Table 1.

Recommendations for renin-angiotension-aldosterone system inhibitors based on creatinine change³⁷

Change in renal function compared with baseline	HFpEF (assuming no other prognostic indication)	HFrEF
Increase in serum creatinine by <30%	Consider stopping ACEi/ARB/ARNi Review MRA according to fluid status	Continue unless symptomatic hypotension
Increase in serum creatinine by 30–50%	Stop RAASi	Consider reducing dose or temporary withdrawala
Increase in serum creatinine by >50%	Stop RAASi	Temporarily stop RAASia
Severe renal dysfunction, for example, eGFR <20 mL/min/1.73 m2	Stop RAASi	Stop RAASi if symptomatic uraemia irrespective of baseline function

^a = Re-initiate and/or re-titrate when renal function improved in patients with HFrEF; ACEi = angiotensin converting enzyme inhibitor; ARNi = angiotensin receptor neprilysin inhibitor; ARB = angiotensin receptor blocker; eGFR = estimate glomerular filtration rate; HFpEF = heart failure and preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; MRA = mineralocorticoid receptor antagonist; RAASi = renin-angiotension-aldosterone system inhibitors. Reproduced with permission from Clark AL, Kalra PR, Petrie MC et al. Change in renal function associated with drug treatment in heart failure: national guidance. Heart 2019;105:904-10.