The aim of the updated 2021 European Society of Cardiology (ESC) heart failure guidelines is to help health care professionals manage people with cardiac failure according to the best available evidence. There is now a wealth of clinical trial data to help select the best management to improve outcomes for people with heart failure; for many, it is now both a preventable and treatable condition. This paper reviews the new advice on lifestyle, rehabilitation, remote monitoring, and the use of devices in this patient population.
Introduction
The 2021 European Society of Cardiology Congress saw the release of an update of the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure (HF).1 This timely and comprehensive new set of guidelines is particularly noteworthy because of its inclusion of the Patient Forum as full members of the task force; a first for ESC HF guidance.
HF management programmes
Evident within the updated guidance is an emphasis on putting patients at the centre of HF care and empowering them to take ownership of their condition. Since the 2016 ESC HF guidelines2 were published, a growing body of evidence has placed increasing importance on multidisciplinary heart failure management programmes (HFMPs) throughout the patient journey,3,4 from diagnosis to end of life. Central to these HFMPs should be a patient-centred approach that considers the patient in a holistic manner rather than one that focusses only on HF management.4,5 The ESC guidelines highlight specific characteristics of a HFMP (class I recommendation) with an expanded list which includes:
- the provision of psychosocial support to patients
- follow-up after discharge with easy access to healthcare
- assessment of changes to weight, nutritional and functional status
- assessment of sleep disturbance and psychosocial problems.
Moreover, recognition is made of the benefits derived from integrating palliative and supportive care services early in the patient journey, regardless of the stage of illness. This is of relevance for the UK where regional discrepancies remain in the provision of HF services and, specifically, integration with palliative care.
Lifestyle
Patient education is key in facilitating patient autonomy and promoting self-care and management of HF. This, in turn, results in better quality of life, lower readmission rates and reduced mortality.4 Education should not be limited to explanations about HF and disease trajectory but should incorporate lifestyle management advice on sleep, exercise, fluid management, diet, alcohol, immunisation, smoking cessation, travel and sexual activity. Guidance on symptom monitoring and self-management of medications, including adjustment of diuretic doses, is outlined, an area that is often missed in time-pressured outpatient services. The psychosocial impact of living with HF is emphasised and the focus expanded to include the supporting of family and carers, with onward referral to specialist services as needed. Patient education is resource intensive and approaches need to be flexible, taking into account barriers to communication alongside educational grade, health literacy and patients’ wishes.
Rehabilitation
The guidelines propose exercise for all capable patients with HF to improve exercise capacity, quality of life and reduce HF hospitalisations (class I recommendation). For those with more severe disease, frailty, or co-morbidities, a supervised, exercise-based cardiac rehabilitation programme should also be considered (class IIa recommendation). Uncertainty remains on the effects of exercise on mortality, but the new guidance acknowledges that exercise training improves exercise tolerance and quality of life while meta-analyses show reduced all-cause and HF hospitalisations.6,7 Within the UK, there remains an unmet need in cardiac rehabilitation. Data from the National Heart Failure Audit indicate that only 13.3% of patients are referred for rehabilitation during hospitalisation, although this figure does not capture patients referred by outpatient services and community teams.8
Telemonitoring
In the last five years, telemonitoring has gained increasing importance within HF care. The COVID-19 pandemic has accelerated its use and implementation. Information on symptoms, weight, heart rate and blood pressure can be used to guide therapy remotely. Numerous home monitoring/telemonitoring systems exist with different mediums available for patient sharing of data. Despite the heterogeneity in trials using such technology, a 2017 Cochrane review found that home telemonitoring was associated with a 20% reduction in all-cause mortality and a 37% reduction in HF hospitalisations.9
The global pandemic has changed clinical practice forever in the UK. For many elderly co-morbid patients, the management of HF without face-to-face consultation has proved challenging. It has, however, required HF services to evolve and develop at a pace far faster than might have otherwise been achieved. The adoption of multiple virtual or wireless technologies, some of which were already available (e.g. HF algorithms on implantable devices) may facilitate clinical management, reduce physical attendances at hospital, and further enable and promote patient-directed self-care. The 2021 ESC guidance recognises the potential benefits of telemonitoring and notes that telemonitoring devices should be considered for patients with HF as part of their overall management programme.
