New ESC guidelines released for the diagnosis and treatment of heart failure

The European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of acute and chronic heart failure are published online today in European Heart Journal. This was the first ESC guideline to include patients as full members of the working group.

About 2% of adults worldwide suffer from heart failure. The prevalence increases with age, from 1% among those under 55 to over 10% among those aged 70 and over. In developed countries, the most common causes are coronary heart disease and high blood pressure. Patients with heart failure have a poor prognosis and a markedly reduced quality of life. The main symptoms are shortness of breath, swelling of the ankles and fatigue. After diagnosis, patients are hospitalized once a year on average, and more than half die within five years.

Chronic heart failure is a disease in which the heart is unable to properly pump blood throughout the body. This usually happens because the heart has become too weak or stiff. The ejection fraction, which is the percentage of blood in the ventricles that is ejected during the cardiac cycle, is the most important measure of heart function. When the pumping action of the heart is weak, it is called “heart failure with reduced ejection fraction” and when it is stiff and does not relax properly, it is called “heart failure with ejection fraction.” preserved ”. Acute heart failure is life threatening condition requiring urgent assessment and treatment; it may be the first manifestation of heart failure (new onset) or, more frequently, it is due to an acute worsening of chronic heart failure.

Regarding the diagnosis, in case of suspected chronic heart failure, the recommendations recommend measuring the level of hormones produced by the heart (natriuretic peptides). If the levels are normal, the patient can be reassured that heart failure is very unlikely. If it is high, this should prompt asking for an echocardiogram to detect the underlying heart problem.

All patients with heart failure are normally treated with diuretics to reduce shortness of breath and swelling in the ankle. For heart failure with reduced ejection fraction, there are many drug treatments available that improve survival, namely angiotensin converting enzyme (ACE) inhibitors, neprilysin receptor inhibitors angiotensin (RNAI), beta blockers and mineralocorticoid receptor antagonists (MRA). In addition, the guidelines recommend a new class of drugs, sodium-glucose-2 co-transporter inhibitors (SGLT2), also known as gliflozins, because dapagliflozin and empagliflozin reduce the risk of death from cardiovascular and / or cardiovascular causes. or hospitalizations for heart failure when added. to standard treatment. Some heart failure patients with reduced ejection fraction may also benefit from devices such as cardiac resynchronization therapy defibrillators and pacemakers.

The guidelines indicate that no treatment has reduced mortality and morbidity in patients with heart failure with preserved ejection fraction to date.

Exercise is recommended for all chronic heart patients capable of improving quality of life and reducing hospitalizations for heart failure. In people with more severe disease, frailty, or co-morbidities, a supervised, exercise-based cardiac rehabilitation program should be considered.

The vast majority of drug treatments that improve survival and reduce hospitalizations also have beneficial effects on quality of life and symptoms. Some interventions have no impact on survival but improve quality of life and symptoms – for example, exercise rehabilitation – which should also be offered to patients with chronic heart failure. “

Professor Theresa McDonagh, chairman of the guidelines working group, King’s College Hospital, London, United Kingdom

The guidelines recommend that all patients have access to a multiprofessional heart failure management program to ensure that their heart failure is properly diagnosed and managed. These programs have been associated with better care and better outcomes. In addition, patients with heart failure should be encouraged to actively participate in the management of their disease. Self-care includes adopting healthy habits such as physical activity, avoiding excessive salt intake, maintaining a healthy body weight, avoiding excessive alcohol consumption, and not smoking. It is also important to avoid drinking large amounts of fluids, recognizing sleep problems, monitoring symptoms for progress, and knowing when to contact a healthcare professional.

Patients with heart failure are at increased risk for infections, which can worsen symptoms and be a precipitating factor for acute heart failure. The guidelines state that vaccination against influenza, pneumococcus and COVID-19 should be considered in patients with heart failure.

The guidelines provide general advice on how to prevent heart failure. This includes regular physical activity, not smoking, eating a healthy diet, consuming little or no alcohol, getting the flu shot, and treating high blood pressure and high cholesterol. Recommendations are also given on how to manage patients with heart failure who have coexisting conditions such as atrial fibrillation and valvular heart disease.

“It is crucial to address the underlying causes of heart failure and its co-morbidities,” said the chair of the guidelines working group, Professor Marco Metra of the University of Brescia, Italy. “Proper treatment of high blood pressure, diabetes and coronary heart disease can prevent the development of heart failure. Atrial fibrillation, valve disease, diabetes, chronic kidney disease, iron deficiency and other comorbidities frequently coexist with heart failure and the adoption of specific treatments can have a major impact on the clinical course of our patients. “