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Document Reviewers: Rudolf A. de Boer, (CPG Review Co-ordinator) (Netherlands), P. Christian Schulze, (CPG Review Co-ordinator) (Germany), Elena Arbelo (Spain), Jozef Bartunek (Belgium), Johann Bauersachs (Germany), Michael A. Borger (Germany), Sergio Buccheri (Sweden), Elisabetta Cerbai (Italy), Erwan Donal (France), Frank Edelmann (Germany), Gloria Färber (Germany), Bettina Heidecker (Germany), Borja Ibanez (Spain), Stefan James (Sweden), Lars Køber (Denmark), Konstantinos C. Koskinas (Switzerland), Josep Masip (Spain), John William McEvoy (Ireland), Robert Mentz (United States of America), Borislava Mihaylova (United Kingdom), Jacob Eifer Møller (Denmark), Wilfried Mullens (Belgium), Lis Neubeck (United Kingdom), Jens Cosedis Nielsen (Denmark), Agnes A. Pasquet (Belgium), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Bianca Rocca (Italy), Xavier Rossello (Spain), Leyla Elif Sade (United States of America/Türkiye), Hannah Schaubroeck (Belgium), Elena Tessitore (Switzerland), Mariya Tokmakova (Bulgaria), Peter van der Meer (Netherlands), Isabelle C. Van Gelder (Netherlands), Mattias Van Heetvelde (Belgium), Christiaan Vrints (Belgium), Matthias Wilhelm (Switzerland), Adam Witkowski (Poland), and Katja Zeppenfeld (Netherlands)

All experts involved in the development of this Focused Update have submitted declarations of interest. These have been compiled in a report and simultaneously published in a supplementary document to the Focused Update. The report is also available on the ESC website www.escardio.org/guidelines

See the European Heart Journal online for supplementary documents that include evidence tables.

Keywords Guidelines • Acute heart failure • Comorbidities • Chronic kidney disease hospitalization • Diagnosis • Ejection fraction • Heart failure • Multidisciplinary management • Natriuretic peptides • Neurohormonal antagonists • Pharmacotherapy • Prevention

Table of contents

1. Preamble .............................................................................................................. 3629 2. Introduction ....................................................................................................... 3631 3. Chronic heart failure ...................................................................................... 3631 4. Acute heart failure ........................................................................................... 3634 4.1. Medical therapy ....................................................................................... 3634 4.1.1. Diuretics ............................................................................................. 3634 4.1.2. Sodium–glucose co-transporter 2 inhibitors ...................... 3634 4.2. Management strategies ........................................................................ 3634 4.2.1. Admission phase ............................................................................. 3634 4.2.2. Pre-discharge and early post-discharge phases .................. 3634 5. Comorbidities .................................................................................................... 3635 5.1. Chronic kidney disease and type 2 diabetes mellitus ............. 3635 5.1.1. Sodium–glucose co-transporter 2 inhibitors ...................... 3635 5.1.2. Finerenone ......................................................................................... 3636 5.2. Iron deficiency ......................................................................................... 3636 6. Data availability statement ........................................................................... 3637 7. Author information ......................................................................................... 3637 8. Appendix ............................................................................................................. 3638 9. References .......................................................................................................... 3638

Tables of Recommendations

Recommendation Table 1 — Recommendation for the treatment of patients with symptomatic heart failure with mildly reduced ejection fraction ...................................................................................................................... 3633 Recommendation Table 2 — Recommendation for the treatment of patients with symptomatic heart failure with preserved ejection fraction ...................................................................................................................... 3633 Recommendation Table 3 — Recommendation for pre-discharge and early post-discharge follow-up of patients hospitalized for acute heart failure ............................................................................................................. 3635

Disclaimer. The ESC Guidelines and Focused Updates represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and Focused Updates and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines and Focused Updates fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines and Focused Updates do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines and Focused Updates exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. This article is co-published with permission in the European Heart Journal and the European Journal of Heart Failure. All rights reserved. © The European Society of Cardiology 2023. The articles are identical except for stylistic differences in keeping with each journal’s style. Either citation can be used when citing this article. For permissions, please e-mail: journals.permissions@oup.com No part of this publication may be reproduced, stored in a retrieval system, transmitted, used for text and data mining, or used for training artificial intelligence, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license or under terms agreed with the appropriate reprographics rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. ESC Guidelines are protected by copyright. As per opt out option under Article 4 §3 of EU Directive 2019/790, the European Society of Cardiology (ESC) reserves all rights to license uses of ESC Guidelines to train or develop generative artificial intelligence (AI) models, large language models or other deep learning or machine learning models. Downloaded from academic.oup.com/eurheartj/article/44/37/3627/7246292 by guest on 07 October 2026