The goals of heart failure treatment vary depending on the patient, but they generally aim to reduce hospitalizations, improve symptoms, slow disease progression, and help individuals live longer, more active lives with fewer symptoms [6, 10, 25]. Depending on the treatment needed and available healthcare facilities, care may be administered in the inpatient or outpatient setting.

Heart failure clinical practice guidelines

Healthcare providers rely on clinical practice guidelines to determine the most appropriate treatment strategies. Guideline recommendations are based on medical research and clinical practice standards, and are updated every few years to incorporate the latest advancements [6, 10, 25, 26]. People with heart failure can also use these guidelines to make informed healthcare decisions and to be aware of their treatment options [26].

Understanding recommendation strength

Heart failure guidelines principally categorize treatment recommendations based on EF because clinical trials typically enroll people on this basis and different medications may have varying effects depending on the severity of heart failure [10]. Guideline recommendations are based on the level of supporting evidence and the balance of benefits versus risk, with different organizations using a variety of grading recommendations [27]. Recommendations are assigned a designated ‘strength’ or ‘class’ to indicate how strongly each should be followed [27]. Strong recommendations are based on well-established and convincing clinical evidence, whereas those considered to be weak will have limited evidence of efficacy (which does not necessarily mean a particular treatment isn’t valid) or the potential benefits do not clearly outweigh the safety risks [27]. Table 2 outlines the different recommendation types used in current heart failure guidelines from the European Society of Cardiology (ESC) and ACC/AHA/HFSA [10, 25].

Table 2 ACC/AHA/HFSA and ESC clinical practice guideline recommendation gradingGuideline-directed treatment for heart failure

People with heart failure should have a clear understanding of their prescribed treatments, including their purpose and possible side effects [28]. There are several effective medications, which help the heart or both the heart and the kidney. Such medications include [6, 7, 10, 25]:

Angiotensin-converting enzyme inhibitor (ACEi)

Angiotensin receptor blocker (ARB)

Angiotensin receptor/neprilysin inhibitor

Beta-blocker

Diuretic

Mineralocorticoid receptor antagonist (MRA)

Sodium–glucose cotransporter 2 inhibitor (SGLT2i)

Medications are usually started at a low dose, then the dose is increased to the highest one tolerated (without major side effects) to enable the maximum effect.

Some patients may also require an implantable cardioverter-defibrillator and/or cardiac resynchronization therapy with defibrillation, depending on factors such HFrEF severity, NYHA classification, and other cardiac conditions including specific arrhythmias. Patients in the advanced stages of HFrEF may require mechanical circulatory support and heart transplantation, depending on individual circumstances [6, 10]. An example of mechanical circulatory support is a left ventricular assist device [29]. A left ventricular assist device is a surgically implanted device that assists with pumping blood from the heart to the body [29].

In patients with severe heart failure symptoms, progressive functional decline, poor quality of life, and who are not suitable/eligible for advanced therapies, end-of-life (palliative) care should be considered [6]. Palliative care comprises improving or maintaining quality of life, symptom relief, psychological and spiritual care according to need/preference, and advanced care planning [6].

Both the AHA/ACC/HFSA and ESC guidelines recommend treatment according to left ventricular EF (LVEF) (Fig. 4). As guidelines are only updated every few years, healthcare providers may also consider new treatments that have not yet been added to the recommendations, and patients can ask about these.

Fig. 4

ESC and AHA/ACC/HFSA guidelines for the treatment of HFpEF, HFmrEF, and HFrEF [6, 10, 25]. †Diuretics are recommended to reduce the signs and/or symptoms of congestion. ‡Patients with HFpEF should receive either an ARNi or an ARB but not both. §An ARB with appropriate evidence is recommended to reduce the risk of heart failure hospitalization and cardiovascular death in symptomatic patients unable to tolerate an ACE-I or ARNI (patients should also receive a beta-blocker and an MRA). ACC, American College of Cardiology; ACEi, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; ARNi, angiotensin receptor/neprilysin inhibitor; ESC, European Society of Cardiology; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HFSA, Heart Failure Society of America; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium–glucose cotransporter 2 inhibitor

Ongoing care is needed for heart failure

Living with heart failure means regular monitoring by healthcare providers to assess changes in symptoms; medication reactions; comorbidities; and heart, lung, and kidney function. This may involve discussion and follow-on tests (as detailed above). Patients should also understand how to monitor the signs and symptoms of their heart failure potentially worsening and how to contact their healthcare providers if these are present [10].

If treatment needs change over time, doses of current medications may need to be increased/decreased and/or new therapies may be needed (referred to as treatment intensification). Patients may view this as an undesirable management outcome, with a perception that treatment intensification indicates a failure with their current therapies and lifestyle changes. Healthcare provider–patient conversations are necessary to address this perception, with emphasis that treatment intensification in heart failure is a guideline-recommended and proactive approach that will help the patient achieve their objectives.

