[What is established in the medical treatment of heart failure?]

The treatment of heart failure varies depending on left ventricular ejection fraction (LVEF) and poses a significant clinical challenge in patients with reduced (HFrEF), mildly reduced (HFmrEF), or preserved ejection fraction (HFpEF). In HFrEF/HFmrEF, the diagnosis is based on clinical symptoms such as dyspnea or peripheral edema, as well as an LVEF < 50%. Treatment primarily relies on renin-angiotensin system (RAS) inhibitors (preferably angiotensin receptor-neprilysin-inhibitors, ARNIs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter 2 inhibitors (SGLT2i). These agents have a class I recommendation and significantly reduce both mortality and hospitalization rates. Rapid and comprehensive implementation of this therapeutic strategy substantially improves prognosis. Additional agents such as ivabradine or vericiguat can be considered. With the recent publication of the DIGIT-HF study, evidence now also supports the use of digitoxin in advanced HFrEF to further reduce mortality and hospitalizations. Iron deficiency is common in HFrEF and is associated with worse outcomes. Intravenous iron supplementation improves exercise capacity and reduces the risk of hospitalization especially after a decompensation. In patients with HFpEF, treatment focuses on symptomatic relief and rigorous management of comorbidities. Diuretics for volume overload have a class I recommendation, as they effectively alleviate symptoms. SGLT2i also play a key role in HFpEF and are recommended with class I evidence in current guidelines. FINEARTS-HF recently showed promising results for the non-steroidal MRA finerenone, which reduces cardiovascular death/hospitalizations. Furthermore, metabolically targeted therapies such as GLP‑1 receptor agonists are gaining importance in obese HFpEF patients, as they have been shown to improve quality of life and reduce heart failure-related events.