Cardiac rehabilitation is helpful to support drug titration, monitor symptoms, improve health status, and increase exercise tolerance, but remains underused in terms of both prescription and access (51). During the COVID-19 pandemic, virtual care to allow for outpatient GDMT titration has been useful in certain patients (52) and will likely take on a larger role in HFrEF care post- pandemic. High-risk features (conveniently summarized by the acronym I NEED HELP in Figure 4 and Table 6) should trigger consideration for referral for an advanced HF consultation (53). Features triggering referral to advanced HF care are also discussed in Section 5.3 and Table 6. 5.2.4. Imaging When to Order an Echocardiogram An echocardiogram, with strain imaging when available, is recommended in the evaluation of the patient with incident HF to assess LVEF, diastolic function, chamber size, ventricular wall thickness, valvular abnormalities, and hemodynamic parameters including estimated right ventricular systolic pressure, central venous pressure, and LV lling pressures. Once optimal doses of GDMT have been achieved for 3 to 6 months, repeat imaging can be useful in making decisions regarding device therapy (implantable cardioverter de brillator, cardiac resynch- ronization therapy, or transcatheter mitral valve repair) or referral for advanced therapies (ventricular assist device J Maddox et al. or transplant). In some patients, it may be reasonable to wait longer for such decisions if there is an expectation that LV remodeling might further progress. For example, in the PROVE-HF study, increases in LVEF and reduction in LV volumes continued over 12 months in some patients (11). Repeat imaging may also be considered at the time of important changes in clinical status (3). Routine surveil- lance echocardiograms (e.g., annually) in the absence of FIGURE 4 Testing and Medication Titration Following Diagnosis of HFrEF Maddox et al. 