Reference: McMurray JJV, et al. Eur Heart J. 2012.



European Guidelines for Heart Failure

Current ESC standards in disease management

How is heart failure defined?


According to European Society of Cardiology (ESC) guidelines, “HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.” 1


For information regarding the definitions of HFrEF, HFmrEF and HFpEF, please see Table 3.1 within the guidelines, which can be found here



NYHA classification is important for evaluating patient symptoms


The New York Heart Association (NYHA) functional classification is widely used and accepted based on exercise capacity and symptoms of the disease.1


For information regarding NYHA classes, please see Web Table 3.2 within the web addenda of the guidelines, which can be found here



Recommended guidelines for care1


The overall goals for chronic heart failure management, including patients with established HFrEF, “are to improve their clinical status, functional capacity and quality of life, prevent hospital admission and reduce mortality.”

  • Recent studies have shown that including a focus on reducing hospitalisations can be highly important to patients and health care systems

Treatment effectiveness at slowing or preventing progressive worsening of disease can be determined by reductions in the rates of both hospital admissions and mortality.


To view the therapeutic algorithm for patients with symptomatic HFrEF, please see Figure 7.1 within the guidelines, which can be found here



Recommended treatment guidelines in patients with symptomatic (NYHA class II–IV) HFrEF1


For information regarding pharmacological treatments for patients with symptomatic HFrEF, please see Section 7.2.1 within the guidelines, which can be found here.



Other recommended treatment guidelines in patients with symptomatic
(NYHA class II–IV) HFrEF1


For information regarding pharmacological treatments for selected patients with symptomatic HFrEF, please see Section 7.3 within the guidelines, which can be found here.


For more information, the ESC Guidelines can be found here



Benefits of a multidisciplinary approach to care


During the management of heart failure, it is imperative to provide a system of care that ensures optimal management of every patient. Thus, a multifaceted approach to care – focused on holistic management, including exercise training and multidisciplinary management programmes, patient monitoring, and palliative care – can play an important role in the lives of heart failure patients. 1

Despite these treatment strategies, the survival rate for heart failure patients across the globe is poor. Continuing research and new pharmacological treatments are essential to addressing unmet needs in caring for patients with heart failure.2,3

For further information regarding the quality of care measures recommended by ESC, please click here.


1. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–200. 2. Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008. 3. Ponikowski P, Anker SD, AlHabib KF, et al. Heart failure: preventing disease and death worldwide. ESC Heart Failure. 2014;1(1):4-25.


Economic Burden

The economic burden of heart failure goes beyond the cost of medicine

What is the cost of heart failure on the global economy?



Economic Burden of Heart Failure



Cost of Heart Failure



Economics of Heart Failure

Country name Direct cost of
HF ($ million)
Indirect cost of
HF ($ million)
Overall HF costs
($ million)
United States 20.900 9.800 30.700
Japan 7.844 3.576 11.420
Germany 5.340 2.040 7.380
France 4.314 1.568 5.882
United Kingdom 3.223 1.461 4.684
Canada 2.891 1.093 3.984
Italy 2.716 1.208 3.924
Russian Federation 1.774 1.209 2.983
Australia 1.951 912 2.863
Spain 1.810 810 2.619
Korea, Rep. 1.156 678 1.834
Netherlands 1.311 463 1.775
Switzerland 975 379 1.354


References: 1. Neumann T, Biermann J, Neumann A, et al. Heart failure: the commonest reason for hospital admission in Germany. Dtsch Arztebl Int. 2009;106(16):269-275. 2. Cook C, Cole G, Asaria P, Jabbour R, Francis DP. The annual global economic burden of heart failure. Int J Cardiol. 2014;171(3):368-376.

