Grades are shown as the source states them. The KSHF guidelines use classes of recommendation (I recommended, IIa reasonable, IIb may be considered, III not recommended) with levels of evidence A to C, as in European and American guidelines.
Key recommendations
In heart failure with reduced ejection fraction (HFrEF), four drug classes are the standard of care to cut cardiovascular death and admissions: an ARNI (or an ACE inhibitor, or an ARB if neither is tolerated), an evidence-based beta-blocker, a mineralocorticoid receptor antagonist (MRA) and an SGLT2 inhibitor.
Class I; level AHFrEF: treatment algorithmKorean Society of Heart Failure (KSHF) 2023
Keep the full treatment going even if symptoms improve and the ejection fraction rises above 40%; in one trial, heart failure worsened within 6 months in 45% of people who stopped.
Class I; level BHFrEF: treatment algorithmKorean Society of Heart Failure (KSHF) 2023
Measure BNP or NT-proBNP as the first test when heart failure is suspected. Outside an acute setting, BNP below 35 pg/mL or NT-proBNP below 125 pg/mL makes heart failure very unlikely; in the acute setting the cut-offs are 100 and 300 pg/mL.
Class I; level ADiagnostic tests for heart failure; Table 3Korean Society of Heart Failure (KSHF) 2023
In heart failure with mildly reduced or preserved ejection fraction, give an SGLT2 inhibitor (empagliflozin or dapagliflozin) whether or not the person has diabetes, a diuretic for congestion, and look for and treat comorbidities such as hypertension, atrial fibrillation, diabetes and kidney disease.
SGLT2 inhibitor Class I; level B; diuretics and comorbidities Class I; level CHFmrEF and HFpEFKorean Society of Heart Failure (KSHF) 2023
Provide multidisciplinary care, support self-management and enrol people in heart failure programmes, all of which reduce admissions and deaths. Offer exercise training to everyone, supervised for those who are frail, severely ill or multimorbid.
Class I; level A; supervised rehabilitation Class IIa; level CMultidisciplinary care; Cardiac rehabilitationKorean Society of Heart Failure (KSHF) 2023
Diagnosis
Classify by ejection fraction: reduced (40% or less), mildly reduced (41–49%), or preserved (50% or more, with raised natriuretic peptides or structural or diastolic abnormality). Atypical features include weight gain or loss, poor appetite and palpitations.
Classification of HF; Table 1Korean Society of Heart Failure (KSHF) 2023
Initial tests: a 12-lead ECG, natriuretic peptide, blood count, lipids, urea and electrolytes, iron studies (transferrin saturation and ferritin), fasting glucose and HbA1c, kidney, liver and thyroid function, echocardiography and a chest X-ray.
Class I; level B–CDiagnostic algorithm for HFKorean Society of Heart Failure (KSHF) 2023
Natriuretic peptides can be raised without heart failure in advanced age, anaemia, stroke, chronic kidney disease, cirrhosis, acute coronary syndrome, COPD, sepsis and thyrotoxicosis, and can be low despite heart failure in obesity and some valve conditions. Interpret them with symptoms, signs and echocardiography.
Diagnosis and differential diagnosis; Table 4Korean Society of Heart Failure (KSHF) 2023
Preserved ejection fraction mainly affects older women with hypertension, atrial fibrillation, ischaemic heart disease, diabetes and kidney disease; lung disease, anaemia and obesity can mimic its symptoms.
HFmrEF and HFpEFKorean Society of Heart Failure (KSHF) 2023
Transthyretin cardiac amyloidosis is under-recognised. Clues include intolerance of beta-blockers or ACE inhibitors, previously high blood pressure becoming normal or low, low ECG voltages for the wall thickness, bilateral carpal tunnel syndrome, lumbar spinal stenosis and biceps tendon rupture. Tafamidis is recommended for NYHA class I–II disease.
