Abstract

Guidelines for management of heart failure with reduced ejection fraction (HFrEF) emphasize personalized care, patient engagement, and shared decision‐making. Medications and cardiac rhythm management (CRM) devices are recommended with a high level of evidence. However, there are significant disparities: patients who could benefit from devices are frequently referred too late or not at all. Misconceptions about device therapy and the notion that the needs of patients (especially the prevention of sudden cardiac death) can now be met by expanding drug therapies may play a role in these disparities. This state‐of‐the‐art review is produced by members of the DIRECT HF initiative, a patient‐centred, expert‐led educational programme that aims to advance guideline‐directed use of CRM devices in patients with HFrEF. This review discusses the latest evidence on the role of CRM devices in reducing HFrEF mortality and morbidity, and provides practical guidance on patient referral, device selection, implant timing and patient‐centred follow‐up.