d. Use of an SGLT2 inhibitor should also be considered as concomitant treatment for HFrEF in African Americans. Importantly, given the risk of HF in African Americans, use of an SGLT2 inhibitor is especially important in the pre-HF stage to reduce the onset of the disease in those with known diabetes. e. Social barriers to GDMT and optimal HFrEF manage- ment should be assessed and, where present, addressed to avoid health inequities in HFrEF outcomes (137). f. All treatment decisions should be determined in the context of an informed, culturally competent, shared decision-making discussion with the patient that con- siders the risks and bene ts of treatment. Older adults. Older adults, especially the very elderly, represent yet another conundrum for treatment of HF. The upper range for inclusion in HF clinical trials has typically been age 75  5 years; in essence, there are no randomized data for drugs or devices in patients older than 80 years of age. And although data from DAPA-HF can inform the use of a SGLT2 inhibitor in persons over the age of 75 years, for other evidence-based therapies in HFrEF, observational data represent the only lines of evidence supporting similar treatment bene ts in older patients. Nevertheless, target doses for GDMT should be attempted in older patients, with close surveillance for any adverse drug reactions. The pharmacokinetic pro le for GDMT as a function of age is not known, and higher risks of adverse events (133) have been described in older populations. Accordingly, optimal doses for older patients may be lower than those studied in trials or tolerated in younger patients. Furthermore, medication and dosing decisions should be made in a holistic context of the pa- tient. 