KSHF Guidelines for the Management of Acute Heart Failure: Part II. Treatment of Acute Heart Failure

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment

The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment

The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.

Factors Related to Patients' Self-care and Self-care Confidence in Korean Patients With Heart Failure and Their Caregivers: A Cross-sectional, Correlational Study

BACKGROUND

The relationships of patient factors and caregiver contribution to patients' self-care to different types of self-care have been rarely examined in Korean patients with heart failure.

OBJECTIVE

The aim of this study was to examine patient (ie, age, depressive symptoms, and self-care confidence) and caregiver (ie, caregiver contribution to self-care maintenance and self-care management, and caregiver confidence in contributing to self-care) factors related to different types of self-care (ie, self-care maintenance, symptom perception, and self-care management) and self-care confidence in Korean patients with heart failure.

METHODS

In this cross-sectional, correlational study, data from 41 pairs of patients (mean age, 68.0 years) and caregivers (mean age, 54.1 years) were collected and analyzed using multiple regression.

RESULTS

Higher levels of self-care confidence in patients were related to higher levels of self-care maintenance in patients. Higher levels of self-care confidence in patients were related to higher levels of symptom perception. Higher levels of self-care confidence in patients and caregiver contribution to self-care maintenance were related to higher levels of self-care management. Less severe depressive symptoms in patients and higher levels of caregiver confidence in contributing to self-care were related to higher levels of self-care confidence.

CONCLUSION

Different patient and caregiver factors were related to different types of self-care and self-care confidence in Korean patients, but patients' self-care confidence was related to all types of self-care. Clinicians and researchers need to develop and deliver effective interventions to both patients and their caregivers to improve patients' self-care confidence and, in turn, self-care, considering different factors associated with each type of self-care.

Characteristics and outcomes of heart transplant recipients with a pretransplant history of malignancy

We aimed to investigate the characteristics and outcomes of HTx recipients with a history of pretransplant malignancy (PTM). Among 1062 HTx recipients between 1997 and 2013, 73 (7.1%) patients had PTMs (77 cancer cases). We analyzed post-HTx outcome, recurrence of PTM, and development of de novo malignancies. Post-HTx outcome included overall survival, 10-year survival, 10-year freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Four most common PTMs were lymphoproliferative disorders (18.2%), prostate cancers (18.2%), non-melanoma skin cancers (18.2%), and breast cancers (13.0%). Median time from PTM and HTx was 9.0 years. During a median follow-up of 8.6 years after HTx, patients with PTM, compared to those without, showed significantly higher incidence of posttransplant malignancies (43.8% vs. 20.8%, p < .001) including 9.6% (n = 7) of PTM recurrences. However, patients with PTM, compared to those without, showed comparable overall survival, 10-year survival, 10-year freedom from CAV, NF-MACE, ATR, ACR, and AMR. Therefore, a history of PTM should not disqualify patients from HTx listing, while further research is necessary for early detection of posttransplant malignancies in these patients.

A dose-response relationship of renin-angiotensin system blockers and beta-blockers in patients with acute heart failure syndrome: a nationwide prospective cohort study

AIMS

It remains unclear if patients with acute heart failure syndrome (AHFS) need to reach the maximally tolerated doses of renin-angiotensin system blockers (RASBs) or beta-blockers (BBs) to obtain a survival benefit. This study evaluated the dose-response relationship between RASBs or BBs and survival in AHFS patients.

METHODS AND RESULTS

In total, 5331 patients in the Korean Acute Heart Failure registry were analysed based on the doses of RASBs and BBs at discharge. In AHFS patients, RASB use at discharge was associated with a significant reduction in all-cause mortality risk. This effect was dose-dependent for heart failure with reduced ejection fraction (HFrEF) but did not attain statistical significance for heart failure with preserved ejection fraction (HFpEF). BB use at discharge was associated with reduced all-cause mortality in HFrEF patients but not in HFpEF patients. In an additional analysis of 4613 patients with dosage information at the first post-discharge follow-up visit, a significantly higher mortality risk was associated with the maintenance or withdrawal of RASBs compared with up-titrating the dose in HFrEF patients.

