1Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
2Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
3Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
4Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
5Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
6Division of Endocrinology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
7Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
Copyright © 2023 Korean Diabetes Association
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
CONFLICTS OF INTEREST
Kyu-Chang Won has been publisher of the Diabetes & Metabolism Journal since 2022. Kyung Mook Choi has been editor-inchief of the Diabetes & Metabolism Journal since 2022. They were not involved in the review process of this article. Otherwise, there was no conflict of interest.
FUNDING
None
Diagnostic criteria | HFrEF | HFmrEF | HFpEF |
---|---|---|---|
1 | Symptom±signa | Symptom±signa | Symptom±signa |
2 | LVEF ≤40% | LVEF 41%–49% | LVEF ≥50% |
3 | - | - | 1. Elevation of natriuretic peptide |
2. Objective evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/or increased LV filling pressure |
HFrEF, heart failure reduced ejection fraction; HFmrEF, heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; LVEF, left ventricular ejection fraction; LV, left ventricular.
a Sings of HF may not be present and/or nonspecific in the early stage of HF (especially in HFpEF) and/or in patients treated with optimal medical treatment, including diuretics.
Tests | Recommendations |
---|---|
Natriuretic peptide (BNP or NT-proBNP) | BNP or NT-proBNP is recommended as an initial diagnostic test in patients with symptoms and signs suggestive of HF to rule out the diagnosis of HF. Cutoff value: BNP ≥35 (pg/mL) or NT-proBNP ≥125 pg/mLa |
ECG | The ECG may reveal abnormalities such as ST elevation, ST depression, atrial fibrillation, Q wave, LV hypertrophy, and a widened QRS complex (for example, LBBB) that increase the likelihood of a diagnosis of HF. |
Chest X-ray | A chest X-ray is recommended to evaluate the presence or absence of pulmonary congestion and cardiomegaly in patients with suspected HF. |
Echocardiography | LVEF, chamber size, degree of wall thickness, regional wall motion abnormalities, valvular function, RV function, pulmonary hypertension, and parameters of diastolic function |
Standard blood tests | CBC, serum urea, electrolytes, creatinine, thyroid, and liver function tests, fasting glucose, HbA1c, lipids, and iron statuses (TSAT and ferritin) |
BNP, B-type natriuretic peptide; NT-proBNP, N-terminal pro-B-type natriuretic peptide; HF, heart failure; ECG, electrocardiogram; LV, left ventricular; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; RV, right ventricular; CBC, complete blood count; HbA1c, glycosylated hemoglobin; TSAT, transferrin saturation.
a Cutoff values may have lower specificity, especially in older patients or those with atrial fibrillation or chronic kidney disease. Usually, higher cutoff values are recommended for the diagnosis of HF in these patients.
Starting dose | Target dose | |
---|---|---|
ACEI | ||
Captopril | 6. 25 mg t.i.d. | 50 mg t.i.d. |
Enalapril | 2.5 mg b.i.d. | 10–20 mg b.i.d. |
Lisinopril | 2.5–5 mg q.d. | 20–35 mg q.d. |
Ramipril | 2.5 mg b.i.d. | 5 mg b.i.d. |
Trandolapril | 0.5 mg q.d. | 4 mg q.d. |
ARNIa | ||
Sacubitril/Valsartan | 49/51 mg b.i.d. | 97/103 mg b.i.d. |
Beta-blockers | ||
Bisoprolol | 1.25 mg q.d. | 10 mg q.d. |
Carvedilol | 3.125 mg b.i.d. | 25 mg b.i.d. |
Metoprolol | 12.5–25 mg q.d. | 200 mg q.d. |
Nebivolol | 1.25 mg q.d. | 10 mg q.d. |
MRAs | ||
Eplerenone | 25 mg q.d. | 50 mg q.d. |
Spironolactoneb | 25 mg q.d. | 50 mg q.d. |
SGLT2 inhibitors | ||
Dapagliflozin | 10 mg q.d. | 10 mg q.d. |
Empagliflozin | 10 mg q.d. | 10 mg q.d. |
ARBs | ||
Candesartan | 4 mg q.d. | 32 mg o.d. |
Losartan | 50 mg q.d. | 150 mg q.d. |
Valsartan | 40 mg b.i.d. | 160 mg b.i.d. |
Other agents | ||
Ivabradine | 5 mg b.i.d. | 7.5 mg b.i.d. |
Vericiguat | 2.5 mg q.d. | 10 mg q.d. |
Digoxin | 62.5 µg q.d. | 250 µg q.d. |
ACEI, angiotensin-converting enzyme inhibitor; t.i.d., ter in die (three times a day); b.i.d., bis in die (twice daily); q.d., quaque die (once daily); ARNI, angiotensin receptor neprilysin inhibitor; MRA, mineralocorticoid receptor antagonist; SGLT2, sodium-glucose co-transporter 2; ARB, angiotensin II receptor blocker.
a Sacubitril/valsartan may have an optional lower starting dose of 24/26 mg b.i.d. for patients with a history of symptomatic hypotension,
b Spironolactone has an optional starting dose of 12.5 mg in patients with renal impairment or hyperkalemia.
HF, heart failure; NYHA, New York Heart Association; ICD, implantable cardioverter defibrillation; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; BNP, B-type natriuretic peptide; NT-proBNP, N-terminal pro-B-type natriuretic peptide; LVEF, left ventricular ejection fraction.
HF, heart failure; ASCVD, atherosclerotic cardiovascular disease; SGLT2, sodium-glucose co-transporter 2; DKA, diabetic ketoacidosis; eGFR, estimated glomerular filtration rate; GI, gastrointestinal; GLP-1 RA, glucagon-like peptide-1 receptor agonist; SQ, subcutaneous; DPP4, dipeptidyl peptidase-4; SU, sulfonylurea; TZD, thiazolidinedione; NASH, nonalcoholic steatohepatitis.