General National Heart Failure – Consolidated Recommendations
General National Heart Failure – Consolidated Recommendations
(Adapted from ESC Guidelines 2018–2024)
Definition
Heart failure is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling, fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, peripheral oedema), caused by a structural and/or functional cardiac abnormality, leading to reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.
1. Classification by LVEF
1.1 HFrEF: LVEF ≤40%
1.2 HFmrEF: LVEF 41–49%
1.3 HFpEF: LVEF ≥50% + structural/functional abnormality + elevated natriuretic peptides
2. Diagnosis and Initial Assessment
2.1 Measure BNP or NT-proBNP in suspected HF.
2.2 Confirm diagnosis and classify by echocardiography.
2.3 Support with ECG, chest X-ray, CBC, electrolytes, thyroid, glucose, HbA1c, lipids, iron studies.
3. Core Pharmacological Therapy
3.1 HFrEF (Foundational drugs):
• ACE-I/ARNI
• Beta-blocker
• MRA
• SGLT2 inhibitor
3.2 If symptoms persist: ivabradine, vericiguat, digoxin, hydralazine/isosorbide dinitrate.
3.3 HFmrEF: Same drugs may be considered; benefit less certain.
3.4 HFpEF: Symptom relief (diuretics), comorbidity management; SGLT2 inhibitors reduce admissions.
4. Device & Interventional Therapy
4.1 ICD: For LVEF ≤35% with persistent symptoms despite optimal therapy and life expectancy >1 year.
4.2 CRT: For sinus rhythm, LVEF ≤35%, QRS ≥150 ms with LBBB pattern; avoid in QRS <130 ms.
4.3 Valve disease: SAVR/TAVI or percutaneous repair as indicated.
5. Multidisciplinary & Lifestyle Management
5.1 Enroll in multidisciplinary HF programs to reduce mortality and hospitalizations.
5.2 Educate patients on symptoms, adherence, and self-management.
5.3 Exercise training recommended in stable HF.
5.4 Vaccinate against influenza and pneumococcus.
5.5 Restrict sodium in symptomatic HF; complete smoking cessation and alcohol limitation.
6. Monitoring and Follow-Up
6.1 Post-discharge follow-up within 1–2 weeks.
6.2 Annual ECG to detect CRT eligibility.
6.3 Echocardiography if deterioration or 3–6 months after HFrEF therapy optimization.
6.4 Telemonitoring may reduce hospitalizations and mortality (Class IIb).
7. Acute Heart Failure
7.1 Rapid assessment: airway, breathing, circulation, perfusion.
7.2 Oxygen only if SpO₂ <90%.
7.3 IV loop diuretics for congestion.
7.4 Vasodilators if SBP >110 mmHg and congestion.
7.5 Inotropes for hypoperfusion; vasopressors for shock.
7.6 Address triggers (ACS, arrhythmia, infection).
8. Advanced Heart Failure – Key Points (ESC 2021–2024)
8.1 Inotropes & Diuretics
• Used in haemodynamic instability or persistent low output.
• Indication: “rescue therapy” for shock or severe hypoperfusion.
• Escalate diuretic therapy if resistant (double loop dose → add thiazide/metolazone).
• Renal Replacement Therapy (RRT): hemodialysis, peritoneal dialysis, or ultrafiltration may be considered for refractory congestion.
• Class/Level: IIb, C.
8.2 Mechanical Circulatory Support (MCS)
• Short-term MCS (ECMO, Impella, IABP): for INTERMACS profile 1–2 (critical shock or progressive decline).
Purpose: Bridge to Decision (BTD), Bridge to Recovery (BTR), or Bridge to Bridge (BTB).
Class/Level: IIa, C.
• Long-term LVAD: indicated in refractory HF despite OMT ± device therapy.
Roles: Bridge to Transplant (BTT), Bridge to Candidacy (BTC), or Destination Therapy (DT).
Class/Level: IIa, B.
8.3 LVAD Eligibility Criteria
• Severe HF despite optimal therapy, no major contraindications.
• At least one of:
• LVEF <25% with poor exercise capacity (peak VO₂ <12 mL/kg/min)
• ≥3 HF hospitalizations in past 12 months
• Dependence on IV inotropes or temporary MCS
• Progressive end-organ dysfunction with haemodynamic compromise (PCWP ≥20 mmHg, SBP ≤90 mmHg, cardiac index ≤2 L/min/m²)
8.4 Heart Transplant
• Indicated in advanced HF refractory to all medical/device therapy.
• Contraindications: active infection, severe comorbidity, advanced malignancy, uncontrolled substance abuse, poor psychosocial support.
• Class/Level: I, C.
