Perspective:

This is a summary and guideline document on heart failure (HF) from the European Society of Cardiology (ESC). The following are 10 points to remember:

1. HF affects 1-2% of the adult population in developed countries. HF with preserved ejection fraction (EF) accounts for about 50% of cases.

2. Standard HF therapy in patients with a reduced EF (≤40%) includes beta-blockers, angiotensin-converting enzyme inhibitors (ACEi), or angiotensin-receptor blockers (ARB) (in those with ACEi intolerance) titrated to maximum tolerated doses (Class I recommendation, Level of Evidence A). In patients with persistent symptoms on standard therapy with a left ventricular (LV) EF ≤35%, a mineral corticoid antagonist is recommended (Class I, Level of Evidence A).

3. Ivabradine is a sinus node I_f channel inhibitor that may be added to standard therapy in those with sinus rhythm, an LVEF ≤35%, New York Heart Association (NYHA) class II-IV symptoms, and a heart rate ≥70 bpm on maximum tolerated doses of beta-blocker therapy to reduce HF hospitalizations (Class IIa, Level of Evidence B). It may also be considered in those unable to tolerate beta-blocker therapy (Class IIb, Level of Evidence C).

4. Digoxin and/or combination therapy with hydralazine and nitrates can be considered to reduce HF hospitalizations in patients with an LVEF ≤45% on maximally tolerated doses of standard therapy (Class IIb, Level of Evidence B). Diuretics should be used for treatment of congestion.

5. There is no evidence to support oral anticoagulation to reduce morbidity or mortality in patients in sinus rhythm. In patients with atrial fibrillation, anticoagulation should be guided by CHA₂DS₂-VASc score and bleeding risk (HAS-BLED score).

6. Therapies thought to increase the risk of harm in systolic heart failure include thiazolidinediones (Class III, Level of Evidence A), nondihydropyridine calcium channel blockers (Class III, Level of Evidence B), nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 inhibitors (Class III, Level of Evidence B), and the addition of an ARB or direct renin inhibitor therapy to simultaneous use of ACEi and mineral corticoid antagonist therapies (Class III, Level of Evidence C).

7. Implantable cardioverter-defibrillators (ICDs) for primary prevention of sudden death are recommended in patients with NYHA class II-III HF and an LVEF ≤35% despite ≥3 months of optimal therapy, who are expected to live >1 year. For patients with ischemic cardiomyopathy, implant should take place within 40 days of an acute infarction (Class I, Level of Evidence A). ICD therapy is NOT indicated in refractory NYHA class IV HF or in those with a ventricular assist device or with HF after cardiac transplant.

8. Cardiac resynchronization therapy (CRT) is recommended to reduce the risk of HF hospitalization/death in patients with NYHA class III to ambulatory class IV HF who are in sinus rhythm with a left bundle branch block morphology QRS of ≥120 ms and an LVEF ≤35% (Class I, Level of Evidence A). CRT can be considered in similar patients with a wide QRS (≥150 ms) who do not have a left bundle branch block morphology (Class IIa, Level of Evidence A).

9. In patients with NYHA class II HF, CRT is recommended to reduce death/HF hospitalization in those with a left bundle branch morphology QRS of ≥130 ms and an LVEF ≤30% (Class I, Level of Evidence A). CRT can be considered in similar patients with a wide QRS (≥150 ms) who do not have a left bundle branch block morphology (Class IIb, Level of Evidence A).

10. In HF with preserved ejection fraction, no therapy has consistently been shown to reduce morbidity or mortality. Therapy should aim to treat potential underlying causes (hypertension, myocardial ischemia) of HF with preserved EF and to correct fluid retention with diuretics.