NICE issued updated guidelines on management in 2025, key points are summarised here.

Whilst loop diuretics play an important role in managing fluid overload it should be remembered that no long-term reduction in mortality has been demonstrated for loop diuretics such as furosemide.

Heart failure with reduced ejection fraction

The first-line treatment for all patients is a combination of the following 4 medications:

• ACE-inhibitor
  • if not tolerated (e.g. due to a cough) switch to angiotensin receptor-neprilysin inhibitor (ARNI)
  • if angioedema develops, switch to an angiotensin receptor blocker (ARB)
• beta-blocker
• mineralocorticoid receptor antagonist (MRA)
• SGLT2-inhibitor

NICE recommend using clinical judgement when initiating these medications. In practice, not all four are usually started simultaneously, as this would make it difficult to identify which drug is responsible if an adverse reaction occurs.

If patients on the above combination of 4 medications continue to have symptoms

• switch ACE-inhibitor for an angiotensin receptor-neprilysin inhibitor
  • e.g. sacubitril-valsartan
  • NICE recommend seeking advice from a heart failure specialist before initiating this treatment

Other aspects of management

Assess for iron deficiency

• check transferrin saturation (TSAT), ferritin, haemoglobin
• consider IV iron therapy if haemoglobin < 150 g/L and
  • TSAT of less than 20% or
  • serum ferritin of less than 100 ng/mL
• if iron-deficiency is found, other causes should of course be excluded first (e.g. colonoscopy etc)

Heart failure with preserved ejection fraction

The first-line treatment for all patients is a combination of the following medications:

• mineralocorticoid receptor antagonist
• SGLT2-inhibitor