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

A focused update of the 2021 ESC Guidelines for heart failure (HF)1 was presented yesterday by Professor Marco Metra (University of Brescia - Brescia, Italy) and Professor Theresa McDonagh (King’s College Hospital - London, UK), Chairs of the original Guidelines Task Force.

Prof. Metra comments on the need for the update: “Since the 2021 ESC Guidelines for HF,2 more than 10 randomised controlled trials have been published that should change patient management ahead of the next scheduled full guideline. Based on this recent evidence, new recommendations are provided in three areas: chronic HF, acute HF and comorbidities.”

Regarding chronic HF, there were no recommendations in the 2021 guidelines on the use of sodium–glucose co-transporter 2 (SGLT2) inhibitors in patients with HF with mildly reduced ejection fraction (HFmrEF) and HF with preserved ejection fraction (HFpEF) as there was a lack of evidence. Since then, the EMPEROR-Preserved and DELIVER trials were published and the focused update now recommends dapagliflozin or empagliflozin in patients with HFmrEF and HFpEF to reduce the risk of HF hospitalisation or CV death.

“The task force also discussed changing the description of HFpEF to ‘HF with normal ejection fraction (HFnEF)’ and altering the LVEF threshold for HFnEF,” notes Prof. McDonagh. “However, we ultimately decided to keep the term ‘HFpEF’ and we left any further changes in terminology to be considered by the next ESC HF Guidelines Task Force.”

For acute HF management after hospital admission, the STRONG-HF trial recently showed the safety and efficacy of an approach based on starting and titrating oral HF therapies within 2 days before anticipated hospital discharge and in follow-up visits occurring early after discharge. These findings led to a new recommendation of high-intensity care for initiation and rapid up-titration of oral HF therapies with close follow-up in the first 6 weeks after discharge to reduce HF readmission or all-cause death. The focused update stresses that particular attention should be paid to symptoms and signs of congestion, blood pressure, heart rate, NT-proBNP values, potassium concentrations and estimated glomerular filtration rate during follow-up appointments.

Turning to comorbidities, the focused update provides a new recommendation for the prevention of HF in patients with chronic kidney disease (CKD) and type 2 diabetes (T2DM) based on the results of the DAPA-CKD and EMPA-KIDNEY SGLT2 inhibitor trials, and a meta-analysis of 4 trials. Dapagliflozin or empagliflozin is now recommended for patients with CKD and T2DM to reduce the risk of HF hospitalisation or CV death. A second recommendation follows the FIDELIO-DKD and FIGARO-DKD trials, and advocates the use of the mineralocorticoid receptor antagonist, finerenone, in patients with CKD and T2DM to reduce the risk of HF hospitalisation.


Want to know more? ‘Ask the Guidelines Task Force’ and ‘Guidelines in Practice’ sessions today provide opportunities to discuss the new document and its implications for day-to-day HF management.


  1. McDonagh TA, 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. doi:10.1093/eurheartj/ehad195.
  2. McDonagh TA, et al. Eur Heart J. 2021;42:3599–3726.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.