Preview of the 2021 ESC/HFA heart failure guidelines

News - June 29, 2021

Session chaired by Giuseppe Rosano (London, UK), Andrew Coats (Coventry, UK) and Franz Weidinger (Vienna, Austria).

The 2021 European Society of Cardiology (ESC) and Heart Failure Association (HFA) Guidelines for treatment of Heart Failure were partially presented at the virtual ESC HF Congress. This was a first look at the HF guidelines, which will be presented in full later this year at the ESC congress. The presentation was focussed on new recommendations for medical therapies in HF.

The two major messages were:

  • Early drug treatment for HFrEF patients is based on four classes of drugs: ACEi/ARNI, betablockers, MRA and SGLT2 inhibitors
  • Tailored-treatment approaches are available for HFrEF patients based on phenotypes (such as difference in etiology and presence of comorbidities)

For the management of patients with HFrEF ACEi/ARNI, beta-blocker, MRA, dapagliflozin/empagliflozin are recommended, and then loop diuretics may be considered for fluid retention. New is the addition of dapagliflozin or empagliflozin recommendations to reduce the risk of HF hospitalization and death (class I, level A). Also new is the recommendation for considering initiation of sacubitril/valsartan in ACEi naïve (de novo) patients with HFrEF (class IIb, level B).

Other new drugs that may be considered in selected patients with HFrEF are vericiguat (class IIb, level B) and omecamtiv mecarbil may be considered in the future (not licensed yet).

The updated guidelines provide recommendations for patients with HFmrEF. The name of the category has changed from mid-range ejection fraction to mildly reduced ejection fraction to better define this patient population. Recommendations or considerations for pharmacological treatments include diuretics (class I, level C), ACEi, ARB, beta-blocker, MRA and sacubitril/valsartan (all class IIb, level C). No new recommendations for HFpEF treatment were included in the updated guidelines.

To classify acute HF. a table with four categories of clinical presentations of acute HF was presented with information on main mechanisms, main cause of symptoms, onset, main hemodynamic abnormalities, main clinical presentations and main treatment .

Other recommendations in the updated guidelines include recommendations for pre-discharge and early post-discharge follow-up of patients hospitalized for acute HF, treatment of AF in patients with HF (DOACs recommended in preference to VKAs), treatment of patients with diabetes (recommendation of SGLT2 inhibitors), management of patients with cancer and HF.

New in the recommendations for anemia and iron deficiency in HF is the recommendation that all patients with HF should be periodically screened for anemia and iron deficiency with a full blood count, serum ferritin concentration and TSAT. In addition, IV iron supplementation with ferric carboxymaltose should be considered in symptomatic HF patients recently hospitalized for HF and with LVEF <50% and iron deficiency to reduce risk of HF hospitalization (class IIa, level B).

Finally, tafamidis is recommended for treatment of transthyretin amyloidosis-cardiac amyloidosis in patients with genetic testing proven hereditary hTTR-CMP and NYHA class I or II symptoms and in patients with wtTTR-CA and NYHA class I or II symptoms (class I, level B).

A complete overview of the guidelines will be presented at the ESC 2021 congress.

Click here for the key changes in the HF guidelines presented at ESC 2021

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