CONCLUSION

Using RASBs or BBs at discharge was associated with improved survival. A dose-response relationship between RASBs and all-cause mortality was evident in AHFS patients with a reduced ejection fraction but not BBs. It is important to initiate and up-titrate RASBs to the maximally tolerated dose in AHFS patients during the transition period, especially for patients with a reduced ejection fraction.

Development of Core Educational Content for Heart Failure Patients in Transition from Hospital to Home Care: A Delphi Study

Heart failure (HF) patients should be systematically educated before discharge on how to manage with standard written materials for patient self-management. However, because of the absence of readily available written materials to reinforce their learned knowledge, patients with HF feel inadequately informed in terms of the discharge information provided to them. This study aimed to develop core content to prepare patients with HF for transition from hospital to home care. The content was validated by expert panelists using Delphi methods. Nineteen draft items based on literature review were developed. We established a consensus on four core sections, including 47 categories and 128 subcategories through the Delphi survey: (1) understanding HF (five categories and 23 subcategories), (2) HF medication (19 categories and 45 subcategories), (3) HF management (20 categories and 47 subcategories), and (4) HF diary (three categories and 13 subcategories). Each section provided easy-to-understand educational contents using cartoon images and large or bold letters for older patients with HF. The developed core HF educational contents showed high consensus between the experts, along with clinical validity. The contents can be used as an educational booklet for both planning discharge education of patients with HF and for post-discharge management when transitioning from hospital to home. Based on this study, a booklet series for HF patients was first registered at the National Library of Korea. Future research should focus on delivering the core content to patients with HF in convenient and accessible format through various media.

Physician adherence and patient-reported outcomes in heart failure with reduced ejection fraction in the era of angiotensin receptor-neprilysin inhibitor therapy

This Korean nationwide, multicenter, noninterventional, prospective cohort study aimed to analyze physician adherence to guideline-recommended therapy for heart failure (HF) with reduced ejection fraction (HFrEF) and its effect on patient-reported outcomes (PROs). Patients diagnosed with or hospitalized for HFrEF within the previous year were enrolled. Treatment adherence was considered optimal when all 3 categories of guideline-recommended medications (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors; beta-blockers; and mineralocorticoid receptor antagonists) were prescribed and suboptimal when ≤ 2 categories were prescribed. The 36-Item Short Form Survey (SF-36) scores were compared at baseline and 6 months between the 2 groups. Overall, 854 patients from 30 hospitals were included. At baseline, the optimal adherence group comprised 527 patients (61.7%), whereas during follow-up, the optimal and suboptimal adherence groups comprised 462 (54.1%) and 281 (32.9%) patients, respectively. Patients in the suboptimal adherence group were older, with a lower body mass index, and increased comorbidities, including renal dysfunction. SF-36 scores were significantly higher in the optimal adherence group for most domains (P < 0.05). This study showed satisfactory physician adherence to contemporary treatment for HFrEF. Optimal adherence to HF medication significantly correlated with better PROs.

Prognostic and Therapeutic Implications of Renal Insufficiency in Heart Failure

The heart and kidneys are closely related vital organs that significantly affect each other. Cardiorenal syndrome is the term depicting the various spectra of cardiorenal interaction mediated by the hemodynamic, neurohormonal, and biochemical cross-talk between these two organs. In patients with heart failure (HF), both the baseline and worsening renal function are closely related to prognosis. However, for both investigational and clinical purposes, the unified definition and classification of renal injury are still necessary. Renal insufficiency is caused by multiple factors, and categorizing them into monogenous subgroups of phenotype is difficult. Various clinical scenarios related to the chronicity of HF, progression of renal dysfunction, and issues related to pharmacologic therapies associated with the prognosis of patients with HF have been reviewed in this study.

Myocardial strain to identify benefit from beta-blockers in patients with heart failure with reduced ejection fraction

AIMS

Not all patients with heart failure with reduced ejection fraction (HFrEF) benefit equally from beta-blockers. Previous studies suggest that myocardial strain that reflects myocardial deformation may have a better prognostic value than the left ventricular ejection fraction. We aimed to evaluate the differential effect of beta-blockers according to the global longitudinal strain (GLS) in patients with HFrEF.

