Summarize the latest European Society of Cardiology (ESC) guidelines for the management of heart failure.

ESC Guidelines for Heart Failure Management (2016)

The 2016 ESC guidelines establish a comprehensive framework for heart failure management centered on three distinct phenotypes (HFrEF, HFmrEF, HFpEF), with foundational pharmacotherapy for HFrEF including ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists to reduce mortality and hospitalization. 1

Diagnosis and Classification

Initial Diagnostic Approach

• Transthoracic echocardiography (TTE) is mandatory for all patients with suspected heart failure to assess myocardial structure, function, and LVEF, enabling classification into HFrEF, HFmrEF, or HFpEF 1
• Measure plasma natriuretic peptides (BNP, NT-proBNP, or MR-proANP) immediately upon presentation in all patients with acute dyspnea to differentiate acute heart failure from non-cardiac causes 1

Heart Failure Phenotypes

The guidelines introduce three distinct classifications based on LVEF, requiring different management strategies 1:

• HFrEF: Reduced ejection fraction (most evidence-based therapies apply here)
• HFmrEF: Mid-range ejection fraction (emerging category requiring further research)
• HFpEF: Preserved ejection fraction (limited treatment options)

Chronic Heart Failure with Reduced Ejection Fraction (HFrEF)

Foundational Pharmacotherapy (Class I Recommendations)

All symptomatic HFrEF patients require triple therapy as the cornerstone of treatment 1:

1. ACE inhibitor (or ARB if ACE inhibitor not tolerated) in addition to beta-blocker to reduce HF hospitalization and death (Class I, Level A) 1

2. Beta-blocker in addition to ACE inhibitor for stable, symptomatic patients to reduce HF hospitalization and death (Class I, Level A) 1

3. Mineralocorticoid receptor antagonist (MRA) for patients remaining symptomatic despite ACE inhibitor and beta-blocker to reduce HF hospitalization and death (Class I, Level A) 1

Diuretic Therapy

• Diuretics are recommended in patients with signs and symptoms of congestion to improve symptoms and exercise capacity 1
• Dosing and duration should be adjusted according to clinical status and symptoms 1

Device Therapy Considerations

TTE assessment of LVEF is required to identify patients suitable for evidence-based device treatment (ICD, CRT) recommended for HFrEF 1

Prevention Strategies (Asymptomatic Patients)

Pre-Heart Failure Management

For patients with asymptomatic LV systolic dysfunction and prior myocardial infarction 1:

• ACE inhibitor is mandatory to prevent or delay onset of HF and prolong life (Class I, Level A) 1
• Beta-blocker is mandatory to prevent or delay onset of HF and prolong life (Class I, Level B) 1

Hypertension Control

• Treatment of hypertension is essential to prevent or delay HF onset and prolong life (Class I, Level A) 1

Acute Heart Failure Management

Immediate Assessment and Monitoring

For cardiogenic shock, immediate ECG and echocardiography are mandatory, with rapid transfer to a tertiary center with 24/7 cardiac catheterization and ICU/CCU capabilities including short-term mechanical circulatory support 1

Diuretic Management

Intravenous loop diuretics are the primary treatment for acute decompensation 1:

• Initial dosing: 20-40 mg IV furosemide (or equivalent) for new-onset AHF or patients not on chronic diuretics 1
• For chronic diuretic users: Initial IV dose should equal or exceed the oral maintenance dose 1
• Administration: Either intermittent boluses or continuous infusion, adjusted based on symptoms and clinical status 1
• Mandatory monitoring: Regularly assess symptoms, urine output, renal function, and electrolytes during IV diuretic use 1

Inotropic Agents

Inotropic agents are contraindicated unless the patient has symptomatic hypotension or hypoperfusion due to safety concerns (Class III, Level A) 1

Continuation of Chronic Medications

During acute decompensation of chronic HFrEF, continue all evidence-based disease-modifying therapies unless hemodynamic instability or contraindications exist 1

Non-Pharmacological Management

Exercise and Rehabilitation

Regular aerobic exercise is mandatory for all stable HF patients 1:

• Improves functional capacity and symptoms (Class I, Level A) 1
• Reduces risk of HF hospitalization in stable HFrEF patients (Class I, Level A) 1

Multidisciplinary Care

Enrollment in a multidisciplinary care management program is required to reduce HF hospitalization and mortality (Class I, Level A) 1

Medications to Avoid

NSAIDs and COX-2 inhibitors are contraindicated in heart failure patients as they increase risk of HF worsening and hospitalization 1

Critical Gaps and Future Directions

The 2016 guidelines acknowledge several areas requiring further research 1:

• HFmrEF and HFpEF: Limited understanding of pathophysiology and effective treatments
• Device therapy: Optimal patient selection for ICDs and CRT, particularly in specific subgroups
• Acute heart failure: Need for treatments improving mortality and morbidity, strategies to prevent early rehospitalization
• Comorbidities: Better management approaches for elderly patients, advanced renal disease, and diabetes

Note: These are the 2016 ESC guidelines. More recent updates may include SGLT2 inhibitors and ARNI (sacubitril/valsartan) as foundational therapies, which were emerging at the time of these guidelines but have since become standard of care based on subsequent evidence 2, 3.