Device therapy
The updated 2021 guidance evaluates the current evidence base and associated uncertainties with device therapy (table 1). Implantable cardioverter-defibrillator (ICD) therapy remains a class I indication for secondary prevention and for primary prevention in patients with ischaemic cardiomyopathy and a left ventricular ejection fraction (LVEF) ≤35% despite ≥3 months optimal medical therapy (OMT), in those who are expected to survive for more than one year. The guidance, however, recognises that the evidence for ICD therapy in primary prevention in those with a non-ischaemic aetiology is not as strong and has downgraded the class of recommendation from Ia to IIa. This is largely based on the results of the DANISH (Danish Study to Assess the Efficacy of ICDs in Patients with Non-ischemic Systolic Heart Failure on Mortality) trial, where rates of sudden death were low in patients with non-ischaemic aetiology.10,11
Table 1. Recommendations for device therapy and class of recommendation/level of evidence in the 2021 ESC guidance1 (Indications in bold represent a change from 2016 guidance2)
| ICD recommendations | Class of recommendation (level of evidence) | CRT recommendations | Class of recommendation (level of evidence) |
|---|---|---|---|
| Recommended for secondary prevention in patients who have recovered from a ventricular arrhythmia causing haemodynamic instability, and who are expected to survive for >1 year with good functional status, in the absence of reversible causes or unless the ventricular arrhythmia has occurred <48 h after an MI | I (A) | Recommended for symptomatic patients with HF in SR with a QRS duration ≥150 ms and LBBB QRS morphology and with LVEF ≤35% despite OMT to improve symptoms and reduce morbidity and mortality | I (A) |
| Recommended for primary prevention in patients with symptomatic HF (NYHA class II-III) of an ischaemic aetiology (unless they have had an MI in the prior 40 days, and an LVEF ≤35% despite ≥3 months of OMT, provided they are expected to survive substantially longer than 1 year with good functional status) | I (A) | CRT rather than RV pacing is recommended for patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high degree AV block to reduce morbidity. This includes patients with AF | I (A) |
| An ICD should be considered for primary prevention in patients with symptomatic HF (NYHA class II-III) of a non-ischaemic aetiology, and an LVEF ≤35% despite ≥3 months of OMT, provided they are expected to survive substantially longer than 1 year with good functional status | IIa (A) | CRT should be considered for symptomatic patients with HF in SR with a QRS duration ≥150 ms and non-LBBB QRS morphology and with LVEF ≤35% despite OMT to improve symptoms and reduce morbidity and mortality | IIa (B) |
| CRT should be considered for symptomatic patients with HF in SR with a QRS duration of 130–149 ms and LBBB QRS morphology and with LVEF ≤35% despite OMT to improve symptoms and reduce morbidity and mortality | IIa (B) | ||
| Patients with an LVEF ≤35% who have received a conventional pacemaker or an ICD and subsequently develop worsening HF despite OMT, and who have a significant proportion of RV pacing, should be considered for ‘upgrade’ to CRT | IIa (B) | ||
| CRT may be considered for symptomatic patients with HF in SR with a QRS duration of 130–149 ms and non-LBBB QRS morphology and with LVEF ≤35% despite OMT to improve symptoms and reduce morbidity and mortality | IIb (B) | ||
| Compiled from data in McDonagh TA et al.1 with permission Key: AF = atrial fibrillation; AV = atrioventricular; CRT = cardiac resynchronisation therapy; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; ICD = implantable cardioverter defibrillator; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; MI = myocardial infarction; NYHA= New York Heart Association; OMT= optimal medical therapy; RV = right ventricular; SR = sinus rhythm |
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In all large randomised trials of cardiac resynchronisation therapy (CRT), QRS width was included within the inclusion criteria and predicted CRT response.12 Patients with left bundle branch block (LBBB) morphology are more likely to respond to CRT than non-LBBB morphology13 although patients with LBBB are also more likely to have a wider QRS width. Individual patient data meta-analyses indicate that when accounting for QRS width, there is little evidence to suggest that QRS morphology influences the effect of CRT on morbidity or mortality.12,14 Compared to the 2016 guidance, the 2021 guidance has therefore changed the class of recommendation from I to IIa for CRT therapy in those with a QRS duration of 130–149 ms, LBBB morphology and a LVEF ≤35%.
