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2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

BIÈUHIÊNLÂMSÄNGSUYTIMCÂP
Acutedecompensated Acutepulmonary Isolatedright Cardiogenicshock
heartfailure oedema ventricularfailure
Mainmechanisms LVdysfunction Increasedafterloadand/or RVdysfunctionand/or Severecardiacdysfunction
Sodiumandwaterrenal predominantLVdiastolic pre-capillarypulmonary
retention dysfunction hypertension
Valvularheartdisease
Maincauseof Fluidaccumulation,increased Fluidredistributiontothe Increasedcentralvenous Systemichypoperfusion
symptoms intraventricularpressure lungsandacuterespira- pressureandoftensys-
toryfailure temichypoperfusion
Onset Gradual(days) Rapid(hours) Gradualorrapid Gradualorrapid
Mainhaemodynamic IncreasedLVEDPandPCWpi IncreasedLVEDPand IncreasedRVEDP IncreasedLVEDPand
abnormalities Lowornormalcardiacoutput PCWPil Lowcardiacoutput PCWPR
NormaltolowSBP Normalcardiacoutput LowSBP Lowcardiacoutput

NormaltohighSBP LowSBP
Mainclinical WetandwarmORDryand Wetandwarmb DryandcoldORWetand Wetandcold
presentations',446 cold cold
Maintreatment Diuretics Diuretics Diureticsforperipheral Inotropicagents/
Inotropicagents/vasopressors Vasodilators° congestion vasopressors

(ifperipheralhypoperfu- Inotropicagents/vasopres- Short-termMCS

sion/hypotension) sors(ifperipheralhypo- RRT

Short-termMCSorRTif

@ESC2021
perfusion/hypotension)
needed Short-termMCSorRTif
needed

2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

DIÈUTRISUYTIMMÄTBÙCÂP
Managementofpatientswithacutedecompensatedheartfailure

Congestion/Fluldoverload

Hypoperfusion

Loopdiuretics* Loopdiuretics'(Class1)
andconsider
(ClassI)
inotropes(ClasslIb)

Hypoperfusionand
Congestionrelief
congestionrelief

Increasediureticdoses Considervasopressors
(ClassI)and/orcombine (I.e.norepinephrine)
diuretics(ClassIla) (ClassIlb)

Diureticresistanceor Medicaltherapyoptimization Persistenthypoperfusion

end-stagerenalfailure (ClassI) Organdamage

Renalreplacement
MCS
therapy
(ClassIla)
(ClassIla)
OR AND/OR

Renalreplacement
Consider
therapy
palliativecare
(ClassIla)
OR

Consider
palliativecare

CESC
2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronichearttailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

DIÈUTRIPHÙPHÕICÄP
Managementofpatientswithpulmonaryoedema

Oxygen(ClassI)or
ventilatorysupport
(ClassIla)

SP≥110mmHg

Signsofhypoperfusion

Loopdiuretics(ClassI) Loopdiuretics(ClassI)
Loopdiuretics
and/orvasodilators andinotropes/vasopressors
(ClassI)
(ClassIlb) (ClassIlb)

Congestionrelief

ConsiderRT,MCS, Medicaltherapyopti
(ClassI)
mization
otherdevices(Classlla)

OR

Consider
palliativecare

@ESC.
2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

DIÈUTRISUYTHÄTPHÀIDONDÔC
Managementofpatientswithisolatedrightventricularfailure

ACSwithRVinvolvementor
acutepulmonaryembolism

Optimizefluidstatus Specifictreatments

Markedcongestion

Loopdiuretics Considercareful
(ClassI) fluidadministration

Peripheralhypoperfusion/
persistenthypotension

Vasopressors
and/orinotropes*
(ClassIlb)

Reliefofsignsandsymptams

Follow-up
RVAD

AND/OR

Renalreplacement
therapy

OR

Consider
palliativecare

CESC
2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

CÁCGIAIDOANDIÈUTRISUYTIMCÄP
Managementofpatientswithsuspectedacuteheartfailure

Pharmacologicalsupport

Urgentphaseafter Cardiogenicshockand/or
Ventilatorysupport
firstmedicalcontact respiratoryfailure

MCS

Identificationofacuteaetiology

acuteCoronarysyndrome
Hypertensionemergency
Arrhythmia Immediateinitiation
Immediatephase
Mechanicalcause
(initial60-|20min) ofspecifictreatment
Pulmonaryembolism
Infections
Tamponade

Furthertreatment°

@ESC
2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

DIÈUTRILO1TIÈUÖBÊNHNHÂNSUY
Managementofdiuretictherapyinpatientswithacuteheartfailure

Onoralloopdiuretic

>2040mgi.v. 1-2timesdaily
furosemide oraldosei.v.

