Heart failure and atrial fibrillation have become two of the most significant problems of cardiovascular disease in the 21st century.E, Braunwald noted that heart failure is the last great battlefield in the treatment of heart disease. The incidence of congestive heart failure is increasing year by year with the progress of aging population, the increase of myocardial infarction survival rate and the increase of life expectancy of heart failure patients. Therefore, it is essential to take appropriate preventive measures for patients with risk factors for heart failure as early as possible. Yancy, chair of the 2013 ACCF/AHA Heart Failure Guidelines Editorial Committee, noted that if the right patient is treated in the right way at the right time, the risk of death can be reduced very significantly, perhaps by as much as 50%. That’s a real benefit. It dwarfs the benefit of many other cardiovascular treatments. So what is the right time, the right way, the right patient and the best treatment?The ACCF/AHA guidelines for the management of heart failure were published in the US in 2013, the NICE guidelines for the diagnosis and management of acute heart failure in adults (draft) were published in the UK in 2014, and in the same year China issued the Chinese guidelines for the diagnosis and treatment of heart failure (2014). The latter is the basis for guiding the clinical practice of heart failure in China. I. Pathogenesis of heart failure There are three major theories of the pathogenesis of heart failure that guide drug therapy: hemodynamic, neuroendocrine, and load cardiomyopathy theories. Myocardial injury from any cause can lead to a decline in cardiac function, causing over-activation of the sympathetic and RAS systems; in the acute phase of heart failure, it can play a compensatory role to improve cardiac function; if the compensation fails, after entering the chronic phase of heart failure, the over-activation of the sympathetic and RAS systems can aggravate cardiac remodeling and cause further damage to the heart. Neurohormones (over-activation) play a pivotal role in the progression of heart failure. This update of pathogenesis has led to a dramatic change in the treatment strategy and philosophy of heart failure. II. Treatment of heart failure (a) Treatment strategies for acute heart failure The Chinese guidelines for the diagnosis and treatment of heart failure (2014) highlight the importance of flow and reaffirm the status of diuretics in the treatment of heart failure (Class I recommendation), as well as their importance in improving symptoms. Short-term hemodynamic and pharmacological measures in acute heart failure include increasing cardiac output, decreasing pulmonary gross pressure and reducing resistance to pulmonary circulation. (ii) Treatment strategies for chronic heart failure The goals of treatment for chronic heart failure include improving symptoms, preventing and delaying ventricular remodeling, and reducing hospitalizations. For patients with diagnosed chronic heart failure, the original focus was primarily on improving prognosis and survival; improving patient symptoms, improving quality of life, and reducing rehospitalization rates were also critical. Long-term, restorative strategies to modify the biology of the failing heart are used to delay and prevent myocardial remodeling. For patients with EF <49%, the "golden partner" or "golden triangle" of biological therapy is emphasized; for patients with EF >50%, emphasis is placed on controlling hypertension, improving myocardial ischemia and secondary prevention of coronary artery disease, controlling ventricular rate in atrial fibrillation, and improving diastolic function in hypertrophic ventricles; and for patients with EF between 40 and 40%, the “golden triangle” of biological therapy is emphasized. of diastolic function; EF between 40%-50% may be HFPEF critical or HFREF improved. (3) Standard drug therapy 1. Drugs to improve prognosis (1) ACEI/ARB: ACEI is a milestone in the treatment of heart failure, which can inhibit sympathetic and RAAS, and is the key and cornerstone of the treatment of heart failure. The Chinese guidelines for the diagnosis and treatment of heart failure (2014) emphasize the indications for ACEI as mandatory and lifelong use in all heart failure patients with decreased ejection fraction (EF), unless contraindications exist (Class I, Level A). ACEIs should be considered for heart failure prevention in those at high risk of heart failure (stage A), although no structural or functional abnormalities of the heart have yet been observed (class IIa, level A). ACEI drugs such as captopril, enalapril, fosinopril, lenopril, perindopril, ramipril, and benazepril are indicated for the treatment of heart failure, but attention should be paid to their respective target doses (target doses are based on evidence-based medical evidence.) The application of ACEI/ARB drugs should be started at small doses and gradually increased until the target dose is reached. Contraindications include: previous laryngeal edema, anuric renal failure and pregnancy. (2) Beta-blockers: reduce mortality and sudden death rates in patients with heart failure; they should be used in all patients with chronic heart failure who are relatively stable and need to be used for life, unless contraindicated or intolerable. Dose should be increased carefully and slowly (judged by heart rate) starting with very small amounts to avoid worsening heart failure by too rapid withdrawal of adrenergic support; use at steady state (dry weight) – maintain dry weight before and during use of beta-blockers. β-blockers (3) Aldosterone receptor antagonists: At present, domestic and foreign and new guidelines, the recommendation of indications for aldosterone receptor antagonists is expanded from cardiac function class III/IV to cardiac function class II. Chinese guidelines for the diagnosis and treatment of heart failure (2014) recommend: all patients with ACEI/ARB and β-blockers who are still persistently symptomatic (NYHA class II-IV) and have EF ≤ 35% are recommended (class I, level A). It is also recommended for patients after acute myocardial infarction, LVEF ≤ 40%, with symptoms of heart failure or previous history of diabetes mellitus (Class I, Level B); start with a small dose and gradually increase the dose. The guidelines recommend that ACEI/ARB + β-blocker + aldosterone receptor antagonist should be used as soon as the patient has an indication, forming a “golden triangle” to avoid hypotension, hyperkalemia and renal impairment. Avoid the combination of ACEI + ARB + aldosterone receptor antagonist. The above three types of drugs are known as the “golden partner” in the biological treatment of heart failure. 2. Drugs to improve symptoms include diuretics, digitalis and ivabradine. Diuretics should be given first priority, especially for patients with edema. Our 2014 heart failure guidelines re-emphasize the primary fundamental and key role of diuretics in the treatment of heart failure. Diuretic control provides immediate relief of heart failure symptoms and is the basis for any other effective “biological treatment”. The combination of sympathetic and RAAS-inhibiting drugs is necessary in chronic heart failure. The US Heart Failure Guidelines emphasize the importance of salt restriction. In stage A/B heart failure, salt intake should be less than 3 or 8 g/d, and in stage C/D, it should be even lower. (iv) New concept of GDMT – guideline-directed medication therapy The American College of Cardiology Committee (ACCF)/American Heart Association (AHA), published on June 5, 2013, clearly introduced the concept of guideline-directed medication therapy (GDMT), which makes heart failure medication therapy more standardized. Evidence-based, patient-centered heart failure treatment, education, and self-management; giving the best treatment plan, the best application (timing and dose), and getting the best outcome.