Heart failure with reduced ejection fraction
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
symptomatic HF: LVEF ≤40%
renin-angiotensin system inhibitor
Renin-angiotensin system inhibitors include: sacubitril/valsartan (an angiotensin receptor-neprilysin inhibitor [ARNi]; ACE inhibitors; and angiotensin-II receptor antagonists.
The American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) guidelines recommend sacubitril/valsartan for all patients with HF with reduced ejection fraction (HFrEF) and New York Heart Association (NYHA) class II to III symptoms, in preference to an ACE inhibitor or angiotensin-II receptor antagonist, because of improvement in morbidity and mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com An ACE inhibitor is recommended when use of ARNi is not feasible.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
European and UK guidelines recommend ACE inhibitors in all patients unless contraindicated or not tolerated.[9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication]. https://www.nice.org.uk/guidance/ng106 European guidelines recommend sacubitril/valsartan as a replacement for an ACE inhibitor in patients with HFrEF who remain symptomatic despite optimal treatment, to reduce the risk of hospitalisation and death.[9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Concomitant administration of an ARNi with an ACE inhibitor, or within 36 hours of the last dose of an ACE inhibitor, is not recommended.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
Angiotensin-II receptor antagonists are considered a reasonable alternative to an ARNi or ACE inhibitor in patients who are intolerant of ACE inhibitors and when use of ARNi is not feasible.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication]. https://www.nice.org.uk/guidance/ng106 [147]Heran BS, Musini VM, Bassett K, et al. Angiotensin receptor blockers for heart failure. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD003040. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003040.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/22513909?tool=bestpractice.com
Primary options
sacubitril/valsartan: treatment-naive or treatment-experienced on a low dose: 24 mg (sacubitril)/26 mg (valsartan) orally twice daily initially, increase gradually according to response, maximum 97 mg (sacubitril)/103 mg (valsartan) twice daily; treatment-experienced on a usual dose: 49 mg (sacubitril)/51 mg (valsartan) orally twice daily initially, increase gradually according to response, maximum 97 mg (sacubitril)/103 mg (valsartan) twice daily
More sacubitril/valsartanPatients not taking an ACE inhibitor or angiotensin-II receptor antagonist (treatment-naive) or those on a low dose of an ACE inhibitor or angiotensin-II receptor antagonist should be started on a lower dose of sacubitril/valsartan. Patients who were being treated with an ACE inhibitor or angiotensin-II receptor antagonist (treatment-experienced) should be started on a higher dose of sacubitril/valsartan.
Allow 36 hours between stopping an ACE inhibitor and starting this drug.
OR
captopril: 6.25 to 50 mg orally three times daily
OR
enalapril: 2.5 to 20 mg orally twice daily
OR
fosinopril: 5-40 mg orally once daily
OR
lisinopril: 2.5 to 40 mg orally once daily
OR
perindopril: 2-16 mg orally once daily
OR
quinapril: 5-20 mg orally twice daily
OR
ramipril: 1.25 to 10 mg orally once daily
OR
trandolapril: 1-4 mg orally once daily
Secondary options
candesartan: 4-32 mg orally once daily
OR
losartan: 25-150 mg orally once daily
OR
valsartan: 40-160 mg orally twice daily
beta-blocker
Treatment recommended for ALL patients in selected patient group
All patients with chronic HF should receive a beta-blocker, unless there is a contraindication based on bradycardia, reactive airway disease, and unstable or low-output HF.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication]. https://www.nice.org.uk/guidance/ng106
AHA/ACC/HFSA guidelines recommend either bisoprolol, carvedilol, or sustained-release metoprolol succinate; European Society of Cardiology (ESC) guidelines also recommend nebivolol.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Carvedilol seems superior to metoprolol, although there is no evidence of superiority to other beta-blockers.[249]Poole-Wilson PA, Swedberg K, Cleland JG, et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomised controlled trial. Lancet. 2003 Jul 5;362(9377):7-13. http://www.ncbi.nlm.nih.gov/pubmed/12853193?tool=bestpractice.com In the SENIORS study, nebivolol, a cardioselective beta-blocker with nitric oxide-mediated vasodilating properties, was found to be an effective and well-tolerated treatment for HF in patients aged 70 years or more.[250]Flather MD, Shibata MC, Coats AJ, et al. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J. 2005 Feb;26(3):215-25. https://academic.oup.com/eurheartj/article/26/3/215/2888055 http://www.ncbi.nlm.nih.gov/pubmed/15642700?tool=bestpractice.com Data suggest that initiation with moderate doses of nebivolol is not associated with the adverse haemodynamic effects usually observed with other beta-blockers in patients with HF; therefore, a long up-titration period may not be necessary with nebivolol.[251]Triposkiadis F, Giamouzis G, Kelepeshis G, et al. Acute hemodynamic effects of moderate doses of nebivolol versus metoprolol in patients with systolic heart failure. Int J Clin Pharmacol Ther. 2007 Feb;45(2):71-7. http://www.ncbi.nlm.nih.gov/pubmed/17323786?tool=bestpractice.com
Beta-blockers have been shown to decrease the morbidity and mortality associated with HF.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
[9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726.
https://academic.oup.com/eurheartj/article/42/36/3599/6358045
http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
[122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication].
https://www.nice.org.uk/guidance/ng106
They are initiated at low doses and titrated to target dosages.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
[9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726.
https://academic.oup.com/eurheartj/article/42/36/3599/6358045
http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
[122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication].
https://www.nice.org.uk/guidance/ng106
[144]Chatterjee S, Biondi-Zoccai G, Abbate A, et al. Benefits of beta-blockers in patients with heart failure and reduced ejection fraction: network meta-analysis. BMJ. 2013 Jan 16;346:f55.
https://www.bmj.com/content/346/bmj.f55
http://www.ncbi.nlm.nih.gov/pubmed/23325883?tool=bestpractice.com
[ ]
How does nurse-led titration of heart failure medication compare with usual care for heart failure with reduced ejection fraction?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1391/fullShow me the answer One meta-analysis found that irrespective of pre-treatment heart rate, beta-blockers reduced mortality in patients with HF with reduced ejection fraction (HFrEF) in sinus rhythm.[145]Kotecha D, Flather MD, Altman DG, et al. Heart rate and rhythm and the benefit of beta-blockers in patients with heart failure. J Am Coll Cardiol. 2017 Jun 20;69(24):2885-96.
