2021 CCS/CHFS Heart Failure Guidelines Update:
Selected Highlights

Updated treatment algorithm for the management of HFrEF from the 2021 CCS/CHFS Heart Failure Guidelines Update3†

Treat comorbidities per ccs hf recommendations (INCL.AF,functional mr, Iron Def, Ckd,DM)

Treat comorbidities per ccs hf recommendations (INCL.AF,functional mr, Iron Def, Ckd,DM)

HFrEF: LVEF ≤40% AND SYMPTOMS

Initiate Standard Therapies

ARNI or
ACEi/ARB
then substitute
forARNI‡

BETA
BLOCKER

MRA

SGLT2
INHIBITOR†

Assess Clinical Factors for Additional Interventions

HR >70 bpm and
sinus rhythm
  • • Consider
    ivabradine§
Recent HF
hospitalization
  • • Refer to CCS
    Guidelines
    for complete
    considerations
Black patients on optimal GDMT, or patients unable to tolerate ARNI/ACE/ARB
  • • Consider combination
    hydralazine-nitrates
Suboptimal rate
control for AF, or
persistent symptoms
despite optimized
GDMT
  • • Consider digoxin

Initiate standard therapies as soon as possible and titrate every 2-4 weeks to target
or maximally tolerated dose over 3-6 months

Reassess LVEF, Symptoms, Clinical Risk

NYHA III/IV, Advanced HF
or High-Risk Markers

CONSIDER

  • • Referral for advanced
    HF therapy (mechanical circulatory support/ transplant)
  • • Referral for supportive/ palliative care

LVEF ≤35% and
NYHA I-IV (ambulatory)

Refer to CCS CRT/ICD
recommendations

LVEF >35%, NYHA I, and
Low Risk

Continue present
management, reassess as
needed

Treat comorbidities per ccs hf recommendations (INCL.AF,functional mr, Iron Def, Ckd,DM)

Treat comorbidities per ccs hf recommendations (INCL.AF,functional mr, Iron Def, Ckd,DM)

“Standard therapies are applicable to most patients with HFrEF for reducing cardiovascular mortality and hospitalization for HF.”3

“Every attempt should be made to initiate and titrate therapies with the goal of medication optimization by 3–6 months after a diagnosis of HFrEF.”3


2021 CCS recommendation†

ARNI: Recommended as a standard therapy for HFrEF “The 2021 CCS HF Guidelines recommend ARNI as a standard therapy for HFrEF, in combination with other standard therapies.”3

2021 CCS recommendation†

“We recommend that an ARNI be used in place of an ACEi or ARB, in patients with HFrEF, that remain symptomatic despite treatment with appropriate doses of GDMT… (was assigned strong recommendation, high-quality evidence).”3

† Please consult guidelines for complete recommendations.3 ‡ ARNI and SGLT2 inhibitor are not indicated as first-line treatments for HFrEF. Please refer to the separate Product Monographs for complete prescribing information. § Ivabradine is indicated in patients with HFrEF and HR ≥77 bpm in sinus rhythm. ACEi: angiotensin converting enzyme inhibitor; AF: atrial fibrillation; ARB: angiotensin receptor blocker; ARNI: angiotensin receptor-neprilysin inhibitor; CCS: Canadian Cardiovascular Society; CHFS: Canadian Heart Failure Society; CKD: chronic kidney disease; CRT: cardiac resynchronization therapy; DM: diabetes mellitus; GDMT: guideline-directed medical therapy; HFrEF: heart failure with reduced ejection fraction; HR: heart rate; ICD: implantable cardioverter defibrillator; LVEF: left ventricular ejection fraction; MR: mitral regurgitation; MRA: mineralocorticoid receptor antagonist; NYHA: New York Heart Association; SGLT: sodium glucose transport.