SGK 2016 Session: Postgraduate Course in Heart Failure Lausanne, 15. June 2016 Heart Failure Guidelines 2016 Matthias Nägele, MD University Hospital Zurich
Disclosures I have nothing to disclose.
The new guidelines
New aspects 1. Definition 2. Types of HF: HFrEF, HFmrEF, HFpEF 3. Algorithms in chronic and acute heart failure 4. Valsartan/sacubitril 5. Modified CRT indications 6. Focus on comorbidities
Definition of HF
Type and diagnosis of HF Type of HF HF with reduced EF (HFrEF) HF with mid-range EF (HFmrEF) HF with preserved EF (HFpEF) Symptoms ± signs Symptoms ± signs Symptoms ± signs LVEF <40% LVEF 40-49% LVEF 50% Necessary Criteria - NT-proBNP >125 pg/ml or BNP >35 pg/ml At least one criteria: 1. Structural heart disease LA enlargement (LAVI >34 ml/m 2 ) and/or LV hypertrophy (LVMI >115/95 g/m 2 ) 2. Diastolic dysfunction E/e 13 or septal/lateral e <9 cm/s
Diagnostic algorithm (non-acute onset)
Diagnostic algorithm (non-acute onset)
Initial work-up after diagnosis In all patients TTE (LVEF, RV function, valves, pulmonary hypertension) Laboratory Hb and leukocytes Na, K, urea, creatinine Bilirubin, AST, ALT, GT Glucose, HbA1c Lipid profile, TSH Ferritin, TF saturation Natriuretic peptides 12-lead ECG Chest X-Ray In selected patients Cardiac MRI Non-invasive stress imaging Exercise testing Coronary angiography Cardiac CT Right heart catheterization Endomyocardial biopsy
Treatment of HFrEF Diuretics to relieve symptoms and signs of congestion
Treatment of HFrEF ICD if LVEF 35% despite Optimal medical therapy or history of symptomatic VT/VF
Background on valsartan/sacubitril PARADIGM-HF Trial McMurray et al. NEJM 2014
Guidance on valsartan/sacubitril Contraindications: Angioedema egfr <10ml/min/1.73m 2 Pregnancy Titration: Low prior ACEI/ARB (i.e. <10mg lisinopril): 50mg b.i.d. Higher ACEI/ARB dose: 100mg b.i.d. Increase every 2-4 weeks to target dose: 200mg b.i.d Precautions: Discontinue ACEI at least 36h before starting valsartan/sacubitril Do not combine with ACEI, aliskiren or ARB Hyperkalemia, Systolic blood pressure <100mmHg egfr 10-30ml/min/1.73m 2 Side effects more common with valsartan/sacubitril Symptomatic hypotension SBP <90mmHg Angioedema* Side effects more common with enalapril Creatinine >2.5mg/dl Potassium >6mmol/l Cough SwissMedic Fachinformation 25.09.2016
Treatment of HFrEF
Treatment of HFrEF
Treatment of HFrEF
Recommendations on ICD
Recommendations on CRT
Recommendations on CRT EchoCRT Trial IPD meta-analysis of five RCTs All-cause mortality HR 1.81 (1.11-2.93) p= 0.02 Ruschitzka et al. NEJM 2013 Cleland et al. EHJ 2013
Treatment of HFmrEF and HFpEF No treatment has yet been shown, convincingly, to reduce morbidity or mortality in patients with HFpEF or HFmrEF. Important comorbidities: Hypertension Atrial fibrillation Diabetes Ischemia Exercise training
Comorbidities: Iron, Diabetes, CSA, Arthritis
Comorbidities: CKD
Comorbidities: COPD
Comorbidities: Obesity
Acute heart failure: Initial Assessment Congestion (e.g. pulmonary congestion, orthopnea, edema, jugular venous distension) No Yes Hypoperfusion (e.g. cold extremities, oliguria, confusion, dizziness, narrow pulse pressure, elevated lactate) No Warm and Dry Warm and Wet Yes Cold and Dry Cold and Wet
Acute heart failure: Algorithms
Acute heart failure: Algorithms
Acute heart failure: Treatment
Acute heart failure: Treatment
Exercise and (tele-)monitoring programs
Prevention of HF
Conclusions New guidelines: Consistent incorporation of last 4 year s evidence HF with mid-range EF (40-49%) New subtype to boost research efforts Valsartan/Sacubitril: Use when symptomatic on optimal ACEI, BB and MRA CRT: Contraindicated in QRS duration <130ms HFpEF/HFmrEF: Lack of treatments, focus on symptoms and comorbidities Acute HF: Congestion/perfusion assessment to triage treatment, effective therapies still lacking New recommendations on comorbidities (i.e. iron, diabetes, ASV) Strong recommendations for exercise in HF patients Prevention of HF in diabetic patients: consider empagliflozin
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