Finally, another relevant change is that patients with LVEF ≤35%, a high burden of right ventricular pacing and worsening HF, should be considered for an ‘upgrade’ to CRT (change in level of recommendation from IIb to IIa). The evidence base for this remains limited and therefore the change in class of recommendation remains marginal.
Discussion
The latest 2021 ESC HF guidance goes some way towards laying the foundations of a comprehensive HFMP and recognises the importance of a patient-centred holistic approach with the patient actively involved in the management of their own condition. There is recognition of the mounting evidence base of the importance of multidisciplinary management of HF patients and this is directly relevant in the UK, where results from the 2018 UK Heart Failure Specialist Nurse (HFSN) audit report that less than half of HFSNs had access to an MDT with a physician with a subspecialty in heart failure.15
Since the publication of the 10 recommendations to improve HF care in England in 2016 by the All-Party Parliamentary Group on Heart Disease, the focus has been on reducing disparity in access to HF services, integrating services and ensuring equitable provision of community services including exercise-based cardiac rehabilitation programmes.16 In 2019, HF was included as a priority in the NHS Long Term Plan for England17 but unfortunately, as with most other services, this ground to a halt during the COVID-19 pandemic. Even though NICOR data indicate that survival in chronic HF has improved, one third of patients not admitted to a cardiology ward still do not see a HF specialist and only 41% of patients are recorded as having appropriate follow-up in place on discharge.8
The pandemic has allowed us to practise using different models of care and the evidence thus far is that no particular service model has been shown to be consistently superior than another.18 We should embrace the positives that virtual consultations afford, particularly embedding technological advances that will facilitate this and allow medication optimisation and patient-led care. At the same time HF services must ensure equitable care for all and face to face consultations must be available wherever needed. A hybrid model of working will require the necessary resources together with greater integration between primary and secondary care so that patient information can be shared, reviewed, interpreted and actioned appropriately and in a timely manner.
Conclusion
Aside from a significantly increased armoury of medical and device therapy for use in patients with HF, we readily collect real world HF data and compare against key performance indicators. With the publication of this updated guidance and as we restart our health care services after a temporary pause during the pandemic, now is the ideal opportunity to transform our heart failure care in line with the NHS Long Term Plan. This will require adequately resourced, multidisciplinary teams working across primary care networks to provide equitable, clearly defined, and integrated pathways for HF patients.
Key messages
- Updated guidance puts patients at the centre of heart failure (HF) care and empowers them to take ownership of their condition
- Education on lifestyle is a key factor facilitating patient autonomy
- Adoption of multiple virtual or wireless technology monitoring and implantable devices is integral to HF management programmes
Funding
None.
Conflicts of interest
SH: none declared. RL has previously received lecturing fees from Boston Scientific.
