Recent-onset cardiomyopathy represents a clinically dynamic and potentially reversible clinical framework of non-ischaemic cardiomyopathy, characterized by high variability in left ventricular (LV) function and arrhythmic risk. This clinical consensus statement provides a structured diagnostic and therapeutic approach based on two prognostic axes: the potential for LV reverse remodelling (LVRR) and the risk of sudden cardiac death (SCD). We operationalize four trajectories in the LV evolution, ranging from recovered LV ejection fraction (LVEF) to persistently reduced LVEF. Multimodal stratification including echocardiography, cardiac magnetic resonance, genetic profiling, biomarkers, and early treatment response allows tailored decision-making on pharmacological and device-based therapies. We propose a unified management algorithm emphasizing early initiation of guideline-directed medical therapy, structured reassessment at 3 and 6 months, and individualized consideration of defibrillators, resynchronization therapy, arrhythmia ablation, transcatheter valve leaflet edge-to-edge repair, and advanced heart failure assessment. This document aims to support clinicians in risk stratification and timely management or referrals.

There is a large spectrum of acute decompensated heart failure presentations resulting from the interaction between an acute precipitant and the patient’s underlying cardiac and non-cardiac conditions. A robust classification scheme at admission is crucial for appropriate triage and targeted treatment of high-risk populations. Such a scheme should incorporate timely actionable items to generate immediate management decisions, including characteristics that suggest life-threatening clinical presentations, the factors that could be favourably modified by in-hospital interventions, such as correctable aetiologies and congestion/hypoperfusion status, and in-hospital trajectories determined by patient responses to inpatient treatment. In-hospital trajectories determine the intensity of escalation therapies and timing for initiation/up-titration of guideline-directed medical treatment. In the long term, some patients experience a progressive downsloping course culminating in advanced heart failure, while others maintain a relatively stable remitting-relapsing trajectory. For future clinical trials, a comprehensive classification scheme integrating in-hospital and long-term trajectories could profoundly affect study design by ensuring interventions are tested in more homogeneous patient populations and facilitating nuanced patient stratification.

Acute heart failure (AHF) is a systemic condition characterised by multiorgan involvement that varies from subclinical to overt organ failure. The liver is particularly vulnerable due to its dual blood supply and sensitivity to haemodynamic and inflammatory disturbances. Abnormal liver function tests are highly prevalent in patients with AHF, reflecting major mechanisms: passive hepatic venous congestion from elevated central venous pressure, hepatocellular ischaemia from low cardiac output, systemic inflammation and poor metabolic status associated with cachexia. In patients with AHF, liver function tests at admission, during hospitalisation and at discharge are independently associated with rehospitalisation, cardiovascular and all-cause mortality. Persistent abnormalities after hospitalisation often reflect incomplete decongestion or irreversible structural liver changes. Therapeutic strategies focus on decongestion, optimisation of cardiac output and medication adjustments to avoid hepatotoxicity. Despite significant advances in understanding cardio-hepatic interactions, major gaps remain, including the lack of standardised definitions, limited mechanistic studies and the underrepresentation of patients with heart failure with preserved ejection fraction in contemporary research. Future research should explore targeted therapies to improve cardiohepatic interactions and patient outcomes.

Peripartum cardiomyopathy (PPCM) can be a serious condition, presenting with heart failure with reduced ejection fraction towards the end of pregnancy or in the months following delivery. Less than half of the patients fully recover their cardiac function within 6 months of diagnosis, with substantial regional variation. This clinical consensus statement addresses the global and regional heterogeneity of epidemiological data on PPCM, substantial variation in access to medical care, and the contributing factors to poor adherence, as well as the impact of socioeconomic factors. The scope of this document encompasses contemporary challenges and approaches for the management of women diagnosed with PPCM. We provide a framework of practical aspects of starting disease-specific and guideline-recommended medical therapy, rapid up-titration, and improving adherence. Furthermore, the importance of involving women with a new diagnosis of PPCM in the decision-making processes regarding various therapeutic options is highlighted, as this also affects the mental health and quality of life for the patient, as well as for the extended family.