https://www.jacc.org/doi/10.1016/j.jacc.2017.04.001
http://www.ncbi.nlm.nih.gov/pubmed/28467883?tool=bestpractice.com
Primary options
carvedilol: 3.125 mg orally (immediate-release) twice daily initially, increase according to response, maximum 50 mg/day (body weight ≤85 kg) or 100 mg/day (body weight >85 kg)
Secondary options
metoprolol: 12.5 to 200 mg orally (extended-release) once daily
OR
bisoprolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
OR
nebivolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
aldosterone antagonist
Treatment recommended for ALL patients in selected patient group
Aldosterone antagonists (e.g., spironolactone, eplerenone) are recommended in patients with HF with reduced ejection fraction (HFrEF) to reduce mortality and morbidity.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Spironolactone and eplerenone can both cause hyperkalaemia, and precautions should be taken to minimise the risk; regular monitoring of serum potassium and renal function is recommended.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com In the EPHESUS trial, the addition of eplerenone to standard care did not increase the risk of hyperkalaemia when potassium was regularly monitored.[149]Pitt B, Bakris G, Ruilope LM, et al; EPHESUS Investigators. Serum potassium and clinical outcomes in the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS). Circulation. 2008 Oct 14;118(16):1643-50. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.108.778811 http://www.ncbi.nlm.nih.gov/pubmed/18824643?tool=bestpractice.com US guidelines advise that if serum potassium cannot be maintained below 5.5 mEq/L, the aldosterone antagonist should be discontinued.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
Primary options
spironolactone: 12.5 to 50 mg orally once daily
OR
eplerenone: 25-50 mg orally once daily
sodium-glucose cotransporter-2 (SGLT2) inhibitor
Treatment recommended for ALL patients in selected patient group
An SGLT2 inhibitor (e.g., dapagliflozin, empagliflozin) is recommended, in addition to optimal medical therapy with a renin-angiotensin system inhibitor, a beta-blocker, and an aldosterone antagonist, for patients with HF with reduced ejection fraction (HFrEF) regardless of diabetes status.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [150]Verma S, Dhingra NK, Butler J, et al; EMPEROR-Reduced trial committees and investigators. Empagliflozin in the treatment of heart failure with reduced ejection fraction in addition to background therapies and therapeutic combinations (EMPEROR-Reduced): a post-hoc analysis of a randomised, double-blind trial. Lancet Diabetes Endocrinol. 2022 Jan;10(1):35-45. http://www.ncbi.nlm.nih.gov/pubmed/34861154?tool=bestpractice.com [151]National Institute for Health and Care Excellence. Empagliflozin for treating chronic heart failure with reduced ejection fraction. Mar 2022 [internet publication]. https://www.nice.org.uk/guidance/ta773 [152]National Institute for Health and Care Excellence. Dapagliflozin for treating chronic heart failure with reduced ejection fraction. Feb 2021 [internet publication]. https://www.nice.org.uk/guidance/ta679
Primary options
dapagliflozin: 10 mg orally once daily
OR
empagliflozin: 10 mg orally once daily
lifestyle changes
Treatment recommended for ALL patients in selected patient group
The success of pharmacological therapy is strongly related to, and greatly enhanced by, encouraging the patient and his/her family to participate in various complementary non-pharmacological management strategies. These mainly include lifestyle changes, dietary and nutritional modifications, exercise training, and health maintenance.[123]Aggarwal M, Bozkurt B, Panjrath G, et al. Lifestyle modifications for preventing and treating heart failure. J Am Coll Cardiol. 2018 Nov 6;72(19):2391-405. https://www.jacc.org/doi/10.1016/j.jacc.2018.08.2160 http://www.ncbi.nlm.nih.gov/pubmed/30384895?tool=bestpractice.com
In patients with HF, cardiac rehabilitation and exercise training improves functional status, exercise tolerance, and quality of life, with decreased morbidity and mortality.[124]Ades PA, Keteyian SJ, Balady GJ, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. JACC Heart Fail. 2013 Dec;1(6):540-7.
https://www.jacc.org/doi/10.1016/j.jchf.2013.09.002
http://www.ncbi.nlm.nih.gov/pubmed/24622007?tool=bestpractice.com
[125]Long L, Mordi IR, Bridges C, et al. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev. 2019 Jan 29;1(1):CD003331.
https://www.doi.org/10.1002/14651858.CD003331.pub5
http://www.ncbi.nlm.nih.gov/pubmed/30695817?tool=bestpractice.com
[126]Chen Z, Li M, Yin C, et al. Effects of cardiac rehabilitation on elderly patients with chronic heart failure: a meta-analysis and systematic review. PLoS One. 2022;17(8):e0273251.
https://www.doi.org/10.1371/journal.pone.0273251
http://www.ncbi.nlm.nih.gov/pubmed/36006944?tool=bestpractice.com
[127]Tegegne TK, Rawstorn JC, Nourse RA, et al. Effects of exercise-based cardiac rehabilitation delivery modes on exercise capacity and health-related quality of life in heart failure: a systematic review and network meta-analysis. Open Heart. 2022 Jun;9(1):e001949.
https://www.doi.org/10.1136/openhrt-2021-001949
http://www.ncbi.nlm.nih.gov/pubmed/35680170?tool=bestpractice.com
[128]Dallas K, Dinas PC, Chryssanthopoulos C, et al. The effects of exercise on VO(2)peak, quality of life and hospitalization in heart failure patients: a systematic review with meta-analyses. Eur J Sport Sci. 2021 Sep;21(9):1337-50.
https://www.doi.org/10.1080/17461391.2020.1846081
http://www.ncbi.nlm.nih.gov/pubmed/33138729?tool=bestpractice.com
[129]Bjarnason-Wehrens B, Nebel R, Jensen K, et al. Exercise-based cardiac rehabilitation in patients with reduced left ventricular ejection fraction: the Cardiac Rehabilitation Outcome Study in Heart Failure (CROS-HF): a systematic review and meta-analysis. Eur J Prev Cardiol. 2020 Jun;27(9):929-52.
https://www.doi.org/10.1177/2047487319854140
http://www.ncbi.nlm.nih.gov/pubmed/31177833?tool=bestpractice.com
[130]Gomes-Neto M, Durães AR, Conceição LSR, et al. Effect of combined aerobic and resistance training on peak oxygen consumption, muscle strength and health-related quality of life in patients with heart failure with reduced left ventricular ejection fraction: a systematic review and meta-analysis. Int J Cardiol. 2019 Oct 15;293:165-75.
http://www.ncbi.nlm.nih.gov/pubmed/31345646?tool=bestpractice.com
[131]Taylor RS, Dalal HM, Zwisler AD. Cardiac rehabilitation for heart failure: 'Cinderella' or evidence-based pillar of care? Eur Heart J. 2023 May 1;44(17):1511-8.
https://www.doi.org/10.1093/eurheartj/ehad118
http://www.ncbi.nlm.nih.gov/pubmed/36905176?tool=bestpractice.com
[132]Paluch AE, Boyer WR, Franklin BA, et al. Resistance exercise training in individuals with and without cardiovascular disease: 2023 update: a scientific statement from the American Heart Association. Circulation. 2024 Jan 16;149(3):e217-e231.
https://www.doi.org/10.1161/CIR.0000000000001189
http://www.ncbi.nlm.nih.gov/pubmed/38059362?tool=bestpractice.com
[ ]
What are the effects of exercise‐based cardiac rehabilitation for adults with heart failure?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2436/fullShow me the answer Patients with stable HF who are able to participate are therefore encouraged to do regular exercise and enrol in a cardiac rehabilitation programme.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
[9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726.
https://academic.oup.com/eurheartj/article/42/36/3599/6358045
http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
[
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What are the benefits and harms of disease management interventions for adults with heart failure?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2462/fullShow me the answer There is developing evidence to support home-based cardiac rehabilitation alternatives to centre-based programmes.[133]Thomas RJ, Beatty AL, Beckie TM, et al. Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation. 2019 Jul 2;140(1):e69-e89.
https://www.doi.org/10.1161/CIR.0000000000000663
http://www.ncbi.nlm.nih.gov/pubmed/31082266?tool=bestpractice.com
[134]McDonagh ST, Dalal H, Moore S, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2023 Oct 27;10(10):CD007130.
https://www.doi.org/10.1002/14651858.CD007130.pub5
http://www.ncbi.nlm.nih.gov/pubmed/37888805?tool=bestpractice.com
[135]Golbus JR, Lopez-Jimenez F, Barac A, et al. Digital technologies in cardiac rehabilitation: a science advisory from the American Heart Association. Circulation. 2023 Jul 4;148(1):95-107.