8.5 Palliative Care
• For patients not eligible for advanced options.
• Focus: symptom relief, quality of life (QOL), patient and family support, advance care planning.
• Class/Level: I, C.
8.6 Digoxin
• Without AF: may be considered to reduce HF hospitalization in HFrEF symptomatic patients. (Class IIb, Level
• With AF (rate control): if beta-blockers insufficient or not tolerated. (Class IIa, Level
• Benefit: reduces hospitalizations but no mortality benefit.
• Caution: narrow therapeutic index, toxicity risk.
8.7 Vericiguat
• Soluble guanylate cyclase stimulator → enhances NO–sGC–cGMP pathway.
• Indication: HFrEF with recent worsening (hospitalization or IV therapy) on GDMT.
• Benefit: reduces CV death and HF hospitalizations.
• Class IIb, Level B.
8.8 BNP vs NT-proBNP
• BNP: active hormone, short half-life (~20 min), less stable.
• NT-proBNP: inactive fragment, longer half-life (~60–120 min), more stable in lab.
• Both accepted in ESC/AHA guidelines; choice depends on lab availability.
• Interpretation:
• Acute HF: NT-proBNP <300 pg/mL (rule-out), BNP <100 pg/mL (rule-out).
• Chronic HF: NT-proBNP <125 pg/mL (rule-out).
8.9 INTERMACS Profiles (1–7) (American “Interagency Registry for Mechanically Assisted Circulatory Support”)
• Profile 1 – Critical shock: crashing, imminent death → immediate short-term MCS. Class IIa, C.
• Profile 2 – Progressive decline: on inotropes but worsening → early LVAD/transplant. Class IIa, C.
• Profile 3 – Stable on inotropes: dependent but stable → consider durable LVAD/transplant. Class IIa, B.
• Profile 4 – Resting symptoms: severe symptoms at rest → evaluate for advanced therapies. Class IIa, B.
• Profile 5 – Exertion intolerant: symptoms with minimal activity → outpatient advanced HF evaluation. Class IIb, C.
• Profile 6 – Exertion limited: symptoms with moderate exertion → monitor, may progress. Class IIb, C.
• Profile 7 – Advanced NYHA III: stable but frequent hospitalizations → early identification, structured follow-up. Class IIb, C.
9. Cardiomyopathy Integration (for GPs and National Protocols)
9.1 Cardiac Amyloidosis
• When to suspect: LV wall thickness ≥12 mm plus red flags such as:
* Peripheral neuropathy (numbness, weakness)
* Bilateral carpal tunnel syndrome
* Unexplained hypotension or orthostatic hypotension
* Family history of amyloidosis or unexplained cardiomyopathy
• Treatment: Tafamidis is indicated for transthyretin amyloidosis (ATTR, hereditary or wild-type) in patients with NYHA Class I–II.
9.2 Arrhythmogenic Cardiomyopathy (ACM)
• Screen first-degree relatives of affected patients.
• Recommend genetic counselling and clinical screening.
• Avoid competitive sports; allow only moderate leisure activity.
• Implant ICD in high-risk patients (e.g., survivors of cardiac arrest, sustained VT, or high-risk mutations).
9.3 Hypertrophic Cardiomyopathy (HCM)
• Management depends on LV outflow tract obstruction (LVOTO).
• With LVOTO: use beta-blockers or verapamil; avoid hypovolaemia, digoxin, vasodilators.
• Without LVOTO: treat HF symptoms cautiously (diuretics, verapamil/diltiazem if tolerated).
• Consider septal reduction (surgery or alcohol ablation) if LVOT gradient ≥50 mmHg with severe symptoms despite optimal therapy.
9.4 Dilated Cardiomyopathy (DCM) & Hypokinetic Non-Dilated Cardiomyopathy (HNDC)
• Offer genetic testing to all patients and first-degree relatives of mutation carriers.
• Perform endomyocardial biopsy if inflammatory or autoimmune cardiomyopathy is suspected (e.g., giant cell myocarditis, sarcoidosis).
• Treat according to HFrEF protocols.
• Implant ICD in high-risk gene carriers (e.g., LMNA, FLNC, RBM20, PLN).
10. National System Priorities
10.1 Standardize early post-discharge review within 1–2 weeks.
10.2 Establish referral pathways to advanced HF centers (LVAD, transplant).
10.3 Create a national HF registry to benchmark against ESC standards.
10.4 Develop unified patient education and structured follow-up programs.
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Reference:
Ponikowski P, et al. 2021 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure. Eur Heart J. 2021;42:3599–3726.
McDonagh TA, et al. 2023–2024 ESC Updates on Heart Failure and Cardiomyopathies. Eur Heart J. 2023–2024.