METHODS AND RESULTS

Of the 4312 patients in the Strain for Risk Assessment and Therapeutic Strategies in Patients with Acute Heart Failure registry, we included 2126 HFrEF patients whose data on beta-blocker use and GLS were available. Patients were categorized into two groups: one group of patients had GLS ≥ 10%, and the other group had GLS < 10%. The primary outcome was 5 year all-cause mortality according to beta-blocker use. Of the 2126 patients with HFrEF, 526 (24.7%) and 1600 (75.3%) patients had GLS ≥ 10% and <10%, respectively. Overall, 1399 patients (65.8%) received beta-blockers, and 864 (40.6%) patients died during the 5 year follow-up. Beta-blocker use was associated with improved survival in patients with GLS < 10% in both the inverse probability treatment-weighted (hazard ratio 0.70, 95% confidence interval 0.59-0.83, P < 0.001) and Cox regression analyses (hazard ratio 0.69, 95% confidence interval 0.59-0.81; P < 0.001). However, beta-blocker use was not associated with better survival in patients with GLS ≥ 10% in the inverse probability treatment-weighted and Cox regression analyses (both P > 0.05).

CONCLUSIONS

Beta-blocker use appears to be associated with improved survival in patients with HFrEF and GLS < 10%, but this is not the case in patients with GLS ≥ 10%. Therefore, GLS may be used to identify patients who have attenuated benefits from beta-blockers in HFrEF.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT03513653 (https://clinicaltrials.gov/ct2/show/NCT03513653).

Treatment of heart failure with a preserved ejection fraction

Background: Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent, is associated with high morbidity, and has very few effective treatments.Current Concepts: HFpEF is a heterogeneous syndrome arising from the interplay of cardiac (diastolic, systolic dysfunction, pulmonary hypertension, right ventricular dysfunction, left atrial dysfunction, and chronotropic incompetence) and extracardiac (endothelial dysfunction, skeletal muscle abnormality, pulmonary disease, and renal dysfunction) abnormalities. Although various pharmacological therapies of HFpEF have been introduced and studied, most of them showed a limited clinical benefit. With some advancement in the specific phenotype of HFpEF, diuretics, mineralocorticoid antagonists, sacubitril/valsartan, and lifestyle modifications are recommended as important treatments. Recently, EMPEROR-Preserved trials showed that empagliflozin reduced the combined risk of cardiovascular death or hospitalization for patients with HFpEF, regardless of the presence or absence of diabetes. Several non-pharmacological therapies, including interatrial septal shunt and pacing therapies, have been introduced and are under investigation.Discussion and Conclusion: HFpEF has been recognized as the single greatest unmet need in cardiovascular medicine. Further research is required to understand the concrete pathophysiology for each phenotype of HFpEF. Prevention and management of comorbidities and risk factors for HFpEF are of great importance. Sodiumglucose cotransporter 2 inhibitors may contribute to a change in clinical practice, given the lack of therapeutic options available for patients with HFpEF.

Post-transplantation outcomes of sensitized patients receiving durable mechanical circulatory support

BACKGROUND

Sensitization, defined as the presence of circulating antibodies, presents challenges, particularly in patients undergoing heart transplantation (HTx) bridged with durable mechanical circulatory support (MCS). We aimed to investigate the post-transplantation outcomes of sensitized MCS patients.

METHODS

Among 889 consecutively enrolled heart transplant (HTx) recipients between 2010 and 2018, 86 (9.7%) sensitized MCS patients (Group A) were compared with sensitized non-MCS patients (Group B, n = 189), non-sensitized MCS patients (Group C, n = 162), and non-sensitized non-MCS patients (Group D, n = 452) regarding post-HTx outcomes, including the incidence of primary graft dysfunction (PGD), 1-year survival, and 1-year freedom from antibody-mediated rejection (AMR).

