2021 ESC Guidelines for heart failure diagnosis and treatment prioritise earlier, comprehensive disease management

Prof. Andrew Coats


Prof. Andrew Coats, President of the Heart Failure Association of the European Society of Cardiology

Despite significant advances in treatment and prevention, people living with heart failure (HF) continue to face unacceptably high rates of hospitalisation and death, along with a progressive, debilitating decline in their capacity for physical activity.1-3

As a cardiologist specialising in HF, I believe we have reached a turning point in our ability to change this picture. New insights into the drivers of HF allow us to fine-tune the application of therapeutics at our disposal. Our community recognises the urgency of putting these advances to prompt use, as demonstrated by the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic HF. The 2021 ESC Guidelines make clear that we have the means to diagnose and classify HF early, the tools to change its trajectory, and the duty to apply those tools proactively and intensively. 


Why are these heart failure updates needed?

HF is a leading cause of avoidable hospitalisations worldwide.3 The condition often progresses following hospitalisation, and with no available cure except for a heart transplant.4 This positions the treatment decisions made immediately following critically important for patient outcomes.5 Yet, it’s estimated that 50% of patients will be undertreated by 2023.6

The need for an agile, timely approach to HF care is at the centre of the 2021 ESC Guidelines and has been increasingly supported by real-world evidence.7

Since ESC’s last update five years ago, the 2021 ESC Guidelines factor in new evidence that has proven 1st-line therapies can be implemented during this critical time to help people with HF with reduced ejection fraction (HFrEF) manage this challenging disease.7


What has changed for patients with heart failure?

ESC is calling for a drastic change in treatment that moves away from lengthy sequential approaches of care to on-time strategies that focus on keeping people out of the hospital and from experiencing complications from HFrEF, such as diabetes and chronic kidney disease (CKD).7 The guidelines encourage an agile and timely approach to care, incorporating a simplified treatment algorithm focused on the early initiation of 1st-line treatment.7 This puts the patient first and is a significant step forward.

Based on the latest evidence, new classes of 1st-line therapies are now recommended to be administered as early as possible. Healthcare providers should also consider pre-existing conditions or co-morbidities and tailor HF treatment accordingly.7 The reality is that many patients are living with, or prone to developing multiple cardiorenal conditions and require individualised treatment.8


The significance of new 1st-line treatments

Regardless of the specific combination of HF treatments needed for an individual patient, the most important recommendation in the 2021 ESC Guidelines is initialising treatment in the shortest time possible and personalising the approach based on any other conditions the patient might have.

The classes of medicines recommended by the 2021 ESC Guidelines can be easily and quickly integrated into a person’s treatment protocol and can also eliminate the need for titration.7

Considering approximately 40% of patients with HF also have CKD or diabetes,8 the significance of recommending the use of new 1st-line treatments underscores the importance of managing multiple risks, and recognises the connections science is uncovering across CV, metabolic and renal diseases.

These updates indicate a radical shift in the way we must treat and manage HF and encourage a patient-centric, tailored approach that focuses on saving lives.


1.       Savarese G, et al. Global Public Health Burden of Heart Failure. Card Fail Rev. 2017;3(1):7-11.
2.       Mayo Clinic [Internet]. Heart failure; 2021 [cited 2021 Aug 25]. Available from: https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142.
3.       World Heart Federation. [Internet]. Accelerate Change Together: Heart Failure Gap Review; 2020 [cited 2021 Aug 25]. Available from: https://world-heart-federation.org/wp-content/uploads/HF-Gap-Review-Final.pdf.
4.       Solomon SD, et al. Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure. Circulation. 2007;116:1482-7.
5.       Garbade J, et al. Heart transplantation and left ventricular assist device therapy: Two comparable options in end-stage heart failure? Clin Cardiol 2013; 36(7):378–82.
6.       AstraZeneca PLP. Data on File. August 2021.
7.       European Society of Cardiology [Internet]. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Available from: https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehab368.
8.       Savarese G, et al. Heart failure drug titration, discontinuation, mortality and heart failure hospitalization risk: a multinational observational study (US, UK and Sweden). Eur J Heart Fail. 2021; doi: 10.1002/ejhf.2271. Epub ahead of print. PMID: 34132001.
9.       European Society of Cardiology [Internet]. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Available from: https://academic.oup.com/eurheartj/article/37/27/2129/1748921.
10.     Shiba N, Shimokawa H. Chronic kidney disease and heart failure--Bidirectional close link and common therapeutic goal. J Cardiol 2011; 57(1):8–17

Veeva ID: Z4-37011
Date of preparation: August 2021