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Heart transplantation is recommended for patients with advanced HF, refractory to medical/device therapy and who do not have absolute contraindications. I Continuous inotropes and/or vasopressors may be considered in patients with low cardiac output and evidence of organ hypoperfusion as bridge to MCS or heart transplantation. IIb Recommendations for management of patients after HF hospitalization It is recommended that patients hospitalized for HF be carefully evaluated to exclude persistent signs of congestion before discharge and to optimize oral treatment. I It is recommended that evidence-based oral medical treatment be administered before discharge. I An early follow-up visit is recommended at 12 weeks after discharge to assess signs of congestion, drug tolerance, and start and/or uptitrate evidence-based therapy. I Recommendations for management of patients with HF and atrial fibrillation Long-term treatment with an oral anticoagulant should be considered for stroke prevention in AF patients with a CHA2DS2-VASc score of 1 in men or 2 in women. IIa Recommendations for management of patients with HF and CCS CABG should be considered as the first-choice revascularization strategy, in patients suitable for surgery, especially if they have diabetes and for those with multivessel disease. IIa In LVAD candidates needing coronary revascularization, CABG should be avoided, if possible. IIa Coronary revascularization may be considered to improve outcomes in patients with HFrEF, CCS, and coronary anatomy suitable for revascularization, after careful evaluation of the individual risk to benefit ratio, including coronary anatomy (i.e. proximal stenosis >90% of large vessels, stenosis of left main or proximal LAD), comorbidities, life expectancy, and patient’s perspectives. IIb PCI may be considered as alternative to CABG, based on Heart Team evaluation, considering coronary anatomy, comorbidities, and surgical risk. IIb Recommendations for management of patients with HF and valvular heart disease Aortic valve intervention, TAVI or SAVR is recommended in patients with HF and severe high-gradient aortic stenosis to reduce mortality and improve symptoms. I It is recommended that the choice between TAVI and SAVR be made by the Heart Team, according to individual patient preference and features including age, surgical risk, clinical, anatomical and procedural aspects, weighing the risks and benefits of each approach. I Percutaneous edge-to-edge mitral valve repair should be considered in carefully selected patients with secondary mitral regurgitation, not eligible for surgery and not needing coronary revascularization, who are symptomatic despite OMT and who fulfil criteria to achieve a reduction in HF hospitalizations. IIa Percutaneous edge-to-edge mitral valve repair may be considered to improve symptoms in carefully selected patients with secondary mitral regurgitation, not eligible for surgery and not needing coronary revascularization, who are highly symptomatic despite OMT and who do not fulfil criteria for reducing HF hospitalization. IIb

Continued Recommendations for management of patients with HF and

diabetes SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, sotagliflozin) are recommended in patients with T2DM at risk of CV events to reduce hospitalizations for HF, major CV events, end-stage renal dysfunction, and CV death. I SGLT2 inhibitors (dapagliflozin, empagliflozin, and sotagliflozin) are recommended in patients with T2DM and HFrEF to reduce hospitalizations for HF and CV death. I The DPP-4 inhibitor saxagliptin is not recommended in patients with HF. III Recommendations for management of patients with HF and iron deficiency It is recommended that all patients with HF are periodically screened for anaemia and iron deficiency with a full blood count, serum ferritin concentration, and TSAT. I Intravenous iron supplementation with ferric carboxymaltose should be considered in symptomatic HF patients recently hospitalized for HF and with LVEF <_50% and iron deficiency, defined as serum ferritin <100 ng/mL or serum ferritin 100299 ng/mL with TSAT <20%, to reduce the risk of HF hospitalization. IIa Treatment of anaemia in HF with erythropoietin stimulating agents is not recommended in the absence of other indications for this therapy. III Recommendations for management of patients with HF and cancer It is recommended that cancer patients at increased risk for cardiotoxicity, defined by a history or risk factors of CV disease, previous cardiotoxicity or exposure to cardiotoxic agents, undergo CV evaluation before scheduled anticancer therapy, preferably by a cardiologist with experience/interest in Cardio-Oncology. I Treatment with an ACE-I and a beta-blocker (preferably carvedilol) should be considered in cancer patients developing LV systolic dysfunction, defined as a 10% or more decrease in LVEF and to a value lower than 50%, during anthracycline chemotherapy. IIa A baseline CV risk assessment should be considered in all cancer patients scheduled to receive a cancer treatment with the potential to cause HF. IIa Recommendations for treatment of patients with HF and amyloidosis Tafamidis is recommended in patients with genetic testing proven hTTR-CA and NYHA class I or II symptoms to reduce symptoms, CV hospitalization and mortality. I Tafamidis is recommended in patients with wtTTR-CA and NYHA class I or II symptoms to reduce symptoms, CV hospitalization and mortality. I

ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; ARNI = angiotensin receptor-neprilysin inhibitor; CABG = coronary artery bypass graft; CCS = chronic coronary syndrome; CHA2DS2-VASc = congestive heart failure or left ventricular dysfunction, Hypertension, Age >_75 (doubled), Diabetes, Stroke (doubled)-Vascular disease, Age 6574, Sex category (female) (score); CMP = cardiomyopathy; CV = cardiovascular; DPP-4 = dipeptidyl peptidase-4; HF = heart failure; HFmrEF = heart failure with mildly reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; HTM = home telemonitoring; hTTR = hereditary transthyretin; LAD = left anterior descending artery; LV = left ventricular; LVAD = left ventricular assist device; LVEF = left ventricular ejection fraction; MCS = mechanical circulatory support; MRA = mineralocorticoid receptor antagonist; NYHA = New York Heart Association; OMT = optimal medical therapy; PCI = percutaneous coronary intervention; SAVR = surgical aortic valve replacement; SGLT2 = sodium-glucose co-transporter 2; T2DM = type 2 diabetes mellitus; TAVI = transcatheter aortic valve implantation; TSAT = transferrin saturation; wtTTR-CA = wild-type transthyretin cardiac amyloidosis. ESC 2021

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