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. 2023 May;39(3):361-390.
doi: 10.6515/ACS.202305_39(3).20230301A.

2023 Consensus of Taiwan Society of Cardiology on the Pharmacological Treatment of Chronic Heart Failure

Chern-En Chiang  1   2   3 , Chung-Lieh Hung  4   5 , Yen-Wen Wu  3   6 , Tsung-Hsien Lin  7   8 , Kwo-Chang Ueng  9 , Shih-Hsien Sung  2   3 , Cho-Kai Wu  10 , Ting-Hsing Chao  11 , Hung-Ju Lin  10 , Yen-Hung Lin  10   12 , Jin-Long Huang  13   14 , Michael Yu Chih Chen  15 , Po-Lin Lin  16 , Tze-Fan Chao  2   17 , Hao-Min Cheng  18   19 , Ming-En Liu  16 , Tzung-Dau Wang  20 , Hung-I Yeh  21   22 , Yi-Heng Li  11 , Ping-Yen Liu  11   23 , Wei-Hsian Yin  3   24 , I-Chang Hsieh  25 , Chun-Chieh Wang  25 , Chen-Huan Chen  3   26 , Pao-Hsien Chu  25   27 , Shing-Jong Lin  28   29 , San-Jou Yeh  25 , Jiunn-Lee Lin  10   30 , Juey-Jen Hwang  10 , Huei-Fong Hung  31 , Wen-Jone Chen  10   32 , Charles Jia-Yin Hou  22   33
Affiliations

2023 Consensus of Taiwan Society of Cardiology on the Pharmacological Treatment of Chronic Heart Failure

Chern-En Chiang et al. Acta Cardiol Sin. 2023 May.

Abstract

The prevalence of heart failure is increasing, causing a tremendous burden on health care systems around the world. Although mortality rate of heart failure has been significantly reduced by several effective agents in the past 3 decades, yet it remains high in observational studies. More recently, several new classes of drugs emerged with significant efficacy in reducing mortality and hospitalization in chronic heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). To integrate these effective therapies and prioritize them in the management of Asian patients, Taiwan Society of Cardiology has recently appointed a working group to formulate a consensus of pharmacological treatment in patients with chronic heart failure. Based on most updated information, this consensus provides rationales for prioritization, rapid sequencing, and in-hospital initiation of both foundational and additional therapies for patients with chronic heart failure.

Keywords: Asia; Chronic heart failure; Consensus; Foundational therapy; Left ventricular ejection fraction.

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Conflict of interest statement

