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Similar to 2021 ESC Guidelines for Heart Failure - What's New and How much to Adapt
2021 ESC Guidelines for Heart Failure - What's New and How much to Adapt
- 1. 2021 ESC Guidelinesfor Heart Failure: What’s New & How much to adapt Speaker: Dr. Md. Samiul Haque, MBBS HMO & FCPS P-2 Trainee MU-2, MMCH
- 2. What’s New inthe Guidelines? ❑ A change of the term ‘heart failure with mid-range ejection fraction’ to ‘heart failure with mildly reduced ejection fraction’ (HFmrEF). ❑ A new simplified treatment algorithm for HFrEF. ❑ The addition of a treatment algorithm for HFrEF according to phenotypes. ❑ Modified classification for acute HF. ❑ Updated treatments for most non-cardiovascular comorbidities including diabetes, hyperkalaemia, iron deficiency, and cancer. ❑ The addition of key quality indicators. •
- 3. Heart Failure: AGlobal Burden ✔ 26 million Number of heart failure patients worldwide. ✔ 74% Heart failure patients suffering from at least 1 comorbidity.
- 4. Definition of HeartFailure According to ESC ✔ Heart failure is not a single pathological diagnosis, but a clinical syndrome consisting of ✔ Cardinal 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). ✔ It is due to a structural and/or functional abnormality of the heart that results in elevated intracardiac pressures and/or inadequate cardiac output at rest and/or during exercise.
- 5. Cont...d Universal Definition HF isclinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion.
- 6. Terminology ✔Definition of heartfailure with reduced ejection fraction, mildly reduced ejection fraction and preserved ejection fraction.
- 7. Cont...d Terminology related tosymptomatic severity of HF
- 8. Diagnostic algorithm forheart failure
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- 11. Recommended diagnostic testsin all patients with suspected chronic heart failure
- 12. General Measures inHF Management ✔ Education: explanation of nature of disease, treatment and self-help strategies ✔ Diet: good general nutrition, salt and fluid restriction & weight reduction for the obese ✔ Smoking: cessation ✔ Alcohol: elimination of alcohol consumption specially in alcohol-induced cardiomyopathy ✔ Exercise: regular moderate aerobic exercise within limit of symptoms ✔ Vaccination: consideration of influenza and pneumococcal vaccination
- 13. Pharmacotherapy for HFrEF Thereare three major goals of treatment for patients with HFrEF: ✔ reduction in mortality, ✔ prevention of recurrent hospitalizations due to worsening HF, and ✔ improvement in clinical status, functional capacity, and quality of life.
- 14. Cont...d The Five Pillarsof Heart Failure Pharmacotherapy
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- 18. ✔ In thePARADIGM-HF trial, sacubitril/valsartan, an ARNI, was shown to be superior to enalapril in reducing hospitalizations for worsening HF, CV mortality, and all-cause mortality in patients with ambulatory HFrEF with LVEF ≤40% ✔ Additional benefits of sacubitril/valsartan includes • improvement in symptoms and QOL • reduction in the incidence of diabetes requiring insulin treatment • reduction in the decline in eGFR • reduced rate of hyperkalaemia. ARNI (Sacubitril/valsartan)
- 19. ❖ Patients beingcommenced on sacubitril/valsartan should have ⮚ adequate blood pressure (SBP>90 mmHg) ⮚ eGFR ≥30 mL/min/1.73 m2 ⮚ A washout period of at least 36 h after ACE-I therapy is required in order to minimize the risk of angioedema Cont...d
- 20. ✔ The DAPA-HFtrial & EMPEROR-Reduced trial found that dapagliflozin and empagliflozin reduced the combined primary endpoint of CV death or HF hospitalization by 26% & 25% respectively in patients with NYHA class II–IV symptoms, and an LVEF ≤40% despite OMT ✔ Therefore, dapagliflozin or empagliflozin is recommended, in addition to OMT with an ACE-I/ARNI, a beta-blocker and an MRA, for patients with HFrEF regardless of diabetes status. SGLT2 inhibitors
- 21. ❖ Contraindicated in ⮚Pregnancy/risk of pregnancy and breastfeeding period ⮚ eGFR <20 mL/min/1.73 m2 ❖ Type 1 diabetes mellitus is not an absolute contraindication, but an individual risk of ketoacidosis should be taken into account when starting this therapy. ❖ Glycosuria may predispose to fungal genito-urinary infections. Cont...d
- 22. Dosage of thedrugs
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- 24. HFpEF differs fromHFrEF and HFmrEF in that HFpEF patients are older and more often female. AF, CKD, and non-CV comorbidities are more common in patients with HFpEF than in those with HFrEF. To date, no treatment has been shown to convincingly reduce mortality and morbidity in patients with HFpEF HFpEF Management
- 25. ✔AHF refers torapid or gradual onset of symptoms and/or signs of HF, severe enough for the patient to seek urgent medical attention, leading to an unplanned hospital admission or an emergency department visit. ✔Four major clinical presentations- i. Acute decompensated heart failure ii. Acute pulmonary edema iii. Isolated right ventricular failure iv. Cardiogenic shock Acute Heart Failure