The importance of lifestyle modifications, nutrition, and mental healthcare

Adopting healthy habits is a key aspect of heart failure care, both for people already diagnosed with heart failure to help slow progression and minimize symptoms, and for those with risk factors for developing heart failure [5, 6]. It is important that a treatment plan and lifestyle changes take into account the patient’s social circumstances and ethnocultural background [30]. Guidelines recommend several key lifestyle modifications, including [6]:

Engaging in regular physical activity (as recommended by a healthcare provider and according to personal capability)

Maintaining a healthy body weight

Stop smoking and taking recreational drugs

Avoid excessive consumption of alcohol; abstain from alcohol in people with cardiomyopathy caused by high alcohol intake

A healthy diet is a vital part of living with heart failure. Dietary advice may include [6, 31]:

Optimizing salt (sodium) and fluid intake:

In patients with chronic heart failure with no congestion, no/minimal loop diuretic use, and on guideline-directed medical therapy, salt intake should be 1.5 to 4 g a day and fluid intake should be 1.5 to 2.5 L a day. Salt intake up to 5 g a day and fluid intake greater than 2.5 L a day may be considered (guided by thirst/environmental factors)

In patients with acute heart failure, including those with residual congestion, on a loop diuretic, and with guideline-directed medical therapy still being uptitrated, salt intake should be 1.5 to 4 g a day and fluid intake should be 1.5 to 2.5 L a day

In patients with severe or advanced heart failure, a more restrictive intake of fluid may be considered

A ‘Mediterranean’ or ‘DASH’ diet, which include low-fat dairy, vegetables, nuts, olive oil, legumes, whole grains, fruits, fish, and poultry, and are low in red meat, saturated fats, alcohol, and processed foods, taking into account patient medical needs, preferences, and cultural food traditions [32]

People with heart failure may also experience cognitive problems, such as increased difficulty with memory, attention, ‘brain fog’, anxiety, and depression [6, 10, 33, 34]. They can also feel powerless and frustrated about living with heart failure, and worry about being a burden on their caregivers [34, 35]. These factors can impact a person’s heart failure symptoms and their ability to care for themselves [6, 10, 33]. Guidelines suggest assessment of mental health factors, extra care and appropriate support for people experiencing these symptoms [6, 10], such as cognitive behavioral therapy, appropriate exercise, social support, and, if needed, medication [36].

Treating comorbidities and risk factors

It is important that heart failure is treated alongside any other medical conditions, as they can impact heart failure symptoms and progression. These can include high blood pressure (hypertension), other heart conditions, anemia, type 2 diabetes, metabolic syndrome, thyroid problems, chronic kidney disease, obesity, and recreational drug use (including alcohol and smoking) [6, 10].

Careful assessment is needed so that each medical condition is diagnosed separately, but managed in the context of heart failure, as the preferred treatment option depends on what is safest and most appropriate. As shown in Fig. 5, some treatments for heart failure (e.g., lifestyle changes, SGLT2i, ACEi/ARB, MRA, diuretics) can also be used to treat comorbid conditions, making the choice of therapy particularly relevant [6, 10, 25].

Fig. 5

Treatment management of heart failure in people with type 2 diabetes, chronic kidney disease, hypertension, and obesity. A GLP-1 RA and a nonsteroidal MRA are recommended to reduce progression of kidney disease in people with CKD associated with type 2 diabetes. ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CKD, chronic kidney disease; GLP-1 RA, glucagon-like peptide-1 receptor agonist; MRA, mineralocorticoid receptor antagonist; SGLT2i, sodium–glucose cotransporter 2 inhibitor

The role of healthcare providers and patients in managing heart failure

With the patient at the center, a multidisciplinary, coordinated care team – comprising specialist heart failure nurses and clinicians, primary care providers, and caregivers – plays a crucial role in effective heart failure management. This includes improving treatment outcomes and overall patient quality of life [3, 28, 37]. As shown in Fig. 6, fostering positive healthcare professional–patient relationships can [28]:

Encourage adherence to treatment plans

Enhance patient understanding of their condition and medications

Promote healthier lifestyle choices

Fig. 6

Patient-centered care to improve treatment outcomes. GDMT, guideline-directed medical therapy; HCP, healthcare provider; HF, heart failure

To play a key role in the effective management of their disease, it is important for people with heart failure to:

Recognize their symptoms

Understand the significance of any changes in their symptoms

Know when to seek medical attention [28]

Table 3 outlines key resources that can help with this, whether an individual is newly diagnosed or living with established heart failure.

Enhancing communication between patients and healthcare providers

As shown in Fig. 7, poor communication between patients and healthcare providers can negatively impact a patient’s quality of life. This effect is particularly pronounced in vulnerable patients, who may rely more heavily on healthcare providers for guidance [38, 39]. Understanding a patient’s expectations and concerns enables healthcare providers to manage emotions effectively and improve information-sharing, ultimately leading to higher patient satisfaction [38].

Fig. 7

Factors leading to poor communication. HCP Healthcare provider

Checklists can serve as helpful tools to guide discussions between patients and healthcare providers, enabling patients to better understand their condition and allowing healthcare providers to address patient concerns more effectively. Figures 8 and 9 provide examples of key questions that can be used to facilitate more productive conversations. It is vital that healthcare professionals understand a patient’s needs with regard to their social and ethnocultural background, and for the patient to be able to discuss these with them [10, 30].

Fig. 8

Patient checklist. HF, heart failure

Fig. 9

Healthcare provider checklist and considerations. HF, heart failure