In the past six years, many breakthroughs have been made in the treatment of heart failure, especially drug therapy, and the classification of chronic heart failure and the treatment of heart failure and its comorbidities have been constantly updated. In order to apply these achievements to the diagnosis and treatment of heart failure patients in mainland China and further improve the diagnosis and treatment level of heart failure in mainland China, relevant experts in mainland China have written and promulgated the Guidelines for the Diagnosis and Treatment of Heart Failure in China 2024, which comprehensively updates the new consensus in the field of heart failure and the diagnosis and treatment methods with evidence-based medical evidence.
Recently, at the 27th National Interventional Cardiology Forum and the 12th China Chest Pain Center Conference (CCIF&CCPCC 2024), Professor Li Rui of the Southern Theater General Hospital of the Chinese People's Liberation Army interpreted in detail the 12 update points of the "China Heart Failure Diagnosis and Treatment Guidelines 2024".
Update point 1
Pay attention to citing research results in the field of Chinese heart failure and display "Chinese evidence"
From 2012 to 2025, the prevalence of heart failure among adults aged ≥ 35 years in mainland China was 1.3%, an increase of 0.4% compared with 2000. In people aged 25-64 years, 65-79 years, and 80 years of age, the standardized prevalence of heart failure was 0.57%, 3.86%, and 7.55%, respectively. However, through standardized treatment, the case fatality rate of heart failure has decreased year by year, and the case fatality rates of heart failure patients during hospitalization in 1980, 1990 and 2000 were 15.4%, 12.3% and 6.2%, respectively.
In recent years, many research results have been made in the field of heart failure in mainland China, and the new guidelines also attach importance to citing the research results in the field of heart failure in China, showing "Chinese evidence":(1) the new guidelines affirm the "application of His's beam pacing in patients with heart failure with his-Purkinje system conduction lesions" proposed by mainland scholars, and (2) introduce and recommend evidence-based medical evidence for the treatment of heart failure with reduced ejection fraction (HFrEF) with traditional Chinese medicine.
Update point two
Classification and diagnostic criteria for heart failure updated
The new guidelines classify heart failure into heart failure with reduced ejection fraction (HFrEF), heart failure with improved ejection fraction (HFimpEF), heart failure with mildly reduced ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF) based on differences in left ventricular ejection fraction (LVEF) and changes after treatment. In patients with HFrEF, a new subtype of HFimpEF has been added.
Table 1 Classification and diagnostic criteria for heart failure
➤ HFimpEF definition
√ HFimpEF is defined as patients with a prior LVEF ≤ of 40%, a LVEF > 40% at the previous follow-up measure, and a ≥10% increase from baseline. √ Patients with HFrEF have an ejection score of more than 40%, even if the subsequent ejection score exceeds 50%, does not mean that the ejection fraction is restored or converted to HFpEF, which is still only a subtype of HFrEF.
√ Even if the ejection fraction improves in patients with heart failure, it does not mean that the entire myocardium is fully restored or that left ventricular function returns to normal, and structural cardiac abnormalities persist in most patients.
➤ Treatment recommendations for HFimpEF
√ Patients with HFimpEF should continue to use guideline-recommended medical therapy (GDMT) to prevent recurrence of heart failure and left ventricular dysfunction (I, B-R), even though the patient may become asymptomatic. √ LVEF changes are not unidirectional and can be both increased and decreased. Its increase or decrease depends on the underlying cause, duration of disease, adherence to GDMT, and other factors contributing to myocardial toxicity.
√ importantly, for many patients who improve their ejection fraction to the normal range with GDMT, ejection fraction decreases after discontinuation of drug therapy.
Update point 3
Optimize the flow chart of heart failure diagnosis
For patients with suspected heart failure, history, physical examination, chest x-ray, and electrocardiogram (ECG) are performed first, and if the symptoms of heart failure are not present, the possibility of heart failure can be directly ruled out. The new guidelines recommend plasma natriuretic peptide testing for screening, diagnosis, and differential diagnosis of heart failure, followed by echocardiography in patients with NT-proBNP≥125 ng/L or BNP≥35 ng/L. In the case of a strong suspicion of heart failure or the unavailability of NT-proBNP/BNP, echocardiography is still required to determine structural and/or functional abnormalities of the heart.