- 27. ⮚ Troponin ⮚ Serumcreatinine ⮚ Electrolytes ⮚ Blood urea nitrogen or urea ⮚ TSH ⮚ Liver function tests ⮚ D-dimer and procalcitonin when pulmonary embolism or infection are suspected ⮚ Arterial blood gas analysis in case of respiratory distress and ⮚ Lactate in case of hypoperfusion Initial laboratory exams in AHF
- 29. ✔Propped up position ✔Oxygen&/ Mechanical ventilation: Oxygen therapy is recommended in patients with AHF and SpO2 <90% or PaO2 <60 mmHg to correct hypoxaemia. (l) ✔Diuretics (l) ✔Vasodilators: Intravenous vasodilators may be considered to relieve AHF symptoms when SBP is >110 mmHg (llb) ✔Ionotropes: They should be reserved for patients with LV systolic dysfunction, low cardiac output and low SBP (e.g. <90 mmHg) resulting in poor vital organ perfusion. (llb) Management of AHF
- 30. ✔Vasopressors: Norepinephrine maybe preferred in patients with severe hypotension. The aim is to increase perfusion to the vital organs. Some studies, support the use of norepinephrine as first choice, compared with dopamine or epinephrine. (llb) ✔Opiates: Routine use of opiates in AHF is not recommended although they may be considered in selected patients, particularly in case of severe/intractable pain or anxiety or in the setting of palliation. (lll) ✔Thromboembolism prophylaxis: with heparin (e.g. low-molecular-weight heparin) or another anticoagulant is recommended, unless contraindicated or unnecessary (because of existing treatment with oral anticoagulants). (l) Cont...d
- 32. Cardiovascular comorbidities Atrial Fibrillation: ❑The management of patients with concomitant HF and AF includes: ✔ Identification and treatment of possible causes or triggers of AF ✔ Management of HF ✔ Prevention of embolic events by anticoagulation (l) ✔ Rate control if hemodynamically stable ✔ Rhythm control if hemodynamically unstable
- 35. Non-cardiovascular comorbidities Diabetes: Treatment ofHF is similar in patients with and without diabetes. Conversely, antidiabetic drugs differ in their effects in patients with HF and preference must be given to drugs that are both safe and reduce HF-related events.
- 36. ✔ Iron deficiency,which can be present independently of anaemia, is present in up to 55% of chronic HF patients and in up to 80% of those with AHF. ✔ It may be caused by increased loss, reduced intake or absorption (i.e. malnutrition, gut congestion) and/or impaired iron metabolism caused by the chronic inflammatory activation of HF. ✔ It is recommended that all patients with HF are regularly screened for anaemia and iron deficiency with full blood count, serum ferritin concentration, and TSAT Iron deficiency & anaemia:
- 37. ✔ Iron supplementationwith i.v. ferric carboxymaltose is safe and improves symptoms, exercise capacity, and QOL of patients with HFrEF and iron deficiency. ✔ Oral iron therapy is not effective in iron repletion and did not improve exercise capacity in patients with HFrEF and iron deficiency ✔ Erythropoietin stimulating agents are not indicated for the treatment of anaemia in HF
- 38. ✔ CKD andHF frequently coexist. They share common risk factors, such as diabetes or hypertension. ✔ When RAAS inhibitors, ARNI or SGLT2 inhibitors are started, the initial decrease in the glomerular filtration pressure may decrease GFR and increase serum creatinine. However, these changes are generally transient. ✔ There is little direct evidence to support any recommendations for treatment of HF patients with severe CKD as to date. CK D
- 39. ❑ COPD affectsabout 20% of patients with HF and has a major impact on symptoms and outcomes ❑ Due to the overlap in symptoms and signs, the differentiation between HF and COPD may be difficult ❑ Treatment of HF is generally well tolerated in COPD. ❑ Beta-blockers can worsen pulmonary function in individual patients but are not contraindicated in either COPD or asthma, as stated in GOLD and GINA, respectively. Use cardio-selective beta blockers. COP D
- 40. ✔ Patients withHF are classified based on their LVEF. Those with a LVEF between 41% and 49% are defined as ‘mildly reduced LVEF’ (HFmrEF). ✔ Measurement of NPs and echocardiography have key roles in the diagnosis of HF. ✔ ACE-I or ARNI, beta-blockers, MRA, and SGLT2 inhibitors are recommended as cornerstone therapies for patients with HFrEF. ✔ ACE-I/ARNI, beta-blockers, and MRA may be considered in patients with HFmrEF. Key Messages
- 41. ✔ Exercise isrecommended for all patients who are able, to improve exercise capacity and QOL, and reduce HF hospitalization. ✔ Four major clinical presentations of acute HF may occur: ADHF, acute pulmonary oedema, RV failure, and cardiogenic shock. ✔ Treatment of acute HF is based on diuretics for congestion, inotropes, and short- term MCS for peripheral hypoperfusion.
- 42. ✔ It isrecommended that patients with type II diabetes are treated with SGLT2 inhibitors. ✔ Patients should be periodically screened for anaemia and iron deficiency and i.v. iron supplementation with ferric carboxymaltose should be considered in symptomatic patients with LVEF <45% and iron deficiency, and in patients recently hospitalized for HF and with LVEF ≤50% and iron deficiency.