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Guidelines Acute and Chronic HF FT

Guidelines Acute and Chronic HF FT

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ESC GUIDELINES
ESC Guidelines for the diagnosis and treatmentof acute and chronic heart failure 2012
The Task Force for the Diagnosis and Treatment of Acute andChronic Heart Failure 2012 of the European Society of Cardiology.Developed in collaboration with the Heart Failure Association (HFA)of the ESC
Authors/Task Force Members: John J. V. McMurray (Chairperson) (UK)
*
,Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Angelo Auricchio(Switzerland), Michael Bo¨ hm (Germany), Kenneth Dickstein (Norway),Volkmar Falk (Switzerland), Gerasimos Filippatos (Greece), Ca  ˆ ndida Fonseca (Portugal), Miguel Angel Gomez Sanchez (Spain), Tiny Jaarsma (Sweden),Lars Køber (Denmark), Gregory Y. H. Lip (UK), Aldo Pietro Maggioni (Italy),Alexander Parkhomenko (Ukraine), Burkert M. Pieske (Austria), Bogdan A. Popescu(Romania), Per K. Rønnevik (Norway), Frans H. Rutten (The Netherlands), Juerg Schwitter (Switzerland), Petar Seferovic (Serbia), Janina Stepinska (Poland),Pedro T. Trindade (Switzerland), Adriaan A. Voors (The Netherlands), Faiez Zannad(France), Andreas Zeiher (Germany).
ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax (CPG Chairperson) (The Netherlands),Helmut Baumgartner (Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK),Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (The Netherlands),Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK),Cyril Moulin (France), Bogdan A. Popescu (Romania), Z ˇ eljko Reiner (Croatia), Udo Sechtem (Germany),Per Anton Sirnes (Norway), Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France),Stephan Windecker (Switzerland).Document Reviewers: Theresa McDonagh (CPG Co-Review Coordinator) (UK), Udo Sechtem (CPG Co-Review Coordinator) (Germany), Luis Almenar Bonet (Spain), Panayiotis Avraamides (Cyprus), Hisham A. Ben Lamin(Libya), Michele Brignole (Italy), Antonio Coca (Spain), Peter Cowburn (UK), Henry Dargie (UK), Perry Elliott(UK), Frank Arnold Flachskampf (Sweden), Guido Francesco Guida (Italy), Suzanna Hardman (UK), Bernard Iung
*
Corresponding author. Chairperson: Professor John J.V. McMurray, University of Glasgow G12 8QQ, UK. Tel:
+
44 141 330 3479, Fax:
+
44 141 330 6955, Email: john.mcmurray@glasgow.ac.uk Other ESC entities having participated in the development of this document:Associations: European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Echocardiography (EAE), European Heart Rhythm Association(EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) Working Groups: Acute Cardiac Care, Cardiovascular Pharmacology and Drug Therapy, Cardiovascular Surgery, Grown-up Congenital Heart Disease, Hypertension and the Heart,Myocardial and Pericardial Diseases, Pulmonary Circulation and Right Ventricular Function, Thrombosis, Valvular Heart DiseaseCouncils: Cardiovascular Imaging, Cardiovascular Nursing and Allied Professions, Cardiology Practice, Cardiovascular Primary CareThe content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of theESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to OxfordUniversity Press, the publisher of the
 European Heart Journal
 and the party authorized to handle such permissions on behalf of the ESC.
Disclaimer 
. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Healthprofessionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of healthprofessionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient’sguardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.
&
The European Society of Cardiology 2012. All rights reserved. For permissions please email: journals.permissions@oxfordjournals.org
European Heart Journaldoi:10.1093/eurheartj/ehs104
 
(France), Bela Merkely (Hungary), Christian Mueller (Switzerland), John N. Nanas (Greece),Olav Wendelboe Nielsen (Denmark), Stein Ørn (Norway), John T. Parissis (Greece), Piotr Ponikowski (Poland).
The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines
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Keywords
 Heart failure
 