https://www.doi.org/10.1161/CIR.0000000000001150
http://www.ncbi.nlm.nih.gov/pubmed/37272365?tool=bestpractice.com
Dietary sodium intake is an easily modifiable factor that complements pharmacological therapy for HF. There is limited evidence for sodium restriction in patients with HF; however, guidelines recommend that excessive sodium intake should be avoided.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication]. https://www.nice.org.uk/guidance/ng106 [136]Ezekowitz JA, Colin-Ramirez E, Ross H, et al; SODIUM-HF Investigators. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial. Lancet. 2022 Apr 9;399(10333):1391-400. http://www.ncbi.nlm.nih.gov/pubmed/35381194?tool=bestpractice.com
Patients with HF need continuous and close monitoring of their health. A variety of programmes have been shown to decrease morbidity and re-hospitalisation in this context, including home nursing, telephone advice/triage, telemedicine services, and specialised HF clinic-based care.[252]Zwisler AD, Soja AM, Rasmussen S, et al. Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial. Am Heart J. 2008 Jun;155(6):1106-13.
http://www.ncbi.nlm.nih.gov/pubmed/18513526?tool=bestpractice.com
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What are the benefits and harms of structured telephone support or non-invasive telemonitoring in patients with heart failure?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1059/fullShow me the answer
diuretic
Additional treatment recommended for SOME patients in selected patient group
All patients with symptoms and signs of congestion should receive a diuretic, irrespective of the left ventricular ejection fraction (LVEF). In patients with reduced LVEF, diuretics should be used in combination with other guideline-directed medical therapy (e.g., a renin-angiotensin system inhibitor, beta-blocker, and aldosterone antagonist).[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Loop diuretics used for the treatment of HF and congestion include furosemide, bumetanide, and torasemide. The most commonly used agent appears to be furosemide, but some patients may respond more favourably to another loop diuretic. In resistant cases, loop diuretics should be combined with a thiazide diuretic (e.g., hydrochlorothiazide) or a thiazide-like diuretic (e.g., metolazone, indapamide). Careful monitoring of renal function and electrolytes is essential in these patients.
The minimum dose of diuretic should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight. In patients with stable congestive HF, loop diuretics are the preferred agent. In patients with comorbid hypertension and only mild fluid retention, a thiazide diuretic may be considered.
Diuretics produce symptomatic benefits more rapidly than any other drug for HF. They can relieve pulmonary and peripheral oedema within hours or days. Few patients with HF and fluid retention can maintain sodium balance without the use of diuretic drugs.[253]Richardson A, Bayliss J, Scriven AJ, et al. Double-blind comparison of captopril alone against frusemide plus amiloride in mild heart failure. Lancet. 1987 Sep 26;2(8561):709-11. http://www.ncbi.nlm.nih.gov/pubmed/2888942?tool=bestpractice.com
In intermediate-term studies, diuretics have been shown to improve cardiac function, symptoms, and exercise tolerance in patients with HF.[253]Richardson A, Bayliss J, Scriven AJ, et al. Double-blind comparison of captopril alone against frusemide plus amiloride in mild heart failure. Lancet. 1987 Sep 26;2(8561):709-11. http://www.ncbi.nlm.nih.gov/pubmed/2888942?tool=bestpractice.com [254]Wilson JR, Reichek N, Dunkman WB, et al. Effect of diuresis on the performance of the failing left ventricle in man. Am J Med. 1981 Feb;70(2):234-9. http://www.ncbi.nlm.nih.gov/pubmed/7468610?tool=bestpractice.com There have been no long-term studies of diuretic therapy in HF, and thus their effects on morbidity and mortality are not known.
Primary options
furosemide: 20-80 mg/dose orally initially, increase by 20-40 mg/dose increments every 6-8 hours according to response, maximum 600 mg/day
OR
bumetanide: 0.5 to 2 mg orally once daily initially, may repeat every 4-5 hours until response, maximum 10 mg/day given in 1-2 divided doses
OR
torasemide: 5-20 mg orally once daily initially, increase according to response, maximum 40 mg/day
OR
hydrochlorothiazide: 25 mg orally once daily, increase according to response, maximum 200 mg/day
OR
indapamide: 2.5 to 5 mg orally once daily
OR
metolazone: 5-20 mg orally once daily
isosorbide dinitrate/hydralazine
Additional treatment recommended for SOME patients in selected patient group
The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced left ventricular ejection fraction (LVEF) who have persistent symptoms despite receiving optimal medical therapy and has demonstrated benefit in black patients with HF.[199]Carson P, Ziesche S, Johnson G, et al; Vasodilator-Heart Failure Trial Study Group. Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. J Card Fail. 1999 Sep;5(3):178-87. http://www.ncbi.nlm.nih.gov/pubmed/10496190?tool=bestpractice.com [200]Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med. 2004 Nov 11;351(20):2049-57. https://www.nejm.org/doi/full/10.1056/NEJMoa042934 http://www.ncbi.nlm.nih.gov/pubmed/15533851?tool=bestpractice.com
Guidelines recommend the combination of hydralazine and isosorbide dinitrate for black patients with New York Heart Association (NYHA) class III to IV HF with reduced ejection fraction (HFrEF) receiving optimal medical therapy, to improve symptoms and reduce morbidity and mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication]. https://www.nice.org.uk/guidance/ng106
The combined use of hydralazine and isosorbide dinitrate may also be considered as a therapeutic option in symptomatic patients who cannot receive renin-angiotensin system inhibitors because of intolerance or contraindications; consultation with a specialist is advised.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
A combination formulation containing hydralazine and isosorbide dinitrate is available in some countries, and is approved specifically for self-identified black patients with chronic HF.
Primary options
isosorbide dinitrate: 20-40 mg orally (immediate-release) three times daily
and
hydralazine: 25-100 mg orally three times daily
OR
isosorbide dinitrate/hydralazine: 20 mg (isosorbide dinitrate)/37.5 mg (hydralazine) orally three times daily initially, increase according to response, maximum 40 mg (isosorbide dinitrate)/75 mg (hydralazine) three times daily
ivabradine
Additional treatment recommended for SOME patients in selected patient group
Ivabradine can be considered for patients with stable, symptomatic chronic HF with left ventricular ejection fraction (LVEF) ≤35%, who are in sinus rhythm with a resting heart rate ≥70 beats per minute (UK National Institute for Health and Care Excellence [NICE] guidelines advise ≥75 beats per minute) and are either on a maximum dose of beta-blockers or have a contraindication to beta-blockers.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication]. https://www.nice.org.uk/guidance/ng106
Its use should be initiated by a specialist cardiologist and only after a stabilisation period of 4 weeks on optimised standard therapy.[255]National Institute for Health and Care Excellence. Ivabradine for treating chronic heart failure. Nov 2012 [internet publication]. https://www.nice.org.uk/guidance/ta267 Patients should be on a maximally tolerated dose of a beta-blocker prior to initiation.
Primary options
ivabradine: 2.5 to 5 mg orally twice daily for 2 weeks initially, adjust dose according to response and heart rate, maximum 15 mg/day
digoxin
Additional treatment recommended for SOME patients in selected patient group
Digoxin can be beneficial in patients with reduced left ventricular ejection fraction (LVEF), especially those with atrial fibrillation.
