2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

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 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 Recommendation Table 4 — Recommendations for the prevention of heart failure in patients with type 2 diabetes mellitus and chronic kidney disease 3636 Recommendation Table 5 — Recommendations for the management of iron deficiency in patients with heart failure 3637 Table 1 Classes of recommendations 3630 Table 2 Levels of evidence 3630 Table 3 Definition of heart failure with reduced ejection fraction, mildly reduced ejection fraction, and preserved ejection fraction 3632 Figure 1 Management of patients with heart failure with mildly reduced ejection fraction 3633 Figure 2 Management of patients with heart failure with preserved ejection fraction 3633 Angiotensin-converting enzyme inhibitor Acetazolamide in Decompensated Heart Failure with Volume Overload (trial) A Randomized Double-blind Placebo Controlled Trial Comparing the Effects of Intravenous Ferric Carboxymaltose on Hospitalizations and Mortality in Iron Deficient Subjects Admitted for Acute Heart Failure (trial) Angiotensin receptor blocker Angiotensin receptor–neprilysin inhibitor Adjusted risk ratio Confidence interval Chronic kidney disease Combination of Loop Diuretics with Hydrochlorothiazide in Acute Heart Failure (trial) Comparison of Outcomes and Access to Care for Heart Failure (trial) Class of recommendation Clinical Practice Guidelines Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation (trial) Cardiovascular Dapagliflozin And Prevention of Adverse outcomes in Chronic Kidney Disease (trial) Dapagliflozin And Prevention of Adverse outcomes in Heart Failure (trial) Dapagliflozin Evaluation to Improve the LIVEs of Patients with PReserved Ejection Fraction Heart Failure (trial) Estimated glomerular filtration rate EMPAgliflozin once daily to assess cardio-renal outcomes in patients with chronic KIDNEY disease (trial) Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection (trial) Empagliflozin in Patients Hospitalized with Acute Heart Failure Who Have Been Stabilized (trial) European Society of Cardiology Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (trial) Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease (trial) Heart failure Heart failure with mildly reduced ejection fraction Heart failure with normal ejection fraction Heart failure with preserved ejection fraction Heart failure with reduced ejection fraction Hazard ratio Effectiveness of Intravenous Iron Treatment versus Standard Care in Patients with Heart Failure and Iron Deficiency (trial) Intravenous Kidney Disease: Improving Global Outcomes Level of evidence Left ventricular ejection fraction Mineralocorticoid receptor antagonist N-terminal pro-B-type natriuretic peptide New York Heart Association Odds ratio Proactive IV Iron Therapy in Haemodialysis Patients (trial) Revascularization for Ischemic Ventricular Dysfunction (trial) Risk ratio Effect of Sotagliflozin on Cardiovascular and Renal Events in Patients with Type 2 Diabetes and Moderate Renal Impairment Who Are at Cardiovascular Risk (trial) Sodium–glucose co-transporter 2 Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies (trial) Type 2 diabetes mellitus Torsemide Comparison with Furosemide for Management of Heart Failure (trial) Clinical Trial to Evaluate Cardiovascular Outcomes in Patients Treated With the Tricuspid Valve Repair System Pivotal (trial) Guidelines evaluate and summarize available evidence with the aim of assisting health professionals in proposing the best diagnostic or therapeutic approach for an individual patient with a given condition. Guidelines are intended for use by health professionals and the European Society of Cardiology (ESC) makes its Guidelines freely available. ESC Guidelines do not override 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 or the patient’s caregiver where appropriate and/or necessary. It is also the health professional’s responsibility to verify the rules and regulations applicable in each country to drugs and devices at the time of prescription and, where appropriate, to respect the ethical rules of their profession. ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated. ESC Policies and Procedures for formulating and issuing ESC Guidelines can be found on the ESC website (https://www.escardio.org/Guidelines). Interim Focused Updates are created when the publication of new evidence could influence clinical practice before the next full update of a guideline is published. This Focused Update provides new and revised recommendations for the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. View the full 2021 ESC Guidelines here: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure. The members of the Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology. The Task Force performed a critical evaluation of diagnostic and therapeutic approaches, including assessment of the risk–benefit ratio. The strength of every new or updated recommendation and the level of evidence supporting them were weighed and scored according to predefined scales as outlined below. The Task Force followed ESC voting procedures and all approved recommendations were subject to a vote and achieved at least 75% agreement among voting members. 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. 