Friday, February 11, 2022

2021 ESC guidelines for the diagnosis and treatment of acute and chronic hear failure: the “ Ten Commandments “

 Quick Takes

  • The ESC published guidelines for the diagnosis and treatment of acute and chronic heart failure in 2021. This article summarizes the guidelines by identifying 10 key points in the treatment of heart failure with reduced ejection fraction.
  • AHA/ACC Heart Failure Guidelines will be released later in 2022.

Using the European Society of Cardiology's (ESC) 2021"Ten Commandments" for the treatment of heart failure (HF) with reduced left ventricular ejection fraction (LVEF)1 provides a succinct summary treatment standard for clinicians. Treating patients with acute or chronic HF is complex, and the "Ten Commandments" highlights the most important components that should be considered, especially the use of medications and treatments. The use of the term "Commandments" in the title suggests that guidelines are not just suggestions, but standard of quality care. New American College of Cardiology (ACC)/American Heart Association (AHA) Heart Failure Guidelines will be released in 2022.

Some important takeaways from the ESC's "Ten Commandments" include:

  1. Medications are the cornerstone to reducing mortality and HF hospitalizations for all patients with HF with reduced ejection fraction. ECS recommends an angiotensin-converting enzyme inhibitor or angiotensin receptor neprilysin inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist, and a sodium-glucose co-transporter 2 inhibitor.
  2. Cardiac resynchronization therapy is recommended for patients with a left bundle branch block (LBBB) and QRS duration >150ms with an ejection fraction of <35% who are in normal sinus rhythm.
  3. In patients with LVEF <35% an implantable cardioverter-defibrillator is recommended in cases with ischemic etiology and should be considered for those with non-ischemic cardiomyopathy.
  4. Heart transplant is recommended in selected patients with advanced HF refractory to medical therapy. Mechanical circulatory support should be considered.
  5. Treatment for acute HF should include treatment of underlying cause, diuretics, vasodilators, inotropes, vasopressors, short-term mechanical support, and renal replacement therapy.
  6. A pre-discharge visit and early follow-up, at 1-2 weeks following discharge, is recommended to assess for signs of congestion, drug tolerance and start and/or up-titrate evidence-based therapies. 
  7. Patients with HF should be periodically screened for anemia and iron deficiency. Intravenous iron supplementation with ferric carboxymaltose should be considered if the serum ferritin is <100 ng/mL or if the serum ferritin is 100–299 ng/mL.
  8. Patients with atrial fibrillation that is associated with worsening symptoms should be considered for pulmonary vein isolation.
  9. Patients with HF and secondary mitral regurgitation need to be evaluated for possible percutaneous edge-to-edge mitral valve repair.
  10. Patients who are >65 years and increased left ventricular wall thickness should be screened for cardiac amyloidosis. Treatment with tafamidis is recommended for patients with New York Heart Association class I or II.


  1. Adamo M, Gardner RS, McDonagh TA, Metra M. The "Ten Commandments" of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;Dec 18:[Epub ahead of print].


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