When added to ACE inhibitors, beta-blockers, and diuretics, digoxin can reduce symptoms, prevent hospitalisation, control rhythm, and enhance exercise tolerance.[203]Roy D, Talajic M, Nattel S, et al; Atrial Fibrillation and Congestive Heart Failure Investigators. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med. 2008 Jun 19;358(25):2667-77. https://www.nejm.org/doi/full/10.1056/NEJMoa0708789 http://www.ncbi.nlm.nih.gov/pubmed/18565859?tool=bestpractice.com
Digoxin reduces the composite end point of mortality or hospitalisations in ambulatory patients with chronic HF with New York Heart Association (NYHA) class III or IV symptoms, LVEF <25%, or cardiothoracic ratio of >55% and should be considered in these patients.[204]Gheorghiade M, Patel K, Filippatos G, et al. Effect of oral digoxin in high-risk heart failure patients: a pre-specified subgroup analysis of the DIG trial. Eur J Heart Fail. 2013 May;15(5):551-9. https://onlinelibrary.wiley.com/doi/10.1093/eurjhf/hft010 http://www.ncbi.nlm.nih.gov/pubmed/23355060?tool=bestpractice.com
Digoxin reduces the composite end point of mortality or hospitalisations, but does not reduce all-cause mortality.[204]Gheorghiade M, Patel K, Filippatos G, et al. Effect of oral digoxin in high-risk heart failure patients: a pre-specified subgroup analysis of the DIG trial. Eur J Heart Fail. 2013 May;15(5):551-9. https://onlinelibrary.wiley.com/doi/10.1093/eurjhf/hft010 http://www.ncbi.nlm.nih.gov/pubmed/23355060?tool=bestpractice.com Digoxin should be used cautiously with plasma level monitoring; one meta-analysis suggests that digoxin use in patients with HF is associated with a higher risk of all-cause mortality.[205]Vamos M, Erath JW, Hohnloser SH, et al. Digoxin-associated mortality: a systematic review and meta-analysis of the literature. Eur Heart J. 2015 Jul 21;36(28):1831-8. https://academic.oup.com/eurheartj/article/36/28/1831/2398087 http://www.ncbi.nlm.nih.gov/pubmed/25939649?tool=bestpractice.com
Overt digitalis toxicity is commonly associated with serum digoxin levels >2.6 nanomols/L (2 nanograms/mL). However, toxicity may occur with lower levels, especially if hypokalaemia, hypomagnesaemia, or hypothyroidism co-exists.[256]Fogelman AM, La Mont JT, Finkelstein S, et al. Fallibility of plasma-digoxin in differentiating toxic from non-toxic patients. Lancet. 1971 Oct 2;2(7727):727-9. http://www.ncbi.nlm.nih.gov/pubmed/4106228?tool=bestpractice.com [257]Ingelfinger JA, Goldman P. The serum digitalis concentration - does it diagnose digitalis toxicity? N Engl J Med. 1976 Apr 15;294(16):867-70. http://www.ncbi.nlm.nih.gov/pubmed/1250314?tool=bestpractice.com
Lower doses should be used initially if the patient is over 70 years old, has impaired renal function, or has a low lean body mass.[258]Jelliffe RW, Brooker G. A nomogram for digoxin therapy. Am J Med. 1974 Jul;57(1):63-8. http://www.ncbi.nlm.nih.gov/pubmed/4600984?tool=bestpractice.com Higher doses are rarely used or needed. There is no reason to use loading doses of digoxin to initiate therapy.
Primary options
digoxin: 62.5 to 250 micrograms orally once daily
vericiguat
Additional treatment recommended for SOME patients in selected patient group
Vericiguat, an oral soluble guanylate cyclase stimulator, may be considered in selected high-risk patients with HF with reduced ejection fraction (HFrEF) and New York Heart Association (NYHA) class II to IV symptoms, who have had worsening HF despite treatment with an ACE inhibitor or angiotensin-receptor neprilysin inhibitor, a beta-blocker, and an aldosterone antagonist to reduce the risk of cardiovascular mortality or HF hospitalisation.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Primary options
vericiguat: 2.5 mg orally once daily initially, increase according to response, maximum 10 mg/day
omega-3 polyunsaturated fatty acid supplementation
Additional treatment recommended for SOME patients in selected patient group
In patients with New York Heart Association (NYHA) class II to IV symptoms and HF who are already on guideline-directed medical therapy (GDMT) and other evidence-based therapies, omega-3 polyunsaturated fatty acid supplementation may be reasonable to use as adjunctive therapy to reduce mortality and cardiovascular hospitalisations.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
vasopressin antagonist
Additional treatment recommended for SOME patients in selected patient group
Considered for patients with symptomatic or severe hyponatraemia (<130 mmol/L) and persistent congestion despite standard therapy, to correct hyponatraemia and related symptoms.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Primary options
tolvaptan: 15 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day for up to 30 days
implantable device therapy
Additional treatment recommended for SOME patients in selected patient group
Device therapy with implantable cardioverter-defibrillator (ICD) or cardiac re-synchronisation therapy (CRT) should be considered in selected patients to reduce mortality and morbidity.
ICDs are recommended to reduce sudden cardiac death and mortality in selected patients when there is a reasonable expectation of meaningful survival for at least 1 year, left ventricular ejection fraction (LVEF) is ≤35% (New York Heart Association [NYHA] class II-III) or ≤30% (NYHA class I) despite guideline-directed medical therapy (GDMT), and the patient is at least 40 days post-myocardial infarction.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com Specific indications vary in different countries, and guidelines should be consulted for full details.
CRT is recommended in selected patients to reduce morbidity and mortality and improve symptoms. It can be used as a pacemaker alone (CRT-P) or combined with an ICD (CRT-D). Broadly, CRT is recommended in patients with LVEF ≤35% despite GDMT, who are in sinus rhythm, with a left bundle branch block (LBBB) and QRS ≥150 ms.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [233]Chung MK, Patton KK, Lau CP, et al. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm. 2023 Sep;20(9):e17-e91. https://www.doi.org/10.1016/j.hrthm.2023.03.1538 http://www.ncbi.nlm.nih.gov/pubmed/37283271?tool=bestpractice.com CRT should also be considered in those with LBBB and QRS ≥120-149 ms or those with a non-LBBB pattern and QRS ≥150 ms. Again, specific indications vary in different countries, and guidelines should be consulted for full details.
supportive measures +/- nephrology referral
Additional treatment recommended for SOME patients in selected patient group
Some drugs used in the management of heart failure should be used with caution in patients with renal impairment and a dose adjustment may be required. Some drugs may also be contraindicated in patients with renal impairment. Check your local drug information source for more information. Initiation of GDMT for HF with an ACE inhibitor, angiotensin-II receptor antagonist, ARNi, or SGLT2 inhibitor may result in an initial rise in serum creatinine and a drop in estimated glomerular filtration rate (eGFR), but this change is generally transient and should not necessarily be a reason for discontinuation.[9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [246]Ryan DK, Banerjee D, Jouhra F. Management of heart failure in patients with chronic kidney disease. Eur Cardiol. 2022 Feb;17:e17. https://www.doi.org/10.15420/ecr.2021.33 http://www.ncbi.nlm.nih.gov/pubmed/35990402?tool=bestpractice.com
An increase in serum creatinine of <50% above baseline, up to 265 micromols/L, or a decrease in eGFR of <10% from baseline, as long as eGFR is >25 mL/minute/1.73 m², may be considered as acceptable. If the serum creatinine increases to >265 micromols/L, the renal insufficiency can severely limit the efficacy and enhance the toxicity of established treatments.[247]Philbin EF, Santella RN, Rocco TA Jr. Angiotensin-converting enzyme inhibitor use in older patients with heart failure and renal dysfunction. J Am Geriatr Soc. 1999 Mar;47(3):302-8. http://www.ncbi.nlm.nih.gov/pubmed/10078892?tool=bestpractice.com [248]Risler T, Schwab A, Kramer B, et al. Comparative pharmacokinetics and pharmacodynamics of loop diuretics in renal failure. Cardiology. 1994;84 (Suppl 2):155-61. http://www.ncbi.nlm.nih.gov/pubmed/7954539?tool=bestpractice.com
Aldosterone antagonists should be used with caution in patients with CKD and hyperkalaemia. US guidelines advise that they are only initiated in patients with eGFR >30 mL/minute/1.73 m² and serum potassium <5.0 mEq/L.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
Consultation with a nephrology specialist should be considered.
