Heart failure with reduced ejection fraction: a systematic review of clinical practice guidelines and recommendations

Heart failure with reduced ejection fraction (HFrEF) accounts for over half of heart failure cases and its management is directed by international clinical practice guidelines. To evaluate current recommendations, we conducted a systematic review of guidelines on the diagnosis and management of HFrEF in adults. MEDLINE and EMBASE were searched on 10 November 2024 for publications within the past decade, and websites of relevant medical societies were reviewed. Twelve guidelines were identified, of which seven met predefined AGREE II criteria for methodological 'rigour of development' and were included in the final analysis. Across the selected guidelines, there was broad consensus on the prevention of heart failure, the definition of HFrEF, and the initial diagnostic approach. Recommended investigations included coronary CT angiography, cardiac magnetic resonance imaging, and invasive coronary angiography in selected patients. There was also agreement on the principles of pharmacological management, with consistent endorsement of foundational therapies such as renin-angiotensin-aldosterone system (RAAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. However, key differences emerged regarding thresholds for serum natriuretic peptides, sequencing of RAAS inhibitors, and device-based therapies including implantable defibrillators in non-ischaemic HFrEF, cardiac resynchronization therapy, and indications for coronary revascularization. Variability was also noted in staging, particularly the identification and management of stage A (at-risk) and stage B (pre-heart failure). Only a minority of guidelines addressed common comorbidities such as iron deficiency, atrial fibrillation, obesity, sleep-disordered breathing, and frailty. Our findings underscore the need for greater harmonization to standardize and optimize HFrEF care worldwide.