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Diagnosis of heart failure • Measurement of natriuretic peptides and echocardiography have key roles in the diagnosis of HF. Additional testing is useful for aetiologies and phenotypes. • Multimodality aetiology assessment should be sought to find potential treatable causes of HF.

Guideline-recommended therapies • ARNIs or ACE-Is (ARB in case of intolerance) beta-blockers, MRAs, and SGLT2-Is are recommended as FMT for patients with HFrEF, whereas MRAs and SGLT2-Is are recommended as FMT for patients with HFpEF. • ICDs are recommended in selected patients with HFrEF, LVEF ≤35%, and an ischaemic aetiology, and should be considered in those with a non-ischaemic aetiology. • CRT-P or CRT-D is recommended in patients with HFrEF, LVEF ≤35%, in sinus rhythm, with an LBBB ≥150 ms and should be considered in those with an LBBB ≥130–149 ms or non-LBBB ≥150 ms.

Decompensated heart failure • Decompensated heart failure refers to acute or gradual onset of symptoms and/or signs of HF, severe enough to deserve urgent medical attention, leading to an unplanned hospital admission or an emergency department visit or an ambulatory visit, and requiring subsequent initiation or intensification of treatment. • Treatment of DHF is based on addressing any associated triggers urgently, diuretics for congestion with the addition of vasodilators for high blood pressure, inotropes, and/or temporary MCS for hypoperfusion. • Patients hospitalized for HF should be carefully evaluated to exclude persistent signs of congestion. FMT must be started or optimized before discharge and close visits in the early post-discharge period must be planned.

Advanced heart failure • Patients with advanced HF refractory to FMT and GDIT who do not have absolute contraindications must have timely referral for consideration of heart transplantation or MCS.

Cardiovascular comorbidities • Catheter ablation should be considered only in carefully selected patients with HFrEF and symptomatic AF. Selection criteria include high-burden AF, less than 1-year duration of continuous persistent AF, and a clear cause–effect relationship between AF and HF. • Patients with obstructive CAD and HF need to be treated conservatively or invasively (CABG or PCI) according to clinical and anatomical suitability for revascularization, HF phenotype and history, presence of angina, comorbidities, frailty, and patient preference. • Surgical aortic valve replacement or TAVI, as assessed by the Heart Team, is recommended in patient with severe low-flow low-gradient aortic stenosis and HF regardless of LVEF and in patients with severe low-flow low-gradient aortic stenosis and HFrEF. • Mitral TEER is recommended in selected patients with severe ventricular secondary MR and HFrEF after optimization of FMT and CRT implantation (if needed). Non-cardiovascular comorbidities

• Patients should be routinely screened and treated for non-CV comorbidities (e.g. diabetes, CKD, obesity, ID, anxiety and depression) and frailty. • Lifestyle interventions, exercise, diet, and patient education are fundamental steps for body-weight management in patients with HF and obesity, followed by pharmacological and surgical interventions. • It is recommended to switch glucose-lowering treatment from agents without proven CV efficacy or safety to agents with proven CV benefit in patients with HF and diabetes.

Multidisciplinary management • A multidisciplinary HF management programme is recommended. • Cardiac rehabilitation, with exercise training, is a key tool to reduce hospitalizations and improve functional capacity and QoL in patients with HF. • Remote haemodynamic monitoring of PA pressure should be considered in selected patients; non-invasive telemonitoring modalities may be considered.

Specific conditions • Pre-conception care and counselling is recommended for patients with stage B or C HF to facilitate decision-making surrounding pregnancy. • Specific disease-modifying therapies are recommended in patients with CA.

14 Gaps in evidence

Despite advances in the management of HF, multiple areas of uncertainty remain. Future research should address the following gaps. (1) Definitions and prevention

• Consensus regarding normal values/ranges of ejection fraction. • More information on the incidence, prevalence and prognostic importance of HF with improved LVEF, and a need to validate and evaluate the clinical importance of the new definition proposed by the Second Universal Definition of HF.47 • The benefits and risks of various weight-loss methods for HF risk reduction in obesity need further studies. • More research is needed to understand if SGLT2-Is and MRAs prevent HF in patients without diabetes but with comorbidities like obesity, hypertension, and/or CKD. • Studies are needed to better understand if CPAP therapy lowers risk of HF in patients with sleep apnoea. Downloaded from academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehag100/8766302 by guest on 31 August 2026