intravenous iron supplementation
Additional treatment recommended for SOME patients in selected patient group
Patients with iron deficiency anaemia and transferrin saturation <20% should receive intravenous iron supplementation.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [143]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://www.doi.org/10.1093/eurheartj/ehad195 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com
For more details on management, see Iron-deficiency anaemia (Treatment algorithm).
surgical revascularisation
Additional treatment recommended for SOME patients in selected patient group
In selected patients with CAD and HF with LVEF ≤35% and suitable coronary anatomy, surgical revascularisation in addition to GDMT may improve symptoms, cardiovascular hospitalisations, and long-term all-cause mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
For more details, see Chronic coronary disease (Treatment algorithm).
multidisciplinary team management
Additional treatment recommended for SOME patients in selected patient group
Aortic stenosis, aortic regurgitation, mitral regurgitation, and tricuspid regurgitation are associated with adverse outcomes in patients with HF and timely management (by a multidisciplinary team with expertise in HF and VHD) is important to prevent worsening of HF.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
For more details, see Aortic stenosis (Treatment algorithm), Aortic regurgitation (Treatment algorithm), Mitral regurgitation (Treatment algorithm), Tricuspid regurgitation (Treatment algorithm).
rate and rhythm control + anticoagulation
Additional treatment recommended for SOME patients in selected patient group
AF and HF may cause or exacerbate each other and the relationship is complex.
HF therapies should be optimised. Beta-blockers may be used in HFrEF whether or not the patient has associated AF.[145]Kotecha D, Flather MD, Altman DG, et al. Heart rate and rhythm and the benefit of beta-blockers in patients with heart failure. J Am Coll Cardiol. 2017 Jun 20;69(24):2885-96. https://www.jacc.org/doi/10.1016/j.jacc.2017.04.001 http://www.ncbi.nlm.nih.gov/pubmed/28467883?tool=bestpractice.com [146]Cadrin-Tourigny J, Shohoudi A, Roy D, et al. Decreased mortality with beta-blockers in patients with heart failure and coexisting atrial fibrillation: an AF-CHF substudy. JACC Heart Fail. 2017 Feb;5(2):99-106. https://www.jacc.org/doi/10.1016/j.jchf.2016.10.015 http://www.ncbi.nlm.nih.gov/pubmed/28089316?tool=bestpractice.com
Treatment of AF involves correction of the abnormal rate/rhythm, along with anticoagulation. Options for rate and rhythm control are determined by the presence of HF and extent of LV dysfunction.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
For details of management of patients with AF and HF, see Established atrial fibrillation (Treatment algorithm).
treatment of hyperglycaemia
Treatment recommended for ALL patients in selected patient group
Treatment of HFrEF is similar in patients with and without diabetes.
SGLT2 inhibitors are recommended as first-line treatment of hyperglycaemia in patients with type 2 diabetes and HF to reduce HF-related morbidity and mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
See Overview of diabetes.
finerenone
Additional treatment recommended for SOME patients in selected patient group
Finerenone, a non-steroidal mineralocorticoid receptor antagonist, is recommended for the prevention of HF hospitalisation in patients with CKD and type 2 diabetes.[143]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://www.doi.org/10.1093/eurheartj/ehad195 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com
Primary options
finerenone: 20 mg orally once daily
More finerenoneA dose adjustment may be required in patients with renal impairment. Adjust dose according to serum potassium levels and eGFR.
weight loss programme
Additional treatment recommended for SOME patients in selected patient group
Treatment of obesity in patients with HFrEF may improve symptoms, functional status, quality of life, and comorbidities.[38]Powell-Wiley TM, Poirier P, Burke LE, et al. Obesity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2021 May 25;143(21):e984-1010. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000973 http://www.ncbi.nlm.nih.gov/pubmed/33882682?tool=bestpractice.com In advanced HF, weight loss in patients with obesity may allow the option of heart transplantation (obesity may be a contraindication).
lipid-lowering therapy
Additional treatment recommended for SOME patients in selected patient group
All patients with HFrEF and hyperlipidaemia will need lifestyle modifications and most will also require treatment with a statin possibly with additional non-statin lipid-lowering therapy.
For details of management of HF with hypercholesterolaemia, see Hypercholesterolaemia (Treatment algorithm).
referral to endocrinologist
Additional treatment recommended for SOME patients in selected patient group
Both hypo- and hyperthyroidism are associated with HF and assessment of thyroid function is recommended. Thyroid disorders are treated as per endocrinology guidelines; referral to endocrinologist should be considered.
assessment and treatment of sleep apnoea
Additional treatment recommended for SOME patients in selected patient group
Patients with HF and daytime sleepiness may have sleep studies to assess for obstructive sleep apnoea and central sleep apnoea.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
In patients with HF and obstructive sleep apnoea, continuous positive airway pressure is recommended to improve sleep quality and reduce daytime sleepiness; however, it does not seem to reduce mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Adaptive servo-ventilation has been associated with increased mortality and is not recommended for the treatment of central sleep apnoea in patients with HFrEF.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
See Obstructive sleep apnoea in adults (Treatment algorithm) and Central sleep apnoea (Treatment algorithm).
interventions to improve HF self-care
Treatment recommended for ALL patients in selected patient group
Depression is common in patients with HF and is associated with a reduced quality of life and increased mortality.
Treatment with conventional therapies (e.g., antidepressants) does not seem to directly improve these outcomes. However, interventions that focus on improving HF self-care (e.g., psychotherapy, nurse-led support) may reduce hospitalisation and mortality in patients with moderate or severe depression.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
multidisciplinary team management
Treatment recommended for ALL patients in selected patient group
Patients who develop HF and/or depressed LV systolic function secondary to cancer therapy should be treated with guideline directed-medical therapy (GDMT). Generally, GDMT should not be discontinued unless there are specific and compelling reasons to hold these medicines and this should be managed by a multidisciplinary team.