 Natriuretic peptides
 
 Ejection fraction
 
 Renin–angiotensin system
 
 Beta-blockers
 
Digitalis
 
 Transplantation
Table of Contents
Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . 31. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63. Definition and diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . 63.1 Definition of heart failure . . . . . . . . . . . . . . . . . . . . 63.2 Terminology related to left ventricular ejection fraction. 63.3 Terminology related to the time-course of heart failure 73.4 Terminology related to the symptomatic severity of heartfailure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73.5 Epidemiology, aetiology, pathophysiology, and naturalhistory of heart failure . . . . . . . . . . . . . . . . . . . . . . . . . 83.6 Diagnosis of heart failure . . . . . . . . . . . . . . . . . . . . . 83.6.1 Symptoms and signs . . . . . . . . . . . . . . . . . . . . . 83.6.2 General diagnostic tests in patients with suspectedheart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.6.3 Essential initial investigations: echocardiogram,electrocardiogram, and laboratory tests . . . . . . . . . . . . 93.6.4 Natriuretic peptides . . . . . . . . . . . . . . . . . . . . . 93.6.5 Chest X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . 113.6.6 Routine laboratory tests . . . . . . . . . . . . . . . . . . 113.6.7 Algorithm for the diagnosis of heart failure . . . . . . 134. The role of cardiac imaging in the evaluation of patients withsuspected or confirmed heart failure . . . . . . . . . . . . . . . . . . 144.1 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . 144.1.1 Assessment of left ventricular systolic dysfunction . 144.1.2 Assessment of left ventricular diastolic dysfunction . 144.2 Transoesophageal echocardiography . . . . . . . . . . . . . 144.3 Stress echocardiography . . . . . . . . . . . . . . . . . . . . . 164.4 Cardiac magnetic resonance . . . . . . . . . . . . . . . . . . . 164.5 Single-photon emission computed tomography andradionuclide ventriculography . . . . . . . . . . . . . . . . . . . . . 174.6 Positron emission tomography imaging . . . . . . . . . . . . 174.7 Coronary angiography . . . . . . . . . . . . . . . . . . . . . . . 174.8 Cardiac computed tomography . . . . . . . . . . . . . . . . . 175. Other investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175.1 Cardiac catheterization and endomyocardial biopsy . . . 175.2 Exercise testing . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.3 Genetic testing . . . . . . . . . . . . . . . . . . . . . . . . . . . 185.4 Ambulatory electrocardiographic monitoring . . . . . . . . 186. Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187. Pharmacological treatment of heart failure with reducedejection fraction (systolic heart failure) . . . . . . . . . . . . . . . . . 187.1 Objectives in the management of heart failure . . . . . . . 187.2 Treatments recommended in potentially all patients withsystolic heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . 187.2.1 Angiotensin-converting enzyme inhibitors andbeta-blockers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187.2.2 Mineralocorticoid/aldosterone receptor antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217.2.3 Other treatments recommended in selected patientswith systolic heart failure . . . . . . . . . . . . . . . . . . . . . . 237.2.4 Angiotensin receptor blockers . . . . . . . . . . . . . . 237.2.5 Ivabradine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237.2.6 Digoxin and other digitalis glycosides . . . . . . . . . . 247.2.7 Combination of hydralazine and isosorbidedinitrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247.2.8 Omega-3 polyunsaturated fatty acids . . . . . . . . . . 247.3 Treatments not recommended (unproven benefit) . . . . 257.3.1 3-Hydroxy-3-methylglutaryl-coenzyme A reductaseinhibitors (‘statins’) . . . . . . . . . . . . . . . . . . . . . . . . . . 257.3.2 Renin inhibitors . . . . . . . . . . . . . . . . . . . . . . . . 257.3.3 Oral anticoagulants . . . . . . . . . . . . . . . . . . . . . . 257.4 Treatments not recommended (believed to cause harm) 257.5 Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268. Pharmacological treatment of heart failure with ‘preserved’ejection fraction (diastolic heart failure) . . . . . . . . . . . . . . . . . 269. Non-surgical device treatment of heart failure with reducedejection fraction (systolic heart failure) . . . . . . . . . . . . . . . . . 279.1 Implantable cardioverter-defibrillator . . . . . . . . . . . . . 279.1.1 Secondary prevention of sudden cardiac death. . . . 279.1.2 Primary prevention of sudden cardiac death . . . . . 279.2 Cardiac resynchronization therapy . . . . . . . . . . . . . . . 289.2.1 Recommendations for cardiac resynchronization therapy where the evidence is certain . . . . . . . . . . . . . 299.2.2 Recommendations for cardiac resynchronization therapy where the evidence is uncertain . . . . . . . . . . . . 2910. Arrhythmias, bradycardia, and atrioventricular block inpatients with heart failure with reduced ejection fraction andheart failure with preserved ejection fraction . . . . . . . . . . . . . 3010.1 Atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . 3010.1.1 Rate control . . . . . . . . . . . . . . . . . . . . . . . . . 3010.1.2 Rhythm control . . . . . . . . . . . . . . . . . . . . . . . 3110.1.3 Thrombo-embolism prophylaxis . . . . . . . . . . . . 3210.2 Ventricular arrhythmias . . . . . . . . . . . . . . . . . . . . . 3210.3 Symptomatic bradycardia and atrioventricular block . . 33ESC Guidelines
Page 2 of 61
 