Tafamidis Class I; level BCardiac amyloidosis; Table 1Korean Society of Heart Failure (KSHF) 2023
Investigations
Before starting an MRA, check kidney function and potassium; take care if eGFR is below 30 mL/min/1.73 m² or potassium above 5.0 mmol/L.
Iron deficiency (ferritin below 100 ng/mL, or 100–299 with transferrin saturation below 20%) is common. Intravenous ferric carboxymaltose is reasonable for iron-deficiency anaemia; erythropoiesis-stimulating agents are not recommended for unexplained anaemia.
IV iron Class IIa; level A; ESAs Class III; level BIron deficiency and anaemiaKorean Society of Heart Failure (KSHF) 2023
Screen for depression (for example with the Geriatric Depression Scale) and for cognitive impairment (MMSE or MoCA), which affects 45–80% of people admitted with decompensated heart failure.
Depression and cognitive impairmentKorean Society of Heart Failure (KSHF) 2023
Treatment
Replace an ACE inhibitor or ARB with an ARNI even in stable patients, to reduce death and admissions further. Stop the ACE inhibitor 36 hours before the first ARNI dose to avoid angioedema.
Class I; level BHFrEF: renin–angiotensin system inhibitorKorean Society of Heart Failure (KSHF) 2023
Use a beta-blocker with proven mortality benefit (bisoprolol, carvedilol or sustained-release metoprolol); nebivolol can be beneficial from age 70. Start it promptly even if the ACE inhibitor dose is still low.
Class I; level A; nebivolol Class IIa; level BHFrEF: beta-blockersKorean Society of Heart Failure (KSHF) 2023
With SGLT2 inhibitors, a small early fall in eGFR is expected and reversible, so do not stop the drug for it. Watch for genital infection and volume depletion, and, rarely, hypoglycaemia or ketoacidosis in people with diabetes.
Class I; level AHFrEF: SGLT2 inhibitorsKorean Society of Heart Failure (KSHF) 2023
Use diuretics, usually a loop diuretic, for fluid retention whatever the ejection fraction, with salt restriction. Stop NSAIDs and corticosteroids; switch to intravenous furosemide or to torsemide if absorption is poor; add a thiazide briefly for diuretic resistance. Too much diuretic causes low blood pressure, low output and kidney impairment.
Class I; level BHFrEF: diureticsKorean Society of Heart Failure (KSHF) 2023
If symptoms persist on full treatment: ivabradine for ejection fraction 35% or less in sinus rhythm with a resting rate of 70 or more; vericiguat after a recent worsening; digoxin for rate control in atrial fibrillation when beta-blockers are not enough.
Class IIa; level BHFrEF: ivabradine, vericiguat, digoxinKorean Society of Heart Failure (KSHF) 2023
With atrial fibrillation, anticoagulate men with a CHA2DS2-VASc score of 2 or more and women with 3 or more, preferring a direct oral anticoagulant unless there is moderate to severe mitral stenosis or a mechanical valve.
Class I; level AAtrial fibrillationKorean Society of Heart Failure (KSHF) 2023
For hyponatraemia with fluid overload, exclude other causes such as SIADH, hypothyroidism or hypoaldosteronism, restrict fluid to 800–1000 mL a day, and consider tolvaptan only if refractory; it raises sodium but does not improve survival.
Tolvaptan Class IIb; level BHFrEF: tolvaptanKorean Society of Heart Failure (KSHF) 2023
An ICD is recommended in ischaemic heart failure (NYHA II–III) with ejection fraction 35% or less after at least 3 months of full treatment, if survival beyond a year is expected; it is not recommended in NYHA class IV unless the person is a candidate for resynchronisation, a ventricular assist device or transplant.
Class I; level A; NYHA IV Class III; level CCardiac implantable electronic device: ICDKorean Society of Heart Failure (KSHF) 2023
Important geriatric considerations
People aged 75 and over are under-represented in the evidence: fewer than 40% of studies cited by the 2022 AHA/ACC/HFSA guideline enrolled representative older populations. Frailty, cognitive impairment (in up to 43%) and polypharmacy complicate care, and it is unknown whether selective rather than intensive treatment serves frail people better.
