (VV or VA) Severe cardiogenic + respiratory shock; fulminant myocarditis; bridge to decision/VAD Days to weeks 2a
Left Ventricular Assist Device (LVAD) Advanced HF refractory to OMT + device therapy; destination therapy or bridge to transplant; INTERMACS 1–3 Months to years 1

Comorbidity Management in Heart Failure

Atrial Fibrillation (AF) in HF

Management Aspect Recommendation COR
Anticoagulation All HF + AF (paroxysmal, persistent, permanent) require anticoagulation (DOACs or warfarin). DOAC preferred if no contraindication. 1
Rate Control Target resting HR <110 bpm (lenient control acceptable); use BB (first-line), digoxin, or non-DHP CCB (verapamil, diltiazem) if BB not tolerated. Avoid DHP CCB (nifedipine) in HFrEF. 1
Rhythm Control / Ablation AF ablation (catheter or surgical) can be considered in symptomatic HF + AF, especially paroxysmal/persistent AF. May improve LVEF and symptoms. Not all HFrEF patients suitable. 2a
Antiarrhythmic Drugs Avoid Class I agents (flecainide, propafenone) in HFrEF due to proarrhythmia risk. Amiodarone safe (Class III) if rhythm control needed, but reserve for refractory AF. 3

Chronic Kidney Disease (CKD) & Type 2 Diabetes in HF

Use CKD-EPI eGFR calculator to estimate renal function and adjust GDMT dosing.

Drug / Strategy Recommendation in CKD + HF COR
ACEi / ARNi Recommended; renal protective (↓ albuminuria, slow CKD progression). Monitor Cr (↑ <30% acceptable), K+. Continue if ESRD not requiring dialysis. 1
SGLT2i Recommended in CKD + HF (T2DM or non-diabetic); reduce HF hosp, CV death, delay dialysis. Dapagliflozin ↓ eGFR, safer in lower eGFR (10–30). Caution DKA risk. 1
Finerenone (2023) Recommended for T2DM + CKD + HF; reduces HF hosp & CV death. Non-steroidal MRA with renal protection. 1
MRA (Spironolactone / Eplerenone) Use cautiously; risk of hyperkalemia, especially eGFR <45. Monitor K+ closely (target <5.0 mmol/L). Eplerenone less K+-sparing than spironolactone. 1

Iron Deficiency (ID) in HF

Affects ~20–40% HF patients; worsens symptoms & exercise capacity. Recommended to screen & treat:

Definition / Action Criteria COR
ID Screening Check ferritin + TSAT in all HF patients. ID defined as serum ferritin <100 ng/mL or ferritin 100–299 with TSAT <20%. 1
IV Iron Supplementation Symptomatic HF + ID (ferritin <100 or 100–299 TSAT <20%); use ferric carboxymaltose. Improves symptoms, exercise capacity, quality of life. 2a
Dosing Ferric carboxymaltose 500–750 mg IV Q 1–2 weeks until ferritin 100–300 ng/mL & TSAT >20%. 1

Key Do's and Don'ts in HF Management

DO:

  • Start all four GDMT drugs in HFrEF: ACEi/ARNi, BB, MRA, SGLT2i (now foundational). Titrate sequentially if hypotension/renal concerns, but target all four in combination.
  • Measure BNP/NT-proBNP in suspected HF: Negative result (BNP <35 or NT-proBNP <125) excludes HF diagnosis with high confidence.
  • Perform echocardiography in all HF: Mandatory for phenotyping (HFrEF vs HFmrEF vs HFpEF), assessing LVEF, diastolic function, valve disease, regional wall motion.
  • Titrate GDMT to target doses or maximum tolerated: Despite modest hypotension or creatinine rise (<30%), if clinical stability maintained.
  • Anticoagulate all HF + AF: DOAC preferred; continue indefinitely regardless of CHA₂DS₂-VASc (paroxysmal AF also at risk).
  • Optimize diuretic dose: Achieve euvolemia; adjust based on signs/symptoms. Use lowest dose to prevent re-decompensation.
  • Screen & treat iron deficiency: Check ferritin + TSAT; IV iron (ferric carboxymaltose) if ferritin <100 or 100–299 with TSAT <20%.
  • Consider device therapy (ICD/CRT): ICD for primary prevention when LVEF ≤35% despite 3 months OMT. CRT if QRS ≥120 ms, LBBB, NYHA II–IV.

DON'T:

  • Delay GDMT initiation: Start ACEi/ARNi + BB immediately; don't wait for perfect renal function or blood pressure.
  • Use positive inotropes routinely in AHF: Reserve dobutamine/milrinone for cardiogenic shock (cold/wet) or low-output states; not routine acute decompensation.
  • Restrict ACEi/ARNi dosing due to minor renal changes: Creatinine increase <30% and K+ <5.5 acceptable; continue titration.
  • Avoid MRA due to mild hyperkalemia: Monitor closely, but benefit outweighs risk. Finerenone safer than spironolactone in CKD + HF + T2DM.
  • Omit SGLT2i in non-diabetic HF: Benefit independent of diabetes; recommend in all HFrEF, HFmrEF, HFpEF phenotypes.
  • Use Class I antiarrhythmics in HFrEF: Flecainide, propafenone contraindicated (proarrhythmic). Reserve amiodarone for refractory arrhythmias.
  • Over-diurese in AHF: Excessive diuresis causes azotemia, hypotension, worsening renal function. Target euvolemia gradually (48–72 h).
  • Forget comorbidity optimization: HTN, AF, CKD, T2DM, obesity all require tailored management alongside HF therapy.

Related Calculators

Use these tools to optimize HF diagnosis, risk stratification, and medication management:

MAGGIC HF Survival

Mortality risk prediction in chronic HF. Guides prognosis discussion, device therapy decisions, transplant listing urgency.

Seattle HF Model

Mortality risk in HFrEF. Integrates LVEF, medications, comorbidities. Useful for shared decision-making & prognosis.

GDMT Optimizer

Drug sequencing and titration planning for HFrEF. Tracks current doses, target doses, and optimization status.

H2FPEF Score

HFpEF diagnosis probability. Uses clinical, echo, and NP criteria to assess likelihood of HFpEF phenotype.

CHA₂DS₂-VASc Score

Stroke risk in AF. All HF + AF patients need anticoagulation regardless of score; use for thromboembolism counseling.

QTc Correction

Calculate corrected QT interval. Monitor during sotalol, amiodarone, or QT-prolonging drug therapy in HF.

CKD-EPI eGFR

Estimate glomerular filtration rate. Essential for GDMT dosing, diuretic selection, iron therapy in HF + CKD.

Cockcroft-Gault CrCl

Creatinine clearance estimation. Alternative to eGFR; useful for drug renal dosing adjustments.