2023 ESC Focused Update on Heart Failure

What's New from 2021 ESC Guidelines

The 2023 Focused Update incorporates major new trial evidence that shifts recommendations for HF management, particularly for HFmrEF and HFpEF, and expands comorbidity management.

Topic	2021 ESC Guideline	2023 Update
SGLT2i in HFmrEF	Not routinely recommended	Class I, LOE A — now pillar therapy 1
SGLT2i in HFpEF	Could be considered	Class I, LOE A — strong recommendation 1
Acute HF SGLT2i	No acute data	EMPULSE: empagliflozin beneficial in acute HF 1
Finerenone in CKD	Not covered	FIDELIO-DKD & FIGARO-DKD: new MRA option 1
Iron deficiency	Limited guidance	IRONMAN: IV iron supplementation recommended 1
Acute HF discharge	Standard care	STRONG-HF: intensive uptitration before discharge 1
CKD/T2DM prevention	Standard therapies	DAPA-CKD & EMPA-KIDNEY: SGLT2i for HF prevention 1

Key Insight: The 2023 update positions SGLT2 inhibitors as foundational pillar therapy across all HF phenotypes (HFrEF, HFmrEF, HFpEF), both in chronic and acute settings. New trials also expand the HF drug armamentarium to include finerenone and intravenous iron supplementation.

Heart Failure Classification by Ejection Fraction

The 2023 update retains the three-category classification from the 2021 guidelines (HFrEF, HFmrEF, HFpEF) based on LVEF thresholds and symptom status.

HF Type	LVEF	Key Criteria	Diagnostic Features
HFrEF	≤40%	Symptoms ± signs	LV systolic dysfunction; multiple therapies reduce mortality/morbidity
HFmrEF	41–49%	Symptoms ± signs	LV structural/functional abnormalities OR elevated natriuretic peptides
HFpEF	≥50%	Symptoms ± signs	Objective evidence of LV dysfunction or elevated filling pressures

Critical Reminder: HFmrEF diagnosis requires both symptom criteria AND documented LV dysfunction OR elevated natriuretic peptides (NT-proBNP >125 pg/mL). Do not diagnose HFmrEF on LVEF 41–49% alone.

Chronic Heart Failure Management

HFmrEF (LVEF 41–49%)

The 2023 update now recommends SGLT2 inhibitors as pillar therapy for HFmrEF, mirroring the evidence base from HFrEF trials. Both dapagliflozin and empagliflozin are supported by Class I, LOE A recommendations.

Management Algorithm for HFmrEF

Diuretics for fluid retention: First-line for symptom relief. Titrate to euvolemia. 1

SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily): Recommended to reduce HF hospitalization or CV death. 1

ACE-I/ARNi/ARB: Consider for additional CV benefit in patients with hypertension or other indications. 2a

MRA (spironolactone/eplerenone): May be considered for additional benefit in selected patients. 2b

Beta-blocker: May be considered for HR control or hypertension. 2b

SGLT2i Evidence in HFmrEF: Dapagliflozin (DELIVER trial) and empagliflozin (EMPEROR-Preserved trial) both demonstrated significant reduction in HF hospitalization or CV death. The relative risk reduction was comparable to HFrEF trials, supporting Class I recommendation.

HFpEF (LVEF ≥50%)

HFpEF management is now anchored by SGLT2 inhibitors. Symptom control, comorbidity management, and treatment of underlying causes remain essential.

Management Algorithm for HFpEF

Diuretics for fluid retention: First-line for symptom relief. Titrate to euvolemia and normal JVP. 1

SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily): Recommended to improve symptoms and reduce HF hospitalizations. 1

Treatment of aetiology and comorbidities: Aggressive BP control (<130/80 mmHg), AF management, diabetes control. 1

DO — HFpEF Management Priorities

Start SGLT2 inhibitor early (dapagliflozin 10 mg or empagliflozin 10 mg daily)
Aggressively control hypertension to <130/80 mmHg
Screen for and manage atrial fibrillation
Optimize diabetes control if present
Screen and manage sleep apnea (CPAP if OSA)
Encourage weight loss if overweight (target BMI <25 kg/m²)

DON'T — Common HFpEF Mistakes

Don't use beta-blockers as monotherapy; always add SGLT2i
Don't ignore elevated BP; aggressive control is essential
Don't miss atrial fibrillation; screen with ECG and Holter
Don't delay diuretics if volume-overloaded
Don't assume HFpEF is "benign"—morbidity and mortality remain significant

SGLT2 Inhibitors as Pillar Therapy

SGLT2 inhibitors are now recommended as first-line therapy across all HF phenotypes. Key dosing and safety guidance:

Agent	Dosing	Contraindications	Monitoring
Dapagliflozin	10 mg daily (5 mg if eGFR 30–44)	eGFR <20 (caution), Type 1 DM, DKA	eGFR, urine glucose, genital infections
Empagliflozin	10 mg daily	eGFR <20 (caution), Type 1 DM, DKA	eGFR, urine glucose, genital infections

Use the GDMT Optimizer Calculator to sequence and titrate HF medications according to renal function and clinical status.

