2016 ESC Heart Failure Guidelines: what is new? Piotr Ponikowski Wroclaw, Poland

Transcription

1 2016 ESC Heart Failure Guidelines: what is new? Piotr Ponikowski Wroclaw, Poland

2 Disclosures Consultancy fees and speaker s honoraria from: Amgen, Servier, Novartis, Johnson & Johnson, Merck, Berlin Chemie, Bayer, Cibiem, Vifor Pharma, Trevena, Abbott Vascular, Respicardia, and Cardiorentis Research support: Servier, Vifor Pharma, Singulex

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4 In the year 2016, by applying all evidence-based discoveries, heart failure is becoming a preventable and treatable disease. Ponikowski P et al ESC HF Guidelines Eur Heart J 2016 & Eur J Heart Fail 2016

5 What is new in the 2016 HF ESC guidelines for CHF? 1. New definition and classification HFrEF/HFmrEF/HFpEF 2. New diagnostic algorithm based on clinical probability of the disease, the assessment of circulating natriuretic peptides and transthoracic echocardiography 3. Recommendations how to prevent the development of overt HF or death before the onset of symptoms 4. New therapeutic algorithm with new recommendations for ARNI and CRT 5. Expanded chapters on comorbidities and multidisciplinary care

6 Heart Failure: Definition Heart Failure is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, 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. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2016

7 New Classification of Heart Failure HFrEF HFmrEF HFpEF symptoms (+/- signs) symptoms (+/- signs) symptoms (+/- signs) LVEF < 40% LVEF 40-49% LVEF 50% 1. Elevated (NT-pro)BNP 2. Relevant structural heart disease (LVH or LAE) +/- diastolic dysfunction 1. Elevated (NT-pro)BNP 2. Relevant structural heart disease (LVH or LAE) +/- diastolic dysfunction Identifying HFmrEF as a separate group will stimulate research into underlying characteristics, pathophysiology and treatment of this population Ponikowski P et al ESC HF Guidelines Eur Heart J 2016 & Eur J Heart Fail 2016

8 A comprehensive population based characterization of HFmreF: the outcomes Koh AS et al. Eur J Heart Fail 2017 (on line)

9 PATIENT WITH SUSPECTED HF (non-acute onset) ASSESSMENT OF HF PROBABILITY 1. Clinical history: History of CAD (MI, revascularization) History of arterial hypertension Exposition to cardiotoxic drug/radiation Use of diuretics Orthopnoea / paroxysmal nocturnal dyspnoea 2. Physical examination: Rales Bilateral ankle oedema Heart murmur Jugular venous dilatation Laterally displaced/broadened apical beat 3. ECG: Any abnormality Ponikowski P et al ESC HF Guidelines Eur Heart J 2016 & Eur J Heart Fail 2016

10 PATIENT WITH SUSPECTED HF (non-acute onset) ASSESSMENT OF HF PROBABILITY 1. Clinical history; 2. Physical examination; 3. ECG Assessment of natriuretic peptides not routinely done in clinical practice 1 present NATRIURETIC PEPTIDES NT-proBNP 125 pg/ml BNP 35 pg/ml yes no all absent HF unlikely: consider other diagnosis ECHOCARDIOGRAPHY normal If HF confirmed (based on all available data): determine aetiology and start appropriate treatment Ponikowski P et al ESC HF Guidelines Eur Heart J 2016 & Eur J Heart Fail 2016

11 ESC Heart Failure Guidelines: prevention To prevent or delay onset of HF and prolong life treatment of arterial hypertension, use of statins in patients with or at high risk of CAD use of ACE-I in patients with asymptomatic LV dysfunction use of beta-blockers in those with asymptomatic LV dysfunction and a history of myocardial infarction are recommended.

12 ESC Heart Failure Guidelines: prevention To prevent or delay onset of HF and prolong life treatment of arterial hypertension, use of statins in patients with or at high risk of CAD use of ACE-I in patients with asymptomatic LV dysfunction use of beta-blockers in those with asymptomatic LV dysfunction and a history of myocardial infarction are recommended. Empagliflozin should be considered in patients with T2DM in order to prevent or delay onset of HF and prolong life

13 Therapeutic algorithm for a patient with symptomatic HFrEF

14 Therapeutic algorithm for a patient with symptomatic HFrEF

15 Kaplan-Meier Estimate of Cumulative Rates (%) PARADIGM-HF: CV Death or HF Hospitalization (Primary Endpoint) Enalapril (n=4212) Days After Randomization LCZ696 (n=4187) HR = 0.80 ( ) P = Number needed to treat = 21 Patients at Risk LCZ Enalapril

16 The QRS Sweet Spot for CRT Cleland EHJ 2013

17 The Do`s and Don`ts of CRT NO Yes LBB morphology Non- LBB morphology Courtesy of F. Ruschitzka /

18 Co-morbidities to consider in HF & important studies CAD / ischemia & Hypertension Diabetes mellitus & Metabolic syndrome Sleep apnoea Depression & Stroke Anemia and iron deficiency Renal dysfunction and kidney injury COPD Liver & bowel dysfunction consider EMPA-REG-Outcome empagliflozin consider SERVE-HF ASV consider CONFIRM-HF ferric carboxymaltose Cachexia & muscle wasting

