The Curbsiders Internal Medicine Podcast REBOOT #458 Heart Failure with Reduced Ejection Fraction - Kittleson Rules Outpatient Heart Failure Volume 1
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May 12, 2025 
Dr. Michelle Kittleson, a renowned heart failure expert from Cedars-Sinai, dives into the complexities of heart failure with reduced ejection fraction (HFrEF). She shares vital insights on identifying underlying causes and optimizing medication regimens. The discussion covers guideline-directed medical therapies like ARNI and SGLT2 inhibitors, emphasizing the importance of personalized treatment plans and ongoing patient education. Kittleson also highlights when to refer patients to advanced heart failure specialists, ensuring comprehensive care strategies for optimal outcomes.
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Start HFrEF Workup Thoughtfully
- Begin evaluating new heart failure with reduced ejection fraction (HFrEF) by identifying underlying causes like coronary artery disease and thyroid disease.
- Order targeted labs and tests only if results will significantly affect management decisions.
Use BNP Wisely in Heart Failure
- Use BNP to support or exclude heart failure diagnosis but avoid guiding diuresis decisions by serial BNP levels.
- Titrate diuretics based on physical exam and symptoms, not BNP trends.
Pillars and Order of HFrEF Therapy
- Start HFrEF patients on an ARNI first, then add mineralocorticoid antagonist and SGLT2 inhibitor, holding beta blockers until congestion resolves.
- Optimize blood pressure by prioritizing ARNI over others as it lowers blood pressure more.
