Yesterday, major changes in the classification, nomenclature and treatment of heart failure (HF) in the new ESC Guidelines[1] were discussed by Task Force Chairs, Associate Professor Marianna Adamo (Civil Hospital of Brescia - Italy) and Professor Lars Køber (Rigshospitalet - Copenhagen University Hospital - Denmark).
One of the main changes is that the phenotype of HF with mildly reduced ejection fraction (HFmrEF, LVEF 41–49%) has been removed. The two remaining phenotypes are now defined as HF with reduced ejection fraction (HFrEF; LVEF <50%) and HF with preserved ejection fraction (HFpEF; LVEF ≥50%). Explaining why, Associate Prof. Adamo says: “The original rationale for HFmrEF related to trial eligibility criteria. However, HFmrEF and HFrEF share similar pathophysiology and probably respond to similar treatments. We decided to have two phenotypes based on a single LVEF cut-off (50%), thus simplifying clinical practice."
The Task Force has also introduced new classifications to describe medical, device and procedural therapies. “The term ‘guideline-directed medical therapy (GDMT)’ was introduced more than 10 years ago to describe medical therapies with Class I recommendations at the time,” comments Prof. Køber. “However, there have been further advances since then, creating some uncertainty as to what GDMT actually means today.” Now, foundational medical therapy (FMT) includes medical treatments for unselected patients with HF and with a Class I recommendation for reducing HF hospitalisation and/or death. Additional medical therapy (AMT) includes treatments with Class IIa/IIb recommendations or Class I recommendations for improving symptoms/quality of life or reducing morbidity or mortality in specific subsets. To avoid overlooking the important role of devices, guideline-directed interventional therapy (GDIT) covers all guideline-recommended implantable devices or interventional therapies. “These terms are designed to be dynamic and to remain contemporary over time,” notes Prof. Køber.
In another key change in nomenclature, decompensated HF replaces acute HF. “In some patients, ‘acute’ HF is not actually acute, but is a gradual deterioration,” explains Associate Prof. Adamo. “The guidelines also note that some less acute decompensated presentations can be managed in an ambulatory setting without the need for hospitalisation and this is in line with the new AHA/ACC/ESC/WHF universal definition of HF,[2]” she comments. The staging approach used in American guidelines[3] has been adopted, ranging from risk factors (stage A) to advanced HF (stage D), primarily to draw attention to prevention and early diagnosis as part of the broad spectrum of HF.
Important changes to recommendations for specific therapies have been made based on new evidence. These include Class I recommendations for mineralocorticoid receptor antagonists in chronic HF independent of LVEF and Class IIa recommendations for semaglutide or tirzepatide in patients with HFpEF and obesity. There are also upgraded recommendations in specific situations for other treatments, such as digoxin/digitoxin in chronic heart failure, durable mechanical circulatory support and mitral transcatheter edge-to-edge repair.
“In such a fast-moving vast field, there is something of relevance for every cardiology healthcare professional in the new guidelines and the version for patients has been updated too,” the Chairs conclude.