Heart Failure Clinical Practice Guidelines (ESC, 2021) 

European Society of Cardiology (ESC)

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 03, 2021

Clinical practice guidelines on the management of heart failure by the European Society of Cardiology (ESC) were published in August 2021 in the European Heart Journal.[1]

HFpEF (heart failure with preserved ejection fraction) diagnosis requires evidence of cardiac structural or functional abnormalities as well as elevated plasma NP (natriuretic peptide) concentrations consistent with LV diastolic dysfunction and increased LV filling pressures. A diastolic stress test is recommended if these markers are equivocal.

A chest x-ray is recommended to identify other potential causes of breathlessness, such as pulmonary disease.

Treatment of acute HF is based on the use of diuretics for congestion, inotropes, and short-term MCS (mechanical circulatory support) for peripheral hypoperfusion.

ACE-I (angiotensin-converting enzyme inhibitor) or ARNI (angiotensin receptor-neprilysin inhibitor), beta blockers, MRA (mineralocorticoid receptor antagonist), and SGLT2 (sodium-glucose cotransporter 2) inhibitors are recommended for patients with HFrEF (HF with reduced ejection fraction).

Right heart catheterization should be considered in all patients in whom HF is thought to be due to constrictive pericarditis, restrictive cardiomyopathy, congenital heart disease, and high output stress.

Dapagliflozin or empagliflozin is recommended for patients with HFrEF to reduce the risk of hospitalization and death due to HF.

Heart transplantation is recommended for patients who have advanced HF that is refractory to medical/device therapy and who do not have absolute contraindications.

SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, etrugliflozin, sotagliflozin) are recommended in patients with type 2 diabetes mellitus who are at risk for cardiovascular events, to reduce hospitalizations for HF, major cardiac events, end-stage renal dysfunction, and cardiovascular death.

If the patient has a normal ECG, the diagnosis of HF is unlikely. The ECG may reveal abnormalities such as AF, Q waves, LV hypertrophy (LVH), and a widened QRS complex, which increase the likelihood of HF.

Basic tests such as serum urea and electrolytes, creatinine, full blood count, and liver and thyroid function tests are recommended to differentiate HF from other conditions, to provide prognostic information, and to guide potential therapy.

Echocardiography is recommended as the key investigative tool to assess cardiac function and provide information on other parameters such as chamber size, eccentric or concentric LVH, regional wall motion abnormalities, RV function, pulmonary hypertension, valvular function, and markers of diastolic function.

For more information, see Heart Failure.

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