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2 Introduction

The aim of this ESC Guideline is to help health professionals manage people with heart failure (HF) according to the best available evidence. Fortunately, we now have a wealth of clinical trials to help us select the best management to improve the outcomes for people with HF; for many, it is now both preventable and treatable. This guideline provides practical, evidence-based recommendations. We have revised the format of the previous 2016 ESC HF Guidelines1 to make each phenotype of HF stand-alone in terms of its diagnosis and management. The therapy recommendations mention the treatment effect supported by the class and level of evidence and are presented in tables. For HF with reduced ejection fraction (HFrEF), the tabular recommendations focus on mortality and morbidity outcomes. Where there are symptomatic benefits, these are highlighted in the text and/or in the web appendices. Detailed summaries of the trials underpinning the recommendations are available in the web appendices. For diagnostic indications, we have suggested investigations that all patients with HF should receive, and investigations that can be targeted to specific circumstances. As diagnostic tests have rarely been subject to randomized controlled trials (RCTs), most of the evidence would be regarded as level C. However, that does not mean that there has not been appropriate rigorous evaluation of diagnostic tests. In this guideline, we have decided to focus on the diagnosis and treatment of HF, not on its prevention. Management of CV risk and many CV diseases [especially systemic hypertension, diabetes mellitus, coronary artery disease, myocardial infarction (MI), atrial fibrillation (AF), and asymptomatic left ventricular (LV) systolic dysfunction] will reduce the risk of developing HF, which is addressed by many other ESC Guidelines and in section 9.1 of the current guideline.27 This guideline is the result of a collaboration between the Task Force (including two patient representatives), the reviewers, and the ESC CPG Committee. As such, it is a consensus/majority opinion of the experts consulted in its development.

2.1 What is new

In addition to the recommendations listed below, the following table lists some new concepts compared with the 2016 version.

New concepts A change of the term ‘heart failure with mid-range ejection fraction’ to ‘heart failure with mildly reduced ejection fraction’ (HFmrEF). A new simplified treatment algorithm for HFrEF. The addition of a treatment algorithm for HFrEF according to phenotypes. Modified classification for acute HF. Updated treatments for most non-cardiovascular comorbidities including diabetes, hyperkalaemia, iron deficiency, and cancer. Updates on cardiomyopathies including the role of genetic testing and new treatments. The addition of key quality indicators.

HF = heart failure. New recommendations

Recommendations Class

Recommendations for the diagnosis of HF Right heart catheterization should be considered in patients where HF is thought to be due to constrictive pericarditis, restrictive cardiomyopathy, congenital heart disease, and high output states. IIa Right heart catheterization may be considered in selected patients with HFpEF to confirm the diagnosis. IIb Recommendations for treatment of chronic HF HFrEF Dapagliflozin or empagliflozin are recommended for patients with HFrEF to reduce the risk of HF hospitalization and death. I Vericiguat may be considered in patients in NYHA class IIIV who have had worsening HF despite treatment with an ACE-I (or ARNI), a beta-blocker and an MRA to reduce the risk of CV mortality or HF hospitalization. IIb HFmrEF An ACE-I may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb An ARB may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb A beta-blocker may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb An MRA may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb Sacubitril/valsartan may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb HFpEF Screening for, and treatment of, aetiologies, and CV and non- CV comorbidities are recommended in patients with HFpEF (see relevant sections of this document). I Prevention and monitoring Self-management strategies are recommended to reduce the risk of HF hospitalization and mortality. I Either home-based and/or clinic-based programmes improve outcomes and are recommended to reduce the risk of HF hospitalization and mortality. I Influenza and pneumococcal vaccinations should be considered in order to prevent HF hospitalizations. IIa A supervised, exercise-based, cardiac rehabilitation programme should be considered in patients with more severe disease, frailty, or with comorbidities. IIa Non-invasive HTM may be considered for patients with HF in order to reduce the risk of recurrent CV and HF hospitalizations and CV death. IIb Recommendations for management of patients with advanced HF Patients being considered for long-term MCS must have good compliance, appropriate capacity for device handling and psychosocial support. I

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