CONFERENCE UPDATE: ESC 2023
The 2023 focused updates of the ESC 2021 guidelines for the diagnosis and treatment of acute and chronic HF
Since the publication of the 2021 ESC guidelines for diagnosing and treating acute and chronic heart failure (HF), multiple randomized controlled trials (RCT) and meta-analyses have investigated alternative prevention and discharge management strategies for HF patients.1 With additional data on viable alternatives that has been validated by clinical studies between March 2021 and March 2023, an amendment to the 2021 guidelines was needed.1 During the ESC 2023 Congress, Professor Theresa A. McDonagh and Professor Marco Metra, the chairpersons of the ESC Guideline Task Force, presented the most recent recommendations in HF management.1
For the management of chronic HF, which encompassed HF with mildly reduced ejection fraction (HFmrEF) and HF with preserved ejection fraction (HFpEF), the committee suggested the addition of sodium-glucose cotransporter-2 (SGLT2) inhibitors, such as dapagliflozin and empagliflozin, as class I agents for minimizing the risk of HF hospitalization or cardiovascular (CV) death.1 This decision was based on a meta-analysis of the DELIVER and EMPEROR-Preserved trials, in which SGLT2 inhibitors exhibited efficacy in reducing the risk of CV death or first hospitalization for HF, regardless of left ventricular ejection fraction (LVEF) status.1
| Recommendations | Class | Level |
| An SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in patients with HFmrEF to reduce the risk of HF hospitalization or CV death | I | A |
| An SGLT2 inhibitor (dapagliflozin or empagliflozin) is recommended in patients with HFpEF to reduce the risk of HF hospitalization or CV death | I | A |
Table 1. Updated recommendations for the treatment of patients with symptomatic HFmrEF and HFpEF
CV: Cardiovascular; HF: Heart failure; HFmrEF: HF with mildly reduced ejection fraction; HFpEF: HF with preserved ejection fraction; SGLT2: Sodium-glucose cotransporter-2
As for managing acute HF, the guidelines recommended initiating high-intensity treatment during pre-discharge periods and follow-up visits to reduce the risk of HF rehospitalization.1 This statement was evidenced by the results of the STRONG-HF trial, which compared the efficacy between high-intensity and the standard oral HF treatments in HF pre-discharge management.1 After 180 days of treatment, the high-intensity care group exhibited a higher probability of event-free survival (EFS), thus prompting the addition of high-intensity pre-discharge treatment to existing recommendations.1
| Recommendations | Class | Level |
| An intensive strategy of initiation and rapid up-titration of evidence-based treatment before discharge and during frequent and careful follow-up visits in the first 6 weeks following an HF hospitalization is recommended to reduce the risk of HF rehospitalization or death | I | B |
Table 2. Updated recommendations for pre-discharge and early post-discharge follow-up of patients hospitalized for acute
HF: Heart failure
Serval recommendations were amended for HF prevention in accordance with comorbidities.1 A collaborative meta-analysis which included the EMPEROR-PRESERVED, DELIVER, and EMPA-KIDNEY trials established SGLT2 inhibitors’ efficacy in reducing the risk of hospitalization and CV death for patients with type 2 diabetes and chronic kidney disease (CKD).1 Similarly, the FIDELITY pooled analysis provided evidence of finerenone’s ability to reduce CV events in this patient sub-group.1 Hence, both SGLT2 inhibitors and finerenone were incorporated into the guideline update.1
| Recommendations | Class | Level |
| In patients with type 2 diabetes and CKD, SGLT2 inhibitors (dapagliflozin or empagliflozin) are recommended to reduce the risk of HF hospitalization or CV death | I | A |
| In patients with type 2 diabetes and CKD, finerenone is recommended to reduce the risk of HF hospitalization or CV death | I | A |
Table 3. Updated recommendations for the prevention of HF in patients with type 2 diabetes and CKD
CKD: Chronic kidney disease; CV: Cardiovascular; HF: Heart failure; SGLT2: Sodium-glucose cotransporter-2
To address iron deficiency in HF patients, intravenous (IV) iron supplementation is recommended.1 This statement is supported by meta-analyses that included the IRONMAN trial, which investigated the effectiveness of intravenous iron in HF patients with iron deficiency.1
| Recommendations | Class | Level |
| IV iron supplementation is recommended in symptomatic patients with HFrEF and HFmrEF and iron deficiency, to alleviate HF symptoms and improve QoL | I | A |
| IV iron supplementation with ferric carboxymaltose or ferric derisomaltose should be considered in symptomatic patients with HFrEF and HFmrEF and iron deficiency to reduce the risk of hospitalization | Ila | A |
Table 4: Updated recommendations for the management of iron deficiency in patients with HF
HF: Heart failure; HFmrEF: HF with mildly reduced ejection fraction; HFrEF: HF with reduced ejection fraction; IV: Intravenous; QoL: Quality of life
To conclude, the updated guidelines introduced alternative treatment agents such as SGLT2 inhibitors and finerenone for HF prevention and discharge management.1 Additionally, strategies for HF patients with type 2 diabetes, CKD and iron deficiency were also improved based on available clinical evidence.1
