APSC Consensus Statement on the Management of Worsening Heart Failure

This is a verbatim transcript of an interview conducted with Dr David Sim in Oct 2025. The transcript has been lightly edited for clarity.

Can you explain how acute heart failure management has evolved over the years?

So acute heart failure management or now the term that we would like to use is “Worsening Heart Failure”. How has it evolved over the last few years? I think we were so focused on just the decongestion part, which is still critically important to decongest a patient in the first 24-48 hours. But what we now realise is it is also important during the hospitalisation to address the issue of starting initiating GDMT, or what we call Guideline Directed Medical Therapy before the patient gets discharged. And this approach has been proven in pivotal trials like the STRONG-HF that show that by having such an approach where we start the GDMT pre-discharge and uptitrated drug early to the maximum possible dose a patient can tolerate within the first six weeks. That is associated with a very strong signal of benefit in terms of a 8.1% absolute risk reduction in the combined endpoint of heart failure hospitalisation or mortality. 

And of course, we do know that there are many other trials out there. For example, the PIONEER-HF, looking at the use of ARNI, the EMPULSE trials, looking at the use of SGLT2 inhibitors. We know that all this chronic heart failure drug that’s been tested in big trials has also been shown in smaller trials in acute settings that it is safe to use this kind of drug and it also brings about benefits much earlier for patients. And all these are crucial. Why I keep on emphasising before hospitalisation is because before discharge, before we discharge a patient is important. Because the first 30 to 60 days post-discharge is a very vulnerable phase where they are more prone to death and more prone to readmission.

We currently have a full guideline written by the European Society of Cardiology and by the American Guideline, the ACC/AHA, but these are all very long documents. Some of them are even 100 pages long. So you can’t expect the non heart failure specialists, for example, a non heart failure cardiologist or internal medicine specialists who are managing heart failure to go into depth into the whole 100 pages document. So what we thought would be practical for the Asia Pacific region. 

Under the guidance of the APSC or the Asia Pacific Society of Cardiology, we came up with a consensus statement. I had the honor of leading this workgroup that involved 18 other colleagues, so a total of 19 of us from around the ASEAN region and other parts of Asia Pacific, as far down as from Australia. And of course, we do have Professor Alexandre Mebazaa from France. If you wonder why he is in this work group? It’s because he was the principal investigator of a STRONG-HF study. So having him on board, he would give a lot of meaningful insight into the treatment of acute heart failure. How to initiate GDMT early. So together as a group, we had a few meetings. We came up with some important statements. And this is all now being finalised. It has been already presented at the APSC conference in Busan earlier this year and is now accepted for publication in the Journal of APSC. So it should be out in the next few months in the full journal. And in this guideline or this consensus statement, we make it very concise, 5000 words to be exact. So it makes it easier for the non heart failure specialist to read through this thing.

What are some key recommendations for the management of worsening HF?

Key point that we highlight: One, how do we implement STRONG-HF kind of protocol in this part of the world. The key difference from the European guideline and the American guideline is, I will point out is, first, in terms of the number of drugs to start is the same like the rest of the world. The four foundational therapies for heart failure with Reduced Ejection Fraction. But what is different is, instead of limiting it to the first six weeks post-discharge, we give leeway all the way up to three months. We do recognise some of the difficulty and some obstacles that we may face here in Asia Pacific. And we don’t want to be too restrictive on the doctors. Ideally it is still six weeks, but we say that up to three months. 

The other key thing we also emphasise is besides using hemodynamics and the blood pressure, the heart rate, and of course the renal panel to guide us in up-titrating the drug, we also emphasise on the use of NT-proBNP, because it gives a better reflection of how congested the patient is. It can guide us in directing dose and of course, the uptitration or the down-titration of the beta blocker. And lastly, the key difference is, as a group in Asia Pacific, we think that we should be more progressive. We don’t have to always wait for the European guideline or the American guideline. Before we follow their guideline, we decided based on the current evidence, the MRA as a class of drug, can be upgraded from 2b to 2a for the treatment of patients with ejection fraction of above 40%.

What strategies would you recommend for effectively integrating these recommendations into routine clinical practice?

So writing consensus statements and guidelines is only one of the ways we can implement all these strategies in the region. But now the key question is, having it in writing, how do we put it in real world practice? So some advice I will have is, first, I will encourage all the different countries in the Asia Pacific region to think of, do you want to do a simple study of the STRONG-HF kind of protocol in this part of the world? 

For example, in Singapore, we are doing STRONG-HF Singapore. In China, I know there is a big study that is now being conducted. So I call STRONG-HF China. And of course at the same time, I think from the APSC survey that we had for doctors around the region, we found that there’s a lot of gaps in the treatment of heart failure. About half the centre that was being surveyed, there was a lack of heart failure services, lack of heart failure clinic. 

So as we know from other regions in the world, and also for some of the centre in Asia Pacific, we know that having a dedicated heart failure service with inpatient and outpatient services, with dedicated support from nursing and allied health does help to increase implementation of heart failure service into this part of the world, which of course will incorporate the uptitration of GDMT in the clinic, in an inpatient setting, and the appropriate use of biomarker like NT-proBNP in the management of patients. So it works. I can show you from personal experience. 

For example, I gave our example of our Vietnam, where we started a heart failure programme there. And it works within three months. Same thing as far as up north in Mongolia. We started a heart failure programme in Mongolia. They have a collaboration in Singapore. We help them to set up the heart failure service. I just find that the uptake of GDMT increases by a lot after the implementation of the heart failure services. 

I do know that there are different challenges in different countries. It’s not one size fits all. But I think the principle is still the same and how we can help each other. I think, for example, Hong Kong, I actually recommended them to start a heart failure society in Hong Kong. That will increase awareness. So for some of these countries who do not have a society of heart failure may consider setting up society to increase awareness. 

And for those countries who are a bit ahead, for example like Singapore, we can play a part by helping our neighbours in the Asia Pacific region. How we can help to train them. How we can send our team there to help them. And how they come to visit us in Singapore, see our system. So these are all ways that we can do. 

At the end of the day, the important thing is, it is not good enough to say that I have a consensus statement. If we don’t take any action, it is not going to work. So that will take a lot of effort. But I think with the coordinated effort of the whole region, I’m sure heart failure care will be more optimal in the future.

The views and opinions expressed by Dr David Sim are his own views and opinions. Roche disclaims all liability in relation to these views and opinions.