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The management of dyslipidaemia and hypertension in patients with CAD is discussed in sections 4.6 and 4.7, respectively. For ACE inhibitors (or ARBs) and beta-blockers, see also the 2019 ESC Guidelines for diagnosis and management of CCS.622

6.2 Heart failure

The management of HF aims to improve mortality, hospitalization rate, and quality of life.690 To achieve this, multidisciplinary management programmes and structured follow-up with patient education, optimization of medical treatment, using telehealth facilities, lifestyle changes, psychosocial support, and improved access to care are fundamental.691694 Regarding the management of CVD risk factors, similar basic rules apply for those with and without HF. However, in HF, low cholesterol levels695,696 and low body weight are associated with increased mortality.697,698 Initiation of lipid-lowering therapy is not recommended in patients with HF without compelling indications for their use.3 Whereas unintentional weight loss is associated with a worse prognosis regardless of baseline BMI, the effects of intentional weight loss remain unclear. Conversely, regular exercise training (particularly combined aerobic and resistance exercises) improves clinical status in all patients with HF650,699,700 and improves CVD burden and prognosis in HFrEF.700,701 It is recommended to screen all patients with HF for both CV and non-CV comorbidities; if present, they should be treated.690 These diseases include CAD, hypertension, lipid disorders, DM, obesity, cachexia and sarcopenia, thyroid disorders, CKD, anaemia, iron deficiency, and sleep apnoea.690 For patients with symptomatic HFrEF, neurohormonal antagonists [ACE inhibitors,702705 ARBs,706 angiotensin receptor neprilysin inhibitors (ARNIs),707710 beta-blockers,711717 and mineralocorticoid receptor antagonists (MRAs)718,719] improve survival and reduce the risk of HF hospitalizations.690 These drugs also reduce the risk of CV events in patients with symptomatic HFrEF.702719

Importantly, these drugs should be up-titrated to the maximum tolerated doses, which may be different for men and women, particularly in patients recently discharged after HF hospitalization.690,720,721 SGLT2 inhibitors (currently dapagliflozin and empagliflozin) added on top of neurohormonal blockade reduces the risk of CV death and worsening HF in patients with symptomatic HFrEF, with or without DM,600,601 and are recommended for all patients with symptomatic HFrEF already treated with an ACE inhibitor (or ARNI), a betablocker, and an MRA. Recently, an oral soluble guanylate cyclase receptor stimulator (vericiguat), administered along with standard neurohormonal blockade in symptomatic patients with HFrEF with recent HF hospitalization, reduced the composite of death from any cause or HF hospitalization.722 Other drugs bring additional moderate benefits for selected patients with symptomatic HFrEF. Diuretics,723,724 ivabradine,725,726 and hydralazine727,728 should be considered, and digoxin729 may be considered as complementary therapies in specific patients with symptomatic HFrEF. Some of these therapies reduce CV morbidity and mortality (e.g. ivabradine). Additionally, for selected patients with symptomatic HFrEF, there are indications for an implantable cardioverter defibrillator to reduce the risk of sudden death and all-cause mortality, and for cardiac resynchronization therapy to reduce morbidity and mortality (for details, see 2021 HF Guidelines).690

Adding a second antithrombotic drug to aspirin for long-term secondary prevention may be considered in patients with a moderate risk of ischaemic events and without a high bleeding risk.83,622,687689 IIb A ACE inhibitors (or ARB) are recommended if a patient has other conditions (e.g. HF, hypertension, or DM).622 I A Beta-blockers are recommended in patients with LV dysfunction or systolic HF.622 I A In patients with established ASCVD, oral lipidlowering treatment with an ultimate LDL-C goal of <1.4 mmol/L (55 mg/dL) and a >_50% reduction in LDL-C vs. baseline is recommended. I A

ACE = angiotensin-converting enzyme; ACS = acute coronary syndromes; ARB = angiotensin receptor blocker; ASCVD = atherosclerotic cardiovascular disease; CAD = coronary artery disease; CCS = chronic coronary syndromes; DAPT = dual antiplatelet therapy; DM = diabetes mellitus; HF = heart failure; LDL-C = low-density lipoprotein cholesterol; LV = left ventricular. aClass of recommendation. bLevel of evidence. ESC 2021

Recommendations regarding pharmacological and nonpharmacological interventions for patients with symptomatic (New York Heart Association class II2IV) heart failure with reduced ejection fraction (left ventricular ejection fraction <40%) with proven benefits on clinical outcomes, including cardiovascular morbidity and mortality.

Recommendations Classa Levelb

It is recommended that patients with HF are enrolled in a comprehensive CR programme to reduce the risk of HF hospitalization and death.c 691-694 I A EBCR is recommended in stable symptomatic patients with HFrEF to reduce the risk of HF hospitalization.700,701 I A It is recommended to screen patients with HF for both CV and non-CV comorbidities which, if present, should be treated, provided safe and effective interventions exist, not only to alleviate symptoms but also to improve prognosis.c I A An ACE inhibitor is recommended, in addition to a beta-blocker and an MRA, for patients with symptomatic HFrEF to reduce the risk of HF hospitalization and death.702705 I A A beta-blocker is recommended, in addition to an ACE inhibitor (or an ARNI) and an MRA, for patients with stable, symptomatic HFrEF to reduce the risk of HF hospitalization and death.711717 I A

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