Acute Heart Failure in the 2021 ESC Heart Failure Guidelines: a scientific statement from the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology

Abstract

The current European Society of Cardiology (ESC) Heart Failure Guidelines are the most comprehensive ESC document covering heart failure to date; however, the section focused on acute heart failure remains relatively too concise. Although several topics are more extensively covered than in previous versions, including some specific therapies, monitoring and disposition in the hospital, and the management of cardiogenic shock, the lack of high-quality evidence in acute, emergency, and critical care scenarios, poses a challenge for providing evidence-based recommendations, in particular when by comparison the data for chronic heart failure is so extensive. The paucity of evidence and specific recommendations for the general approach and management of acute heart failure in the emergency department is particularly relevant, because this is the setting where most acute heart failure patients are initially diagnosed and stabilized. The clinical phenotypes proposed are comprehensive, clinically relevant and with minimal overlap, whilst providing additional opportunity for discussion around respiratory failure and hypoperfusion.

Keywords: Acute cardiac care; Emergency department; Heart failure guidelines; Acute heart failure.

Figure 1

Weight of AHF in the guidelines. The extension of the HF guidelines has increased over the years. AHF, acute heart failure; CHF, chronic heart failure. The percentage is the proportion of the text addressing AHF in relation to the total text. The number of pages has been calculated excluding the preamble and the final paragraphs addressing key messages, gaps in evidence, quality indicators, and references.

Figure 2

Acute heart failure phenotypes based on pathophysiological alterations. (A) Left: Four clinical forms proposed in the ESC HF guidelines 2016 based on two alterations: hypoperfusion and congestion. Right: Area of each square according to the estimated incidence (see text for explanations). (B) Left: Three main clinical profiles considering pulmonary congestion and systemic congestion separately. Right: Areas of the circles according to their incidence and interactions. The three main clinical forms proposed in the ESC HF Guidelines 2021 are projected on each circle.

Figure 3

General course of AHF patients. The algorithm contents dispositions and crucial issues in the AHF attending process. See text for explanations. ADHF, acutely decompensated heart failure; APO, acute pulmonary oedema; CHAMPIT, acute coronary syndrome, hypertension emergency, arrhythmia, acute mechanical cause; pulmonary embolism, infections; tamponade; CICU, cardiovascular intensive care unit; CS, cardiogenic shock; EMS, emergency medical services; HF, heart failure; ICU, intensive care unit; IRVF, isolated right ventricular failure.

Figure 4

Algorithm for management of acute heart failure at the pre-hospital setting. AHF, acute heart failure; CPAP, continuous positive airway pressure; HF, heart failure; RR, respiratory rate; SBP, systolic blood pressure; SpO₂, oxygen saturation by pulse-oximetry; WOB, work of breathing.

Figure 5

General approach to patients with isolated right ventricular failure based on steps. AMI, acute myocardial infarction; ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; MCS, mechanical circulatory support; NO, nitric oxide; PCI, percutaneous coronary intervention; PDE, phosphodiesterase; PE, pulmonary embolism; RRT, renal replacement therapy; RV, right ventricle.