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. Classes of recommendations Classes of recommendations Levels of evidence Levels of evidence 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 in Reducing Kidney Failure and Disease Progression in Diabetic Kidney in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney of Intravenous Iron Treatment versus Standard Care in Patients with Heart Failure and Iron IV Iron Therapy in Haemodialysis for Ischemic Ventricular Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Comparison with Furosemide for Management of Heart and Pivotal Trial to Evaluate Cardiovascular Outcomes in Patients Treated With the Tricuspid Valve Repair System that to new or recommendations were selected for in Recommendation that have an upon recommendations in ESC Guidelines preparation have not been to This is the for which be considered in the chronic to the trials to be the Task Force also discussed the of HF with preserved ejection fraction to HF with normal ejection fraction and the ventricular ejection fraction for The Task Force to the and any changes in to be considered in the next ESC HF as in the 2021 ESC HF the Task Force on the of This for HF the risk of the time to of the of HF or for a that not each is reduced where the and HF and all the for this and not was that not that were All the new recommendations are to the recommendations of the 2021 ESC HF Guidelines and recommendations those of the 2021 ESC HF After the Task Force to update recommendations for the following of the 2021 ESC HF Chronic HF with mildly reduced ejection fraction and Acute HF Comorbidities and prevention of The 2021 ESC HF Guidelines the of chronic HF according to (Table Definition of heart failure with reduced ejection fraction, mildly reduced ejection fraction, and preserved ejection fraction heart heart failure with mildly reduced ejection heart failure with preserved ejection heart failure with reduced ejection ventricular ejection may not be in the early of HF in and in the diagnosis of the of evidence of heart disease or of makes the diagnosis the diagnosis of the the of the the of Definition of heart failure with reduced ejection fraction, mildly reduced ejection fraction, and preserved ejection fraction heart heart failure with mildly reduced ejection heart failure with preserved ejection heart failure with reduced ejection ventricular ejection may not be in the early of HF in and in the diagnosis of the of evidence of heart disease or of makes the diagnosis the diagnosis of the the of the the of those with with and the Task Force made recommendations in the 2021 ESC HF Guidelines for the use of that have evidence for use in HF with reduced ejection fraction were on of trials that were not to on including trials where the were The Task Force made recommendations for the use of co-transporter 2 those with the Task Force made recommendations for the use of as clinical trials with enzyme inhibitors receptor receptor and receptor–neprilysin inhibitors to their were published trials with inhibitors to at the Since trials have available with the inhibitors and in patients with HF and that an update in the recommendations for and The to report was the EMPEROR-Preserved It patients with HF York Heart Association was and of N-terminal pro-B-type natriuretic peptide for those in or for those in were randomized to once or The was a of or for a follow-up of reduced the ratio interval The was by a in HF with and there was in The were in patients with and without type 2 diabetes mellitus The of patients were on an and and were on an A the DELIVER on the of once with in patients with HF Patients to have an at the time of those an that to were also and hospitalized for HF were of natriuretic were also a in or in Dapagliflozin reduced the of or HF or HF the was to a in HF and there was in Dapagliflozin also The were of The efficacy of was in those that patients may also from The of was also across the of The use of for disease was were on a were on an were on a and were on an A of the trials a in the of or for HF was not reduced HF was reduced by were in the across the individual patient that from (Dapagliflozin And Prevention of Adverse outcomes in Heart in with DELIVER that there was evidence that the of by ejection This also that reduced the risk of from The Task Force discussed the of trials in on the that their by a in HF and not The Task Force to make recommendations on the is with all the recommendations made in the 2021 ESC HF The Task Force not NT-proBNP for with recommendations for in the 2021 ESC HF However, it should be in the diagnostic for HF in the 2021 ESC HF of natriuretic are to that trials the following recommendations have been made for and 1 and Management of patients with heart failure with mildly reduced ejection enzyme receptor receptor–neprilysin heart failure with mildly reduced ejection receptor Recommendation for the treatment of patients with symptomatic heart failure with mildly reduced ejection fraction Recommendation for the treatment of patients with symptomatic heart failure with mildly reduced ejection fraction Recommendation for the treatment of patients with symptomatic heart failure with preserved ejection fraction Recommendation for the treatment of patients with symptomatic heart failure with preserved ejection fraction Management of patients with heart failure with preserved ejection heart failure with preserved ejection Treatment of acute HF was outlined in the 2021 ESC HF Guidelines and a Heart Failure Association scientific statement on Since trials have been with as as on management strategies for patients with acute The are ADVOR was a that patients with acute clinical of or and an NT-proBNP level of or a natriuretic peptide level of were randomized to once or to The of as the of of 3 after and without an for of was achieved in of patients in the and in of patients in the ratio for HF or in patients in the and in patients in the of was 1 with with the and was found for outcomes and may support the of to a to on outcomes and are The CLOROTIC patients with acute HF and randomized them to on glomerular filtration rate or in to The change in and change in from to after Patients on a in at with those on to in were the in in patients on with those on The of HF and were as was of The of an on clinical outcomes any recommendation in the guideline on outcomes and are EMPULSE the efficacy of the early of in patients hospitalized for acute The was a of from any of HF and time to HF or a in change from in the at the HF were as HF HF and HF was considered only if and of HF were and an of therapy as an in or of a or a or was Patients were randomized in when with a time from to of 3 and were for to The was achieved in patients with with ratio Efficacy was of