SGLT2i Safety: Do not initiate SGLT2i in patients with Type 1 diabetes or active DKA. Exercise caution if eGFR <20 mL/min/1.73m². Educate patients about genital infections and rare euglycemic DKA risk.

Acute Heart Failure Management

Diuretics in Acute Decompensated HF

Intravenous diuretics remain first-line for acute HF volume overload. Recent trials refine optimization strategies.

Strategy	Evidence	Class
IV loop diuretics (furosemide, torsemide)	First-line for volume overload. Titrate to euvolemia. Higher doses if eGFR <30.	1
Acetazolamide (adjunctive)	ADVSOR trial: add to IV loop diuretic for improved congestion and symptom relief, especially if COPD/hypokalemia.	2a
Hydrochlorothiazide (adjunctive)	CLOROTIC trial: add to loop diuretic for additional diuretic efficacy.	2b

Acute HF SGLT2 Inhibitors (EMPULSE Trial)

NEW in 2023: EMPULSE trial demonstrated that empagliflozin started early in acute HF hospitalization reduces symptom scores and improves diuretic response.

DO — Acute HF SGLT2i Strategy

Initiate SGLT2 inhibitor early during acute HF hospitalization (if eGFR >20)
Use dapagliflozin 10 mg or empagliflozin 10 mg as add-on to IV diuretics
Continue SGLT2i into discharge and post-discharge period
EMPULSE trial: empagliflozin reduced symptom burden at 21 days vs. placebo (HR 0.86)

Acute HF Admission Phase (COACH Algorithm)

COACH trial developed a stepped intervention for early risk stratification and discharge planning in acute HF.

COACH Risk Assessment (Days 1–3)

Step 1: Assign low, intermediate, or high 30-day risk using clinical/lab variables and BNP/NT-proBNP (>250 pg/mL = higher risk).

Step 2 — Low/Intermediate Risk: Standard outpatient follow-up; discharge after clinical stabilization.

Step 3 — High Risk: Consider longer hospitalization or intensive post-discharge monitoring (home health, telemonitoring).

Step 4 — Outcome: COACH showed 12% reduction in 30-day all-cause death or HF readmission in high-risk cohort.

Pre-discharge & Early Post-discharge Phase (STRONG-HF)

STRONG-HF trial demonstrated that intensive rapid uptitration of HF drugs before discharge with close early follow-up reduces HF rehospitalization and CV death by ~26%.

STRONG-HF Protocol

Rapid uptitration (in-hospital): Start/uptitrate target doses of ACE-I/ARNi, beta-blocker, MRA before discharge. Aim for ≥50% target dose by day 4–6. 1

Early follow-up visits: Schedule at weeks 1, 2, 3, and 6 post-discharge. Uptitrate to full target doses. 1

Close monitoring: Frequent clinical assessment, NT-proBNP, eGFR, K+ checks early post-discharge to detect deterioration.

Outcome: Primary endpoint (first HF readmission or CV death) reduced 26% at 6 months (HR 0.74; P <0.001).

Key STRONG-HF Insight: Intensive, rapid-uptitration strategy before discharge with close post-discharge follow-up is now Class I. This represents a paradigm shift toward aggressive optimization at hospital discharge. Safe if baseline eGFR >30 and K+ normal.

Use the HF Hospitalization Risk Calculator to stratify acute HF patients and guide discharge and early follow-up intensity.

Comorbidity Management in Heart Failure

Chronic Kidney Disease & Type 2 Diabetes

CKD and T2DM are present in >50% of HF patients. New trials (DAPA-CKD, EMPA-KIDNEY, FIDELIO-DKD, FIGARO-DKD) support proactive HF and kidney disease prevention with SGLT2i and finerenone.

SGLT2 Inhibitors in CKD

DAPA-CKD and EMPA-KIDNEY trials demonstrated that SGLT2i reduce HF hospitalizations, CV death, and kidney disease progression in CKD patients, even without diabetes.

