Saudi Heart Failure Guidelines Waleed AlHabeeb, MD, MHA Consultant Heart Failure Cardiologist President of the Saudi Heart Failure Group
Heart Failure Expert committee The Heart Failure Expert Committee, comprising 13 local specialists, representing both the public and private sectors and practicing across the KSA, met on October 7 8, 2016, to reach a consensus on the recommendations
Scope This document is intended for use by local general physicians and cardiac specialists for the management of patients with acute and chronic HF However, physicians are required to manage patients based on the best available evidence and their clinical judgment, and should also take factors such as patient characteristics, drug profile, and available resources into consideration
Definition and class of recommendations Color Class Definition Recommended/indicated Evidence that a given treatment or procedure is useful and effective Conflicting evidence with favorable opinion about Should be considered the usefulness or efficacy of a given treatment or procedure Conflicting evidence and opinion about efficacy May be considered that a given treatment or procedure is not well established by evidence Evidence or general agreement that the given Not recommended treatment or procedure is not useful/effective and, in some cases, may be harmful
Calssification Classification EF (%) Heart failure with reduced ejection fraction (HFrEF) 40 Heart failure with borderline ejection fraction 41 49 (HFbEF) Heart failure with preserved ejection fraction 50 (HFpEF)
Diagnosis
HFpEF
CARDIAC IMAGING AND DIAGNOSTIC WORKUP PREVENTING HEART FAILURE PHARMACOLOGICAL TREATMENT OF HFrEF
No. Recommendations 1 An ACE-I*, in addition to a beta-blocker, is recommended for patients with HFrEF, to reduce the risk of hospitalization and death. 2 A beta-blocker (extended-release metoprolol, bisoprolol, or carvedilol), in addition to an ACE-I*, is recommended for patients with HFrEF, to reduce the risk of hospitalization and death. 3 An MRA is recommended for patients with HFrEF who remain symptomatic despite treatment with an ACE-I* and a beta-blocker, to reduce the risk of hospitalization and death. Renal function and potassium levels should be closely monitored in patients prescribed an MRA.
Angiotensin receptor neprilysin inhibitor 6 Sacubitril/valsartan is recommended as a replacement for an ACE-I (or ARB) to further reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-I/ARB and a beta-blocker. Angiotensin II receptor blockers 7 An ARB is recommended to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients unable to tolerate an ACE-I.
I f -channel inhibitor 10 Ivabradine should be considered to reduce the risk of HF hospitalization in symptomatic patients with a LVEF 35%, sinus rhythm, and who have a resting heart rate 70 bpm, despite treatment with an evidence-based dose of beta-blocker (or maximum tolerated dose below that), in addition to an ACE-I (or ARB) and an MRA. 11 Ivabradine should be considered to reduce the risk of HF hospitalization in symptomatic patients with a LVEF 35%, sinus rhythm, and who have a resting heart rate 70 bpm and are unable to tolerate or have contraindications for beta-blockers. Patients should also receive an ACE-I (or ARB) and an MRA. Other treatments with less-certain benefits 12 Digoxin may be considered in patients who are symptomatic despite treatment with an ACE- I (or ARB), a beta-blocker, and an MRA to reduce the risk of hospitalization (both all-cause and HF hospitalizations). For therapeutic benefit, maintain low digoxin serum concentrations 0.5 0.9 ng/ml.
NON-SURGICAL DEVICE TREATMENT OF HFrEF TREATMENT OF HFpEF ARRHYTHMIAS AND CONDUCTANCE DISTURBANCES COMORBIDITIES
ACUTE HEART FAILURE
MECHANICAL CIRCULATORY SUPPORT AND HEART TRANSPLANTATION MULTIDISCIPLINARY TEAM MANAGEMENT QUALITY METRICS
3 It is recommended that patients with HF are enrolled in a multidisciplinary care management program to reduce the risk of HF hospitalization and mortality. 4 Referral to primary care for long term follow-up may be considered for stable patients with HF who are on optimal therapy to monitor the effectiveness of the treatment, disease progression and patient adherence.
Quality Metrics No. Recommendations 1 Performance measures based on professionally developed clinical practice guidelines should be used with the goal of improving quality of care for HF. 2 Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guidelinebased quality and performance measures can be beneficial in improving the quality of HF care.
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