Chronic Heart Failure: The "Four Pillars" of Therapy and ESC Algorithm

1. ESC Definition and Classification

NYHA Functional Classes

• I — no limitation of physical activity.
• II — shortness of breath with moderate exertion.
• III — with minimal exertion.
• IV — at rest.

2. Etiology

• Coronary artery disease (60–70% of cases).
• Arterial hypertension.
• Valvular heart disease.
• Cardiomyopathies (dilated, hypertrophic, restrictive).
• Myocarditis, toxic damage (alcohol, anthracyclines).
• Arrhythmias (tachyarrhythmia-induced CM), anemia, thyrotoxicosis, renal failure.

3. Pathogenesis

Initial myocardial injury → activation of SNS, RAS, ADH → compensatory responses (tachycardia, peripheral vasoconstriction, sodium/water retention) → progressive LV remodeling (dilation, hypertrophy) → fibrosis → ↓ EF and/or ↓ diastolic function → decompensation. Cytokine storm during exacerbations increases mortality.

4. Clinical presentation

• Dyspnea (inspiratory, progressive), orthopnea, paroxysmal nocturnal dyspnea.
• Fatigue, reduced exercise tolerance.
• Peripheral edema, hepatomegaly, ascites (right ventricular failure).
• Jugular venous distention, positive hepatojugular reflux.
• Basilar rales on auscultation, S3 gallop.
• Nocturia.

5. Diagnostics

• ECG — always performed (a normal ECG practically rules out HF with ↓ EF).
• BNP / NT-proBNP — key biomarker: BNP < 35 pg/mL or NT-proBNP < 125 pg/mL makes HF unlikely.
• Echocardiography — EF, chamber dimensions, diastolic function, valves, pulmonary artery pressure.
• Chest X-ray — cardiomegaly, signs of congestion.
• Cardiac MRI — "gold standard" for cardiomyopathies and myocarditis.
• Coronary angiography — when ischemic etiology is suspected.
• Laboratory tests: CBC, chemistry panel, ferritin/transferrin saturation (iron deficiency), TSH, urinalysis.

6. HFrEF Therapy: The ESC 2021 "Fantastic Four"

1. ARNI (sacubitril/valsartan) — replaces ACE inhibitors; reduces mortality and hospitalizations; starting dose 24/26 or 49/51 mg BID. If unavailable — ACE inhibitor (ramipril, enalapril, perindopril) or ARB.
2. Beta-blockers (bisoprolol, carvedilol, metoprolol succinate, nebivolol) — start low, uptitrate to target every 2 weeks.
3. MRAs (spironolactone or eplerenone) — reduce mortality in EF ≤ 35%; monitor potassium and creatinine.
4. SGLT2 inhibitors (dapagliflozin, empagliflozin) — benefit regardless of diabetes status.

All four classes are prescribed simultaneously in low doses, followed by uptitration over 4–8 weeks. Previously, sequential escalation was used, but STRONG-HF data demonstrated the superiority of rapid simultaneous initiation.

7. Additional HFrEF Therapy

• Loop diuretics (furosemide, torsemide) — symptomatic relief for congestion; do not affect prognosis but improve quality of life.
• Ivabradine — in sinus rhythm with HR > 70 bpm on optimal beta-blocker therapy.
• Vericiguat — for recent decompensation despite triple therapy.
• Digoxin — atrial fibrillation with rapid ventricular response or beta-blocker resistance.
• Omecamtiv mecarbil — investigational cardiac myosin activator.
• IV iron (ferric carboxymaltose) — if ferritin < 100 ng/mL or 100–299 ng/mL + transferrin saturation < 20%.

8. Devices and Surgery

• ICD — primary prevention of sudden cardiac death in EF ≤ 35%, NYHA class II–III, on optimal medical therapy > 3 months.
• CRT (biventricular pacing) — in LBBB with QRS > 130 ms and EF ≤ 35%.
• LVAD — as a bridge to transplantation or destination therapy.
• Heart transplantation — in selected patients with NYHA class IV refractory to medical therapy.
• Revascularization (CABG) in patients with ischemic etiology and multivessel disease.

9. HFpEF Therapy

• Only SGLT2 inhibitors have demonstrated proven benefit (empagliflozin — EMPEROR-Preserved; dapagliflozin — DELIVER).
• Management of comorbidities: hypertension, diabetes mellitus, atrial fibrillation, obesity, obstructive sleep apnea.
• Loop diuretics for congestion.
• MRA (spironolactone) — for low K⁺, frequent hospitalizations, per TOPCAT data.

10. Acute decompensation

• Hemodynamic assessment by "warmth" and "wetness": warm-dry, warm-wet, cold-wet, cold-dry.
• Oxygen, if SpO₂ < 90 % — NIV/CPAP.
• Furosemide IV 40–80 mg bolus or infusion; in case of resistance — combination with a thiazide (metolazone).
• Vasodilators (nitrates) if SBP > 110 mmHg.
• Inotropes (dobutamine, milrinone, levosimendan) for low BP and hypoperfusion.
• Cardiogenic shock — IABP, ECMO, Impella.

11. Prevention and rehabilitation

• Regular physical activity (cardiac rehabilitation, aerobic + strength).
• Salt restriction < 5 g/day, daily weighing.
• Vaccination against influenza, pneumococcus, COVID-19.
• Control of BP, glycemia, lipids, and rhythm.
• Smoking cessation and alcohol abstinence.

12. FAQ

Why are ARNI replacing ACE inhibitors?
According to PARADIGM-HF, sacubitril/valsartan reduces mortality by 16 % compared to enalapril. Rule — a 36-hour washout period between ACE inhibitors and ARNI to prevent angioedema.

When to prescribe SGLT2i in HFrEF?
To all patients with HFrEF, HFmrEF, and HFpEF regardless of diabetes status, if eGFR > 20 mL/min and there are no contraindications.

What monitors β-blocker titration?
Heart rate (target 60–70 bpm), BP (> 90/60), symptoms. In case of CHF exacerbation — do not stop, but temporarily ↓ the dose by half.

What to do for hyperkalemia on MRA?
Discontinue if K⁺ > 5.5; potassium binders (patiromer, sodium zirconium cyclosilicate) may be used.

When does CRT fail?
In patients with non-LBBB, QRS < 130 ms, ischemic etiology, and extensive scar tissue. About 30 % are "non-responders".

See also: Myocardial infarction · Arterial hypertension · PE · Diuretics · Cardiology directory · Clinical scales