The ten commandments for comprehensive heart failure management

Abstract

The South African guidelines for the management of HFrEF also consider the role of invasive therapies-revascularisation, implantable cardioverter defibrillators (ICDs) and cardiac resyn-chronisation therapy (CRT) by implantation of a biventricular pacemaker with (CRT-D) or without (CRT-P) an ICD, left ventricular assist device (LVAD) use and orthotopic heart transplantation-with a goal of ensuring efficient utilisation of these expensive therapies in a resource-limited environment. In addition, the role of additional management strategies-digoxin, the combination of hydralazine and nitrates, ivabradine, iron supplementation-is discussed and advice is provided on general preventive strategies (vaccinations). Importantly, the South African guidelines for the management of HFrEF discuss topics that are of great relevance to the patient with heart failure in sub-Saharan Africa-cardiomyopathy, rheumatic heart disease, HIV-associated cardiovascular disease, peripartum cardiomyopathy and atrial fibrillation-to improve clinical care for these entities that are common causes of heart failure in the region. The South African guidelines for the management of heart failure with a reduced ejection fraction (HFrEF) have been extensively updated and recently published. (1) The guidance is based upon the European Society of Cardiology Guidelines for the treatment of acute and chronic heart failure, (2) and sum-marises the best current evidence for management of patients with heart failure. It provides information on the definition, diagnosis, and epidemiology of HFrEF in the African context. Best evidence-based therapies for HFrEF are discussed, including established therapies-beta-blockers, angiotensin converting enzyme inhibitors (ACE-i), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists (MRAs), diuretics-that form the cornerstone of heart failure management. These revised guidelines also discuss novel therapies that have recently entered clinical use (angiotensin receptor-neprilysin inhibitor (ARNI), sodium/glucose cotrans-porter-2 (SGLT2 inhibitors).