Focus on the 2014 China Heart Failure Diagnosis and Treatment Guidelines The 2014 China Heart Failure Prevention and Treatment Guidelines were officially released. The new guidelines cover four major topics in heart failure treatment: heart failure diagnosis and screening, chronic heart failure treatment, acute heart failure treatment, and comprehensive heart failure treatment and follow-up management. Some of the major changes are: (1) the population of aldosterone antagonists is expanded to include all patients with symptomatic heart failure (NYHA class II-IV); (2) the application of ivabradine, a drug that simply slows the heart rate, is recommended; (3) acute heart failure is added; (4) the population of cardiac resynchronization therapy (CRT) is expanded to include patients with NYHA class II heart failure; (5) the application of BNP/NT-proBNP is recommended. (5) recommended the application of BNP/NT-proBNP dynamic monitoring to assess the effect of chronic heart failure treatment; (6) revision of the names of chronic heart failure types and diagnostic criteria; (7) emphasized the concept of holistic heart failure treatment, and proposed new concepts such as exercise rehabilitation, follow-up management, patient education, herbal medicine treatment, and multidisciplinary management programs. The guideline updates the steps and pathways of chronic heart failure drug therapy, and proposes the “golden triangle” concept of standard (or basic) heart failure therapy. The guideline provides a more detailed description of the indications, side effects, and evidence-based recommendations and levels of evidence for heart failure therapies, and classifies them into different categories for clinical use, such as prognosis improvement and symptom improvement. Drugs that improve prognosis are indicated for all patients with chronic systolic heart failure in cardiac function classes II-IV: (1) angiotensin-converting enzyme inhibitors (ACEI) (I, A); (2) beta-blockers (I, A); (3) aldosterone antagonists (I, A); (4) angiotensin receptor antagonists (ARB) (I, A); (5) ivabre: used to reduce the rate of rehospitalization for heart failure ( IIa, B), and as an alternative for patients who cannot tolerate beta-blockers (IIb, C). Symptom-improving drugs are recommended for all patients with chronic systolic heart failure in classes II-IV: (1) Diuretics (I, C): The effect on mortality and morbidity in chronic heart failure has not been clinically studied, but they can reduce shortness of breath and edema and are recommended for patients with signs and symptoms of heart failure, especially those with significant fluid retention. (2) Digoxin (IIa, B). Drugs that may be harmful and not recommended: (1) thiazolidine-type hypoglycemic agents, which can worsen heart failure; (2) most calcium antagonists, which have negative inotropic effects and worsen heart failure. The exceptions are amlodipine and felodipine, which are available when necessary; (3) nonsteroidal anti-inflammatory agents and COX-2 inhibitors, which can cause water and sodium retention, worsen heart failure, and impair renal function; and (4) ACEI and aldosterone antagonists combined with ARB on top of each other, which increases the risk of renal impairment and hyperkalemia. The guideline highlights aldosterone antagonists and ivabradine, especially aldosterone antagonists to the same important position as ACEI and β-blockers in the treatment of chronic heart failure, from then on the basic treatment plan of heart failure also changed from the “golden partner” (ACEI plus β-blockers) to The “golden triangle” (the first two plus aldosterone antagonists). After beta-blockers, aldosterone antagonists are another drug that has been shown to significantly reduce the rate of sudden cardiac death and can be used in the long term. This beneficial effect, together with the aforementioned good results, has finally made these drugs indispensable in the treatment of heart failure, alongside ACEI and beta-blockers. The addition of ivabradine for more than 2 years, including diuretics and the “Golden Triangle” base therapy, reduced heart rate by 8-11 beats/min in heart failure patients, and significantly reduced cardiovascular death and hospitalization for heart failure by 18% compared to the placebo control group. The new guidelines recommend the following indications for ivabradine: patients with chronic heart failure who have been treated with evidence-based doses of ACEI, ARB, and aldosterone antagonists, but whose basal heart rate is still >70 beats/min and whose symptoms have not improved satisfactorily (Class IIa) or who cannot tolerate beta-blockers (Class IIb). The new guidelines, influenced by international guidelines, standardize and standardize the treatment of chronic systolic heart failure in steps that make it easy for clinicians to