RESULTS

Sensitized MCS patients (Group A) showed comparable rates of PGD, 1-year survival, and 1-year freedom from AMR with Groups C and D. However, Group A showed significantly higher rates of 1-year freedom from AMR (95.3% vs 85.7%, p = 0.02) and an earlier decline in panel-reactive antibody (PRA) levels (p < 0.01) than sensitized non-MCS patients (Group B). Desensitization therapy effectively reduced the levels of PRA in both Groups A and B. When Group A was further divided according to the presence of preformed donor-specific antibodies (DSA), patients with preformed DSA showed significantly lower rates of 1-year freedom from AMR than those without (84.2% vs 98.5%, p = 0.01).

CONCLUSIONS

Sensitized MCS patients showed significantly lower rates of AMR and an earlier decline in PRA levels following HTx than sensitized non-MCS patients. Removal of MCS at the time of transplantation might underlie these observations.

Prognostic impact of chromogranin A in patients with acute heart failure

Background

Chromogranin A (CgA) levels have been reported to predict mortality in patients with heart failure. However, information on the prognostic value and clinical availability of CgA is limited. We compared the prognostic value of CgA to that of previously proven natriuretic peptide biomarkers in patients with acute heart failure.

Methods

We retrospectively evaluated 272 patients (mean age, 68.5±15.6 years; 62.9% male) who underwent CgA test in the acute stage of heart failure hospitalization between June 2017 and June 2018. The median follow-up period was 348 days. Prognosis was assessed using the composite events of 1-year death and heart failure hospitalization.

Results

In-hospital mortality rate during index admission was 7.0% (n=19). During the 1-year follow-up, a composite event rate was observed in 12.1% (n=33) of the patients. The areas under the receiver-operating characteristic curves for predicting 1-year adverse events were 0.737 and 0.697 for N-terminal pro-B-type natriuretic peptide (NT-proBNP) and CgA, respectively. During follow-up, patients with high CgA levels (>158 pmol/L) had worse outcomes than those with low CgA levels (≤158 pmol/L) (85.2% vs. 58.6%, p<0.001). When stratifying the patients into four subgroups based on CgA and NT-proBNP levels, patients with high NT-proBNP and high CgA had the worst outcome. CgA had an incremental prognostic value when added to the combination of NT-proBNP and clinically relevant risk factors.

Conclusion

The prognostic power of CgA was comparable to that of NT-proBNP in patients with acute heart failure. The combination of CgA and NT-proBNP can improve prognosis prediction in these patients.

Pathophysiology of Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a major public health problem that affects half of all patients with HF. It is rising in prevalence, is associated with high morbidity and mortality, and has very few effective treatments. HFpEF is currently understood as a heterogeneous syndrome originating from the interplay of cardiac and extracardiac abnormalities. The most important pathophysiology in patients with HFpEF is diastolic dysfunction, which presents with impairments in relaxation or increases in chamber stiffness that lead to an increase in left ventricular filling pressures at rest or during exercise that causes dyspnea.

Prognostic Value of Leg Muscle Strength in Acute Heart Failure Syndrome

INTRODUCTION

Leg muscle strength (LMS) may be useful as a frailty index in patients with heart failure. However, LMS, until recently, has been indirectly estimated, and its prognostic value in acute heart failure syndrome (AHFS) is unclear. Therefore, we evaluated the prognostic value of direct LMS assessment and its relationship with proinflammatory mediators in patients with AHFS.

METHODS

We directly measured LMS at predischarge using a dynamometer in 110 prospectively and consecutively enrolled patients with AHFS (75 male; 60 ± 14 yr; mean ejection fraction, 29.9% ± 14.6%). The primary end point was cardiovascular (CV) events, defined as CV mortality, cardiac transplantation, or rehospitalization due to heart failure aggravation. Patients were divided into impaired and preserved LMS groups according to Contal and O'Quigley's method.

