2021 ESC guideline on Heart Failure: SGLT2 inhibitors finally entering the centre stage and more.

The ESC Congress, being held in a virtual format this year released update of the European Society of Cardiology (ESC) Guidelines in acute and chronic heart failure, on Friday. The heart failure guidelines were simultaneously published in the European Heart Journal. Soon to be released updates on valvular heart disease (Saturday), cardiac pacing (Sunday), and cardiovascular disease prevention (Monday) will also be summarised on Medical Dialogues.

Sodium glucose co-transporter 2 (SGLT2) inhibitors empagliflozin (Jardiance) and dapagliflozin (Farxiga) are now recommended for treatment of chronic heart failure with reduced ejection fraction (HFrEF) according to the 5-year update.

The other major changes in the guidelines include:

1. A change of the term 'heart failure with mid-range ejection fraction' to 'heart failure with mildly reduced ejection fraction' (HFmrEF) to describe patients with left ventricle ejection fraction (LVEF) of 41% to 49%.

2. A new simplified treatment algorithm for HFrEF.(Figure 2)

3. The addition of a treatment algorithm for HFrEF according to phenotypes.

4. Modified classification for acute HF.

5. Updated treatments for most non-cardiovascular comorbidities including diabetes, hyperkalaemia, iron deficiency, and cancer.

6. Updates on cardiomyopathies including the role of genetic testing and new treatments.

7. The addition of key quality indicators.

SGLT2 inhibitors:

The updated guidelines give Class I recommendation to empagliflozin, dapagliflozin, canagliflozin, ertugliflozin, and sotagliflozin for patients with T2D who are at risk of CV events "to reduce hospitalizations for HF, major CV events, end-stage renal dysfunction, and CV death."

Separately, dapagliflozin, empagliflozin, and sotagliflozin are now recommended (Class I) for those with T2D and HFrEF to reduce hospitalizations for heart failure and CV death.

New recommendations also include:

1. Right heart catheterization for suspected HF due to constrictive pericarditis, restrictive cardiomyopathy, congenital heart disease, and high output states- Class IIa.

2. For HF with chronic coronary syndrome, the guidelines recommend CABG as the preferred revascularization strategy especially in setting of diabetes and multivessel disease.

However, CABG should be avoided in patients with LV assist devices and those with coronary anatomy suitable for PCI.

3. Tafamidis is now recommended as a class I strategy for HF with hereditary and wild type variants of transthyetin amyloidosis.

4. For nonischemic CMP, ICD as a primary prevention strategy is now a Class IIa recommendation instead of Class I as mentioned in the previous guideline update of 2016.

5. Similarly class I recommendation for CRT implantation to improve symptoms and reduce morbidity and mortality in HFrEF and LBBB with QRS duration 130-149ms has now been changed to a Class IIa recommendation.

6. For HF with AF, DOACs have moved up to a Class I recommendation (from previous class IIa) and should be preferred to VKAs.

7. HF and valvular heart disease: Aortic valve intervention, transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) is recommended in patients with HF and severe high-gradient aortic stenosis to reduce mortality and improve symptoms.

8. Patients with HF and iron deficiency. Patients with HF must be screened for anemia and iron deficiency with a full blood count, serum ferritin concentration, and transferrin saturation.

9. An update on algorithmic approach to management of acute decompensated heart failure (Figure1)

10. Therapeutic algorithm of Class I Therapy Indications for a patient with heart failure with reduced ejection fraction-Figure 2.

Source: European Heart Journal: McDonagh TA, Metra M, Adamo M, Gardner RS. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021; doi:10.1093/eurheartj/ehab368