What is the treatment plan for patients with heart failure based on their EHRA (European Heart Rhythm Association) score?

Treatment Plan for Heart Failure Based on EHRA Score

The treatment of heart failure should be guided by evidence-based guidelines with medication choices tailored according to ejection fraction status rather than EHRA score, which is primarily used for symptom classification in atrial fibrillation patients. 1

Understanding EHRA Score

The European Heart Rhythm Association (EHRA) score is a symptom classification system designed specifically for atrial fibrillation (AF), not heart failure. It categorizes symptoms as:

• EHRA Class 1: No symptoms
• EHRA Class 2: Mild symptoms (not affecting daily activity)
  • Class 2a: Not troubled by symptoms
  • Class 2b: Troubled by symptoms
• EHRA Class 3: Severe symptoms (affecting daily activity)
• EHRA Class 4: Disabling symptoms (normal daily activity discontinued)

Heart Failure Management Algorithm

Since the EHRA score is not designed for heart failure management, treatment should follow established heart failure guidelines based on:

1. Heart Failure with Reduced Ejection Fraction (HFrEF)

For patients with HFrEF, implement quadruple therapy in a stepwise approach:

• First-line medications (initiate and titrate to target doses within 6-12 weeks) 2:

  • ARNI (sacubitril/valsartan) as replacement for ACE inhibitor 3
  • Beta-blockers (carvedilol, metoprolol succinate, bisoprolol)
  • Mineralocorticoid receptor antagonists (spironolactone, eplerenone)
  • SGLT2 inhibitors (dapagliflozin, empagliflozin)

• For persistent symptoms despite optimal therapy:

  • Consider diuretics for congestion symptoms 3
  • For NYHA class III-IV: Add digoxin 3
  • For specific populations: Consider hydralazine/isosorbide dinitrate 3

• Device therapy considerations:

  • ICD for patients with LVEF ≤35% despite ≥3 months of optimal medical therapy (with expected survival >1 year) 3
  • CRT for symptomatic patients with QRS duration ≥150 msec and LBBB morphology 3

2. Heart Failure with Preserved Ejection Fraction (HFpEF)

• Focus on treating underlying conditions (hypertension, diabetes)
• Diuretics for symptom relief
• SGLT2 inhibitors to reduce hospitalizations
• Beta-blockers for rate control if atrial fibrillation is present

Management of Atrial Fibrillation in Heart Failure

If a patient has both heart failure and atrial fibrillation (where EHRA score is relevant):

• For HFrEF with AF:

  • Beta-blockers as first-line rate control
  • Digoxin as adjunctive therapy
  • Avoid diltiazem/verapamil (contraindicated in HFrEF) 3, 2

• For HFpEF with AF:

  • Beta-blockers for rate control
  • Diltiazem can be used with caution (not with beta-blockers) 2
  • Consider anticoagulation based on CHA₂DS₂-VASc score

• For symptomatic AF (EHRA 2b-4):

  • Consider rhythm control strategies including cardioversion
  • Evaluate for catheter ablation if symptoms persist despite rate control

Monitoring and Follow-up

• Monitor renal function and electrolytes 1-2 weeks after medication initiation or dose changes 2
• Daily weight monitoring with action plan for weight gain >2kg in 3 days 2
• Regular assessment of symptoms and functional capacity
• Consider serial natriuretic peptide measurements to guide therapy 2

Important Cautions

• Avoid NSAIDs and COX-2 inhibitors in all heart failure patients 3
• Avoid thiazolidinediones (glitazones) in heart failure patients 3
• Do not combine ARB with ACE inhibitor and MRA due to increased risk of renal dysfunction and hyperkalemia 3
• Avoid diltiazem/verapamil in HFrEF patients as they increase risk of worsening heart failure 3

By following this evidence-based approach, clinicians can optimize heart failure management regardless of EHRA score, which should be used primarily for assessing AF symptoms rather than guiding heart failure treatment decisions.