Renal effects of guideline directed medical therapies in heart failure: a consensus document from the Heart Failure Association of the European Society of Cardiology

Wilfried Mullens, Pieter Martens, Jeffrey M. Testani, W. H. Wilson Tang, Hadi Skouri, Frederik H Verbrugge, Marat Fudim, Massimo Iacoviello, Jennifer Franke, Andreas J. Flammer, Alberto Palazzuoli, Paola Morejon Barragan, Thomas Thum, Marta Cobo Marcos, Òscar Miró, Patrick Rossignol, Marco Metra, Johan Lassus, Francesco Orso, Ewa A. JankowskaOvidiu Chioncel, Davor Milicic, Loreena Hill, Petar Seferovic, Guiseppe Rosano, Andrew Coats, Kevin Damman

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Novel pharmacologic treatment options reduce mortality and morbidity in a cost-effective manner in patients with heart failure (HF). Undisputedly, the effective implementation of these agents is an essential element of good clinical practice, which is endorsed by the European Society of Cardiology (ESC) guidelines on acute and chronic HF. Yet, physicians struggle to implement these therapies as they have to balance the true and/or perceived risks versus their substantial benefits in clinical practice. Any worsening of biomarkers of renal function is often perceived as being disadvantageous and is in clinical practice one of the most common reasons for ineffective drug implementation. However, even in this context, they clearly reduce mortality and morbidity in HF with reduced ejection fraction (HFrEF) patients, even in patients with poor renal function. Furthermore these agents are also beneficial in HF with mildly reduced ejection fraction (HFmrEF) and sodium–glucose cotransporter 2 (SGLT2) inhibitors more recently demonstrated a beneficial effect in HF with preserved ejection fraction (HFpEF). The emerge of several new classes (angiotensin receptor–neprilysin inhibitor [ARNI], SGLT2 inhibitors, vericiguat, omecamtiv mecarbil) and the recommendation by the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic HF of early initiation and titration of quadruple disease-modifying therapies (ARNI/angiotensin-converting enzyme inhibitor + beta-blocker + mineralocorticoid receptor antagonist and SGLT2 inhibitor) in HFrEF increases the likelihood of treatment-induced changes in renal function. This may be (incorrectly) perceived as deleterious, resulting in inertia of starting and uptitrating these lifesaving therapies. Therefore, the objective of this consensus document is to provide advice of the effect HF drugs on renal function.

Original languageEnglish
JournalEuropean journal of heart failure
Early online date27 Mar 2022
Publication statusEarly online date - 27 Mar 2022

Bibliographical note

Funding Information:
: W.M. has received research grants from Novartis, Vifor, Medtronic, Biotronik, Abbott and Boston Scientific. P.M. has received a research grant from the Belgian American Education Foundation (BAEF). J.M.T. reports grants and personal fees from Sequana Medical, BMS, Boehringer Ingelheim, Sanofi, FIRE1, personal fees from Astra Zeneca, Novartis, Cardionomic, Bayer, MagentaMed, Reprieve Medical, W.L. Gore, grants from 3ive labs, Otsuka, Abbott. W.H.W.T. has been supported by grants from the NIH and has served as a consultant for the MyoKardia Inc, and Sequana Medical Inc. H.S. received honorarium for advisory boards and lectures from Novartis, Servier, Vifor pharma, Abbott and AstraZeneca. F.H.V. has received speaker's and advisory fees from AstraZeneca, Boehringer Ingelheim, Bristol‐Myers Squibb, Daiichi‐Sankyo, Menarini Group, Novartis, Pfizer & Roche Diagnostics; has received an unrestricted research grant from Roche Diagnostics; is supported by a the Special Research Fund (BOF) of Hasselt University (BOF19PD04). M.F. has received grants from the National Heart, Lung, and Blood Institute (NHLBI) (K23HL151744), the American Heart Association (20IPA35310955), Mario Family Award, Duke Chair's Award, Translating Duke Health Award, Bayer, Bodyport and BTG Specialty Pharmaceuticals; consulting fees from AxonTherapies, Bodyport, Boston Scientific, CVRx, Daxor, Edwards LifeSciences, Fire1, Inovise, NXT Biomedical, Viscardia, Zoll. M.I. has received honoraria or consultant fees from Novartis, AstraZeneca, Boehringher Ingelheim, Merck Serono, Lilly, Vifor, Biomerieux, Roche diagnostics. A.J.F. has received grants/research support form Novartis, AstraZeneca and Berlin Heart, as well as honoraria for consulting, lecturing or advisory boards from Alnylam, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Fresenius, Medtronic, MSD, Mundipharma, Novartis, Pfizer, Pierre Fabre, Roche, Vifor, and Zoll. A.P. has received consulting honoraria from Novartis and AstraZeneca for research support and lectures. T.T. in the last 5 years declares having received honoraria and/or lecture fess from Novo Nordisk, Boehringer Ingelheim, Takeda, Sanofi/Genzyme, Amicus Therapeutics; filed and licensed patents in the field of noncoding RNAs; founder and shareholder of Cardior Pharmaceuticals GmbH. M.C.M. has received honoraria for consulting, lecturing or advisory boards from Novartis, Vifor Pharma, Boehringer Ingelheim, AstraZeneca and Lilly Company. P.R. reports consulting for Idorsia, G3P, honoraria from AstraZeneca, Bayer, CinCor, CVRx, Fresenius, Grunenthal, Novartis, NovoNordisk, Relypsa, Roche, Servier, Stealth Peptides, and Vifor Fresenius Medical Care Renal Pharma; and travel grants from AstraZeneca, Bayer, CVRx, Novartis, and Vifor Fresenius Medical Care Renal Pharma; Cofounder: CardioRenal. M.M. has received consulting honoraria from Bayer, Novartis, and Servier, and speaker's fees from Abbott Vascular and Novartis. J.L. has received consulting honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, Roche Diagnostics and speaker's fees from AstraZeneca, Bayer, Boehringer Ingelheim, Pfizer and ViforPharma. O.C. reports research grants from Servier, Novartis, Vifor; other from Boehringer Ingelheim. P.S. has received grants/research supports from Ministry of education, science and technological development of Republic of Serbia; honoraria or consultation fees from Servier, Boehringer Ingelheim, Hemofarm, Novartis, Astra Zeneca; participation in a company sponsored speaker's bureau: Fondazione Internationale Menarini. A.C. in the last 5 years declares having received honoraria and/or lecture fess from Actimed, AstraZeneca, Faraday, Gore, Impulse Dynamics, Menarini, Novartis, Nutricia, Resmed, Respicardia, Servier, Stealth Peptides, Verona, Vifor. K.D. has received research grants and consultancy fees from Boehringer Ingelheim and speaker fees from AstraZeneca and Abbott. All other authors have nothing to disclose. Conflict of interest

Publisher Copyright:
© 2022 European Society of Cardiology.


  • Heart failure
  • Pharmacological therapy
  • Renal function

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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