Heart Failure pathophysiology

Silent underlying neurohormonal imbalance results in continued disease progression

Neurohormonal imbalance contributes to the pathophysiology of chronic heart failure


In patients with heart failure, left ventricular remodeling leads to changes in cardiac volume and wall thickness. The abnormality in cardiac structure or function contributes to1:

  • Inadequate cardiac output
  • Poor organ perfusion
  • Activation of the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system (SNS)

Activation of the RAAS gives rise to1,2:

  • Vasoconstriction
  • Increased sodium and water retention
  • Fibrosis
  • Hypertrophy
  • Increased blood pressure

Activation of the SNS leads to2:

  • Vasoconstriction
  • Increased heart rate and myocardial contractility
  • Sodium retention
  • Renin release

Natriuretic peptides help counter the effects of the RAAS and SNS in chronic heart failure but this balancing effect is diminished as heart failure progresses. Sustained overactivation of the RAAS and SNS with attenuation of the effects of the natriuretic peptide system leads to neurohormonal imbalance in heart failure.2-4

Even when heart failure symptoms are stabilised by current treatments and it may seem that patients are doing well, the neurohormonal imbalance underlying heart failure is still silently occurring, resulting in sustained progression of cardiac structure and function abnormalities.1


Heart Failure Progression

RAAS = Renin-angiotensin-aldosterone system
SNS = Sympathetic nervous system
NPs = Natriuretic peptides

Heart failure is a complex deteriorating condition driven by neurohormonal imbalance, leading to a spiral of worsening disease and punctuated by acute episodes that result in poor outcomes for patients.1


Progression of Heart Failure

From Gheorghiade M, et al. Am J Cardiol. 2005.

Natriuretic peptides may potentially be an important therapeutic target due to their ability to counterregulate the RAAS and SNS.2,3


Physiology of Heart Failure

BNP =  B-type natriuretic peptide
ANP =  Atrial natriuretic peptide
CNP =  C-type natriuretic peptide
CNS = Central nervous system
NT-proBNP = N-terminal-proBNP
TGF = Transforming growth factor


*Neprilysin is the major enzyme responsible for degrading the natriuretic peptides ANP, BNP, and CNP.4


References: 1. Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008. 2. Boerrigter G, Costello-Boerrigter L, Burnett JC Jr. Alterations in renal function in heart failure. In: Mann DL, ed. Heart Failure: A Companion to Braunwald's Heart Disease. 2nd ed. St Louis: Saunders; 2011. 3. McMurray J, Komajda M, Anker S, Gardner R. Heart failure: epidemiology, pathophysiology and diagnosis. In: Camm AJ, Lüscher TF, Serruys PW, eds. ESC Textbook of Cardiovascular Medicine, 2nd ed. New York: Oxford University Press; 2009. 4. Mann DL, Zipes DP, Libby P, Bonow RO, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia: Saunders; 2015. 5. Gheorghiade M, De Luca L, Fonarow GC, et al. Pathophysiologic targets in the early phase of acute heart failure syndromes. Am J Cardiol. 2005;96(6A):11G-17G. 6. Goetze JP, Friis-Hansen L, Rehfeld JF, Nilsson B, Svendsen JH. Atrial secretion of B-type natriuretic peptide. Eur Heart J. 2006;27(14):1648-1650.


Heart Failure videos, interviews, slides and events. Be sure to check back often to see the latest tools.

Key international cardiology events
Meeting Place Date Attendees
ACC 2018
Annual Scientific Session of the American College of Cardiology
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Orlando, United States 10-12 March 2018 19,000
Annual Congress of the European Society of Cardiology Heart Failure
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Vienna, Austria 26-29 May 2018 5,000
ESC 2018
Annual Congress of the European Society of Cardiology
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Munich, Germany 25-29 August 2018 30,000
Annual Scientific Meeting of the Heart Failure Society of America
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Nashville, United States 15-18 September 2018 1,700
Annual Scientific Sessions of the American Heart Association
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Chicago, United States 10-14 November 2018 18,000

References (from Homepage and Social media post): 1. Roger VL, Weston SA, Redfield MM, et al. Trends in heart failure incidence and survival in a community-based population. JAMA. 2004;292(3):344-350. 2. Krumholz HM, Merrill AR, Schone EM, et al. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes. 2009;2(5):407-413. 3. Moser DK, Dracup K, Evangelista LS, et al. Comparison of prevalence of symptoms of depression, anxiety and hostility in elderly heart failure, myocardial infarction and coronary artery bypass graft patients. Heart Lung. 2010;39(5):378-385.