19 Recurrent event outcomes Meta-analysis on individual patient data with FCM Efficacy outcomes based on 839 patients Rate ratio analysis (recurrent event analyses) FCM (N=504) Placebo (N=335) Rate Ratio (95%CI) p CV hospitalization and CV death 69 (23.0) 92 (40.9) 0.59 ( ) HF hospitalization and CV death 39 (13.0) 60 (26.7) 0.53 ( ) CV hospitalization and all-cause death 71 (23.7) 94 (41.8) 0.60 ( ) HF hospitalization and all-cause death 41 (13.7) 62 (27.6) 0.54 ( ) All-cause hospitalization and all-cause death 108 (36.1) 118 (52.5) 0.73 ( ) HF hospitalization 22 (7.3) 43 (19.1) 0.41 ( ) CV hospitalization 52 (17.4) 75 (33.3) 0.54 ( ) All-cause hospitalization 89 (29.7) 99 (44.0) 0.71 ( ) Anker SD, et al. Eur J Heart Fail 2017

20 What is new in the 2016 HF ESC guidelines for AHF? 1. The concept to shorten diagnostic and therapeutic decisions in the management of a patient with suspected acute HF 2. Recommendation to identify immediately coexisting lifethreatening clinical conditions and/or precipitants (according to the CHAMP acronym - acute Coronary syndrome, Hypertension emergency, Arrhythmia, acute Mechanical cause, Pulmonary embolism) 3. The new algorithm for AHF management based on the clinical profiles: presence/absence of congestion/hypoperfusion

21 Patient with suspected AHF Urgent phase after first medical contact Immediate phase (initial minutes) 1. Cardiogenic shock? no 2. Respiratory failure? no yes yes Circulatory support pharmacological mechanical Ventilatory support oxygen NIPPV(CPAP, BiPAP) mechanical ventilation Immediate stabilization and transfer to ICU/CCU Initial management of a patient with acute HF Identification of acute aetiology: C acute Coronary syndrome H Hypertensive emergency A Arrhythmia M acute Mechanical cause P Pulmonary embolism Diagnostic work-up to confirm AHF Clinical evaluation to select optimal management no yes Immediate initiation of specific treatment Follow detailed recommendations in the specific ESC guidelines Ponikowski P et al ESC HF Guidelines Eur Heart J 2016 & Eur J Heart Fail 2016

22 What is new in the 2016 HF ESC guidelines for AHF? 1. The concept to shorten diagnostic and therapeutic decisions in the management of a patient with suspected acute HF 2. Recommendation to identify immediately coexisting lifethreatening clinical conditions and/or precipitants (according to the CHAMP acronym - acute Coronary syndrome, Hypertension emergency, Arrhythmia, acute Mechanical cause, Pulmonary embolism) 3. The new algorithm for AHF management based on the clinical profiles: presence/absence of congestion/hypoperfusion

23 Management of patients with acute heart failure based on clinical profile during an early phase

24 Management of patients with acute heart failure based on clinical profile during an early phase

25 ED/ICU/CCU Immediate: Improve organ perfusion & haemodynamics Restore oxygenation Alleviate symptoms Limit cardiac & renal damage Prevent thromboembolism Minimize ICU length of stay Goals of treatment in acute heart failure Consecutive phases of AHF management Intermediate: In-hospital / post-discharge Identify aetiology and relevant co-morbidities Titrate therapy to control symptoms and congestion and optimize blood pressure Initiate and up-titrate disease-modifying pharmacological therapy Consider device therapy in appropriate patients Pre-discharge and long-term management: Develop a careful plan that provides: a. schedule for up-titrating and monitoring of pharmacological therapy b. need and timing for review for device therapy c. who will see the patient and when Enrol in disease management programme, educate, initiate lifestyle adjustments Prevent early readmission Improve symptoms, QoL and survival

26 Three-phase terrain of lifetime readmission risk after Heart Failure Hospitalization periods of highest risk for readmission unavoidable readmissions VULNERABLE PHASE Evidence-based strategies needed to prevent readmission Desai AS and Stevenson LW.Circulation. 2012;126:

27 Adherence to the guidelines and the outcomes in HFrEF patients Komajda M et al. Eur J Heart Fail 2017 (on line) Overall mortality HF hospitalization and HF death

28 ESC Heart Failure Guidelines: take-home summary The best physician for a patient with HF would be one with excellent training, extensive experience, and superb judgment with regard to all aspects of the disease. He or she would not necessarily follow guidelines slavishly. J.N. Cohn, Circ Heart Fail 2008;1:87-88

29 4 days of scientific exchange healthcare professionals abstracts and cases submitted 120+ scientific sessions 300+ expert faculty members 100+ countries represented The world s largest meeting on heart failure Call for abstracts 2 November 12 January 45+ industry sessions /workshops