Results; DiscussionJamil Y, et al. (scoping review) 2025
Digoxin toxicity — anorexia, nausea, vomiting, visual change, confusion and fatal arrhythmias — is more likely over 70 and with kidney failure, low body weight, electrolyte disturbance or interacting drugs (macrolides, itraconazole, ciclosporin, amiodarone, quinidine).
HFrEF: digoxinKorean Society of Heart Failure (KSHF) 2023
Avoid tricyclic antidepressants in heart failure (hypotension, worsening heart failure, arrhythmia). Sertraline and escitalopram appear safe, although SSRIs did not improve symptoms or outcomes in trials.
Depression and cognitive impairmentKorean Society of Heart Failure (KSHF) 2023
Hyponatraemia causes cognitive impairment that easily leads to falls, and altered consciousness when severe.
HFrEF: tolvaptanKorean Society of Heart Failure (KSHF) 2023
A rise in creatinine after starting an ACE inhibitor, ARB, ARNI or SGLT2 inhibitor is usually transient and occurs despite long-term benefit; keep diuretics going while the person is congested.
Renal failure and electrolyte imbalanceKorean Society of Heart Failure (KSHF) 2023
Drug doses
Spironolactone: start 12.5–25 mg a day; eplerenone: start 25 mg a day; both can be increased to 50 mg a day.
Acute heart failure with overload: intravenous furosemide 20–40 mg (or torsemide 10–20 mg) if not already on diuretics; if already taking them, an intravenous dose equal to or up to twice the total daily oral dose. Aim for weight loss of 0.75–1 kg a day.
Class I; level BDiureticsKorean Society of Heart Failure (KSHF) 2023
Digoxin: start low, then maintain at 0.125 or 0.25 mg a day, checking serum levels.
HFrEF: digoxin; Advanced and acute HF: digoxinKorean Society of Heart Failure (KSHF) 2023
When to refer
Before discharge after an admission, make sure the person is decongested and that full treatment is started and preferably optimised; review within 1–2 weeks of discharge.
Class I; level CPre- and post-discharge managementKorean Society of Heart Failure (KSHF) 2023
Advanced heart failure that does not respond to treatment and is not suitable for transplant or a ventricular assist device: offer palliative and end-of-life care, using morphine, antiemetics, diuretics and oxygen for symptoms, and plan the preferred place of death and deactivation of ICDs or pacemakers.
Class IIa; level C; symptom drugs Class IIb; level CPalliative and end-of-life careKorean Society of Heart Failure (KSHF) 2023
Refer acute severe heart failure of unknown cause that progresses rapidly despite treatment for endomyocardial biopsy to look for myocarditis.
Class I; level BMyocarditisKorean Society of Heart Failure (KSHF) 2023
Red flags
Acute heart failure needs immediate tests and treatment together: intravenous loop diuretics for congestion and thromboprophylaxis if not already anticoagulated. Opiates are not recommended routinely, and intravenous nitrates may be considered if systolic pressure is above 110 mmHg.
Diuretics Class I; level C; thromboprophylaxis Class I; level A; routine opiates Class III; level CAcute HF; Diuretics; Vasodilators and other drugsKorean Society of Heart Failure (KSHF) 2023
About 30% of people leave hospital still congested, and they have a higher mortality in the following year.
Pre- and post-discharge managementKorean Society of Heart Failure (KSHF) 2023
In advanced heart failure, blood-pressure-lowering drugs taken for long-term benefit can be reduced or stopped to lower the risk of falls.
Palliative and end-of-life careKorean Society of Heart Failure (KSHF) 2023
Recent updates
The 2023 KSHF update makes ARNI first-line ahead of ACE inhibitors, recommends SGLT2 inhibitors across the whole ejection-fraction range, and adds tafamidis for transthyretin amyloid cardiomyopathy.
IntroductionKorean Society of Heart Failure (KSHF) 2023