Dr. C.-E. Chiang has received honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Menarini, MSD, Novartis, Pfizer, and Sanofi. Dr. C.-L. Hung has received honorarium from Astrazeneca, Boehringer Ingelheim, Eli Lilly, MSD, Novartis, Pfizer, and Sanofi. Dr. Y.-W. Wu has received honorarium from AstraZeneca, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, MSD, Novartis, Pfizer, Sanofi, and Takeda. Dr. T.-H. Lin has received honorarium from Astrazeneca, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, MSD, Novartis, Pfizer, Sanofi, Bayer, Viatris, Menariri, Tanabe, and Takeda. Dr. K.-C. Ueng has received honorarium from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, Merck Sharp and Dohme, Novartis, Pfizer, and Sanofi. Dr. S.-H. Sung has received honorarium from Astrazeneca, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, Novartis, Pfizer, Sanofi, Abbott, and Edward. Dr. C.-K. Wu has received honorarium from AstraZeneca, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, Novartis, Pfizer, Sanofi, and Abbott. Dr. T.-H. Chao has received honorarium from Bayer, AstraZeneca, Eli Lilly, Boehringer Ingelheim, Daiichi-Sankyo, Tanabe Taiwan, and Novartis. Dr. Y.-H. Lin has received honorarium from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi-Sankyo, MSD, Novartis, Pfizer, and Sanofi. Dr. M. YC Chen has received honorarium from AstraZeneca, Boehringer Ingelheim, Daiichi-Sankyo, and Pfizer. Dr. P.-L. Lin has received honorarium from AstraZeneca, Abbott, Boehringer Ingelheim, Bayer, Daiichi-Sankyo, Eli Lilly, Novartis, Novo Nordisk, Pfizer, and Sanofi. Dr. T.-F. Chao has received speaker honorarium from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, Novartis, Pfizer, and Sanofi. Dr. H.-M. Cheng has received honorarium from AstraZeneca, Pfizer, Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Novartis, SERVIER, Sanofi, Takeda, and Eli Lilly. Dr. M.-E. Liu has received honorarium from Abbott, AstraZeneca, Bayer, Biotronik, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, Medtronic, MSD, Novartis, Pfizer, and Sanofi. Dr. H.-I. Yeh has received honorarium from AstraZeneca, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, MSD, Novartis, Novo Nordisk, Pfizer, and Sanofi. Dr. Y.-H. Li has received honorarium from AstraZeneca, Boehringer Ingelheim, Daiichi-Sankyo, Eli Lilly, Novartis, Pfizer, and Sanofi. Dr. I.-C. Hsieh has received honorarium from AstraZeneca, Boehringer Ingelheim, Novartis, Bayer, MSD, Sanofi, Daiichi Sankyo, Pfizer, and Eli Lilly. Dr. C.-C. Wang has received honorarium from AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Novartis, and Pfizer. Dr. C.-H. Chen reports honoraria from Novartis and Daiichi Sankyo. Dr. P.-H. Chu has received honorarium from AstraZeneca. Dr. S.-J. Yeh has received honorarium from Tanabe. Dr. W.-J. Chen has received honorarium from Astrazeneca, Boehringer Ingelheim, Daiichi-Sankyo, MSD, Novartis, Pfizer, and Sanofi. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Figure 1
Figure 1
Prevalence and incidence of heart failure in population-based studies around the world.
Figure 2
Figure 2
Proposed new classification of heart failure. HFimpEF, HF with improved ejection fraction (previous LVEF < 40% that improved by 10% in LVEF and now > 40%); HFimpEF,heart failure with improved EF; HFmrEF, heart failure with mildly reduced ejection fraction; HFnEF, heart failure with normal ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HFsrEF, heart failure with severely reduced ejection fraction; LVEF, left ventricular ejection fraction.
Figure 3
Figure 3
Comparison of different rapid sequencing strategies of foundational therapies. (A) Seven different sequencing strategies. (B) The best sequence for reducing the composite of heart failure hospitalization and cardiovascular death was the accelerated sequence of SGLT2i/MRA/ARNI/beta-blocker within 12 weeks. (C) Six different sequencing strategies starting with combination therapy. (D) The best sequencing for reducing the composite endpoints was the sequence starting with the combination of SGLT2i plus MRA, followed by an ARNI and then beta-blocker. * ARNI can be prescribed when systolic blood pressure ≥ 100 mmHg. ARNI, angiotensin receptor-neprilysin inhibitor; BB, beta-blocker; CV, cardiovascular; HHF, heart failure hospitalization; MRA, mineralcorticoidreceptor antagonist; RASi, renin-angiotensin system inhibitor; SGLT2i, sodium-glucose co-transporter 2 inhibitor.
Figure 4
Figure 4
Conventional sequencing and rapid sequencing strategies for HFsrEF. With the rapid sequencing strategy, all 4 classes of foundational therapies can be provided in 4 weeks. SBP, systolic blood pressure; W, week; other abbreviations as in Figure 3.
Figure 5
Figure 5
Treatment algorithm for HFrEF. (A) Efficacy of foundational therapy in full spectrum of LVEF. The tapering of the horizontal blue bar suggests decreasing in efficacy in reducing heart failure endpoint. (B) Strategy for in-hospital initiation of foundational therapies for HFsrEF. (C) Role of additional therapy for HFsrEF. Abbreviations as in Figure 2 and 3.
Figure 6
Figure 6
Treatment algorithm for HFpEF. We recommend in-hospital initiation with combination therapy. Abbreviations similar to those in Figure 3 and Figure 4.
Figure 7
Figure 7
Clinical course of worsening heart failure. After each episode of worsening heart failure (WHF), the left ventricular function does not completely recover to the level before WHF, and the interval between each episode of WHF becomes shorter, resulting in more frequent heart failure hospitalization or urgent heart failure visit. LV, left ventricle.
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