Before starting any cardiotoxic cancer therapy baseline cardiac function should be measured and ongoing monitoring after completion of a course of chemotherapy may be helpful for risk stratification.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
symptomatic HF: LVEF 41% to 49%
sodium-glucose cotransporter-2 (SGLT2) inhibitor
SGLT2 inhibitors are now recommended for patients with HFmrEF, to reduce HF hospitalisations and cardiovascular mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [143]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://www.doi.org/10.1093/eurheartj/ehad195 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com [153]National Institute for Helath and Care Excellence. Dapagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. June 2023 [internet publication]. https://www.nice.org.uk/guidance/ta902 [154]National Institute for Health and Care Excellence. Empagliflozin for treating chronic heart failure with preserved or mildly reduced ejection fraction. November 2023 [internet publication]. https://www.nice.org.uk/guidance/ta929
Primary options
dapagliflozin: 10 mg orally once daily
OR
empagliflozin: 10 mg orally once daily
lifestyle changes
Treatment recommended for ALL patients in selected patient group
The success of pharmacological therapy is strongly related to, and greatly enhanced by, encouraging the patient and his/her family to participate in various complementary non-pharmacological management strategies. These mainly include lifestyle changes, dietary and nutritional modifications, exercise training, and health maintenance.[123]Aggarwal M, Bozkurt B, Panjrath G, et al. Lifestyle modifications for preventing and treating heart failure. J Am Coll Cardiol. 2018 Nov 6;72(19):2391-405. https://www.jacc.org/doi/10.1016/j.jacc.2018.08.2160 http://www.ncbi.nlm.nih.gov/pubmed/30384895?tool=bestpractice.com
In patients with HF, cardiac rehabilitation and exercise training improves functional status, exercise tolerance, and quality of life, with decreased morbidity and mortality.[124]Ades PA, Keteyian SJ, Balady GJ, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. JACC Heart Fail. 2013 Dec;1(6):540-7.
https://www.jacc.org/doi/10.1016/j.jchf.2013.09.002
http://www.ncbi.nlm.nih.gov/pubmed/24622007?tool=bestpractice.com
[125]Long L, Mordi IR, Bridges C, et al. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev. 2019 Jan 29;1(1):CD003331.
https://www.doi.org/10.1002/14651858.CD003331.pub5
http://www.ncbi.nlm.nih.gov/pubmed/30695817?tool=bestpractice.com
[126]Chen Z, Li M, Yin C, et al. Effects of cardiac rehabilitation on elderly patients with chronic heart failure: a meta-analysis and systematic review. PLoS One. 2022;17(8):e0273251.
https://www.doi.org/10.1371/journal.pone.0273251
http://www.ncbi.nlm.nih.gov/pubmed/36006944?tool=bestpractice.com
[127]Tegegne TK, Rawstorn JC, Nourse RA, et al. Effects of exercise-based cardiac rehabilitation delivery modes on exercise capacity and health-related quality of life in heart failure: a systematic review and network meta-analysis. Open Heart. 2022 Jun;9(1):e001949.
https://www.doi.org/10.1136/openhrt-2021-001949
http://www.ncbi.nlm.nih.gov/pubmed/35680170?tool=bestpractice.com
[128]Dallas K, Dinas PC, Chryssanthopoulos C, et al. The effects of exercise on VO(2)peak, quality of life and hospitalization in heart failure patients: a systematic review with meta-analyses. Eur J Sport Sci. 2021 Sep;21(9):1337-50.
https://www.doi.org/10.1080/17461391.2020.1846081
http://www.ncbi.nlm.nih.gov/pubmed/33138729?tool=bestpractice.com
[129]Bjarnason-Wehrens B, Nebel R, Jensen K, et al. Exercise-based cardiac rehabilitation in patients with reduced left ventricular ejection fraction: the Cardiac Rehabilitation Outcome Study in Heart Failure (CROS-HF): a systematic review and meta-analysis. Eur J Prev Cardiol. 2020 Jun;27(9):929-52.
https://www.doi.org/10.1177/2047487319854140
http://www.ncbi.nlm.nih.gov/pubmed/31177833?tool=bestpractice.com
[130]Gomes-Neto M, Durães AR, Conceição LSR, et al. Effect of combined aerobic and resistance training on peak oxygen consumption, muscle strength and health-related quality of life in patients with heart failure with reduced left ventricular ejection fraction: a systematic review and meta-analysis. Int J Cardiol. 2019 Oct 15;293:165-75.
http://www.ncbi.nlm.nih.gov/pubmed/31345646?tool=bestpractice.com
[131]Taylor RS, Dalal HM, Zwisler AD. Cardiac rehabilitation for heart failure: 'Cinderella' or evidence-based pillar of care? Eur Heart J. 2023 May 1;44(17):1511-8.
https://www.doi.org/10.1093/eurheartj/ehad118
http://www.ncbi.nlm.nih.gov/pubmed/36905176?tool=bestpractice.com
[132]Paluch AE, Boyer WR, Franklin BA, et al. Resistance exercise training in individuals with and without cardiovascular disease: 2023 update: a scientific statement from the American Heart Association. Circulation. 2024 Jan 16;149(3):e217-e231.
https://www.doi.org/10.1161/CIR.0000000000001189
http://www.ncbi.nlm.nih.gov/pubmed/38059362?tool=bestpractice.com
[ ]
What are the effects of exercise‐based cardiac rehabilitation for adults with heart failure?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2436/fullShow me the answer Patients with stable HF who are able to participate are therefore encouraged to do regular exercise and enrol in a cardiac rehabilitation programme.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063
http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com
[9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726.
https://academic.oup.com/eurheartj/article/42/36/3599/6358045
http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
[
]
What are the benefits and harms of disease management interventions for adults with heart failure?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2462/fullShow me the answer There is developing evidence to support home-based cardiac rehabilitation alternatives to centre-based programmes.[133]Thomas RJ, Beatty AL, Beckie TM, et al. Home-based cardiac rehabilitation: a scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation. 2019 Jul 2;140(1):e69-e89.
https://www.doi.org/10.1161/CIR.0000000000000663
http://www.ncbi.nlm.nih.gov/pubmed/31082266?tool=bestpractice.com
[134]McDonagh ST, Dalal H, Moore S, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2023 Oct 27;10(10):CD007130.
https://www.doi.org/10.1002/14651858.CD007130.pub5
http://www.ncbi.nlm.nih.gov/pubmed/37888805?tool=bestpractice.com
[135]Golbus JR, Lopez-Jimenez F, Barac A, et al. Digital technologies in cardiac rehabilitation: a science advisory from the American Heart Association. Circulation. 2023 Jul 4;148(1):95-107.
https://www.doi.org/10.1161/CIR.0000000000001150
http://www.ncbi.nlm.nih.gov/pubmed/37272365?tool=bestpractice.com
Dietary sodium intake is an easily modifiable factor that complements pharmacological therapy for HF. There is limited evidence for sodium restriction in patients with HF; however, guidelines recommend that excessive sodium intake should be avoided.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [122]National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. Sep 2018 [internet publication]. https://www.nice.org.uk/guidance/ng106 [136]Ezekowitz JA, Colin-Ramirez E, Ross H, et al; SODIUM-HF Investigators. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial. Lancet. 2022 Apr 9;399(10333):1391-400. http://www.ncbi.nlm.nih.gov/pubmed/35381194?tool=bestpractice.com
Patients with HF need continuous and close monitoring of their health. A variety of programmes have been shown to decrease morbidity and re-hospitalisation in this context, including home nursing, telephone advice/triage, telemedicine services, and specialised HF clinic-based care.[252]Zwisler AD, Soja AM, Rasmussen S, et al. Hospital-based comprehensive cardiac rehabilitation versus usual care among patients with congestive heart failure, ischemic heart disease, or high risk of ischemic heart disease: 12-month results of a randomized clinical trial. Am Heart J. 2008 Jun;155(6):1106-13.
http://www.ncbi.nlm.nih.gov/pubmed/18513526?tool=bestpractice.com
[ ]
What are the benefits and harms of structured telephone support or non-invasive telemonitoring in patients with heart failure?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.1059/fullShow me the answer
diuretic
Additional treatment recommended for SOME patients in selected patient group
All patients with symptoms and signs of congestion should receive a diuretic, irrespective of the left ventricular ejection fraction (LVEF).
