2021 ESC Guidelines for Acute and Chronic Heart Failure: Key Points

McDonagh TA, Metra M, Adamo M, et al.
2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure: Developed by the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC) With the Special Contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2021;Aug 27:[Epub ahead of print].

The following are key points to remember from the 2021 European Society of Cardiology (ESC) Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure (HF):

  1. The nomenclature for HF with left ventricular ejection fraction (LVEF) of 41-49% has been revised to HF with mildly reduced EF (HFmEF). HF with LVEF ≤40% remains HF with reduced EF (HFrEF), and HF with LVEF ≥50% remains HF with preserved EF (HFpEF).
  2. All patients with suspected HF should have an electrocardiogm, transthoracic echocardiogram, chest X-ray, blood tests including cell count, urea and electrolytes, thyroid function, glycated hemoglobin (HbA1c), lipid, iron studies, and B-type natriuretic peptide (BNP/NT-proBNP). Cardiac magnetic resonance imaging is recommended in those with poor acoustic windows with an echo or in patients with suspected infiltrative cardiomyopathy, hemochromatosis, LV noncompaction, or myocarditis.
  3. Guideline-directed medical therapy (GDMT) for patients with HFrEF and New York Heart Association (NYHA) class II symptoms or worse now includes angiotensin receptor neprilysin inhibitor (ARNI) as a replacement for angiotensin-converting enzyme (ACE) inhibitors and addition of SGLT-2 inhibitors (dapagliflozin or empagliflozin) as Class I recommendations.
  4. Implantable cardioverter-defibrillators (ICDs) are recommended for primary prevention of sudden cardiac death for symptomatic ischemic or nonischemic cardiomyopathy with LVEF ≤35% despite 3 months of GDMT if expected survival is >1 year. ICD is NOT recommended within 40 days of a myocardial infarction (MI) or for patients with NYHA class IV symptoms who are not candidates for advanced therapies.
  5. Cardiac resynchronization therapy is recommended for symptomatic HFrEF with EF <35% in sinus rhythm with a left bundle branch block (LBBB) over 150 msec duration despite GDMT. It is also recommended in HFrEF with EF <35% irrespective of symptoms or QRS duration if there is a high-grade atrioventricular (AV) block with need for a pacemaker.
  6. For HFmEF, diuretics are recommended to relieve congestion. ACE inhibitors/angiotensin-receptor blockers/ARNIs/beta-blockers/mineralocorticoid receptor antagonists may be considered as additional therapy to reduce mortality and hospitalization (Class IIa recommendation).
  7. For HFpEF patients, diagnosis and treatment of contributing factors (hypertension, kidney disease, etc.) and use of diuretics are recommended. No specific therapies have been proven to reduce mortality in HFpEF.
  8. For all HF patients, enrollment in a multidisciplinary HF program, home, or clinic-based program and use of self-management strategies are recommended. Exercise is recommended for all HF patients.
  9. For prevention of HF, appropriate treatment of hypertension, use of statins when indicated, SGLT2 inhibitors in diabetics at high risk for or with cardiovascular disease and counseling against smoking, alcohol, drug use, and obesity are all Class I recommendations.
  10. For acute decompensated HF, routine use of inotropes is NOT recommended in the absence of cardiogenic shock and routine use of opioids is NOT recommended. Routine use of intra-aortic balloon pump in post-MI cardiogenic shock is NOT recommended.
  11. Additional Class I recommendations for hospitalized acute HF patients include trial of oral GDMT and careful exclusion of volume overload prior to discharge with early follow-up within 1-2 weeks of discharge.
  12. For patients with atrial fibrillation (AF), routine use of anticoagulation for CHA2DS2-VASc ≥2 in men and ≥3 in women, preferably with direct-acting oral anticoagulants except in the presence of a prosthetic mechanical valve or moderate or severe mitral stenosis, is recommended. Urgent cardioversion for patients in AF with HF and hemodynamic compromise is recommended. Rhythm control including catheter ablation should be considered for AF patients with symptoms including HF.
  13. For patients with HF and severe aortic stenosis, transcatheter/surgical aortic valve replacement is recommended using a heart team approach.
  14. For HF patients with secondary mitral regurgitation, percutaneous edge-to-edge mitral valve repair should be considered if severe symptoms persist despite appropriate GDMT. For patients with secondary mitral regurgitation and coronary artery disease who need revascularization, coronary artery bypass grafting and mitral valve surgery should be considered.
  15. Cancer patients being considered for cardiotoxic chemotherapeutic agents who are at risk for cardiotoxicity, should be evaluated ideally by a cardio-oncologist prior to initiation of therapy.
  16. Tafamidis is a Class I recommendation in patients with TTR amyloidosis with NYHA class I-II symptoms.
  17. All HF patients should be periodically screened for iron deficiency anemia. Ferric carboxymaltose should be considered in symptomatic, ambulatory HF patients with iron deficiency anemia and EF ≤45% or hospitalized HF patients with EF ≤50%.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardio-Oncology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Hypertension

Keywords: ESC Congress, ESC21, Anticoagulants, Antihypertensive Agents, Aortic Valve Stenosis, Atrial Fibrillation, Cardiac Resynchronization Therapy, Cardiac Surgical Procedures, Cardiomyopathies, Cardiotoxicity, Catheter Ablation, Death, Sudden, Cardiac, Defibrillators, Implantable, Diuretics, Echocardiography, Factor Xa Inhibitors, Heart Failure, Hemochromatosis, Hypertension, Kidney Diseases, Magnetic Resonance Imaging, Mitral Valve Stenosis, Myocardial Infarction, Myocarditis, Natriuretic Peptide, Brain, Obesity, Pacemaker, Artificial, Pharmaceutical Preparations, Primary Prevention, Shock, Cardiogenic, Stroke Volume, Transcatheter Aortic Valve Replacement, Ventricular Function, Left

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