In the last decade, the treatment strategy of heart failure has undergone fundamental changes. The European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association (ACC/AHA) update their guidelines for the management of heart failure every 3-4 years, and the Chinese Medical Association (CMA) also updates its guidelines for heart failure in China. The 2005 European and American guidelines confirmed the role of cardiac synchronized pacing therapy (CRT) and intravenous automatic defibrillators (ICDs) in improving heart failure symptoms and reducing mortality. treatment and proposed the concept of heart failure with preserved ejection fraction (PEF) or normal (NEF) instead of diastolic heart failure (DHF), as well as a new classification of heart failure. The description of drug therapy for heart failure has also become more refined. All these changes are based on evidence-based medicine based on the results of large-scale clinical studies. I. European ESC definition of heart failure focuses on diagnosis In 2008, the European ESC definition of heart failure focuses more on diagnosis and lists the typical signs and symptoms of heart failure in detail, proposing that “heart failure is a clinical syndrome containing the following characteristics: 1. Typical symptoms: dyspnea, weakness, ankle edema at rest or during exercise; 2. Tachycardia, shortness of breath, pulmonary rales, pleural effusion, increased jugular venous pressure, peripheral edema, hepatomegaly; 3. Objective evidence of structural or functional abnormalities of the heart: enlarged heart chambers, third heart sound, heart murmur, abnormal echocardiogram, elevated brain natriuretic level”. The addition of elevated plasma brain natriuretic level here indicates the increasing importance of brain natriuretic measurement in the diagnosis of heart failure, especially in the diagnosis of acute heart failure and heart failure with preserved ejection fraction. The ACC/AHA guidelines divide the development of heart failure into four periods (or stages) of ABCD, with different treatment strategies for different periods. This staging better reflects the long-term developmental changes in heart failure, which are generally difficult to reverse from stage A to stage D. The NYHA classification, on the other hand, often reflects short-term changes. The two are somewhat correlated, but not completely compatible, so they are recommended for simultaneous clinical application. II. Reclassification of acute heart failure Currently, heart failure is often simply classified as acute and chronic heart failure, or systolic and diastolic heart failure. These two classification methods have been used for many years, and although they are simple and easy to use, there are many problems. Both conceptual and diagnostic criteria need to be updated. The concept of acute heart failure (AHF) is so general that many clinicians refer to severe cases as acute heart failure regardless of the time of onset, but in fact most of these patients are in a state of chronic heart failure decompensation, which has a different prognosis and treatment principles than new-onset heart failure and transient episodes of heart failure. 2008 European ESC guidelines recommend adding the concept of transient heart failure and classifying heart failure into three categories New-onset heart failure: heart failure that occurs for the first time and can be acute or slow in onset; 2. Transient heart failure: recurrent or intermittent episodes; 3. Chronic heart failure: persistent and can be stable, deteriorating or decompensated. The acute heart failure in the above classification can still be called acute heart failure, but it has nothing to do with the severity of the disease and should be distinguished from severe heart failure as well as decompensated heart failure. The European ESC guidelines for the diagnosis of diastolic heart failure in 2005 suggest that echocardiography has an important role in the diagnosis of diastolic heart failure (DHF), and three conditions need to be met for the diagnosis of DHF: 1. signs and/or symptoms of chronic heart failure; 2. normal or mildly impaired left ventricular systolic function (LVEF ≥45-50%); and 3. evidence of diastolic insufficiency (poor left ventricular relaxation or diastolic restriction). The first two are easily obtained, but direct evidence of diastolic insufficiency (elevated LV filling pressures or cardiac tissue Doppler confirmation) is difficult to obtain on clinical examination. Therefore, indirect evidence, such as elevated plasma brain natriuretic levels coupled with left ventricular hypertrophy or left atrial enlargement and atrial fibrillation, is often used. A subset of patients with diastolic heart failure diagnosed in this way are not predominantly diastolic or even solely due to systolic insufficiency. This leads to a conceptual conflict. Therefore, the 2008 European ESC guidelines recommend the use of heart failure with preserved ejection fraction (HF-PEF) instead of diastolic heart failure in the 2005 guidelines, although the diagnostic criteria for both are identical. 