The new Guidelines: Focus on Chronic Heart Failure

Transcription

1 The new Guidelines: Focus on Chronic Heart Failure Petros Nihoyannopoulos MD, FRCP, FESC Professor of Cardiology Imperial College London and National & Kapodistrian University of Athens

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4 4 The principal changes from the 2012 guidelines relate to: (i) a new term for patients with HF and a LVEF that ranges from 40 to 49% HF with midrange EF (HFmrEF) ; this may stimulate research into the underlying Characteristics, pathophysiology and treatment of this population (ii) clear recommendations on the diagnostic criteria for HF with reduced EF (HFrEF), HFmrEF and HF with preserved EF (HFpEF) (iii) a new algorithm for the diagnosis of HF in the non-acute setting based on the evaluation of HF probability (iv) a new algorithm for a combined diagnosis and treatment of acute HF based on the presence/absence of congestion/hypoperfusion

5 5 The principal changes from the 2012 guidelines (continue): (v) recommendations aimed at prevention or delay of the development of overt HF or the prevention of death before the onset of symptoms; (vi) indications for the use of the new compound sacubitril/valsartan, the first in the class of angiotensin receptor neprilysin inhibitors (ARNIs); (vii) modified indications for cardiac resynchronization therapy (CRT); (viii) the concept of an early initiation of appropriate therapy going along with relevant investigations in acute HF that follows the time to therapy approach already well established in acute coronary syndrome (ACS);

6 6 Definition of heart failure HF is a clinical syndrome characterized by typical symptoms (e.g. SOB, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated JVP, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in: a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress

7 7 New Classification! Heart failure with preserved, mid-range and reduced EF HF comprises a wide range of patients: those with normal LVEF [typically considered as 50% or HF with preserved EF (HFpEF) to those with Reduced LVEF - typically considered as 40% (HFrEF)] Patients with an LVEF in the range of 40 49% represent a grey area,

8 8 New Classification! Heart failure with preserved, mid-range and reduced EF it is only in patients with HFrEF that therapies have been shown to reduce both morbidity and mortality

9 9 New Classification! v The diagnosis of HFpEF is more challenging than that of HFrEF v Patients with HFpEF do not have a dilated LV, but often have: increase in LV wall thickness and/or increased LA size (sign of increased filling pressures) most have additional evidence of impaired LV filling or suction capacity, also classified as diastolic dysfunction

10 10 New Classification! v Identifying HFmrEF as a separate group will stimulate research into the underlying characteristics and treatment of this group Patients with HFmrEF most probably have primarily mild systolic dysfunction, but with features of: diastolic dysfunction relevant structural heart disease (LVH, LA enlargement) elevated BNP

11 11 Diagnosis Demonstration of an underlying cardiac cause is central to the diagnosis of HF. This is usually a myocardial abnormality causing systolic and/or diastolic ventricular dysfunction Abnormalities of the valves, pericardium, endocardium, heart rhythm and conduction can also cause HF Identification of the underlying cardiac problem is crucial for therapeutic reasons

12 12 Diagnosis Symptoms & Signs Non-specific, difficult to identify Detailed clinical history

13 13 Diagnosis initial investigations BNP ECG - Echo Patients with normal plasma NP concentrations are unlikely to have HF AF, age and renal failure are the most important factors impeding the interpretation of NP measurements An abnormal electrocardiogram (ECG) increases the likelihood of the diagnosis of HF but low specificity (rule out) Echocardiography is the most useful, widely available test in patients with suspected HF to establish the diagnosis

14 14 Algorithm for the diagnosis of HF The probability of HF should first be evaluated (History, HT, diuretic use, symptoms, examination, ECG) v Heart Failure unlikely: If no history, -ve examination & N ECG Normal BNP Normal echo v An Echo is indicated if NP level above the exclusion level

15 15 Diagnosis of HFpEF v The diagnosis of HFpEF requires the following: The presence of symptoms and/or signs of HF A preserved EF (defined as LVEF 50% or 40 49% for HFmrEF) Elevated levels of NPs (BNP >35 pg/ml and/or NT-proBNP >125 pg/ml) An abnormal ECG increases the likelihood of HF Objective evidence of other cardiac functional and structural alterations underlying HF The pivotal role of Echo In case of uncertainty, a stress test or invasively measured elevated LV filling pressure may be needed

16 16 Diagnosis of HFpEF Clinical signs & symptoms the same as HFrEF, HFpEF, HFmrEF ECG may be abnormal (LVH, AF, repol abnormalities) Objective evidence of structural/functional cardiac alterations LAVI >34 ml/m2, LVMI 115 g/m2 (M) / 95g/m2 (F) E/e 13, mean e septal & lateral wall <9cm/s GLS, TR velocities Diastolic stress test with echo (semi-supine bicycle ergometer) LV E/e, PAP, GLS, SV, CO Diagnosis difficult when AF