Patients with cancer usually report limitations of their functional capacity, which may range from subclinical impairment of cardiopulmonary exercise reserve to poor quality of life with physical, cognitive, or psychosocial consequences. Exercise training is a potent multi-targeted approach to control pre-existing and new risk factors. Preliminary evidence shows that it is associated with a lower risk of cancer therapy-related cardiotoxicity and increased self-reported well-being in patients with cancer. Current evidence demonstrates that supervised exercise therapy, including high-intensity interval training, is safe and well-tolerated and reduces risk in subjects with cancer in the pre-, active-, and post-treatment settings. The present consensus document will discuss the role of exercise training in cardio-oncology, focusing on patients with cardiovascular diseases induced by cancer treatment and on those who received cardiotoxic therapies.

BACKGROUND AND AIMS:The risk of heart failure progression or mortality in patients with peri-partum cardiomyopathy (PPCM) during subsequent pregnancies (SSPs) is a significant concern for patients, their families, and healthcare providers. However, there is limited contemporary, prospective data on SSP outcomes in PPCM patients from diverse ethnic and sociodemographic groups. This study aimed to assess maternal and neonatal outcomes in PPCM patients undergoing SSPs. METHODS:This is a sub-study on PPCM and SSPs of the global European Society of Cardiology PPCM Registry that recruited patients from 2012 to 2023. Maternal and neonatal outcomes were reported. RESULTS:From 332 patients with PPCM, there were 98 SSPs among 73 women. Of these, 25 (26%) SSPs ended prematurely due to therapeutic termination (20/25), miscarriage (4/25), and stillbirth (1/25). The median follow-up from the end of the SSP was 198 days (inter-quartile range 160-240). Left ventricular ejection fraction (LVEF) was persistently reduced to <50% prior to the SSP in 26% of patients, with only 6% having an LVEF <40%. Patient characteristics were similar, irrespective of SSP baseline LVEF. Clinical worsening [composite of all-cause death, cardiovascular rehospitalization, or decline in LVEF ≥10% (percentage points) and to <50%] occurred in 20% SSPs, with 2% all-cause maternal mortality. Signs/symptoms of heart failure and worsening of New York Heart Association class occurred in 26% and 22% of SSPs, respectively. At follow-up, the mean LVEF was 50% (±12%), and in 69% of SSPs, the LVEF was ≥50%. African women had similar outcome as the other ethnic groups. Pre-term delivery occurred in 24% of SSPs, 20% of babies were of low birth weight, and there was 3% all-cause neonatal mortality. Compared with women with SSP baseline LVEF <50%, fewer women with LVEF ≥50% were on heart failure pharmacotherapies prior to the SSP, and in this group of women, there was a significant decline in LVEF. CONCLUSIONS:Maternal morbidity and mortality rates were lower than anticipated. Baseline LVEF <50% was not associated with an increased frequency of adverse maternal outcomes, and no further decline in LVEF was observed in this group. In contrast, women with SSPs and a baseline LVEF ≥50% experienced a decline in LVEF, potentially attributable to reduced use of heart failure pharmacotherapy during pregnancy and the post-partum period. Therapeutic termination was performed in approximately a fifth of cases. The findings suggest that reclassification of a SSP with persisting mild left ventricular impairment from modified World Health Organization (mWHO) Class IV (contraindicated) to mWHO III may be considered, while remaining under the care of an experienced medical team and with appropriate pharmacological management.