Figure 1 Diagnostic algorithm for chronic heart failure
Update point four
Definitions of the 4 stages of heart failure and updates to heart failure precautions
Table 2 Comparison of the four stages of heart failure with the New York Heart Association (NYHA) cardiac function class
➤ Sodium-glucose cotransporter 2 inhibitor (SGLT-2i) is recommended for patients with diabetes who have comorbid cardiovascular disease or cardiovascular risk factors to reduce the risk of heart failure hospitalization (I, A).
➤ Natriuretic peptide (BNP or NTproBNP) levels are recommended to screen people at high risk of heart failure (HF stage A).
Update point five
To demonstrate the evidence-based medical evidence of SGLT-2i in the treatment of chronic heart failure with total ejection fraction, and to update the treatment recommendations for patients with chronic HFmrEF and chronic HFpEF
➤ Treatment recommendations updated for patients with chronic HFmrEF and chronic HFpEF
√ The new guidelines give SGLT-2i a category I recommendation for chronic HFrEF, chronic HFmrEF, and chronic HFpEF (level A evidence).
√ The new guidelines conclude that the clinical features and response to drug therapy in HFmrEF are more similar to those of HFrEF and not different from HFpEF.
√ The three class I recommendations for the treatment of chronic HFpEF are diuretics, SGLT-2i, and treatment of etiologies and comorbidities.
➤ Evidence-based medical evidence for the treatment of chronic heart failure with total ejection fraction by SGLT-2i
Pooled analysis results from both the DELIVER and DAPA-HF III trials showed that dapagliflozin significantly reduced the composite endpoints of death, HF hospitalization, and cardiovascular death or HF hospitalization across the LVEF range.
Fig. 2 Summary analysis results of DELIVER and DAPA-HF III trials
Update point 6
The cornerstone position of the "new quadruple" in the treatment of patients with chronic HFrEF was emphasized, and the recommendations of other effective treatment drugs were updated
➤ The new guidelines recommend angiotensin receptor neprilysin inhibitor (ARNI)/angiotensin-converting enzyme inhibitor (ACE inhibitor)/angiotensin II receptor blocker (ARB), β blocker, aldosterone receptor antagonist (MRA), SGLT-2i quadruple therapy as the basic treatment regimen for HFrEF, unless the drug is contraindicated or intolerant.
Table 3 New quadruple therapy
NYHA II/III垗推輈使使用ARNI (I,A,A);NYHA II~IV緳使ரACEI戌ARB (I,A,A)。
➤ For patients with heart failure who have recently had a heart failure exacerbation event, NYHA grade II~IV, and LVEF <45%, it is recommended to add vericiguat (IIa,B) as soon as possible on the basis of standard treatment.
√ Vericiguat is currently the only drug that repairs damaged cell signaling pathways;
√ To further improve the prognosis of patients with heart failure in the context of vericiguat in combination with other guideline-recommended drug therapy.
Fig.3 Velisiguat combined with other guidelines-recommended drug therapy to further improve the prognosis of patients with heart failure
➤ Digoxin is indicated for patients with persistent symptoms of HFrEF who have been treated with diuretics, renin-angiotensin system inhibitors, β-blockers, SGLT-2i, and MRA (IIb, B).
Update point 7
Chronic HFrEF treatment flowchart updated
Fig.4 Treatment flow for patients with chronic HFrEF
➤ New guidelines state that all patients diagnosed with HFrEF should receive a variety of drugs that improve prognosis as early as possible.
➤ In the process of optimizing drugs, drugs and starting doses should be reasonably selected according to the drug indications, and drugs with different mechanisms should be recommended to start treatment in combination, and gradually titrated to their respective target doses or maximum tolerated doses, so as to maximize the benefits of patients.
➤ Patients with heart failure with symptoms and/or signs of congestion should be treated with diuretics to reduce fluid retention.
➤ Patients should be monitored for symptoms, signs, blood pressure, heart rate and rhythm, renal function, and electrolytes during treatment.
