The known unknowns of managing acute heart failure

Take Home Messages
  • European and American heart failure (HF) guideline recommendations for the management of unplanned hospitalisations are based on limited randomised controlled trial evidence.
  • Treating fluid overload is key, but how decongestion therapy is initiated and what treatment strategies are used within different local hospitals is not well reported. These variations in practice may impact on length of stay and patient outcomes.
  • Patient views on heart failure treatment goals should be routinely sought particularly in complex, frail patients with multiple comorbidities.
  • Future work will require more targeted research in these areas and a greater focus on shared decisions with patients with increasing awareness of how frailty and multimorbidity can impact on what 'best care’ may look like for each HF patient.

The lack of gold-standard randomised controlled trial (RCT) evidence to support clinical decision-making in acute cardiovascular care represents an area of particular unmet need, where significant variation in practice and underuse or overuse of clinical treatments can occur (1,2). Most recommendations are based on observational analyses rather than RCTs (1). Two recent sets of guidelines for heart failure, published by European and American societies, highlight the substantive gains made in improving patient outcomes wherever there is robust RCT evidence available (3,4). Optimal pharmacotherapy now includes new drug classes such as SGLT2 inhibitors and possible use in traditionally hard to treat groups such as heart failure with preserved ejection fraction (5). However, both guidelines have sections emphasising where gaps persist in the evidence. These ‘known unknowns’ represent areas of heart failure treatment that have suffered from a lack of RCTs to help guide best practice.