Key changes in the 2021 ESC/HFA heart failure guidelines

ESC 2021 New concepts in the 2021 HF guidelines include a simplified treatment algorithm for HFrEF, change of the HFmrEF term to heart failure with mildly reduced ejection fraction and a treatment algorithm for HFrEF according to phenotypes.

Presented at the digital ESC Congress 2021, chaired by Theresa McDonagh (London, UK), Macro Metra (Brescia, Italy) and Coilin Baigent (Oxford, UK).

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In the 2021 HF guidelines focus is on diagnosis and treatment of HF, not on prevention of HF. Many other guidelines address prevention of HF by management of CV risk and CV diseases. New in the development of these guidelines is the inclusion of two patient representatives in the Task Force.

Key changes to HFrEF treatment include:

• A simplified treatment algorithm
• The SGLT2 inhibitors dapagliflozin and empagliflozin are now class I recommend therapy
• The 4 key drug therapies ACE-I/ARNI, betablockers, MRAs and SGLT2i should be initiated as quickly and safely as possible
• Added treatment algorithm for HFrEF according to phenotypes for tailored management
• Primary prevention by ICD in non-ischemic cardiomyopathy is class IIa recommended therapy
• Emphasis on broad left bundle branch blocking (LBBB) in selected patients for CRT

Key changes to diagnosis and treatment of HFmrEF and HFpEF include:

• Instead of heart failure with mid-range ejection fraction (HFmrEF) the term has changed to heart failure with mildly reduced ejection fraction (patients with HFmrEF may benefit from similar therapies to those with HFrEF)
• For the diagnosis of HFmrEF elevated natriuretic peptides plus other evidence of structural heart disease make the diagnosis more likely, but are not mandatory if there is certainty on measurement of LVEF
• Addition of a table of recommendations for the treatment of HFmrEF
• A simplified diagnostic pathway with 3 steps for HFpEF

With regard to treatment of HFpEF, recommendations in the new guidelines have largely remained unchanged. The Task Force acknowledges however that the treatment options for HFpEF are being revised at the time of publication of these guidelines.

Other new concepts in the 2021 guidelines compared with the 2016 version are:

• Classification for acute HF has been modified
• Treatment for most non-CV comorbidities (including diabetes, hyperkalemia, iron deficiency and cancer) has been updated
• There are updates on cardiomyopathies on role of genetic testing and treatment
• Key quality indicators have been added

The new guidelines were simultaneously published in Eur Heart J Watch a video by prof. Lam on the new guidelines