2024 update in heart failure

Abstract

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Keywords: SGLT2 inhibitors; comorbidities; finerenone; heart failure; prevention; prognosis; treatment.

Figure 1

Main topics summarized in this review and key new evidence. AI, artificial intelligence; ANS, autonomic nervous system; ATTR‐CA, transthyretin cardiac amyloidosis; CIEDs, cardiac implantable electronic devices; CKD, chronic kidney disease; HCM, hypertrophic cardiomyopathy; HF, heart failure; ID, iron deficiency; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; M‐TEER, mitral transcatheter edge‐to‐edge repair; PAP, pulmonary artery pressure; PROs, patient‐reported outcomes; SGLT2i, sodium–glucose co‐transporter‐2 inhibitor; siRNA, small interference RNA; T‐TEER, tricuspid transcatheter edge‐to‐edge repair; TTR, transthyretin; TVI, transcatheter valve intervention; VHD, valvular heart disease.

Figure 2

Cardiovascular (CV) and kidney outcomes with sodium–glucose co‐transporter‐2 inhibitor (SGLT2i) and finerenone in patients with chronic kidney disease (CKD). ACR, albumin‐to‐creatinine ratio; CI, confidence interval; eGFR, estimated glomerular filtration rate; ESKD, end‐stage kidney disease; HF, heart failure; HFH, heart failure hospitalization; HR, hazard ratio; MI, myocardial infarction; RR, rate ratio; T2DM, type 2 diabetes mellitus. *ESKD, sustained decrease in eGFR to <10 mL/min/1.73 m², sustained decrease in eGFR of ≥40% from baseline or death from renal causes.

Figure 3

Novel evidence and indications for the treatment of iron deficiency. 6MWT, 6 min walk test; CI, confidence interval; CoR, Class of Recommendation; CV, cardiovascular; FCM, ferric carboxymaltose; FDM, ferric derisomaltose; HF, heart failure; HFH, heart failure hospitalization; HFmrEF, heart failure with mildly reduced ejection fraction; HFrEF, heart failure with reduced ejection fraction; ID, iron deficiency; LoE, Level of Evidence; LVEF, left ventricular ejection fraction; PROBE, prospective, randomized, open‐label, blinded endpoint; QoL, quality of life; RCTs, randomized controlled trials; RR, rate ratio.

Figure 4

Invasive device for haemodynamic pressure monitoring and main findings from trials. HFH, heart failure hospitalization; IVC, inferior vena cava; LAP, left atrial pressure; PAP, pulmonary artery pressure; QoL, quality of life.