RESULTS

CV events occurred in 28 patients (25.5%) (including 5 CV deaths and 6 cardiac transplantations) during follow-up (median, 246 d; range = 11-888 d). Impaired LMS was associated with significantly higher levels of serum monokine induced by gamma interferon and poor clinical outcomes (P < 0.001). Multivariable Cox proportional hazard analysis (controlling for age, sex, body mass index, heart failure type, hemoglobin level, N-terminal pro-b-type natriuretic peptide level, and beta-blocker use) revealed LMS as an independent predictor of CV events (P = 0.017).

CONCLUSION

Impaired LMS, which might be used as a marker of frailty, is associated with increased levels of a proinflammatory chemokine and independently predicts clinical outcomes in patients with AHFS. The direct measurement of LMS is simple and feasible and might have important implications for the risk stratification of patients with AHFS.

Heart Transplant Immunosuppression Strategies at Cedars-Sinai Medical Center

Heart transplant is the optimal treatment for selected patients with end-stage heart failure. Immunosuppression after heart transplantation has significantly reduced the incidence of rejection and improved patient outcomes with the routine use of calcineurin inhibitors. Antimetabolites and proliferation signal inhibitors add to the improvement in patient outcomes as well. The goal of induction therapy is to provide intense immunosuppression when the risk of allograft rejection is highest. Most maintenance immunosuppressive protocols employ a 3-drug regimen consisting of a calcineurin inhibitor, an antimetabolite agent and glucocorticoids. The management of rejection proceeds in a stepwise fashion based on the severity of rejection detected on biopsy and the patient's clinical presentation. This review will cover induction, maintenance, rejection therapy and some special considerations including sensitization, renal sparing protocol, and corticosteroid weaning. It will end in consideration of potential future directions in immunosuppressive strategies to promote patient and graft survival.

Heart Failure with Preserved Ejection Fraction: the Major Unmet Need in Cardiology

Heart failure with preserved ejection fraction (HFpEF) has recently been recognized as the single greatest unmet need in cardiovascular medicine. As the population ages and the comorbidity increases, the prevalence of HFpEF increases considerably. Even though there have been large numbers of studies on pathophysiology, diagnosis, and treatment of HFpEF for latest years, there are no current pharmacologic interventions that can reduce mortality. HFpEF is currently understood as a heterogeneous syndrome originated from the interplay of cardiac and extracardiac abnormalities recognized by systemic inflammation, endothelial and coronary microvascular dysfunction, cardiomyocyte dysfunction and skeletal muscle dysfunction. The difficult “jigsaw puzzle” called HFpEF has been filled with some pieces, but it is still not enough to meet clinical needs. Here, we review recent evidences and unsolved problems about HFpEF to improve our understanding of HFpEF. Finally, we hope to accelerate to completion of the problematic “jigsaw puzzle”.

Cardiovascular Complications of Novel Anti-Cancer Immunotherapy: Old Problems from New Agents?

Many novel anti-cancer therapies have dramatically improved outcomes of various cancer patients. However, it also poses a risk for cardiovascular complications as well. For the novel anti-cancer agent with which physicians does not have enough clinical experiences to determine the characteristics of cardiovascular complications, it is important to assess risk factors for cardiotoxicity before starting anti-cancer therapy. High-risk patient should be consulted to cardiologist before initiating anti-cancer therapy and pre-emptive cardiac function monitoring plan might be prepared in advance. The biomarkers, electrocardiography and echocardiography are useful tools for the detection of subclinical cardiotoxicity during anti-cancer therapy. This review article tried to suggest the cardiac function monitoring strategies for newly encountered potential cardiotoxic anti-cancer agents and to summarize the cardiovascular complications of novel anti-cancer immunotherapies including immune checkpoint inhibitor (ICI) and chimeric antigen receptor (CAR) T-cell therapy. ICIs can cause fatal myocarditis, which usually occurs early after initiation, and prompt treatment with high-dose corticosteroid is necessary. CAR T-cell therapy can cause cytokine release syndrome, which may result in circulatory collapse. Supportive treatment as well as tocilizumab, an anti-interleukin-6 receptor antibody are cornerstones of treatment.

