HFrEF (LVEF < 50%): foundational and additional therapy

Follows the 2026 ESC guideline, which uses a single LVEF cut-off (HFrEF < 50%, HFpEF ≥ 50%) and no longer has HFmrEF. Checks which of the four foundational medical therapy (FMT) classes are missing (ACE inhibitor or ARNI, or ARB; beta-blocker; MRA; SGLT2 inhibitor) and gives target doses with the BP, potassium and kidney-function limits. Adds the additional medical therapies by LVEF band as in the ESC 2026 central illustration: diuretics, IV iron, ivabradine, hydralazine–nitrate, vaccination, digoxin or digitoxin (now class IIa after DIGIT-HF), vericiguat (class IIb up to LVEF 45%), and semaglutide or tirzepatide in obesity, with a chart of every therapy by LVEF and class. A dedicated checklist tests each ESC 2026 criterion for IV iron (iron deficiency definition, class I below LVEF 45%), ivabradine (sinus rhythm, HR > 70 bpm, LVEF ≤ 35% on a maximally tolerated beta-blocker) and digoxin or digitoxin (LVEF < 40%, symptomatic on optimised FMT), and gives the iron repletion dose from haemoglobin and weight, titration, target levels and contraindications. Flags ICD and CRT eligibility and stage D referral. The 2022 AHA/ACC/HFSA guideline, which keeps HFrEF ≤ 40%, HFmrEF 41–49% and HF with improved EF, is shown alongside.