and diabetes a the rate of was the treatment are with those for inhibitors in patients with chronic of and also in those hospitalized for once in patients with at risk of those with when is reduced or of inhibitors are not in patients with type 1 trials have been published the COACH and The COACH was a including patients the phase and the at in the the Heart Failure Mortality Risk to patients a or risk of or The that patients be early and be with care to it was that and patients be to the early at a rate in the and the was in a in the of or in the with the with a of post-discharge The may before any recommendation on its approach can be in a The of pre-discharge and early post-discharge assessment in patients to for an of acute HF was in the 2021 ESC HF The the and efficacy of an approach on and medical therapy for HF 2 before and in follow-up early after this patients hospitalized for acute not on full of HF were with NT-proBNP at and a in and were before to care or Patients in the care received early and of HF treatment with or and The of the which before was to at least of the of to full of was 2 after with appropriate including and including NT-proBNP were performed at and after to assess the and of medical Patients to care were to full of those in the care inhibitors and The was early for The of HF or at in of patients in the care and in of patients in the care for HF were reduced by was not of and were in each upon the of care for and of HF and follow-up in the after for an acute HF is to HF or the follow-up should be to and of heart NT-proBNP and has several the was on NT-proBNP and their the of patients in the received of full of and and, to clinical their may have the care the was to evidence and recommendations for which were not in the Recommendation for pre-discharge and early post-discharge follow-up of patients hospitalized for acute heart failure Recommendation for pre-discharge and early post-discharge follow-up of patients hospitalized for acute heart failure The 2021 ESC HF Guidelines recommendations for the prevention of HF in patients with This update provides new recommendations for prevention of HF in patients with chronic kidney disease and trials have the of in HF in patients with the Kidney Disease: Improving Global Outcomes and the Diabetes Association of Medical Care in Diabetes and recommendations treatment with an or for patients with and or randomized controlled which were early for and a were published. DAPA-CKD was a randomized including and patients with a ratio and an of were to once daily or of the patients a of a follow-up of a in the a of in of kidney or or was reduced by by with the risk of the of HF or was by with a risk with EMPA-KIDNEY a of patients with with including patients with in the of or with an of and a ratio Patients were randomized to once daily or of the patients a of a follow-up of a in the of of kidney disease or was The risk of HF or for was not reduced and Renal Events in Diabetes With Established Nephropathy Clinical and of Sotagliflozin on Cardiovascular and Renal Events in Patients with Type 2 Diabetes and Moderate Renal Impairment Who Are at Cardiovascular were with HF trials in a The in HF and was of a of diabetes when HF and trials were in patients with and in those without However, were not in patients without diabetes when only trials were for HF and of in patients with and of in patients without on inhibitors are in patients with and and with the of the in including an to the risk of HF or The was in trials in patients with kidney The FIDELIO-DKD patients with a ratio an and or a ratio and an The of the in a was a of kidney a of in the from a of or from Kidney failure was as kidney disease or an kidney disease was as the of or kidney The of the was reduced by with by a follow-up of was evidence of a in HF with was with a of the a of and for HF Patients with and were from the However, patients with or or with or could be that of the patients a of The of on the of and including HF were of a of the the in a was a of from or for The patients with and with a inhibitor at the was according to of of ratio to and an 2 to 4 or ratio and an 1 or 2 Patients were to have a level of at the time of The patients to or a follow-up of the rate of the or HF was in the treatment with The was by a of HF with with in FIDELIO-DKD and the of was in the with the However, the rate of was the A individual including patients with kidney disease followed for a of from the FIDELIO-DKD and a in the including and HF as as in HF with and is for the prevention of HF in patients with and Recommendations for the prevention of heart failure in patients with type 2 diabetes mellitus and chronic kidney disease Recommendations for the prevention of heart failure in patients with type 2 diabetes mellitus and chronic kidney disease Recommendations for the diagnosis and treatment of iron deficiency were given in the 2021 ESC HF for the diagnosis of iron A to HF and of and to HF for treatment with A new has been This was a including patients with and or were to or The patients were were an HF and an HF in the After a follow-up of the rate ratio for the a of and HF and was for HF were not reduced with care in Randomized Double-blind Placebo Controlled Trial Comparing the Effects of Intravenous Ferric Carboxymaltose on Hospitalizations and Mortality in Iron Deficient Subjects Admitted for Acute Heart a follow-up on a in the risk of the with was a in the with Heart Failure with treatment to in or of findings in outcomes might be by the of for and to not the have been in meta-analyses of the randomized controlled trials the of iron therapy with of care or in patients with HF and iron the by including trials with iron reduced the of HF and and HF or ratio was on or were found in the the a iron with a reduced the of and HF in patients for on trials and iron is in patients with or and iron to and of and should be considered to the risk of HF Iron deficiency was by a or a in patients were if and The new recommendations are below. 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