Role of Cardiac Computed Tomography for Etiology Evaluation of Newly Diagnosed Heart Failure with Reduced Ejection Fraction

Delayed-enhanced dual-energy computed tomography (DECT) can evaluate the extent and degree of myocardial fibrosis while coronary CT angiography (CCTA) is a widely accepted coronary artery evaluation method. We sought to describe the role of combined cardiac CT for the evaluation of underlying etiology in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF). Sixty-three consecutive patients (31 men, 63 ± 16 years) with newly diagnosed HFrEF were enrolled in this prospective study. Coronary artery disease and myocardial fibrosis were evaluated on CCTA and DECT, respectively, and the tentative underlying etiologies of heart failure (HF) were determined with combinations of findings from both CTs. Concordance between tentative etiologies from cardiac CT and final etiologies from clinical decisions within a 2-year follow-up was assessed. Eighteen patients were diagnosed with ischemic HF on initial cardiac CT, and the final diagnosis was not changed. Another 45 patients with nonischemic HF included tentative etiologies of dilated cardiomyopathy (n = 32, 71.1%), sarcoidosis or myocarditis (n = 8, 17.8%), amyloidosis (n = 2, 4.4%), noncompaction (n = 2, 4.4%) and arrhythmogenic right ventricular cardiomyopathy (n = 1, 2.2%). Five nonischemic HF patients showed different etiologies between initial cardiac CT and clinical decisions. The concordance between cardiac CT and clinical decisions was 92.1%. A high degree of concordance was achieved between tentative etiologies from cardiac CT and final diagnoses from clinical decisions. Combined cardiac CT is a feasible, safe and effective imaging tool for the initial evaluation of newly diagnosed HFrEF patients.

Is the use of RAS inhibitors safe in the current era of COVID-19 pandemic?

Antihypertensive drugs are one of the most widely used pharmacologic agent in the world and it is predominantly used in the elderly subjects. Pneumonia is the most common cause of death in the extremely old subject. During infection and its complication such as sepsis, hypotension could be exacerbated by antihypertensive drugs because homeostasis mechanisms such as sodium balance, renin angiotensin aldosterone system and/or sympathetic nervous system can be mitigated by antihypertensive drug therapy. Severe Acute Respiratory Syndrome-Coronavirus-1 and 2 viral surface protein is known to attach angiotensin converting enzyme 2 (ACE2) on the cell membrane to facilitate viral entry into the cytoplasm. Despite the theoretical concerns of increased ACE2 expression by Renin-Angiotensin-Aldosterone system (RAS) blockade, there is no evidence that RAS inhibitors are harmful during COVID-19 infection and have in fact been shown to be beneficial in animal studies. Therefore, it is recommended to maintain RAS blockade during the current corona virus pandemic.

Focused Update of 2016 Korean Society of Heart Failure Guidelines for the Management of Chronic Heart Failure

The incidence of heart failure (HF) is increasing in South Korea and devising the optimal care plan is crucial to promote appropriate and effective treatment of HF. To this end, the first Korean guideline for management of chronic HF was published in 2016 by the HF research group under the Korean Society of Cardiology (KSC). After this publication, considerable data have been accumulated and a new guideline for the management of HF was published in Europe, and an update regarding pharmacological therapy was published in the United States, which made it warrant to update the Korean guideline. Under this premise, The Clinical Practice Guidelines Committee under the Korean Society of Heart Failure (KSHF) founded in 2018 decided to publish a focused update management guideline for chronic HF and selected 15 topics that need an update regarding the diagnosis, definition, diagnostic algorithm, monitoring, novel biomarkers, drug therapy related to non-vitamin K antagonist oral anticoagulants and angiotensin receptor neprilysin inhibitors, and with respect to comorbidities changes in the guidelines of relevant institutions, such as new guidelines for the management of hypertension, a procedure used to treat severe aortic stenosis, information on sodium glucose co-transporter-2 inhibitor, and that about sleep apnea. Among nonpharmacological therapies, changes to the recommendations for implantable cardioverter defibrillator, cardiac resynchronization therapy, and cardiac rehabilitation were updated. Subsequent and continuous updates based on additional clinical research findings, with continual supervision by the KSHF will be needed.