If the volume status is unclear, consider performing right heart catheterization and/or referral to an HF specialist. Chronic ambulatory pulmo- nary artery pressure monitoring may be considered in patients with hospitalizations in the past year who have persistent symptoms with minimal exertion. Principle 6: Tolerability and side effects depend, in part, on how and when GDMT is prescribed. Scenario: Worsening renal function or hyperkalemia. Use less than target doses of an ARNI/ACEI/ARB and discontinue aldosterone antagonist if estimated creati- nine clearance <30 ml/min or serum potassium >5.0 mEq/L. Available data support a survival bene t even with a low-dose ACEI, which may be the default choice in the setting of renal insuf ciency and marginal blood pressure. Scenario: Symptomatic hypotension. Hypotensive symptoms may be due to over-diuresis, use of non-CV drugs with hemodynamic effects (e.g., anticholinergic agents, treatments for prostate enlarge- ment, others), autonomic dysfunction, or simultaneous administration of multiple HF medications. All of these should be addressed before deciding to lower doses of evidence-based therapies. After excluding other causes of hypotension, use best-tolerated doses of GDMT, accept- ing that less data exist for the impact of lower doses in HF management. Clinical comorbidities and clinical judge- ment should be used to guide which GDMTs are reduced. For persistent hypotension, consider referral to an advanced HF specialist. Principle 7: Primary prevention implantable cardioverter-de brillator and cardiac resynchronization therapy should be considered after consistent use of optimal doses of all GDMTs for at least 3 to 6 months, followed by reassessment of EF and other indications for device therapy. Principle 8: Transcatheter mitral valve repair may be considered among symptomatic patients with chronic moderate-severe to severe mitral regurgitation despite optimal doses of all GDMTs. Principle 9: Focus on the patient s symptoms, func- tional capacity, and cardiac function. 