COR LOE Recommendations Patients with chronic severe secondary MR (Stages C and D) and HF with reduced LVEF should receive standard GDMT for HF, including ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and/or sacubitril/valsartan, and biventricular pacing as indicated.1 11 In patients with chronic severe secondary MR and HF with reduced LVEF, a cardiologist expert in the management of patients with HF and LV systolic dysfunction should be the primary MDT member responsible for implementing and monitoring optimal Synopsis GDMT for HF with reduced LVEF in patients with se- vere secondary MR should be provided, in conjunc- tion with a cardiology expert, in the management of HF. Recommendation-Specific Supportive Text 1. Chronic secondary MR usually develops as a result of LV systolic dysfunction. Thus, standard GDMT for HF forms the mainstay of therapy. Diuretics, beta blockers, ACE inhibitors or ARBs, and aldo- sterone antagonists help improve symptoms and/ or prolong life in patients with HF in general and probably do so even when HF is complicated by chronic secondary MR. GDMT can reduce LV volumes (reverse remodeling) in many patients, which reduces severity of secondary MR.1 11 2. Secondary MR is often responsive to GDMT (including coronary revascularization or car- diac resynchronization therapy in appropriate patients). Optimization of GDMT should be under the supervision of a cardiologist expert in the treatment of patients with HF to achieve optimal results and to determine with the MDT when symptoms are truly refractory to GDMT before decisions are made for surgical or transcatheter Table 18. 