How to treat different types of chronic heart failure

SGLT2i dapagliflozin can significantly reduce the risk of worsening heart failure, cardiovascular death and all-cause death in patients with HFrEF.
Heart failure (referred to as "heart failure") has become a major clinical and public health problem worldwide due to its high prevalence, high risk of hospitalization and death, and high medical burden caused by the disease.
According to left ventricular ejection fraction (LVEF), heart failure can be divided into heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF). ) three types. Most patients with acute heart failure can relieve some of their symptoms after hospitalization, and then turn into chronic heart failure; patients with chronic heart failure often have acute exacerbations due to various incentives and need hospitalization[1]. Overall, early identification and diagnosis of heart failure and targeted treatment are crucial.
Guide full solution:
how to treat different types of chronic heart failure?
Overall, the goals of treatment for patients with chronic heart failure are to relieve symptoms and reduce the occurrence of disabling events, improve survival rates, and delay disease progression. According to the guideline recommendation [2], the treatment plan for chronic heart failure can be subdivided as follows:
Treatment of chronic HFrEF
The treatment of chronic HFrEF mainly includes three aspects: general treatment, drug treatment and non-drug treatment [2-3].
General treatment mainly refers to removing the inducing factors of HFrEF and adjusting lifestyle. Infection, arrhythmia, ischemia, electrolyte disturbance and acid-base imbalance, anemia, renal dysfunction, excessive salt intake, excessive intravenous fluid rehydration, and the use of drugs that damage the myocardium or heart function are all inducing factors for HFrEF, so patients in daily life These events should be avoided. Lifestyle intervention should start with sodium restriction, low-fat diet, smoking cessation, weight loss (for obese patients), regular exercise, and emotional intervention. Nutritional support should be given to patients with severe HFrEF and significant wasting [2-3].
In terms of drug treatment, guidelines [2-3] respectively recommend diuretics, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor antagonists (ARBs), and β-blockers for patients with chronic HFrEF. , aldosterone receptor antagonist (MRA), angiotensin receptor neprilysin inhibitor (ARNI), sodium-glucose cotransporter 2 inhibitor (SGLT2i) and other therapeutic drugs.
At the beginning of this century, on the basis of a series of large-scale experimental evidence, the "Golden Triangle" program with the main goal of improving the long-term prognosis of heart failure was formed, that is, the treatment mode of ACEI/ARB+β receptor blocker+MRA[4] . In recent years, a large number of clinical benefit evidences of SGLT2i and ARNI have made the drug treatment model for improving the prognosis of HFrEF patients advanced from the "Golden Triangle" to the "New Drug Treatment Mode" consisting of ARNI or ACEI/ARB, SGLT2i, β-blockers, and MRA. Quadruple".
What distinguishes it from other heart failure drugs is that SGLT2i does not require dose titration and is more convenient to use. In addition, the Declare study analyzed 17,160 subjects from 33 countries from 2013 to 2018 [8162 cases (47.6%) had an eGFR of at least 90 mL/min/1.73 m⊃2 at baseline; 7732 cases (45.1%) eGFR at baseline was 60 to <90 mL/min/1.73 m⊃2;, 1265 patients (7.4%) had eGFR <60 mL/min/1.73 m⊃2 at baseline; 6974 patients (40.6%) had established arterial Atherosclerotic cardiovascular disease, 10186 cases (59.4%) have multiple risk factors, SGLT2i group can reduce major cardiovascular adverse events (cardiovascular death, myocardial infarction or ischemic stroke) in patients with type 2 diabetes compared with placebo group composite endpoint), but did not yet show a statistical difference (8.8% vs. 9.4%; HR 0.93 [95% CI 0.84-1.03], p = 0.17), but significantly reduced cardiovascular death or hospitalization for heart failure ( HHF) composite endpoint 17% (HR: 0.83, 95% CI: 0.73~0.95, P=0.005) [5]. The clinical characteristics of SGLT2i confirmed the necessity of its addition to the "new quadruple".
The DAPA-HF study [1] completed in 2019 confirmed that SGLT2i dapagliflozin can significantly reduce the risk of heart failure deterioration, cardiovascular death risk and all-cause death risk in HFrEF patients regardless of whether they are complicated with diabetes or not. In February 2021, Dapagliflozin was approved in China for the indication of HFrEF treatment, and became the first SGLT2i used to treat non-diabetic HFrEF patients in China, benefiting the majority of patients.
In addition, for sinus rhythm, persistent symptoms after at least 3-6 months of standard and optimized drug therapy, decreased LVEF, expected survival of more than 1 year, or coronary heart disease (NYHA) class III-IVa Patients, implantable cardioverter defibrillator (ICD) are suitable for clinical treatment. Cardiac resynchronization therapy (CRT) can be applied to patients with ischemic heart failure and non-ischemic heart failure, both of which can reduce sudden cardiac death and total mortality [2].
The guidelines for the treatment of chronic HFpEF and HFmrEF
[3] suggest that clinicians should screen and evaluate cardiovascular disease and non-cardiovascular comorbidities in patients with HFpEF and HFmrEF, and provide appropriate treatment to improve symptoms and prognosis (I, C).
When the diagnosis of HFpEF and HFmrEF is not clear, stress echocardiography or invasive examination can be performed to confirm whether the left ventricular filling pressure is elevated. As for treatment, the treatment of HFpEF patients mainly focuses on symptoms, basic cardiovascular diseases and comorbidities, and risk factors of cardiovascular diseases, and adopts comprehensive treatment methods [3].
Daily management of chronic heart failure:
standardized supervision and active intervention
In the daily management of chronic heart failure, grassroots doctors should have the ability to identify patients with high risk of heart failure and participate in the multidisciplinary treatment management plan for heart failure patients. Responsible for the diagnosis and treatment of patients with relatively stable heart failure, providing standardized disease assessment and monitoring, health education, follow-up management, drug treatment, cardiac rehabilitation and other services for patients with heart failure [3].
After clinical diagnosis and treatment, not only the frequency and content of follow-up visits should be formulated according to the patient's condition, but also the psychological state of the patient such as anxiety and depression should be paid attention to, and the risk factors of heart failure should be actively intervened

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