ESC Releases Focused Update on Heart Failure Guideline Recommendations

Marco Metra, MD
Credit: Translational Medicine Academy

The European Society of Cardiology (ESC) has released a focused update to their heart failure guidelines to incorporate data from nearly a dozen new clinical trials published since 2021, including EMPEROR-Preserved, DELIVER, STRONG-HF, IRONMAN, and more.

The new guidelines, which were published on the opening day of ESC Congress 2023, include new recommendations related to SGLT2 inhibitor use in patients with heart failure with mildly reduced ejection fraction (HFmrEF) or with preserved ejection fraction (HFpEF) as well as updated guidance surrounding management of comorbidities.

“In 2021, the ESC published Guidelines for the diagnosis and treatment of acute and chronic heart failure,” said Marco Metro, MD, guidelines task force chairperson and director of the Institute of Cardiology of the Civil Hospital and University of Brescia.² “Since then, more than 10 randomized controlled trials have been released that should change patient management ahead of the next scheduled full guideline, necessitating a focused update. New recommendations are provided in three areas: chronic heart failure, acute heart failure, and comorbidities.”

Since the turn of the century, the field of heart failure had experienced years of gradual progression in both knowledge and pharmacological therapies, but the rate of advancement has exploded in recent years. Often, the annual ESC Congress has served as a platform to showcase these advancements, beginning with the presentation of DAPA-HF in 2019 and subsequently followed by DAPA-CKD in 2020, EMPEROR-Preserved in 2021, and DELIVER in 2022.¹

At the same time, other major trials, including and FIDELIO-DKD, FIGARO-DKD, IRONMAN, and STRONG-HF, debuted in medical journals and at other major meetings. With so many landmark advances in understanding and pharmacotherapy occurring after the debut of the 2021 ESC Heart Failure guidelines, the ESC Clinical Practice Guidelines organized a task force to provide updated recommendations for health professionals managing people with heart failure (HF) according to the best available evidence.¹

Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the ESC, with the special contribution of the Heart Failure Association of the ESC, the document breaks down the updated guidance into 3 specific categories: Chronic Heart Failure, Acute Heart Failure, and Comorbidities. The recommendations included are highlighted below according to category.¹

Chronic Heart Failure Recommendations¹

• An SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in patients with HFmrEF to reduce the risk of heart failure hospitalization or cardiovascular death. (Class I, Level A)
• An SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in patients with HFpEF to reduce the risk of heart failure hospitalization or cardiovascular death. (Class I, Level A)

Acute Heart Failure Recommendations¹

• An intensive strategy of initiation and rapid up-titration of evidence-based treatment before discharge and during frequent and careful follow-up visits in the first 6 weeks following a heart failure hospitalization is recommended to reduce risk of heart failure rehospitalization or death. (Class I, Level B)

Comorbidities Recommendations¹

• In patients with type 2 diabetes and chronic kidney disease, SGLT2 inhibitors (dapagliflozin or empagliflozin) are recommended to reduce the risk of heart failure hospitalization or cardiovascular death. (Class I, Level A)
• In patients with type 2 diabetes and chronic kidney disease, finerenone is recommended to reduce the risk of heart failure hospitalization. (Class I, Level A)
• Intravenous iron supplementation is recommended in symptomatic patients with HFrEF and HFmrEF, and iron deficiency, to alleviate heart failure symptoms and improve quality of life. (Class I, Level A)
• Intravenous iron supplementation with ferric carboxymaltose or ferrite derisomaltose should be considered in symptomatic patients with HFrEF and HFmrEF, and iron deficiency, to reduce the risk of heart failure hospitalization. (Class IIa, Level A)

“Heart failure is a fast-moving area of research and exciting new trials are expanding the treatment options for patients,” said Professor Theresa McDonagh, MBChB, MD, guidelines task force chairperson and consultant cardiologist in the School of Cardiovascular Medicine and Sciences at King’s College Hospital.² “This focused update incorporates the latest evidence-based treatments into state-of-the-art management recommendations with the aim of improving the outcome of patients with heart failure.”

References:

1. McDonagh TA, Metra M, Adamo M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure [published online ahead of print, 2023 Aug 25]. Eur Heart J. 2023;ehad195. doi:10.1093/eurheartj/ehad195
2. Focused update of ESC Heart Failure Guidelines published today. ESC Congress 2023. August 25, 2023. Accessed August 25, 2023. https://www.escardio.org/The-ESC/Press-Office/Press-releases/focused-update-of-esc-heart-failure-guidelines-published-today.