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Aiming at harmony. Comparing and contrasting International HFrEF Guidelines
Daniela Tomasoni1, Marianna Adamo1, Biykem Bozkurt2
1Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
Insights
Recent guidelines for heart failure with reduced ejection fraction (HFrEF) emphasize four key drug classes. Early initiation of these treatments is crucial for improving cardiovascular outcomes and reducing hospitalizations.
Area of Science:
- Cardiology
- Clinical Practice Guidelines
Background:
- Large randomized controlled trials (RCTs) have significantly advanced heart failure with reduced left ventricular ejection fraction (HFrEF) treatment.
- Recent European Society of Cardiology (ESC) and ACC/AHA/HFSA guidelines (2021/2022) incorporate these advances.
Purpose of the Study:
- Compare the 2021 ESC and 2022 ACC/AHA/HFSA guidelines for HFrEF.
- Highlight consistent recommendations and identify minor differences between the guidelines.
Main Methods:
- Comparative analysis of the European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) guidelines.
- Review of evidence supporting drug classes for HFrEF treatment.
Main Results:
- Both guidelines recommend four foundational drug classes for HFrEF: angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors.
- Emphasis is placed on early administration of all four drug classes, rather than specific sequences.
- Additional therapies like ivabradine, hydralazine nitrates, digoxin, and vericiguat are considered for select patients.
Conclusions:
- The ESC and ACC/AHA/HFSA guidelines demonstrate substantial alignment in HFrEF management.
- The guidelines reflect a growing body of evidence for novel HFrEF treatments and comorbidities.
Abstract:
Large randomized controlled trials (RCTs) have led to major changes in the treatment of patients with heart failure and reduced left ventricular ejection fraction (HFrEF) and these advances are included in the recent European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) guidelines issued in 2021 and 2022, respectively. According to both guidelines, treatment of patients with HFrEF is based on the administration of four classes of drugs that reduce the primary endpoint of cardiovascular death and HF hospitalizations in RCTs: angiotensin-converting enzyme or angiotensin receptor neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors. Specific sequences of treatment are not recommended but emphasis is given to reaching treatment with all four drugs as early as possible. Further treatments are considered in selected patients including ivabradine, hydralazine nitrates, digoxin, and the new agent vericiguat. Specific treatments, mostly new, for cardiovascular and non-cardiovascular comorbidities are also given. The aim of this article is to compare the two recent guidelines issued by the ESC and ACC/AHA/HFSA and show the few differences and the many consistent recommendations, now more numerous given the evidence available for many new treatments.
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