The European Society of Cardiology (ESC) recently published the 2012 Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure (HF). The editors of MPR have provided a comprehensive summary of the recommended pharmacological treatment strategies in the 2012 guidelines. Part 1 of MPR’s summary will cover the recommended treatment strategies. Part 2 will cover treatments to avoid that may cause potential harm.

Since its last publication in 2008, the primary changes made by the ESC to the pharmacological management of HF in the 2012 guidelines include:

  • an expanded indication for mineralocorticoid receptor antagonists (MRA)
  • a new indication for ivabradine, a sinus node inhibitor
  • a focus on decreasing not only mortality, but also reducing the rate of hospitalizations
  • recommendations that three neurohumoral antagonists—an ACE inhibitor (or angiotensin receptor blocker), a beta-blocker, and a mineralocorticoid receptor antagonist—are fundamentally important in modifying the course of systolic HF and should at least be considered in every patient
  • practical guidance on the use of concomitant diuretics and disease-modifying drugs


Beta-Blockers and Angiotensin-Converting Enzyme Inhibitors (ACEI)

  • A beta-blocker and an ACE inhibitor (or ARB if ACEI is not tolerated) should be started as soon as possible after diagnosis of heart failure (HF) with an ejection fraction (EF) ≤40% (Class I; Level A recommendation)
      •  An ACE inhibitor should only be used in patients with adequate renal function (creatinine ≤221μmol/L or ≤2.5mg/dL or eGFR ≥30mL/min/1.73m2) and a normal serum potassium level
          • ARBs can be used in patients who cannot tolerate ACEIs (Class I; Level A recommendation)
          • NOT first line for patients with an LVEF ≤40% and still symptomatic despite ACEI therapy (addition of MRA preferred)
      • Beta-blockers should usually be initiated in stable patients, and used only with caution in recently decompensated patients (initiate in hospital). Continuation of beta-blockers during a decompensation episode has been shown in an RCT to be safe, although dose reduction may be necessary. Temporary discontinuation is advised in shocked or severely hypoperfused patients. Re-institution of treatment should be attempted before discharge.