Update point eight
Initial evaluation of acute heart failure updated
Fig.5 Initial evaluation of acute heart failure
➤ Emphasizing the rapid identification of clinical conditions requiring urgent treatment in patients with acute heart failure, such as acute coronary syndrome (C), hypertensive emergency (H), severe arrhythmia (A), acute cardiac mechanical complications (M), acute pulmonary embolism (P), infection (I), and cardiac tamponade (T), and early corresponding treatment.
➤ For patients with new-onset acute heart failure, drugs to improve the prognosis of heart failure should be given as soon as possible after hemodynamic stability.
➤ The "Flow chart for the treatment of acute left heart failure" continues to be used.
Update point nine
Criteria for defining end-stage (or advanced) heart failure have been added
To diagnose end-stage (or advanced) heart failure, the following criteria must be met:
➤ Severe or persistent heart failure symptoms (NYHA Class III/IV);
➤ Severe cardiac insufficiency with at least 1 of the following:
(1) LVEF ≤30%;(2) isolated right ventricular failure (e.g., arrhythmogenic right ventricular cardiomyopathy);(3) severe inoperable valvular abnormality, (4) inoperable severe congenital anomaly, (5) persistently high (or elevated) BNP or NT-proBNP, and severe left ventricular diastolic dysfunction or structural abnormality;
➤ Congestion requiring treatment with high-dose intravenous diuretics (or a combination of diuretics), or hypoperfusion of peripheral organs due to decreased cardiac output (low cardiac output) requiring inotropic or vasoactive drug therapy, or episodes of malignant arrhythmias resulting in more than 1 unplanned visit or hospitalization in the past 12 months.
➤ Exercise capacity is severely impaired, unable to exercise or the 6-minute walking test distance is short (<300m), or the peak oxygen consumption is <12 ml·kg-1·min-1 or <50% of the predicted value.
Diagnosis of refractory end-stage heart failure requires caution, with irreversible other causes and appropriate treatments.
Update Summary 10
Updated recommendations for the treatment of heart failure comorbidities
➤ Catheter ablation is recommended to improve cardiac function in patients with HFrEF and heart failure in patients with HFrEF and heart failure (I, B) if arrhythmic cardiomyopathy is highly suspected (I, B).
➤ It is proposed that catheter ablation (I, C) is recommended for patients with frequent premature ventricular contractions (PVC)-induced/aggravated cardiomyopathy (referred to as PVC-induced cardiomyopathy) that should be taken seriously.
➤ Aortic valve intervention, including transcatheter aortic valve grafting or surgical aortic valve replacement, is recommended for patients with heart failure and severe aortic stenosis to reduce mortality and improve symptoms (I, B).
➤ Regular checks of complete blood count, serum ferritin concentration, and transferrin saturation are recommended for all patients with heart failure to determine whether anemia or iron deficiency is present (I, C). Intravenous iron supplementation is recommended for symptomatic heart failure patients with an LVEF <45% and iron deficiency to reduce HF symptoms and improve quality of life (I, A).
Table 4 Principles for the management of common comorbidities of heart failure
Update Summary 11
The effect of different stages of new chronic kidney disease (CKD) on the choice of drug for the treatment of heart failure
Emphasize the urgency of clinicians to calculate estimated eGFR in patients with heart failure.
Fig.6 Medication adjustment at the beginning of HFrEF treatment or during the change of renal function indexes
Update Highlights 12
The long-term management of patients with heart failure has been emphasized and updated
➤ Emphasizing that appropriate diagnosis and treatment and long-term management of heart failure patients require a multidisciplinary heart failure management team.
➤ According to the results of the seventh national population census, the number of elderly people aged 60 in ≥mainland China has reached 264 million, accounting for 18.70% of the total population, and the population aged 80 in ≥ 2020 accounted for 2.54% of the total population. The incidence and prevalence of heart failure increase with age, and the prevalence of heart failure in ≥ 80-year-old population has exceeded 12%.
➤ Elderly patients with heart failure have a high risk of heart failure deterioration and readmission, and advanced age is a risk factor for poor prognosis of heart failure patients, which should be paid great attention to in clinical practice.
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