What’s new in the ESC 2021 heart failure (HF) guidelines
Heart Failure Classification
What has changed?- Natriuretic peptides are one of the criteria in the definition of HF.
- The nomenclature for HF with LVEF of 41-49% has been revised to HF with mildly reduced ejection fraction or HFmrEF.
HF signs and symptoms. Evidence of structural and/or functional cardiac abnormalities and/or raised NPs
LVEF – 41% – 49%Mildly reduced
LV ejection fraction
Significant reduction
in LV ejection fraction
Updated Criteria for the Definition of Advanced Heart Failure
All of the following criteria must be present despite optimal medical treatment:
Severe and persistent symptoms of heart failure [NYHA class III (advanced) or IV]. 
Severe cardiac dysfunction defined by at least one of the following:
- LVEF ≤30%
- Isolated RV failure (e.g., Arrhythmogenic right ventricular cardiomyopathy)
- Non-operable severe valve abnormalities
- Non-operable severe congenital abnormalities
- Persistently high (or increasing) BNP or NT-proBNP values and severe LV diastolic dysfunction or structural abnormalities (according to the definitions of HFpEF)
Natriuretic peptides (NP) are part of the definition of advanced heart failure.
- Natriuretic peptides are a family of structurally related but genetically distinct hormones/paracrine factors that regulate blood volume, blood pressure, ventricular hypertrophy, pulmonary hypertension, fat metabolism, and long bone growth. The natriuretic peptide system is composed of 3 distinct peptides: atrial natriuretic peptide or ANP, B-type natriuretic peptide or BNP, and C-type natriuretic peptide or CNP.
Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics or episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned visit or hospitalization in the last 12 months. 
Severe impairment of exercise capacity with inability to exercise or low 6MWT distance (<300 m) or pVO2 <12 mL/kg/min or <50% predicted value, estimated to be of cardiac origin.Patient Care Pathway
PATIENT WITH SUSPECTED HF
- Shows typical signs and symptoms – breathlessness, fatigue, and ankle swelling
- Presence of risk factors
- Abnormal ECG
INITIAL DIAGNOSTIC TESTS
BNP <35 pg/mL Or NT-proBNP <125 pg/mL Or MR-proANP <40 pmol/L- HF unlikely
- Consider other diagnoses
- Plasma concentrations of NPs are recommended as initial diagnostic tests in patients with signs and symptoms suggestive of HF to rule out the diagnosis.
- Class I recommendation (recommended or indicated) for use of NPs in diagnosis of chronic HF.
- Elevated NP concentrations support a diagnosis of HF, are useful for prognostication, and may guide further cardiac investigation.
BNP ≥ 35 pg/mL
- May be HF
- Proceed to echocardiography
- Alternative causes of an elevated NP can include AF, increasing age, and acute or chronic kidney disease.
- NP can be disproportionately low in obese patients.
ECHOCARDIOGRAPHY
ECHOCARDIOGRAPHY should be conducted if:
- Elevated NPs concentrations
- or HF strongly suspected
- or NT-proBNP/BNP unavailable
- HF unlikely
- Consider other diagnoses
- HF is confirmed
- Define HF phenotype
≤40%▼HFrEF
41-49%▼HFmrEF
≥50%▼HFpEF
TREATMENT
HFrEF▼
HFmrEF▼
HFpEF▼
Guideline Recommended Pharmacological Treatment
Treatment for HFrEF and NYHA class II symptoms or worse:
- Angiotensin receptor neprilysin inhibitor (ARNI) as a replacement for angiotensin-converting enzyme (ACE) inhibitors – Class I recommendations.
- Addition of SGLT-2 inhibitors (dapagliflozin or empagliflozin) – Class I recommendations.
Treatment for HFmrEF
- Diuretics to relieve congestion.
- ACE inhibitors/angiotensin-receptor blockers/ARNIs/beta-blockers/mineralocorticoid receptor antagonists may be considered as additional therapy to reduce mortality and hospitalization (Class IIa recommendation).
