As such, a focused update to the 2017 ECDP that in- corporates these advances into the recommendations is warranted. This update can serve as interim guidance to clinicians while we await the comprehensive and de ni- tive heart failure (HF) guideline update under develop- ment by the ACC. The treatment of HFrEF can feel overwhelming, and many opportunities to improve pa- tient outcomes are being missed; hopefully, this ECDP will streamline care to realize the best possible patient outcomes in HF. The prevalence of HF is escalating rapidly (5). Com- pounding this, HF is an illness that consumes substantial healthcare resources, in icts considerable morbidity and mortality, and greatly affects quality of life. Important breakthroughs have rede ned opportunities to change Maddox et al. J the natural history of the disease with a broad range of medical therapies, devices, and care strategies. The purpose of this focused ECDP update is to sup- plement the 2017 ECDP with data from emerging studies and to continue to provide succinct, practical guidance for managing patients with HFrEF. The format of the 10 Pivotal Issues in the 2017 ECDP was preserved, and their associated treatment algorithms and tables have been updated to accommodate this new, evolving evidence. Ten Pivotal Issues in HFrEF 1. How to initiate, add, or switch therapies to new evidence-based guideline-directed treatments for HFrEF. 2. How to achieve optimal therapy given multiple drugs for HF including augmented clinical assessment (e.g., imaging data, biomarkers, and lling pressures) that may trigger additional changes in guideline-directed therapy. 3. When to refer to an HF specialist. 4. How to address challenges of care coordination. 5. How to improve medication adherence. 6. What is needed in speci c patient cohorts: African Americans, older adults, and the frail. 7. 