p.5 抽出テキスト

The experts of the writing and reviewing panels provided declaration of interest forms for all relationships that might be perceived as real or potential sources of conflicts of interest. Their declarations of interest were reviewed according to the ESC declaration of interest rules and can be found on the ESC website (http://www.escardio.org/ guidelines) and have been compiled in a report published in a supplementary document with the guidelines. The Task Force received its entire financial support from the ESC without any involvement from the healthcare industry. The ESC Clinical Practice Guidelines (CPG) Committee supervises and coordinates the preparation of new Guidelines and Focused Updates and is responsible for the approval process. ESC Guidelines and Focused Updates undergo extensive review by the CPG Committee and external experts, including members from across the whole of the ESC region and from relevant ESC Subspecialty Communities and National Cardiac Societies. After appropriate revisions, Guidelines and Focused Updates are signed off by all the experts involved in the Task Force. Finalized documents are signed off by the CPG Committee for publication in the European Heart Journal. This Focused Update was developed after careful consideration of the scientific and medical knowledge and the evidence available at the time of writing. Tables of evidence summarizing the findings of studies informing development of the Focused Update are included. The ESC warns readers that the technical language may be misinterpreted and declines any responsibility in this respect. Off-label use of medication may be presented in this Focused Update if a sufficient level of evidence shows that it can be considered medically appropriate for a given condition. However, the final decisions concerning an individual patient must be made by the responsible health professional giving special consideration to: • The specific situation of the patient. Unless otherwise provided for by national regulations, off-label use of medication should be limited to situations where it is in the patient’s interest with regard to the quality, safety, and efficacy of care, and only after the patient has been informed and has provided consent. • Country-specific health regulations, indications by governmental drug regulatory agencies, and the ethical rules to which health professionals are subject, where applicable.

2 Introduction

Since the publication of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (HF),1 there have been several randomized controlled trials that should change patient management ahead of the next scheduled full guidelines. This 2023 Focused Update addresses changes in recommendations for the treatment of HF because of this new evidence. New evidence was considered until 31 March 2023. All major randomized controlled clinical trials and meta-analyses were presented, discussed, and then voted upon for inclusion. Members with declared interests in specific topics were asked to abstain from voting on those topics. The trials were presented and discussed in detail before a consensus was reached about any possible classes of recommendations (COR) (Table 1) and levels of evidence (LOE) (Table 2) to be assigned. The Task Force considered and discussed the following new trials and any meta-analyses including them: ADVOR (Acetazolamide in Decompensated Heart Failure with Volume Overload),2 CLOROTIC (Combination of Loop Diuretics with Hydrochlorothiazide in Acute Heart Failure),3 COACH (Comparison of Outcomes and Access to Care for Heart Failure),4 DAPA-CKD (Dapagliflozin And Prevention of Adverse outcomes in Chronic Kidney Disease),5 DELIVER (Dapagliflozin Evaluation to Improve the LIVEs of Patients with PReserved Ejection Fraction Heart Failure),6 EMPA-KIDNEY (EMPAgliflozin once daily to assess cardio-renal outcomes in patients with chronic KIDNEY disease),7 EMPEROR-Preserved (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction),8 EMPULSE (Empagliflozin in Patients Hospitalized with Acute Heart Failure Who Have Been Stabilized),9

FIDELIO-DKD (Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease),10 FIGARO-DKD (Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease),11 IRONMAN (Effectiveness of Intravenous Iron Treatment versus Standard Care in Patients with Heart Failure and Iron Deficiency),12 PIVOTAL (Proactive IV Iron Therapy in Haemodialysis Patients),13,14 REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction),15 STRONG-HF (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies),16 TRANSFORM-HF (Torsemide Comparison with Furosemide for Management of Heart Failure),17 and TRILUMINATE Pivotal (Clinical Trial to Evaluate Cardiovascular Outcomes in Patients Treated With the Tricuspid Valve Repair System Pivotal).18 Only results that would lead to new or changed class I/IIa recommendations were selected for inclusion in Recommendation Tables. Trials that would have an impact upon recommendations in other ESC Guidelines under preparation have not been included to avoid discordance. This is the case for REVIVED-BCIS2, which will be considered in the upcoming chronic coronary syndrome Guidelines. In addition to selecting the trials to be included, the Task Force also discussed changing the description of HF with preserved ejection fraction (HFpEF) to HF with normal ejection fraction (HFnEF) and the left ventricular ejection fraction (LVEF) threshold for HFnEF. The Task Force ultimately decided to keep the term HFpEF and left any further changes in terminology to be considered in the next ESC HF Guidelines. In assigning recommendations, as in the 2021 ESC HF Guidelines, the Task Force focused on the primary endpoints of trials. This means that, for most HF trials, effective treatments reduce the risk of the time to first occurrence of the composite of either HF hospitalization or cardiovascular (CV) death (the correct convention for describing such a composite). Of course, that does not mean each component is reduced individually. For total-event trials, where the primary composite outcome included total (first and repeat) HF hospitalizations and all CV deaths, the convention for describing this composite, i.e. and not or, was used. Once again that does not mean that both components were reduced. All the new recommendations are additive to the recommendations of the 2021 ESC HF Guidelines and changed recommendations substitute those of the 2021 ESC HF Guidelines. After due deliberation, the Task Force decided to update recommendations for the following sections of the 2021 ESC HF Guidelines: • Chronic HF: HF with mildly reduced ejection fraction (HFmrEF) and HFpEF • Acute HF • Comorbidities and prevention of HF.

3 Chronic heart failure

The original 2021 ESC HF Guidelines adopted the classification of chronic HF according to LVEF (Table 3).

ESC Guidelines                                                                                                                                                                                          3631

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