Loop diuretics used for the treatment of HF and congestion include furosemide, bumetanide, and torasemide. The most commonly used agent appears to be furosemide, but some patients may respond more favourably to another loop diuretic. In resistant cases, loop diuretics should be combined with a thiazide diuretic (e.g., hydrochlorothiazide) or a thiazide-like diuretic (e.g., metolazone, indapamide). Careful monitoring of renal function and electrolytes is essential in these patients.
The minimum dose of diuretic should be used to relieve congestion, keep the patient asymptomatic, and maintain a dry weight. In patients with stable congestive HF, loop diuretics are the preferred agent. In patients with comorbid hypertension and only mild fluid retention, a thiazide diuretic may be considered.
Diuretics produce symptomatic benefits more rapidly than any other drug for HF. They can relieve pulmonary and peripheral oedema within hours or days. Few patients with HF and fluid retention can maintain sodium balance without the use of diuretic drugs.[253]Richardson A, Bayliss J, Scriven AJ, et al. Double-blind comparison of captopril alone against frusemide plus amiloride in mild heart failure. Lancet. 1987 Sep 26;2(8561):709-11. http://www.ncbi.nlm.nih.gov/pubmed/2888942?tool=bestpractice.com
In intermediate-term studies, diuretics have been shown to improve cardiac function, symptoms, and exercise tolerance in patients with HF.[253]Richardson A, Bayliss J, Scriven AJ, et al. Double-blind comparison of captopril alone against frusemide plus amiloride in mild heart failure. Lancet. 1987 Sep 26;2(8561):709-11. http://www.ncbi.nlm.nih.gov/pubmed/2888942?tool=bestpractice.com [254]Wilson JR, Reichek N, Dunkman WB, et al. Effect of diuresis on the performance of the failing left ventricle in man. Am J Med. 1981 Feb;70(2):234-9. http://www.ncbi.nlm.nih.gov/pubmed/7468610?tool=bestpractice.com There have been no long-term studies of diuretic therapy in HF, and thus their effects on morbidity and mortality are not known.
Primary options
furosemide: 20-80 mg/dose orally initially, increase by 20-40 mg/dose increments every 6-8 hours according to response, maximum 600 mg/day
OR
bumetanide: 0.5 to 2 mg orally once daily initially, may repeat every 4-5 hours until response, maximum 10 mg/day given in 1-2 divided doses
OR
torasemide: 5-20 mg orally once daily initially, increase according to response, maximum 40 mg/day
OR
hydrochlorothiazide: 25 mg orally once daily, increase according to response, maximum 200 mg/day
OR
indapamide: 2.5 to 5 mg orally once daily
OR
metolazone: 5-20 mg orally once daily
renin-angiotensin system inhibitor
Additional treatment recommended for SOME patients in selected patient group
Guidelines advise that use of renin-angiotensin system inhibitors may be considered in patients with HFmrEF to reduce risk of HF hospitalisation and cardiovascular mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [143]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://www.doi.org/10.1093/eurheartj/ehad195 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com
Primary options
sacubitril/valsartan: treatment-naive or treatment-experienced on a low dose: 24 mg (sacubitril)/26 mg (valsartan) orally twice daily initially, increase gradually according to response, maximum 97 mg (sacubitril)/103 mg (valsartan) twice daily; treatment-experienced on a usual dose: 49 mg (sacubitril)/51 mg (valsartan) orally twice daily initially, increase gradually according to response, maximum 97 mg (sacubitril)/103 mg (valsartan) twice daily
More sacubitril/valsartanPatients not taking an ACE inhibitor or angiotensin-II receptor antagonist (treatment-naive) or those on a low dose of an ACE inhibitor or angiotensin-II receptor antagonist should be started on a lower dose of sacubitril/valsartan. Patients who were being treated with an ACE inhibitor or angiotensin-II receptor antagonist (treatment-experienced) should be started on a higher dose of sacubitril/valsartan.
Allow 36 hours between stopping an ACE inhibitor and starting this drug.
OR
captopril: 6.25 to 50 mg orally three times daily
OR
enalapril: 2.5 to 20 mg orally twice daily
OR
fosinopril: 5-40 mg orally once daily
OR
lisinopril: 2.5 to 40 mg orally once daily
OR
perindopril: 2-16 mg orally once daily
OR
quinapril: 5-20 mg orally twice daily
OR
ramipril: 1.25 to 10 mg orally once daily
OR
trandolapril: 1-4 mg orally once daily
Secondary options
candesartan: 4-32 mg orally once daily
OR
losartan: 25-150 mg orally once daily
OR
valsartan: 40-160 mg orally twice daily
aldosterone antagonist
Additional treatment recommended for SOME patients in selected patient group
Guidelines advise that use of an aldosterone antagonist may be considered in patients with HFmrEF to reduce risk of HF hospitalisation and cardiovascular mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [143]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://www.doi.org/10.1093/eurheartj/ehad195 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com
Primary options
spironolactone: 12.5 to 50 mg orally once daily
OR
eplerenone: 25-50 mg orally once daily
beta-blocker
Additional treatment recommended for SOME patients in selected patient group
Guidelines advise that use of a beta-blocker may be considered in patients with HFmrEF to reduce risk of HF hospitalisation and cardiovascular mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [143]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://www.doi.org/10.1093/eurheartj/ehad195 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com
Primary options
carvedilol: 3.125 mg orally (immediate-release) twice daily initially, increase according to response, maximum 50 mg/day (body weight ≤85 kg) or 100 mg/day (body weight >85 kg)
Secondary options
metoprolol: 12.5 to 200 mg orally (extended-release) once daily
OR
bisoprolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
OR
nebivolol: 1.25 mg orally once daily initially, increase according to response, maximum 10 mg/day
supportive measures +/- nephrology referral
Additional treatment recommended for SOME patients in selected patient group
Some drugs used in the management of HF should be used with caution in patients with renal impairment and a dose adjustment may be required. Some drugs may also be contraindicated in patients with renal impairment. Check your local drug information source for more information.
Consultation with a nephrology specialist should be considered.
intravenous iron supplementation
Additional treatment recommended for SOME patients in selected patient group
Patients with iron deficiency anaemia and transferrin saturation <20% should receive intravenous iron supplementation.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [143]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://www.doi.org/10.1093/eurheartj/ehad195 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com
For more details on management, see Iron-deficiency anaemia (Treatment algorithm).
surgical revascularisation
Additional treatment recommended for SOME patients in selected patient group
In selected patients with CAD and HF with LVEF ≤35% and suitable coronary anatomy, surgical revascularisation in addition to GDMT may improve symptoms, cardiovascular hospitalisations, and long-term all-cause mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
For more details, see Chronic coronary disease (Treatment algorithm).
multidisciplinary management
Additional treatment recommended for SOME patients in selected patient group
Aortic stenosis, aortic regurgitation, mitral regurgitation, and tricuspid regurgitation are associated with adverse outcomes in patients with HF and timely management (by a multidisciplinary team with expertise in HF and VHD) is important to prevent worsening of HF.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
For more details, see Aortic stenosis (Treatment algorithm), Aortic regurgitation (Treatment algorithm), Mitral regurgitation (Treatment algorithm), Tricuspid regurgitation (Treatment algorithm).
rate and rhythm control + anticoagulation
Additional treatment recommended for SOME patients in selected patient group
AF and HF may cause or exacerbate each other and the relationship is complex.