Hospitalisation for heart failure presents a critical event associated with significant risk of readmission and mortality. It also offers a window of opportunity to optimise patient management with a goal to improve clinical outcomes, functional status, and quality of life. This narrative review summarises contemporary, evidence-based strategies for optimising heart failure management before and after hospital discharge. Firstly, comprehensive assessment of congestion status is necessary before discharge because residual congestion is a major contributor to poor outcomes. In addition, robust evidence supports the early initiation and rapid up-titration of core guideline-directed medical therapies in all patients without known contraindications, irrespective of left ventricular ejection fraction. The core guideline-directed medical therapies classes include renin-angiotensin system inhibitors, sacubitril/valsartan, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. Intensive strategy to optimisation of renin-angiotensin system inhibitors, beta-blockers, and mineralocorticoid receptor antagonists has been shown to reduce the risk of death or readmission by 34% at six months compared to standard care. Likewise, initiating sodium-glucose cotransporter-2 inhibitors during hospitalisation has demonstrated favourable effects on clinical outcomes, including lower risk of all-cause mortality and readmission. Furthermore, multidisciplinary care and early and sustained postdischarge follow-up are essential to address comorbidities, ensure continuity of care and allow further optimisation of medical therapy. They also enable timely management of potential issues concerning drug intolerance, side effects, nonadherence, or changes in clinical status. Successful long-term management and adherence to treatment recommendations also requires structured patient education and empowerment for self-care.

AIMS:The Central/Eastern Europe (CEE) Quality of Care Centres (QCC) Survey evaluated the implementation of guideline-directed medical therapies (GDMT) and device use at discharge after heart failure (HF) hospitalization in CEE, where GDMT underutilization remains a concern. METHODS AND RESULTS:Between March 2024 and January 2025, 2251 patients (mean age 70.0 years, 60.4% male) were enrolled at discharge from 21 centres across 12 CEE countries. The patient population included HF with reduced ejection fraction (HFrEF) (55.5%), HF with mildly reduced ejection fraction (15.3%) and HF with preserved ejection fraction (27.9%). In the total population, from admission to discharge there was a increase in the use of angiotensin receptor-neprilysin inhibitor (ARNI) (17.1% to 34.3%), beta-blockers (69.4% to 92.4%), mineralocorticoid receptor antagonists (MRA) (44.0% to 82.1%) and sodium-glucose co-transporter 2 inhibitors (SGLT2i) (30.8% to 79.9%), with a reduction in angiotensin-converting enzyme inhibitor (ACEI) use (all p < 0.05). Similar trends were observed across HF phenotypes, including HFrEF (increased use of ARNI, 26.3% to 55.1%, beta-blockers, 69.8% to 95.3%, MRA 49.5% to 89.0%, and SGLT2I 36.2% to 79.8%, and lower ACEI use, all p < 0.05). At discharge, 53.5% of patients received quadruple therapy (63.9% with HFrEF), while ≥50% target doses of titratable drugs were achieved in 18.8% (17.8% in HFrEF). Predictors of GDMT underuse included older age, lower education, living alone, non-ischaemic HF, higher ejection fraction, chronic kidney disease, hypotension, hyperkalaemia, prolonged hospitalization, and residual oedema. Among eligible HFrEF patients, 21.3% were discharged with, or referred for implantable cardioverter-defibrillator, and 17.4% for cardiac resynchronization therapy. CONCLUSIONS:The CEE-QCC Survey highlights substantial in-hospital GDMT implementation and up-titration, though device use remains limited. Targeted strategies are needed to enhance guideline implementation and ensure optimal HF care across the CEE region.

The aim of the present clinical consensus statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases is to review the current knowledge on the epidemiology, pathogenesis, diagnosis, therapy, and outcomes of myocardial and pericardial complications of coronavirus disease 2019 (COVID-19) and vaccination in order to improve the awareness and clinical confidence on the management of patients with these complications. The risk of myopericardial complications is especially higher within 1 month of COVID-19 disease and vaccination. Forms related to the disease are generally more common and severe than those related to vaccination. Even if vaccination against COVID-19 increases myocarditis risk, this risk is lower in vaccinated than non-vaccinated COVID-19 individuals, supporting the vaccine use. Overall, COVID-19 related complications, especially myocarditis, are relatively rare.