Savvas Hadjiphilippou
Cardiology Registrar
Rebecca Lane
Consultant Cardiologist
Royal Brompton and Harefield Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH
Articles in this supplement
Introduction
New developments in the investigations and diagnosis of heart failure
Drug therapy in heart failure – an update from the 2021 ESC heart failure guideline
References
1. McDonagh TA, Metra M, Adamo M et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42:3599–726. https://doi.org/10.1093/eurheartj/ehab368
2. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016;37:2129–200. https://doi.org/10.1093/eurheartj/ehw128
3. Van Spall HGC, Rahman T, Mytton O et al. Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis. Eur J Heart Fail 2017;19:1427–43. https://doi.org/10.1002/ejhf.765
4. Jonkman NH, Westland H, Groenwold RHH et al. What are effective program characteristics of self-management interventions in patients with heart failure? An individual patient data meta-analysis. J Card Fail 2016;22:861–71. https://doi.org/10.1016/j.cardfail.2016.06.422
5. Kalogirou F, Forsyth F, Kyriakou M, Mantle R, Deaton C. Heart failure disease management: a systematic review of effectiveness in heart failure with preserved ejection fraction. ESC Heart Fail 2020;7:194–212. https://doi.org/10.1002/ehf2.12559
6. Taylor RS, Long L, Mordi IR et al. Exercise-based rehabilitation for heart failure: Cochrane Systematic Review, meta-analysis, and trial sequential analysis. JACC Heart Fail 2019;7:691–705. https://doi.org/10.1016/j.jchf.2019.04.023
7. Flynn KE, Piña IL, Whellan DJ et al. Effects of exercise training on health status in patients with chronic heart failure HF-ACTION randomised controlled trial. JAMA 2009;301:1451–9. https://doi.org/10.1001/jama.2009.457
8. NICOR. National Heart Failure Audit (NHFA), 2021 Summary Report (2019/20 data). https://www.nicor.org.uk/wp-content/uploads/2020/12/National-Heart-Failure-Audit-2020-FINAL.pdf (last accessed 28th February 2022)
9. Lin MH, Yuan WL, Huang TC, Zhang HF, Mai JT, Wang JF. Clinical effectiveness of telemedicine for chronic heart failure: A systematic review and meta-analysis. J Investig Med 2017;65:899–911. https://doi.org/10.1136/jim-2016-000199
10. Beggs SAS, Jhund PS, Jackson CE, McMurray JJV, Gardner RS. Non-ischaemic cardiomyopathy, sudden death and implantable defibrillators: A review and meta-analysis. Heart 2018;104:144–50. https://doi.org/10.1136/heartjnl-2016-310850
11. Køber L, Thune JJ, Nielsen JC et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med 2016;375:1221–30. https://doi.org/10.1056/nejmoa1608029
12. Cleland JG, Abraham WT, Linde C et al. An individual patient meta-analysis of five randomized trials assessing the effects of cardiac resynchronization therapy on morbidity and mortality in patients with symptomatic heart failure. Eur Heart J 2013;34:3547–56. https://doi.org/10.1093/eurheartj/eht290
13. Cunnington C, Kwok CS, Satchithananda DK et al. Cardiac resynchronisation therapy is not associated with a reduction in mortality or heart failure hospitalisation in patients with non-left bundle branch block QRS morphology: Meta-analysis of randomised controlled trials. Heart 2015;101:1456–62. https://doi.org/10.1136/heartjnl-2014-306811
14. Woods B, Hawkins N, Mealing S et al. Individual patient data network meta-analysis of mortality effects of implantable cardiac devices. Heart 2015;101:1800–6. https://doi.org/10.1136/heartjnl-2015-307634
15. Pumping Marvellous. UK Heart Failure Nurse Audit 2018 – Heart Failure Foundation. https://www.pumpingmarvellous.org/uk-heart-failure-nurse-audit-2018/ (last accessed 9th February 2022)
16. British Heart Foundation. All-Party Parliamentary Group (APPG) on Heart Disease. Focus on heart failure. September 2016. https://www.bhf.org.uk/informationsupport/publications/focus-on-heart-failure-appg-report# (last accessed 9th February 2022)
17. NHS England. NHS Long Term Plan, 2019. https://www.longtermplan.nhs.uk (last accessed 9th February 2022)
18. Takeda A, Martin N, Taylor RS, Taylor SJC. Disease management interventions for heart failure. Cochrane Database Syst Rev 2019;1(1): CD002752. https://doi.org/10.1002/14651858.CD002752.pub4
