Heart Failure Guidelines Update: What the ESC Got Right

Ileana L. Piña, MD, MPH


September 08, 2023

This transcript has been edited for clarity.

Hello. I'm Ileana Piña. I'm a professor of medicine at Thomas Jefferson University Hospital. This is my usual blog, except I am here from the absolutely beautiful city of Amsterdam, where the European Society of Cardiology (ESC) 2023 meeting has been going on.

SGLT2 Inhibitors for HFpEF and HFrEF

I'm going to review very briefly the 2023 focused update to the ESC heart failure guidelines. Theresa McDonagh was the first author of this and of the previous ESC or European guidelines. These are a little bit different than the American guidelines, which were presented in 2022. We know that we need an update. The Europeans have gotten ahead of us, and now we have the European update, which I find incredibly well written and it really highlights the areas that I think the takeaways are for the clinicians.

First, we have been seeing now for several years — since 2018 — the benefits of the sodium-glucose cotransporter 2 (SGLT2) inhibitors. Every time we lift the veil on something, there they are in a positive light. We have learned about heart failure with reduced ejection fraction (HFrEF) for both empagliflozin and dapagliflozin. There are very similar results. One population may be enriched with a little of this and a little of that, but the basic messages are the same. In HFrEF, both of these drugs improve outcomes and it happens quickly. You don't have to wait 1 or 2 years to see this. Within months, and actually within days, you start to see the curves split apart statistically.

The next logical ground was heart failure with preserved ejection fraction (HFpEF). The definition, when we started the HFpEF trials, was 45% or greater. I want the audience to realize that, in the midst of all these trials, we came out — we meaning the American Heart Association, the American College of Cardiology, and the Heart Failure Society — with the new definition of heart failure, which said that true HFpEF is 50% or greater. That in-between zone of 40%-50% or 41%-49% is mRF, or mid-range, what I call middle of the road. I think the Europeans have really emphasized that to us. I believe that those patients really behave much more like a HFrEF population.

Now that we have very positive findings with the SGLT2 inhibitors, both dapagliflozin and empagliflozin, in HFpEF — defined, as I said, as 40% or 45% or greater, not necessarily 50% —with excellent point estimates that just line up, one on top of the other. It doesn't matter if patients have diabetes or not; the results are exactly the same.

This has been so promising that I am not surprised that the Europeans elevated the SGLT2 inhibitors to a class 1A indication. In the US in 2022, we thought we were really way ahead by calling it a class 2A indication. Well, now it's a class 1A indication in Europe, and I have a feeling that the American Heart Association and the American College of Cardiology are going to start talking about an update because the data are so strong.

Now, we even have data on initiating these drugs in the hospital. EMPULSE was a very large trial, presented here, about the benefits of starting these drugs in the hospital. You do not have to wait until the patient is in the outpatient setting. You can start it in the hospital.

When? I have no specific day that I start it. I used to try to do a good diuresis first, get the patients somewhat decongested, and then start it. I don't want to deprive the patients of the benefits of these drugs that happen very early by waiting until the patients are in the outpatient setting.

In the United States, we've had some issues with coverage of some of these drugs. In my institution, we now have both on the formulary, and I pick the drug depending upon the patient's coverage. Medicare pretty much covers most of them. If the patient is older but not yet a Medicare patient, they may have a very large copay. I advise you to get your offices or your health system to look into this so that, when you give the prescription to the patient, whether they're leaving the hospital or are now in your clinics, they can actually get the drug.

Finerenone and Intravenous Iron

There is an additional recommendation in these guidelines for finerenone, the mineralocorticoid receptor agonist (MRA) that I've discussed before on this blog, that has some really promising data on type 2 diabetes with chronic kidney disease (CKD). They have called that a class 1A indication for finerenone. I think there is more to come.

One more: the iron deficiency. Giving intravenous (IV) iron actually does improve symptoms and quality of life. I have seen this in my own patients, so I have been very diligent at looking for iron deficiency.

It is a new era. We have more tools, obviously, for our patients. It means one more drug, and that's always a challenge. We've already been doing the pillars of care. This is the fourth pillar of care, but now with a class 1A indication.

Take a look. They're easy to read. Professor McDonagh is the first author, and I think they've been extremely well done.

I hope this helps, and I am looking forward to future blogs on perhaps some of the findings from this meeting.

I'm Ileana Piña, signing off. Have a great day.

Ileana L. Piña, MD, MPH, is a heart failure and cardiac transplantation expert. She serves as an advisor/consultant to the FDA's Center for Devices and Radiological Health and has been a volunteer for the American Heart Association since 1982. Originally from Havana, Cuba, she is passionate about enrolling more women and minorities in clinical trials. She also enjoys cooking and taking spin classes.

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