AIMS:The Heart Failure Association (HFA) of the European Society of Cardiology (ESC), together with the National Heart Failure Societies (NHFS), designed the European Heart Failure (HF) Survey with an aim of assessing contemporary HF epidemiology, management resources, availability and reimbursement of guideline-directed medications and devices, and structure of professional and patient organizations. This document presents data on HF epidemiology. METHODS AND RESULTS:The European HF Survey was conducted in 43 ESC member countries. Epidemiology data were exclusively collected from national health statistics from 2019, and standardized according to the European Standard Population, with variable response rates and data completeness among the countries. Median annual HF incidence was 3.9 patients per 1000 person-years (interquartile range [IQR] 3.1-6.5), and median HF prevalence was 1937 patients (IQR 1463-3416) per 100 000 population. Median in-hospital mortality of patients admitted for HF was 8.0% (IQR 4.9-9.6%), and median 1-year all-cause mortality of patients with HF was 14.5% (IQR 8.2-21.6%). Median number of HF-related hospitalizations was 333 (IQR 230-469) per 100 000 population, and median length of stay for HF-related hospitalizations was 8.5 (IQR 7.2-9.2) days. A heterogeneity in HF epidemiology statistics was observed across different countries. CONCLUSIONS:The European HF Survey provides a contemporary insight into HF epidemiology and outcomes across the ESC member countries. These data are valuable to inform strategies to improve prevention, diagnosis, and management of HF. The persisting gaps and considerable heterogeneity in epidemiology statistics highlight the need to further unify data collection and reporting practices across European countries.

A rift has opened and is widening between basic research (bench) and clinical research and patients (bed) who need their new treatments, diagnostics and preventive strategies. This problem involving the 'translation' of basic scientific findings into clinical applications and potential treatments or biomarkers for a condition like heart failure is widely recognized both in academia and industry. Despite the attempts that have been made by both sides to improve this situation, the high attrition rates of drug development and the problem with reproducibility and translatability of preclinical findings to human applications still persist. As a result, the return on investment of basic research has been limited in terms of clinical impact. In this scientific statement we describe and discuss various issues with relevance to this theme and try to dissect how to move our field towards the development of more effective heart failure drugs. We zoom in on facilitating the process of heart failure drug development, the unnecessary gaps ('valley of death') between the critical steps in heart failure drug development, validation and de-validation of new concepts as early as possible ('rigorous translation'). We describe forums on how to stimulate cross-talk and interaction between clinician-scientists, basic heart failure researchers, biotech and industry, and how to enable them to speak the same language, and lessons learned from successes outside the heart failure field.

AIMS:The Heart Failure Frailty Score (HFFS) is a novel, multidimensional tool to assess frailty in patients with heart failure (HF). It has been developed to overcome limitations of existing frailty assessment tools while being practical for clinical use. The HFFS reflects the concept of frailty as a multidimensional, dynamic and potentially reversible state, which increases vulnerability to stressors and risk of poor outcomes in patients with HF. METHODS AND RESULTS:The HFFS was developed through a Delphi consensus process involving 54 international experts. This approach involved iterative rounds of questionnaires and interviews, where a panel of experts provided their opinions on specific questions prepared by the Steering Committee. The experts were invited to vote and share their views anonymously, using a 5-point Likert scale over iterative rounds. An 80% threshold was set for agreement or disagreement for each statement. Twenty-two variables from four domains (clinical, functional, psycho-cognitive and social) have been selected for inclusion in the HFFS after the third round of the Delphi process. A shorter version (S-HFFS), including 10 variables, has also been developed for daily clinical use. CONCLUSIONS:The HFFS is a new multidimensional tool for the identification of frailty in patients with HF. It should also enables healthcare providers to identify potential 'red flags' for frailty in order to develop personalized care plans. The next step will be to validate the new score in patients with HF.