understand at a glance and promote the use of the drug treatment process, the non-drug treatment process, and the acute heart failure management process, respectively. The timing of ACEI and/or β-blocker initiation used to emphasize that diuretics must be applied to eliminate fluid retention before starting to add these two drugs, otherwise the efficacy and adverse effects will be compromised. This view is not inappropriate, but it may delay the initiation of these two prognostic drugs. In patients with heart failure who are hospitalized, it is difficult to use only diuretics for the first few days. The new guidelines do not require this anymore, and the implication is to leave it up to the clinician’s discretion, case by case, to treat each patient individually. In patients with mild to moderate edema, especially those hospitalized and under close observation, ACEIs and/or beta-blockers can be used in conjunction with diuretics. Since tab diuretics are powerful and can eliminate or reduce retained fluid over several days, and only small doses of both drugs are applied during this time period, they generally do not cause adverse effects. This has the positive effect of making the application of drugs that improve prognosis as early as possible without creating safety problems. However, for patients with significant and severe edema in heart failure, ACEI and/or β-blockers should be started only after the diuretics are fully functional and the edema has been eliminated or has significantly subsided, to be on the safe side. Adverse effects of ACEI and aldosterone antagonists can be additive, such as electromediator disorders, elevated blood creatinine, and even renal impairment. Ways to prevent adverse reactions include close observation, starting with small doses, gradually increasing the dose, and even crossing over the same day’s drug application. ACEI and ARB relationship The new guidelines still recommend applying ACEI first, and those who cannot tolerate it can switch to ARB, and the recommendation is reasonable. However, the clinical situation is complicated, and the incidence of ACEI adverse reactions (especially cough) in Chinese heart failure patients is 20%-30%, while the biggest advantage of ARB is less adverse reactions and good compliance. For a drug that needs long-term or even lifelong application, safety and tolerability are more important than efficacy. The role of beta-blockers in reducing all-cause mortality, especially sudden cardiac death, in chronic heart failure is indispensable and irreplaceable. It can be used in patients with diabetes mellitus, chronic obstructive pulmonary disease, and in the elderly, even in patients with a history of previous asthma attacks. The new guidelines actively recommend the use of beta-blockers and require that the target or maximum tolerated dose be achieved, which is supported by a large body of research evidence and is reasonable, an attitude that cannot be shaken. The effectiveness of heart failure treatment is usually evaluated based on the improvement of three clinical conditions, namely, symptoms and/or signs, indicators of cardiac function, such as left ventricular ejection fraction (LVEF), NYHA classification, 6-min walk distance, and indicators of myocardial remodeling, such as heart size, especially left ventricular size. Significant improvement in these parameters is considered as effective treatment and maintenance is given. However, improvement in these parameters and clinical outcomes (including death rate and 30-d readmission) are not strongly correlated. The new guidelines recommend a reduction in BNP/NT-proBNP of ≥30% from the pre-treatment baseline level as a criterion for effective treatment. If this is not achieved, even if there is improvement in clinical parameters, the treatment should still be classified as unsatisfactory and should be intensified, including increasing the drug class or dose. The new guidelines recommend expanding the population of CRT to include NYHA class II heart failure patients. This recommendation is based on the MADIT-CRT, REVERSE, and RAFT trials. These studies enrolled patients with NYHA class I and II (mainly class II) heart failure. The results showed that CRT application significantly reduced the composite endpoint of major cardiovascular events, thereby reducing cardiovascular mortality and all-cause mortality, and could delay ventricular remodeling and progression of the disease. On top of standard and optimized drug therapy, CRT can further reduce the primary composite endpoint by approximately 35% in patients with chronic systolic heart failure for which there is an indication. The new guidelines provide more stringent criteria for the indication of CRT: CRT is primarily recommended for patients with left bundle branch block with significant ventricular excitation asynchrony.