New ESC updated guidelines on diagnosis and treatment of acute and chronic heart failure

 A focused update of the 2021 European Society of Cardiology (ESC) guidelines for heart failure (HF) was presented at the 2023 ESC Congress in Amsterdam by Prof Marco Metra, University of Brescia, Brescia, Italy; and Prof Theresa McDonagh, King’s College Hospital, London, UK; Chairs of the original guidelines taskforce.

“Since the 2021 ESC guidelines for HF, more than 10 randomised controlled trials have been published that should change patient management ahead of the next scheduled full guideline. Based on this recent evidence, new recommendations are provided in three areas: chronic HF, acute HF and comorbidities,” Prof Metra commented on the need for the update.

Regarding chronic HF, there were no recommendations in the 2021 guidelines on the use of sodium–glucose co-transporter 2 (SGLT2) inhibitors in patients with HF with mildly reduced ejection fraction (HFmrEF) and HF with preserved ejection fraction (HFpEF) as there was a lack of evidence. Since then, the EMPEROR-Preserved and DELIVER trials were published and the focused update now recommends dapagliflozin or empagliflozin in patients with HFmrEF and HFpEF to reduce the risk of HF hospitalisation or cardiovascular (CV) death.

“The taskforce also discussed changing the description of HFpEF to ‘HF with normal ejection fraction (HFnEF)’ and altering the left ventricular ejection fraction threshold for HFnEF,” noted Prof McDonagh. “However, we ultimately decided to keep the term ‘HFpEF’ and we left any further changes in terminology to be considered by the next ESC HF guidelines taskforce.”

For acute HF management after hospital admission, the STRONG-HF trial recently showed the safety and efficacy of an approach based on starting and titrating oral HF therapies within two days before anticipated hospital discharge and in follow-up visits occurring early after discharge. These findings led to a new recommendation of high-intensity care for initiation and rapid up-titration of oral HF therapies with close follow-up in the first six weeks after discharge to reduce HF readmission or all-cause death. The focused update stresses that particular attention should be paid to symptoms and signs of congestion, blood pressure, heart rate, NT-proBNP values, potassium concentrations, and estimated glomerular filtration rate (eGFR) during follow-up appointments.

Turning to comorbidities, the focused update provides a new recommendation for the prevention of HF in patients with chronic kidney disease (CKD) and type 2 diabetes (T2DM) based on the results of the DAPA-CKD and EMPA-KIDNEY SGLT2 inhibitor trials and a meta-analysis of four trials. Dapagliflozin or empagliflozin is now recommended for patients with CKD and
T2DM to reduce the risk of HF hospitalisation or CV death. A second recommendation follows the FIDELIO-DKD and FIGARO-DKD trials, and advocates the use of the mineralocorticoid receptor antagonist, finerenone, in patients with CKD and T2DM to reduce the risk of HF hospitalisation.