New ESC guidelines on HF management

The European Society of Cardiology (ESC) has launched new guidelines for the diagnosis and treatment of acute and chronic heart failure (HF), which have been published online in the European Heart Journal. This was the first ESC
guideline to include patients as full members of the taskforce.

Approximately 2 per cent of adults worldwide have HF. Prevalence increases with age, from 1 per cent in those under 55 years to more than 10 per cent in people aged 70 and above. These new ESC guidelines on HF have revised the format of the previous 2016 version to make each phenotype of HF stand-alone in terms of its diagnosis and management. The therapy recommendations mention the treatment effect supported by the class and level of evidence and are presented in tables.
For HF with reduced ejection fraction (HFrEF), the tabular recommendations focus on mortality and morbidity outcomes. For diagnostic indications, the guidelines suggest investigations that all patients with HF should receive, and investigations that can be targeted to specific circumstances. As diagnostic tests have rarely been subject to randomised controlled trials (RCTs), most of the evidence would be regarded as level C. However, that does not mean that there has not been appropriate rigorous evaluation of diagnostic tests.

In this guideline, the ESC decided to focus on the diagnosis and treatment of HF, not on its prevention. Regarding diagnosis, when there is a suspicion of chronic HF, the guidelines recommend measuring the level of natriuretic peptides. If levels are normal the patient can be reassured that HF is very unlikely. If high, this should prompt referral for an echocardiogram to detect the underlying heart problem.

All HF patients are normally treated with diuretics to reduce breathlessness and ankle swelling. For HFrEF, there
are many drug treatments that improve survival, namely angiotensin converting enzyme (ACE) inhibitors, angiotensin-receptor neprilysin inhibitors (ARNIs), beta-blockers and mineralocorticoid receptor antagonists (MRAs).
In addition, the guidelines recommend sodium-glucose co-transporter-2 (SGLT2) inhibitors, also called gliflozins, as both dapagliflozin and empagliflozin reduce the risk of cardiovascular death and/or hospitalisations for HF when
added to standard treatment. Some patients with HFrEF may also benefit from devices such as defibrillators and
cardiac resynchronisation therapy pacemakers.

The guidelines state that no treatment has been shown to reduce mortality and morbidity in patients with HF with preserved ejection fraction (HFpEF) to date. Exercise is recommended for all capable chronic HF patients to improve quality-of-life and reduce HF-related hospitalisation. In those with more severe disease, frailty, or comorbidities, a supervised, exercise-based, cardiac rehabilitation programme should be considered. “The vast majority of drug treatments that improve survival and reduce hospitalisations also have beneficial effects on quality-of-life and symptoms,” said guidelines taskforce chairperson Prof Theresa McDonagh of King’s College Hospital, London, UK. “There are some interventions that do not impact survival, but do improve quality-of-life and symptoms – for example exercise rehabilitation – that should also be offered to patients with chronic heart failure.”

The guidelines recommend that all patients have access to a multidisciplinary HF disease management programme to ensure that their HF is correctly diagnosed and managed. In addition, patients with HF should be encouraged to be actively involved in managing their condition. Self-care includes adopting healthy habits, such as physical activity, avoiding excessive salt intake, maintaining a healthy body weight, avoiding excessive alcohol consumption, and not smoking. As patients with HF are at increased risk of infections, which may worsen symptoms and be a precipitant factor for acute HF, the guidelines state that influenza, pneumococcal and Covid-19 vaccination should be considered in patients with HF.

The guidelines also provide general advice on how to prevent HF. This includes regular physical activity, not
smoking, healthy diet, no/light alcohol intake, influenza vaccination, and treatment of high blood pressure and
high cholesterol. Recommendations are also given on how to manage patients with HF who have co-existing conditions, such as atrial fibrillation and valvular heart disease. “It is crucial to treat the underlying causes of heart failure and its comorbidities,” said guidelines taskforce chairperson Prof Marco Metra of the University of Brescia, Italy.

“Proper treatment of high blood pressure, diabetes and coronary artery disease can prevent the development of
heart failure. Atrial fibrillation, valvular heart disease, diabetes, chronic kidney disease, iron deficiency, and
other comorbidities frequently co-exist with heart failure and the adoption of specific treatments may have a
major impact on the clinical course of our patients.”

Reference
McDonagh T, Metra M, et al. 2021 ESC Guidelines for the
diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021. doi:10.1093/eurheartj/ehab368