17 17 Cardiac Imaging Imaging tests should only be performed when they have a meaningful clinical consequence Central role in the diagnosis of HF and in guiding treatment Echocardiography is the method of choice in patients with suspected HF (accuracy, availability, portability, safety and cost) Other modalities can be complimentary, chosen according to their ability to answer specific clinical questions and taking account of contraindications to and risks of specific tests Reliability depends on the operator, centre experience and imaging quality

18 18 Chest X-ray Of limited use Pulmonary venous congestion Most useful in identifying alternative, pulmonary explanation of symptoms

19 19 Transthoracic Echocardiography The Teichholz and Quinones methods of calculating LVEF from M-mode, as well as a measurement of FS, are not recommended! For LVEF, the modified biplane Simpson s rule is recommended. Contrast should be used in case of poor imaging! 3D echocardiography of adequate quality improves the quantification of LV volumes and LVEF and has the best accuracy compared with values obtained through CMR Doppler for calculating haemodynamic variables (Svi and CO) TDI (S wave) and deformation imaging (strain & strain rate) are reproducible and feasible for clinical use

20 20 Transthoracic Echocardiography

21 21 Assessment of LV diastolic function v Diastolic dysfunction may be the underlying pathophysiological abnormality in patients with HFpEF and perhaps HFmrEF v Echocardiography is at present the only imaging technique that can allow for the diagnosis of diastolic dysfunction Objective evidence of structural/functional cardiac alterations LAVI >34 ml/m2, LVMI 115 g/m2 (M) / 95g/m2 (F) E/e 13, mean e septal & lateral wall <9cm/s GLS, TR velocities Diastolic stress test with echo (semi-supine bicycle ergometer) LV E/e, PAP, GLS, SV, CO

22 22 Assessment of RV function & PA Pressures An obligatory element of echocardiography examination! v RV structure & function v RA size v Estimate RV systolic function: TAPSE <17mm S <9.5m/sec PASP from TR velocity 3D echo volumes is recommended speckle tracking specialised centres

23 23 Transoesophageal Echocardiography (TOE) v Not needed in the routine diagnostic assessment of HF But may be valuable in: valve disease and assessing severity aortic dissection suspected endocarditis congenital heart disease for ruling out thrombi in AF patients requiring cardioversion

24 24 Stress Echocardiography v Exercise or pharmacological stress echocardiography may be used for the assessment of inducible ischaemia and/or viability v In valve disease, e.g. dynamic mitral regurgitation, low-flow low-gradient aortic stenosis v For the detection of diastolic dysfunction in patients with exertional dyspnoea, preserved LVEF and inconclusive diastolic parameters at rest

25 25 Cardiac magnetic resonance v CMR is the gold standard for the measurements of volumes, mass and EF of both the left and right ventricles v The best alternative cardiac imaging modality for patients with non-diagnostic echocardiographic studies v The method of choice in patients with complex congenital heart diseases v CMR is the preferred imaging method to assess myocardial fibrosis using LGE along with T1 mapping and can be useful for establishing HF aetiology

26 26 Cardiac magnetic resonance v CMR may also be used for the assessment of myocardial ischaemia and viability in patients with HF and CAD v Clinical limitations: local expertise, lower availability and higher costs uncertainty about safety in patients with metallic implants (devices) less reliable measurements in patients with tachyarrhythmias claustrophobia contrast agents contraindicated in individuals with a GFR <30 ml/min/1.73m2 - nephrogenic systemic fibrosis (NSF)

27 27 Single-photon emission computed tomography and radionuclide ventriculography v Single-photon emission CT (SPECT) may be useful in assessing ischaemia and myocardial viability v Gated SPECT can also yield information on ventricular volumes and function, but exposes the patient to ionizing radiation v PET useful in ishaemia and viability but limited availability, radiation exposure and cost are the main limitations

28 28 Cardiac CT v Cardiac CT may be considered in patients with HF and low to intermediate pre-test probability of CAD or those with equivocal non-invasive stress tests in order to rule out CAD (IIb C)

29 29 Coronary angiography v In concordance with the recommendations of other relevant ESC guidelines v Coronary angiography is recommended in patients with HF and angina pectoris recalcitrant to medical therapy, provided that are suitable for revascularisation (IC) v Coronary angiography recommended in patients with a history of symptomatic ventricular arrhythmia or aborted cardiac arrest v Should be considered in patients with HF and intermediate to high pre-test probability of CAD and presence of ischaemia in non-invasive stress tests in order to establish CAD severity (IIa C)

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31 31 Recommendations IIa

32 32 Thank you