11. Importance and management of other co-morbidity in heartfailure with reduced ejection fraction and heart failure withpreserved ejection fraction . . . . . . . . . . . . . . . . . . . . . . . . . 3511.1 Heart failure and co-morbidities . . . . . . . . . . . . . . . 3511.2 Anaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3511.3 Angina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3511.4 Asthma: see chronic obstructive pulmonary disease . . 3511.5 Cachexia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3511.6 Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3511.7 Chronic obstructive pulmonary disease. . . . . . . . . . . 3511.8 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3611.9 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3611.10 Erectile dysfunction . . . . . . . . . . . . . . . . . . . . . . . 3711.12 Gout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3711.13 Hyperlipidaemia . . . . . . . . . . . . . . . . . . . . . . . . . 3711.14 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . 3711.14 Iron deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . 3811.15 Kidney dysfunction and cardiorenal syndrome . . . . . 3811.16 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3811.17 Prostatic obstruction . . . . . . . . . . . . . . . . . . . . . . 3811.18 Renal dysfunction . . . . . . . . . . . . . . . . . . . . . . . . 3811.19 Sleep disturbance and sleep-disordered breathing . . . 3812. Acute heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3812.1 Initial assessment and monitoring of patients . . . . . . . 3912.2 Treatment of acute heart failure . . . . . . . . . . . . . . . 3912.2.1 Pharmacological therapy . . . . . . . . . . . . . . . . . . 3912.2.2 Non-pharmacological/non-device therapy . . . . . . 4112.3 Invasive monitoring . . . . . . . . . . . . . . . . . . . . . . . . 4512.3.1 Intra-arterial line . . . . . . . . . . . . . . . . . . . . . . . 4512.3.2 Pulmonary artery catheterization . . . . . . . . . . . . 4512.4 Monitoring after stabilization . . . . . . . . . . . . . . . . . . 4512.5 Other in-patient assessments . . . . . . . . . . . . . . . . . 4512.6 Readiness for discharge . . . . . . . . . . . . . . . . . . . . . 4512.7 Special patient populations . . . . . . . . . . . . . . . . . . . 4512.7.1 Patients with a concomitant acute coronarysyndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4512.7.2 Isolated right ventricular failure . . . . . . . . . . . . . 4612.7.3 Acute heart failure with ‘cardiorenal syndrome’ . . 4612.7.4 Perioperative acute heart failure . . . . . . . . . . . . 4612.7.5 Peripartum cardiomyopathy . . . . . . . . . . . . . . . 4612.7.6 Adult congenital heart disease . . . . . . . . . . . . . . 4613. Coronary revascularization and surgery, including valvesurgery, ventricular assist devices, and transplantation . . . . . . . 4613.1 Coronary revascularization . . . . . . . . . . . . . . . . . . . 4613.2 Ventricular reconstruction . . . . . . . . . . . . . . . . . . . 4713.3 Valvular surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 4713.3.1 Aortic stenosis . . . . . . . . . . . . . . . . . . . . . . . . 4713.3.2 Aortic regurgitation . . . . . . . . . . . . . . . . . . . . . 4713.3.3 Mitral regurgitation . . . . . . . . . . . . . . . . . . . . . 4713.4 Heart transplantation . . . . . . . . . . . . . . . . . . . . . . 4813.5 Mechanical circulatory support . . . . . . . . . . . . . . . . 4813.5.1 End-stage heart failure . . . . . . . . . . . . . . . . . . . 4913.5.2 Acute heart failure . . . . . . . . . . . . . . . . . . . . . 4914. Holistic management, including exercise training andmultidisciplinary management programmes, patient monitoring,and palliative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5014.1 Exercise training . . . . . . . . . . . . . . . . . . . . . . . . . . 5014.2 Organization of care and multidisciplinary managementprogrammes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5114.3 Serial natriuretic peptide measurement . . . . . . . . . . . 5214.4 Remote monitoring (using an implanted device) . . . . . 5214.5 Remote monitoring (no implanted device) . . . . . . . . 5214.6 Structured telephone support . . . . . . . . . . . . . . . . . 5214.7 Palliative/supportive/end-of-life care . . . . . . . . . . . . . 5215. Gaps in evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5215.1 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5215.2 Co-morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5215.3 Non-pharmacological, non-interventional therapy . . . . 5315.4 Pharmacological therapy . . . . . . . . . . . . . . . . . . . . 5315.5 Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5315.6 Acute heart failure . . . . . . . . . . . . . . . . . . . . . . . . 5315.7 End-of-life care. . . . . . . . . . . . . . . . . . . . . . . . . . . 53References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Appendix: six tables (3,10,11,12,13,15) are available on the ESC Website only at www.escardio.org/guidelines-surveys/esc-guidelines/Pages/acute-chronic-heart-failure.aspx and labelled as‘Web Tables’ throughout the document.
Abbreviations and acronyms
ACE angiotensin-converting enzymeACHD adult congenital heart diseaseAF atrial brillationAF-CHF Atrial Fibrillation and Congestive Heart FailureAHF acute heart failureAIRE Acute Infarction Ramipril EfficacyARB angiotensin receptor blockeARR absolute risk reductionATLAS Assessment of Treatment with Lisinopril AndSurvivalAV atrioventriculaAVP arginine vasopressinBEAUTIFUL MorBidity-mortality EvAlUaTion of the I
f  
 inhibi- tor ivabradine in patients with coronary diseaseand left ventricULar dysfunctionBEST Beta-Blocker Evaluation of Survival TrialBiVAD bi-ventricular assist deviceBNP B-type natriuretic peptideb.p.m. beats per minuteBTC bridge to candidacyBTD bridge to decisionBTR bridge to recoveryBTT bridge to transplantationCABG coronary artery bypass graftCAD coronary artery diseaseCARE-HF Cardiac Resynchronization in Heart Failure StudyCCB calcium-channel blocke
ESC Guidelines
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