ESC Guidelines on Heart Failure Management Published

August 27, 2021—The European Society of Cardiology (ESC) announced the launch of the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. The society noted that these are the first ESC guidelines drafted by a task force that included patients as full members.

The guidelines were published by Theresa A. McDonagh, MBChB, MD, et al and are available online in European Heart Journal.

As noted in the ESC press release, basic facts about heart failure include:

• Approximately 2% of adults worldwide have heart failure.
• The prevalence of heart failure increases with age, from 1% in people age < 55 years to ≥ 10% in people age ≥ 70.
• In developed countries, the most common causes of heart failure are coronary artery disease and high blood pressure.
• Patients with heart failure have a poor prognosis and markedly reduced quality of life.
• The main symptoms are breathlessness, ankle swelling, and tiredness.
• After diagnosis, patients are hospitalized once every year on average, and more than half of patients die within 5 years.

The following key guidelines on diagnosis and treatment are summarized in the announcement:

• For diagnosis when there is a suspicion of chronic heart failure, the guidelines recommend measuring the level of the natriuretic peptide hormones produced by the heart. If levels are normal, the patient can be reassured that heart failure is very unlikely. If high, this should prompt referral for an echocardiogram to detect the underlying heart problem.
• All heart failure patients are normally treated with diuretics to reduce breathlessness and ankle swelling. For heart failure with reduced ejection fraction, there are many drug treatments that improve survival: angiotensin‑converting enzyme (ACE) inhibitors, angiotensin-receptor neprilysin inhibitors (ARNIs), beta-blockers, and mineralocorticoid receptor antagonists.
• A new class of drugs, the sodium-glucose co-transporter-2 inhibitors, also called gliflozins, as both dapagliflozin and empagliflozin reduce the risk of cardiovascular death and/or hospitalization for heart failure when added to standard treatment.
• Some patients with heart failure with reduced ejection fraction may also benefit from devices such as defibrillators and cardiac resynchronization therapy pacemakers.

No treatment has been shown to reduce mortality and morbidity in patients with heart failure with preserved ejection fraction to date, advised the ESC.

Additionally, the guidelines include the following patient-focused recommendations:

• All capable chronic heart patients should exercise to improve quality of life and reduce heart failure hospitalization.
• For patients with more severe disease, frailty, or comorbidities, a supervised, exercise-based, cardiac rehabilitation program should be considered.
• All patients should have access to a multiprofessional heart failure disease management program to ensure that their heart failure is correctly diagnosed and managed. These programs have been associated with better care and improved outcomes.
• Patients with heart failure should be encouraged to be actively involved in managing their condition.
• Patient 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; avoiding drinking large volumes of fluid; recognizing sleeping problems; monitoring changes in symptoms; and knowing when to contact a health professional.
• Patients with heart failure are at increased risk of infections, which may worsen symptoms and be a precipitant factor for acute heart failure. Therefore, influenza, pneumococcal, and COVID-19 vaccination should be considered in patients with heart failure.

Finally, ESC noted that the guidelines provide the following:

• General advice on how to prevent heart failure, including regular physical activity, not smoking, healthy diet, no/light alcohol intake, influenza vaccination, and treatment of high blood pressure and high cholesterol.
• Recommendations on managing patients with heart failure who have coexisting conditions, such as atrial fibrillation and valvular heart disease.

The writing task force chairs, Professor McDonagh, who is with King’s College Hospital in London, United Kingdom, and Professor Marco Metra, MD, who is with the University of Brescia in Brescia, Italy, commented on the publication of the guidelines in the ESC announcement.

Professor McDonagh stated, “The vast majority of drug treatments that improve survival and reduce hospitalizations also have beneficial effects on quality of life and symptoms. 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.”

Professor Metra added, “It is crucial to treat the underlying causes of heart failure and its comorbidities. 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 coexist with heart failure, and the adoption of specific treatments may have a major impact on the clinical course of our patients.”