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

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

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

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

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