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......................................................... 3 Definition, epidemiology and prognosis

3.1 Definition of heart failure

Heart failure is not a single pathological diagnosis, but a clinical syndrome consisting of cardinal symptoms (e.g. breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, and peripheral oedema). It is due to a structural and/or functional abnormality of the heart that results in elevated intracardiac pressures and/or inadequate cardiac output at rest and/or during exercise. Identification of the aetiology of the underlying cardiac dysfunction is mandatory in the diagnosis of HF as the specific pathology can determine subsequent treatment. Most commonly, HF is due to myocardial dysfunction: either systolic, diastolic, or both. However, pathology of the valves, pericardium, and endocardium, and abnormalities of heart rhythm and conduction can also cause or contribute to HF. 3.2 Terminology

3.2.1 Heart failure with preserved, mildly reduced, and reduced ejection fraction Traditionally, HF has been divided into distinct phenotypes based on the measurement of left ventricular ejection fraction (LVEF) (Table 3). The rationale behind this relates to the original treatment trials in HF that demonstrated substantially improved outcomes in patients with LVEF <_40%. However, HF spans the entire range of LVEF (a normally distributed variable), and measurement by echocardiography is subject to substantial variability. We have decided on the following classification of HF (Table 3): • Reduced LVEF is defined as <_40%, i.e. those with a significant reduction in LV systolic function. This is designated as HFrEF. • Patients with a LVEF between 41% and 49% have mildly reduced LV systolic function, i.e. HFmrEF. Retrospective analyses from RCTs in HFrEF or HF with preserved ejection fraction (HFpEF) that have included patients with ejection fractions in the 4050% range suggest that they may benefit from similar

Recommendations for management of patients with HF and AF DOACs are recommended in preference to VKAs in patients with HF, except in those with moderate or severe mitral stenosis or mechanical prosthetic heart valves. I For patients with HF and non-valvular AF eligible for anti-

coagulation based on a CHA2DS2-VASc score, NOACs rather than warfarin should be considered for anticoagulation as NOACs are associated with a lower risk of stroke, intracranial haemorrhage, and mortality, which outweigh the increased risk of gastrointestinal haemorrhage. IIa

Beta-blockers should be considered for short- and longterm rate control in patients with HF and AF. IIa For patients in NYHA class IIII, a beta-blocker, usually

given orally, is safe and therefore is recommended as firstline treatment to control ventricular rate, provided the patient is euvolaemic. I

In cases of a clear association between paroxysmal or persistent AF and worsening of HF symptoms, which persist despite medical therapy, catheter ablation should be considered for the prevention of AF. IIa AV node catheter ablation may be considered to control

heart rate and relieve symptoms in patients unresponsive or intolerant to intensive pharmacological rate and rhythm control therapy, accepting that these patients will become pacemaker-dependent. IIb

Recommendations for management of patients with HF and CCS Coronary revascularization should be considered to relieve persistent symptoms of angina (or an anginaequivalent) in patients with HFrEF, CCS, and coronary anatomy suitable for revascularization, despite OMT including anti-anginal drugs. IIa Myocardial revascularization is recommended when angina

persists despite treatment with anti-anginal drugs.

I

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 Empagliflozin should be considered in patients with T2DM in order to prevent or delay the onset of HF and prolong

life. IIa

AF = atrial fibrillation; AHF = acute heart failure; AV = atrio-ventricular; BTB = bridge to bridge; BTD = bridge to decision; BTR = bridge to cardiac recovery; CAD = coronary artery disease; 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); CRT = cardiac resynchronization therapy; CT = computed tomography; CTCA = computed tomography coronary angiography; CV = cardiovascular; DCM = dilated cardiomyopathy; DOAC = direct oral anticoagulant; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; ICD = implantable cardioverter-defibrillator; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; MCS = mechanical circulatory support; NOAC = non-vitamin K antagonist oral anticoagulant; NYHA = New York Heart Association; OMT = optimal medical therapy; QRS = Q, R, and S waves of an ECG; RV = right ventricular/ventricle; SBP = systolic blood pressure; SGLT2 = sodium-glucose co-transporter 2; T2DM = type 2 diabetes mellitus; VKA = vitamin K antagonist. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026