2009 US ACC/AHA guidelines use heart failure with normal ejection fraction (HF-NEF) instead of diastolic heart failure, also for these reasons, where HF- NEF is equivalent to HF-PEF. IV. ACE inhibitors remain the cornerstone of treatment of chronic heart failure ACE inhibitors can reduce the overall mortality of chronic systolic heart failure by an average of 24%, and the 2001 guidelines identified them as the cornerstone of treatment for this group of patients. However, it is important to be aware that ACE inhibitors may aggravate renal insufficiency and cause hyperkalemia. The new guidelines set lower pre-drug levels of potassium and creatinine. Contraindications are a history of angioneurotic edema, bilateral renal artery stenosis, potassium >5.0 mmol/L, creatinine >220 μmol/L (2.5 mg/dL), and severe aortic stenosis. Although there is evidence that the efficacy of ARB is equivalent to that of ACE inhibitors, it fails to surpass that of ACE inhibitors, and the combination of the two drugs will increase the incidence of adverse effects. Therefore, the 2008 European ESC guidelines suggest that the indications remain: patients with heart failure who cannot tolerate ACE inhibitors; or who are symptomatic despite the use of ACE inhibitors and β-blockers, but should not be combined with aldosterone receptor antagonists. VI. Better evidence for beta-blockers The CIBIS II, MERIT-HF and COPERNICUS studies published in 1999 and 2001, respectively, confirmed that bisoprolol, metoprolol succinate and carvedilol reduced overall mortality in chronic systolic heart failure by 34%-35% and were considered landmark studies. As a result, the 2001 European ESC and US ACC/AHA guidelines included beta-blockers as a cornerstone of treatment for chronic systolic heart failure, while emphasizing the superiority of high doses over low doses, with gradual increments to target doses as tolerated by patients. However, not all beta-blockers are equally effective. the BEST study confirmed the ineffectiveness of buspirone and the COMET study confirmed that carvedilol was better than metoprolol tartrate in reducing mortality. Some patients may be considered for use before ACE inhibitors. Beta-blockers can also be used safely and effectively in elderly patients. VII. Aldosterone receptor antagonists are indicated for severe heart failure or post-acute myocardial infarction heart failure The diuretic effect of spironolactone, an aldosterone receptor antagonist, is weak. Spironolactone is used in chronic heart failure mainly to improve long-term prognosis and also to prevent hypokalemia after the use of loop diuretics or thiazide diuretics. The indication for aldosterone receptor antagonists is the addition of aldosterone receptor antagonists to already appropriate doses of ACEI or ARB, beta-blockers in heart failure patients with EF ≤ 35%, NYHA class III-IV, and should be initiated prior to discharge from the hospital. The new guidelines emphasize that aldosterone receptor antagonists should not be added to patients already on a combination of ACE inhibitors + ARBs. The guidelines do not clarify whether this class of drugs should be used in NYHA class I or II patients, apparently because their benefit in improving long-term prognosis has not been adequately demonstrated. VIII. Adequate use of diuretics should be used in severe heart failure Loop diuretics and thiazide diuretics have different sites of action, and their combined use can enhance the diuretic effect, especially when diuretic resistance occurs Loop diuretics can be combined with thiazide diuretics. Continuous intravenous drip loop diuretics (e.g., furosemide 5-40 mg/h) are more effective and can avoid sodium reabsorption during intermittent dosing. The addition of small doses of dopamine when blood pressure is low can improve renal blood flow and enhance the effect of diuretics. Digoxin can improve symptoms but not reduce mortality, the current recommended dose is less than the previous dose, the recommended blood concentration: 0.6-1.2ng/mL, and sinus rhythm without loading dose, generally 0.25mg/d; elderly renal insufficiency 0.125-0.0625mg/d. For the purpose of atrial fibrillation to reduce the ventricular rate can be used in larger doses. The indications are atrial fibrillation resting ventricular rate >80bpm, or exercise ventricular rate >110-120bpm. X. Nitrate can also reduce the mortality of heart failure Nitrate has been used in clinical practice for more than 100 years, and is now mainly used to relieve angina symptoms and heart failure symptoms. And whether it can reduce the mortality of coronary heart disease and heart failure is uncertain, clinical research results are inconsistent. The reason for this is related to the use of high doses of short-acting nitrate and frequent administration of nitrate resistance and activation of the RAAS system, etc. The A-HeFT study published in 2004 used a nitrate dose of 60 mg/d, significantly less than the previous dose of 160 mg/d. The results confirmed that nitrate and hydrazidiazide treatment for 18 months resulted in a 43% increase in survival and a 33% reduction in heart failure hospitalization rates. The 2009 ACC/AHA guidelines suggest that the combination of hydrazide/nitrate may be used in black American patients with heart failure who remain symptomatic after optimal treatment with ACE inhibitors, B-receptors, and diuretics, and increase the recommended intensity from Class IIa to Class I. XI. Cardiac synchronization therapy (CRT) is becoming increasingly mature CRT can correct cardiac electro-mechanical asynchrony and reverse ventricular remodeling in many ways, and clinical studies have confirmed that it is not only effective in improving symptoms, exercise tolerance, and quality of life in patients with heart failure, but also in reducing hospitalization and mortality. 2009 ACC/AHA guidelines suggest that cardiac synchronization therapy (CRT) is indicated for LVEF ≤35%, sinus rhythm, NYHA class III or IV, with manifestations of cardiac asynchrony using optimized drug therapy: QRS interval ≥0.12 ms, and clarified that CRT is possible with or without ICD function. It is proposed that some patients with atrial fibrillation can be considered for CRT or CRT-D therapy. In contrast, the indications for an intracorporeal automatic defibrillator (ICD) are heart failure patients with non-ischemic dilated cardiomyopathy or coronary artery disease at least 40 days after myocardial infarction, LVEF ≤35%, NYHA class II or III, who have started long-term optimal drug therapy and are expected to maintain a better cardiac functional status and survive for at least 1 year.