The known unknowns of managing acute heart failure
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Introduction
The lack of gold-standard randomised controlled trial (RCT) evidence to support clinical decision-making in acute cardiovascular care represents an area of particular unmet need, where significant variation in practice and underuse or overuse of clinical treatments can occur (1,2). Most recommendations are based on observational analyses rather than RCTs (1). Two recent sets of guidelines for heart failure, published by European and American societies, highlight the substantive gains made in improving patient outcomes wherever there is robust RCT evidence available (3,4). Optimal pharmacotherapy now includes new drug classes such as SGLT2 inhibitors and possible use in traditionally hard to treat groups such as heart failure with preserved ejection fraction (5). However, both guidelines have sections emphasising where gaps persist in the evidence. These ‘known unknowns’ represent areas of heart failure treatment that have suffered from a lack of RCTs to help guide best practice.