HF therapies should be optimised. Beta-blockers may be used in HFrEF whether or not the patient has associated AF.[145]Kotecha D, Flather MD, Altman DG, et al. Heart rate and rhythm and the benefit of beta-blockers in patients with heart failure. J Am Coll Cardiol. 2017 Jun 20;69(24):2885-96. https://www.jacc.org/doi/10.1016/j.jacc.2017.04.001 http://www.ncbi.nlm.nih.gov/pubmed/28467883?tool=bestpractice.com [146]Cadrin-Tourigny J, Shohoudi A, Roy D, et al. Decreased mortality with beta-blockers in patients with heart failure and coexisting atrial fibrillation: an AF-CHF substudy. JACC Heart Fail. 2017 Feb;5(2):99-106. https://www.jacc.org/doi/10.1016/j.jchf.2016.10.015 http://www.ncbi.nlm.nih.gov/pubmed/28089316?tool=bestpractice.com
Treatment of AF involves correction of the abnormal rate/rhythm, along with anticoagulation. Options for rate and rhythm control are determined by the presence of HF and extent of LV dysfunction.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
For details of management of patients with AF and HF, see Established atrial fibrillation (Treatment algorithm).
treatment of hyperglycaemia
Treatment recommended for ALL patients in selected patient group
Treatment of HFrEF is similar in patients with and without diabetes.
SGLT2 inhibitors are recommended as first-line treatment of hyperglycaemia in patients with type 2 diabetes and HF to reduce HF-related morbidity and mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com See also information above on SGLT2 inhibitors.
See Overview of diabetes.
finerenone
Additional treatment recommended for SOME patients in selected patient group
Finerenone, a non-steroidal mineralocorticoid receptor antagonist, is recommended for the prevention of HF hospitalisation in patients with CKD and type 2 diabetes.[143]McDonagh TA, Metra M, Adamo M, et al. 2023 Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://www.doi.org/10.1093/eurheartj/ehad195 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com
Primary options
finerenone: 20 mg orally once daily
More finerenoneA dose adjustment may be required in patients with renal impairment. Adjust dose according to serum potassium levels and eGFR.
weight loss programme
Additional treatment recommended for SOME patients in selected patient group
Treatment of obesity in patients with HFrEF may improve symptoms, functional status, quality of life, and comorbidities.[38]Powell-Wiley TM, Poirier P, Burke LE, et al. Obesity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2021 May 25;143(21):e984-1010. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000973 http://www.ncbi.nlm.nih.gov/pubmed/33882682?tool=bestpractice.com In advanced HF, weight loss in patients with obesity may allow the option of heart transplantation (obesity may be a contraindication).
lipid-lowering therapy
Additional treatment recommended for SOME patients in selected patient group
All patients with HFrEF and hyperlipidaemia will need lifestyle modifications and most will also require treatment with a statin possibly with additional non-statin lipid-lowering therapy.
For details of management of HF with hypercholesterolaemia, see Hypercholesterolaemia (Treatment algorithm).
referral to endocrinologist
Additional treatment recommended for SOME patients in selected patient group
Both hypo- and hyperthyroidism are associated with HF and assessment of thyroid function is recommended. Thyroid disorders are treated as per endocrinology guidelines; referral to endocrinologist should be considered.
assessment and treatment of sleep apnoea
Additional treatment recommended for SOME patients in selected patient group
Patients with HF and daytime sleepiness may have sleep studies to assess for obstructive sleep apnoea and central sleep apnoea.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
In patients with HF and obstructive sleep apnoea, continuous positive airway pressure is recommended to improve sleep quality and reduce daytime sleepiness; however, it does not seem to reduce mortality.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Adaptive servo-ventilation has been associated with increased mortality and is not recommended for the treatment of central sleep apnoea in patients with HFrEF.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
See Obstructive sleep apnoea in adults (Treatment algorithm) and Central sleep apnoea (Treatment algorithm).
interventions to improve HF self-care
Treatment recommended for ALL patients in selected patient group
Depression is common in patients with HF and is associated with a reduced quality of life and increased mortality.
Treatment with conventional therapies (e.g., antidepressants) does not seem to directly improve these outcomes. However, interventions that focus on improving HF self-care (e.g., psychotherapy, nurse-led support) may reduce hospitalisation and mortality in patients with moderate or severe depression.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
See Depression in adults.
multidisciplinary team management
Treatment recommended for ALL patients in selected patient group
Patients who develop HF and/or depressed LV systolic function secondary to cancer therapy should be treated with guideline directed-medical therapy (GDMT). Generally, GDMT should not be discontinued unless there are specific and compelling reasons to hold these medicines and this should be managed by a multidisciplinary team.
Before starting any cardiotoxic cancer therapy baseline cardiac function should be measured and ongoing monitoring after completion of a course of chemotherapy may be helpful for risk stratification.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
advanced HF
referral to specialist care for advanced HF therapies
Patients with indicators of advanced HF require timely referral to specialist care to assess suitability for management options that may include inotropic support, mechanical circulatory support (MCS), cardiac transplantation, and palliative care.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Inotropic support: in patients with advanced HF refractory to optimal medical and device therapy, prolonged intravenous inotropic support may be used as a bridge to long-term mechanical circulatory support or cardiac transplant.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com Continuous intravenous inotropic support may also be considered as palliative therapy for the relief of symptoms in patients without other treatment options.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
MCS: helps to maintain sufficient end organ perfusion by unloading the heart. Temporary MCS, such as percutaneous and extracorporeal ventricular assist devices, may be used in patients with advanced HF and haemodynamic compromise or shock as a bridge to recovery or bridge to decision about future care.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com Long-term MCS, such as a durable left ventricular assist device (LVAD), is considered in carefully selected patients who have end-stage HF despite optimal medical and device therapy, or dependence on intravenous inotropes or temporary MCS, either as a bridge to transplantation or as destination therapy (permanent pump implantation in patients not eligible for cardiac transplantation).[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com [236]Peura JL, Colvin-Adams M, Francis GS, et al. Recommendations for the use of mechanical circulatory support: device strategies and patient selection. A scientific statement from the American Heart Association. Circulation. 2012 Nov 27;126(22):2648-67. https://www.ahajournals.org/doi/full/10.1161/cir.0b013e3182769a54 http://www.ncbi.nlm.nih.gov/pubmed/23109468?tool=bestpractice.com [237]Gopinathannair R, Cornwell WK, Dukes JW, et al. Device therapy and arrhythmia management in left ventricular assist device recipients: a scientific statement from the American Heart Association. Circulation. 2019 May 14;139(20):e967-89. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000673 http://www.ncbi.nlm.nih.gov/pubmed/30943783?tool=bestpractice.com
Cardiac transplantation: significantly improves quality of life and functional status and is the established treatment for eligible patients with advanced HF refractory to optimal medical and device therapy.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
Palliative and supportive care: should be provided to all patients with HF to improve quality of life, and this care intensifies as disease progresses to advanced and end-of-life stages.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com Palliative and supportive care is a multidisciplinary approach that includes high-quality communication, discussion of prognosis, shared decision-making, advance care planning, relief from pain and other distressing symptoms, attention to emotional, psychological, and spiritual aspects of care, and support for families and carers during illness and bereavement.[7]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [9]McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com
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