Perspective:

The following are 10 points to remember about these guidelines:

1. A mineralocorticoid receptor antagonist (MRA) is recommended for all patients with persisting symptoms (New York Heart Association [NYHA] class II-IV) and an ejection fraction [EF] ≤35%, despite treatment with an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-receptor blocker [ARB] if an ACE inhibitor is not tolerated) and a beta-blocker, to reduce the risk of heart failure (HF) hospitalization and the risk of premature death.

2. Ivabradine should be considered to reduce the risk of HF hospitalization in patients in sinus rhythm with an EF ≤35%, a heart rate remaining ≥70 bpm, and persisting symptoms (NYHA class II-IV) despite treatment with an evidence-based dose of beta-blocker (or maximum tolerated dose below that), ACE inhibitor (or ARB), and a mineralocorticoid receptor antagonist (MRA) (or ARB).

3. An n-3 polyunsaturated fatty acid preparation may be considered to reduce the risk of death and the risk of cardiovascular hospitalization in patients treated with an ACE inhibitor (or ARB), beta-blocker, and an MRA (or ARB).

4. The addition of an ARB (or renin inhibitor) to the combination of an ACE inhibitor AND a mineralocorticoid antagonist is NOT recommended because of the risk of renal dysfunction and hyperkalaemia.

5. Cardiac resynchronization therapy (CRT)-P/CRT-D is recommended in patients in sinus rhythm with a QRS duration of ≥120 ms, left bundle branch block QRS morphology, and an EF ≤35%, who are expected to survive with good functional status for >1 year, to reduce the risk of HF hospitalization and the risk of premature death.

6. The CHA₂DS₂-VASc and HAS-BLED scores are recommended to determine the likely risk–benefit (thromboembolism prevention vs. risk of bleeding) of oral anticoagulation in patients with symptomatic HF (NYHA functional class II-IV) and paroxysmal or persistent/permanent atrial fibrillation.

7. Coronary artery bypass grafting is recommended for patients with angina and significant left main stenosis, or two- or three-vessel coronary disease, including a left anterior descending stenosis, who are otherwise suitable for surgery and expected to survive >1 year with good functional status, to reduce the risk of hospitalization for cardiovascular causes and the risk of premature death from cardiovascular causes.

8. A left ventricular assist device (LVAD) or BiVAD is recommended in selected patients with end-stage HF despite optimal pharmacological and device treatment and who are otherwise suitable for heart transplantation, to improve symptoms and reduce the risk of HF hospitalization for worsening HF, and to reduce the risk of premature death while awaiting transplantation.

9. It is recommended that regular aerobic exercise is encouraged in patients with HF to improve functional capacity and symptoms.

10. It is recommended that patients with HF are enrolled in a multidisciplinary care management program to reduce the risk of HF hospitalization.