Urinaryspotsodium after2h250-70mEq/L
Urineoutput after6h 2100-150mL/h

Repeatsimilardose Doubledosei.v.until
i.v.every12h maximumi.v.dose"

Urinaryspotsodium250-70mEq/Lat2-6h
Urineoutput 2100-150mL/h

Checkserum
Continueuntil Combination
creatinineand
complete diuretic
electrolytesatleast
decongestion therapies"
every24h

DESC

2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

DIÈUTR]RUNGNHÌ&BÊNHNHÂNSUYTIM
ManagementofarrialfibrillationinpatientswithHFrEF

Anticoagulationforpreventingembolicevents(ClassI)

Treatmentoftrigger(s)(Class1)

Optimizationofheartfailuretherapies(ClassI)

Haemodynamic
instability

Rhythmcontrol

ECV
(ClassI)

Sinusrhychm

Follow-Up

Rhythmcontrol

PVablation
(ClassIla)
OR
Amiotarone
(ClassIlb)

ECV
(ClassIlb)
Ratecontrol

AVNablation
(ClassIlb) Sinusrhythm

OESC
2021ESCGuidelinesforthediagnosisandtreatmentoracuteandchronichearttallure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

DIÈUTRIHÖICHUNGMACHVÄNHMANÖBÊNHNHÂNSUYTIMEF
Useofanti-anginalmedicationsinpatientswithCCSandHFrEF

Beta-blockers
(Class1)

Persistenceof
CCSsymptoms

HR≥70bpm,and HR<70bpm,and/or
sinusrhythm atrialfibrillation

Trimetazidine Ranolazine
OR
(ClassIlb) (ClassIlb)
Inabsenceof
improvement
Ivabradine Nicorandil OR Nitrates
(Classlla) (ClassIlb) (ClassIlb)

Felopidine OR
Amlodipine
(ClassIlb) (ClasslIb)

Diltiazem(ClassIll)

Verapamil(ClasslI)

)ESC

2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

DIÈUTRIBÊNHNHÂNSUYTIMVÓIHEPVANDÖNGMACHCHÙLUULUONGTHÂPDÔ
Managementofpatientswithheartfailureandsuspectedseverelow-flowlow-gradientAS

LVEF<50%

Clinicaland
Dobutamineecho
echocriteria®

Flowreservet
Highcalciumscored
byCT

Severelow-flow
low-gradientAS

Medicaltherapy
optimization
HeartTeam* HeartTears Follow-up
(ClassI) (ClassI)
(ClassI)

SAVR SAVR
(Class1) (Classlla)
OR OR

TAVI TAVI -

(ClassI) (Classlla)

@ESC

2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

DIÈUTRIBÊNHNHÂNDANGDÜNGTHUÔCDIÈUTRIUNGBUÓUDÔC
Managementofpatientsreceivingpotentialcardiotoxietreatments

Beforecardiotoxic
cancertreatment
Baselineriskassessmentincludingclinical
assessment,ECG,restingechocardiogramand
cardiacbiomarkers(NP,troponin)

Pre-existingheartfailureorhigh-risk
cardiovasculardisease

Medium-andhigh-riskpatient Low.riskpatient

Duringcardiotoxic
concertreatment"

IncreasedsurveillancewithECG
andcardiacbiomarkers Standardsurveillance
duringtreatment

Reassessmentat Reassessmentat
3monthsand12months 12months
aftercompictionofcancertherapy aftercompletionofcancerthcrapy

Aftercardiotoxic
concertreatment

Surveillanceevery5yearsfollowingtherapies
withestablishedcardiotoxicity
(e.g.high-doseanthracyclinechemotherapy)*

Follow-upbyheartfilureorcardio-oncolopyteamfor
newheartfailureorleftventricularsystolicdysfunction

@ESC

2021ESCGuidelinesforthediagnosisandtreatmentofacuteandchronicheartfailure.EuropeanHeartJournal,Volume42,Issue36,21
September2021,Pages3599-3726

SoM
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