Acute heart failure (AHF) affects millions of people each year and vasodilators have been a central part of treatment for over 25 years. The haemodynamic effects of vasodilators vary considerably among individual agents. Some vasodilators, such as nitrates, primarily act on the venous system by redistributing the circulating blood volume away from the heart towards the venous capacitance system. Other vasodilators, such as nesiritide, lead to balanced vasodilatation in the arteries and veins, decreasing left ventricular afterload and preload. Considering mechanisms of action, intravenous vasodilators are thought to be effective in patients with AHF, particularly in those with acute pulmonary oedema, where increased cardiac filling pressures and elevated systemic blood pressures occur in the absence of, or with minimal systemic fluid accumulation. However, the 2021 European heart failure guidelines have downgraded the use of vasodilators due to two recent studies and several contemporary meta-analyses failing to show benefit in terms of survival. Thus, there remains no firm recommendation suggesting the use of vasodilator treatment over usual care. In addition, despite repeated efforts to develop new vasodilatory agents, no novel therapy has outperformed traditional AHF management. In parallel with the development of novel vasodilators, changing the design of clinical trials for AHF to consider phenotype diversity of AHF patients remains an unmet need. New randomized clinical trials should particularly focus on subgroups that may mechanistically derive benefit from vasodilators, which may entail moving enrolment of patients to clinical settings close to moment of decompensation, such as the emergency department.

Genetic family screening following the detection of a pathogenic or likely pathogenic variant in a proband with dilated cardiomyopathy (DCM) remains one of the main applications of genetic testing. While cardiac screening is recommended for all first-degree relatives, the a priori risk among family members varies. Consequently, screening regimens should be tailored according to both genetic and clinical information at the individual and familial level. This clinical consensus statement provides tools to help with the risk assessment and follow-up of screening for family members and discusses the utility for integration of genotype-specific information, cardiac imaging, and electrocardiogram findings to personalize cardiac screening regimens, which in conjunction will likely improve individualized risk prediction. Early phenotypic detection of DCM in family members remains an active area of research and innovation. In addition, data are starting to accrue on the utility of early therapeutic intervention in family members with very mild phenotypes that may inform future management in addition to screening. A systematic strategy is proposed to determine the a priori risk of developing DCM for a family member, and the potential of integrating genotype-phenotype knowledge towards family management. Lastly, there is a focus on the current knowledge gaps and ongoing and future opportunities to improve risk prediction, early disease detection, and treatment of family members of patients with DCM.

AIMS:The European Heart Failure (HF) Survey was developed by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) to map HF management resources, reimbursement of drugs/devices for HF treatment, and structure and activities of HF professional and patient organizations. METHODS AND RESULTS:The survey encompassed 43 ESC member countries. The median number of hospitals with dedicated HF centres was 2.6 (interquartile range [IQR] 0.9-4.7) per million people. Natriuretic peptide assessment was available at a median of 6.1 (IQR 1.8-10.6) emergency departments and 8.2 (IQR 1.3-14.7) hospitals per million people, respectively, whilst cardiac magnetic resonance was available at a median of 2.0 (IQR 0.9-3.8) hospitals per million people. Short-term and long-term mechanical circulatory support and heart transplantation were available at a median of 1.1 (IQR 0.5-2.4), 0.4 (IQR 0.0-0.5) and 0.3 (0.2-0.5) hospitals per million people, respectively. Whilst essential HF medications were mostly available and reimbursed, gaps were observed in availability and funding of newer and advanced therapies. Density of all diagnostic and therapeutic capabilities was greater in countries with more favourable socioeconomic status. National HF societies were reported in 98% of countries, whilst HF patient organizations in 45% of countries.anaemia. CONCLUSIONS:The European HF Survey is the result of long-standing HFA/ESC efforts to monitor HF epidemiology, management resources, educational and awareness activities. It offers a valuable assessment of current management capabilities, highlighting challenges in providing contemporary standards of care. It also provides insights into future directions needed to address these gaps.