Management of heart failure in patients with kidney disease: updates from the 2021 ESC guidelines

The wide overlap between the syndromes of chronic kidney disease and chronic heart failure means that familiarity with the 2021 European Society of Cardiology guidelines is of importance to nephrologists. The common risk factors for the two syndromes together with the adverse cardiac structural remodelling associated with chronic kidney disease means that many kidney disease patients are breathlessness and fall within the heart failure phenotypes categorised in the guidelines. The management of heart failure is evolving rapidly leading to significant changes in the latest guideline iteration. The 2021 guideline has changed from the 2016 version firstly by an increased focus on identifying the three phenotypes of heart failure to guide appropriate evidence based management. Secondly a new and simplified treatment algorithm for heart failure with reduced ejection fraction involving the rapid sequential initiation and up-titration of 4 ‘pillars’ of drug treatment—ACE inhibitors or angiotensin-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists and now, thanks to convincing trial data, sodium-glucose co-transporter-2 inhibitors. Thirdly, guidelines for device therapy have been changed with down-graded advice on indications for primary prevention implantable cardioverter defibrillator therapy for patients with non-ischaemic heart failure and for cardiac resynchronisation therapy with left bundle branch block and a QRS duration < 150 ms. There are updated treatment plans for heart failure associated with non-cardiovascular co-morbidities including chronic kidney disease.