Treatment for HFpEF
- Diagnosis and treatment of contributing factors (hypertension, kidney disease, etc.).
- Use of diuretics.
- Evidence based therapies proven with reducing the major heart failure outcomes.
FOLLOW-UP CARE
- General follow-up every 6 months.
- Current evidence does not support the routine measurement
of BNP or NT-proBNP to guide titration of therapy.
- Natriuretic peptides are undoubtedly good prognostic markers in therapy monitoring, however current evidence does not support the routine measurement to guide titration of therapy.
- Follow-up intervals should be more frequent if recently discharged from hospital, or in those undergoing uptitration of medication.
- Check for symptoms, heart rate and rhythm, blood pressure, full blood count, electrolytes, and renal function.
- Promote healthy lifestyle and dietary choices.
- Use circulating biomarkers and imaging techniques to monitor cardiac dysfunction before, periodically during, and after cancer treatment.
Patient Care Pathway
PATIENT WITH SUSPECTED ACUTE HF
- Clinical history
- Signs and/or symptoms suspected of acute HF
DIAGNOSTIC TESTS
- Electrocardiogram
- Pulse oximetry
- Echocardiography
- Initial laboratory investigations including troponin
- Chest x-ray
- Lung ultrasound
- Coronary angiography, if suspected ACS
- CT, if suspected pulmonary embolism
Initial laboratory investigations include
- Troponin
- Serum creatinine
- Electrolytes
- Blood urea nitrogen or urea,
- TSH
- Liver function tests
- D-dimer
- Procalcitonin, if pulmonary embolism or infection suspected
- Arterial blood gas analysis, if respiratory distress
- Lactate, if hypoperfusion
NATRIURETIC PEPTIDES MEASUREMENT
Normal levels of NPs- BNP <100 pg/mL
- NT-proBNP <300 pg/mL
- MR-proANP <120 pg/mL
- Rule out AHF
- BNP ≥100 pg/mL
- NT-proBNP ≥300 pg/mL
- MR-proANP ≥120 pg/mL
- AHF confirmed
- Plasma NP levels measurement is required when the diagnosis is uncertain, and a point-of-care assay is available.
- The ESC 2021 has included a IIA recommendation for the use of NPs (should be considered) in diagnosis of acute HF.
- It should be noted that apart from AHF, elevated NP values can be associated with a wide range of cardiac and non-cardiac conditions.
PRE-HOSPITAL PHASE
- Non-invasive monitoring – Started within minutes
of patient contact and in the ambulance if possible - Oxygen therapy
- Non-invasive ventilation, if respiratory distress
IN-HOSPITAL MANAGEMENT
Cardiogenic shock and/or respiratory failure YES
YES
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- Ventilator support
- Mechanical circulatory support
Identify acute aetiology
A new acronym has been introduced to identify the specific causes of AHF:
- C acute Coronary syndrome
- H Hypertension emergency
- A Arrhythmia
- M Mechanical cause
- P Pulmonary embolism
- I Infections
- T Tamponade
Start specific treatment immediately
NOFurther treatment differs according to the clinical presentations
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PRE-DISCHARGE ASSESSMENT
- Optimize treatment to keep the patient free of congestion
- Continue oral optimal medical therapy in ADHF (reduce dose or withdraw if haemodynamic instability, severely impaired renal function or hyperkalaemia)
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POST-DISCHARGE MANAGEMENT
- One follow-up visit within 1 to 2 weeks after discharge
- Monitoring of signs and symptoms of HF
- Assessment of volume status, BP, heart rate
- Laboratory tests – renal function, electrolytes, and NPs
- Assessment of iron status and hepatic function
- Consider further optimization and/or initiation of disease-modifying treatment for HFrEF
The ESC 2021 has included a IIA recommendation for use of NPs (should be considered) at admission and at discharge