Agent & Trial	Key Criteria	Outcome	Class
Dapagliflozin (DAPA-CKD)	eGFR 25–75; ACR ≥200 mg/g	29% reduction in kidney disease progression/CV death/HF hosp. HF risk ↓26% (HR 0.74)	1A
Empagliflozin (EMPA-KIDNEY)	eGFR 20–45; or ≥45 with ACR ≥200	39% reduction in kidney disease/CV death. HF hosp ↓31% (HR 0.71)	1A

DO — SGLT2i in CKD

Prescribe SGLT2i (dapagliflozin 10 mg or empagliflozin 10 mg daily) to all CKD patients with or without T2DM, eGFR 20–75
DAPA-CKD and EMPA-KIDNEY demonstrate HF hospitalization reduction of ~26–31%
SGLT2i are now first-line preventive therapy for HF in CKD, independent of diabetes
Monitor eGFR and K+ at baseline, 1–2 weeks, then regularly (transient eGFR dip common in first 2 weeks)

Finerenone in CKD (FIDELIO-DKD & FIGARO-DKD)

Finerenone is a nonsteroidal MRA that reduces kidney disease progression and CV events in CKD/T2DM patients, offering an alternative to spironolactone/eplerenone.

Trial	Population	HF Hospitalization Reduction	Class
FIDELIO-DKD	CKD + T2DM; eGFR 25–90	32% reduction (HR 0.68; 95% CI 0.53–0.88)	1A
FIGARO-DKD	CKD + T2DM; eGFR 25–90	Consistent HF hosp reduction vs. placebo	1A

DO — Finerenone in CKD/T2DM

Consider finerenone 10 mg daily in CKD patients with T2DM for kidney disease progression prevention and HF hospitalization reduction
Finerenone can be alternative to spironolactone/eplerenone if additional renal protection desired
Combine with SGLT2i for synergistic kidney and CV protection
Monitor K+ and eGFR; K+ rise typically modest vs. traditional MRAs

Finerenone vs. Spironolactone: Finerenone offers selective MRA activity without significant potassium/hormonal side effects. In CKD/T2DM patients on SGLT2i + ACE-I/ARNi, finerenone may be preferred due to lower hyperkalemia risk and additional renal benefits. Either agent can be used based on clinical context.

Estimate renal function: CKD-EPI eGFR | Cockcroft-Gault CrCl

Iron Deficiency in Heart Failure (IRONMAN Trial)

Iron deficiency is present in 30–50% of HF patients and independently predicts poor outcomes. NEW: IRONMAN trial (2023) demonstrates IV iron supplementation improves symptoms and exercise capacity.

Parameter	Diagnostic Criteria / Recommendations
Iron Deficiency Definition	Ferritin <100 μg/L; OR ferritin 100–299 μg/L AND transferrin saturation <20%
Applies to	HFrEF, HFmrEF, and HFpEF with symptoms and iron deficiency
Intervention	IV iron supplementation (e.g., ferric carboxymaltose) to improve HF symptoms and exercise capacity 1
Iron Repletion Target	Ferritin >100 μg/L and/or transferrin saturation >20%

DO — Iron Supplementation in HF

Ferric carboxymaltose: 500–1000 mg IV; typical dose 500 mg at weeks 0 and 4 for repletion, then maintenance every 3–6 months
IRONMAN outcomes: IV iron improved QoL, 6-minute walk distance, NYHA class vs. placebo in HF + iron deficiency
Screen all HF patients for iron deficiency (ferritin, transferrin saturation) at baseline and annually
Prioritize IV iron in symptomatic HF + iron deficiency patients; do not await oral iron response
Monitor for hypophosphatemia (rare with ferric carboxymaltose)

Iron Deficiency in HF: Do not overlook iron deficiency. Ferritin <100 μg/L or transferrin saturation <20% is independent risk factor. Patients with ferritin 100–299 μg/L but low transferrin saturation (<20%) meet criteria for IV repletion and may benefit significantly.

Atrial Fibrillation in Heart Failure

AF is present in ~30% of HF patients and worsens outcomes. Stroke risk assessment and anticoagulation are essential.

DO — AF Management in HF

Assess stroke risk with CHA₂DS₂-VASc score in all HF + AF patients
Most HF + AF patients warrant anticoagulation (CHA₂DS₂-VASc ≥1 in males, ≥2 in females)
Assess bleeding risk with HAS-BLED score
Prefer rate control strategy (target HR <110 bpm at rest) with beta-blockers or rate-limiting CCB
Consider rhythm control in select HFrEF patients; refer for catheter ablation if appropriate

Related Calculators

These tools support risk stratification, medication optimization, and comorbidity management in HF patients.