Updates in Heart Failure Management

Heart failure care has changed more in the last few years than in the decade before. This review brings together the recommendations that matter most in everyday practice.

Four drug classes, started early

For heart failure with reduced ejection fraction, four drug classes form the foundation of therapy:

• An ACE inhibitor, ARB or ARNI (sacubitril/valsartan)
• An evidence-based beta-blocker
• A mineralocorticoid receptor antagonist
• An SGLT2 inhibitor (dapagliflozin or empagliflozin)

The emphasis has moved from slow, one-at-a-time introduction to starting all four early, at low doses, and titrating as tolerated.

Early, rapid optimisation of therapy after a heart failure admission saves lives, provided patients are followed up closely.

Beyond reduced ejection fraction

The 2023 ESC focused update recommends SGLT2 inhibitors for patients with mildly reduced and preserved ejection fraction, to reduce heart failure hospitalisation or cardiovascular death. More recently, finerenone reduced worsening heart failure events in patients with mildly reduced or preserved ejection fraction in the FINEARTS-HF trial.

After a hospital admission

The STRONG-HF trial showed that rapid up-titration of guideline-directed therapy after an acute admission, with close clinical and laboratory follow-up, reduced death or readmission at 180 days.

Iron deficiency

Check ferritin and transferrin saturation in every patient. Intravenous iron is recommended in symptomatic patients with reduced or mildly reduced ejection fraction and iron deficiency, to improve symptoms and quality of life.

In practice

1. Start all four drug classes during, or soon after, the index admission.
2. Recheck potassium and creatinine one to two weeks after each change.
3. Screen for iron deficiency at diagnosis and at follow-up.