ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 Heart esrigl 2012139, 1787-1847 if re (2012) 14, 803-869doi:10.1099/eurheartj/ehs104 ESC GUIDELINES ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 The Task Force for the Diagnosis and Treatment of Acute and Chronic 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 Bohm (Germany), Kenneth Dickstein (Norway), Volkmar Falk (Switzerland), Gerasimos Filippatos (Greece), Candida Fonseca (Portugal), Miguel Angel Gomez-Sanchez (Spain), Tiny Jaarsma (Sweden), Lars Kaber (Denmark), Gregory Y.H. Lip (UK), Aldo Pietro Maggioni (Italy), Alexander Parkhomenko (Ukraine), Burkert M. Pieske (Austria), Bogdan A. Popescu (Romania), Per K. Rennevik (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). Journal (2012) 33, 1787-1847 o Failure (2012) 14, 803-869 eT oesdoi:10.1099/eurheartj/ehs104 ESC GUIDELINES 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 (|srael), Amo Hoes (The Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK), Cyril Moulin (France), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Simes (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 Cowbum (UK), Henry Dargie (UK), Perry Elliott (UK), Frank Amold Flachskampf (Sweden), Guido Francesco Guida (Italy), Suzanna Hardman (UK), Bemard lung (France), Bela Merkely (Hungary), Christian Mueller (Switzerland), John N. Nanas (Greece) Olav Wendelboe Nielsen (Denmark), Stein @m (Norway), John T. Parissis (Greece), Piotr Ponikowski (Poland), ESC staff and Oxford University Press Veronica Dean, Catherine Després, Nathalie Cameron (ESC); Sue Bell (OUP). st Journal (2012) 33, 1787-1847 allure (2012) 14, 803-869 Pesce Ret ies)Outline 1. Linking evidence and recommendations Journal (2012) 33, 1787-1847 somes fHeart Fallure (2012) 14, 803-869 Socierr or Pesce tei sieClass of recommendation Pies Class Il Conflicting evidence and/ora divergence of opinion about the usefulness/efficacy of the given treatment or procedure. Class lla Weight of evidence/opinion is in Should be considered. favour of usefulness/efficacy. Class IIb Usefulness/efficacy is less well May be considered. established by evidence/opinion. Class Ill Evidence or general agreement that __Is not recommended. the given treatment or procedure is notuseful/effective, and in some cases may be harmful. st Journal (2012) 33, 1787-1847 Failure (2012) 14, 803-869Level of evidence a rod Data derived from multiple randomized PATTY clinical trials or meta-analyses. ere Data derived from a single randomized Evidence B CTT CE UC Cibo Ce (oom journal (2012) 33, 1787-1867 Failure (2012) 14, 803-869 ere eM oTTreatment recommendations linked to treatment effects Class | Level Recommendations An ACE inhibitor is recommended, in addition to a beta-blocker, for all patients with an EF = 40% to reduce the risk of HE hospitalization and the risk of premature death. Heart Journal (2012) 33, 1787-1847 Pa oe eee Ty Fallure (2012) 14, 803-869Outline 2. Diagnosis journal (2012) 33, 1787-1847 @ eart Fallure (2012) 14, 803-869 Socierr or See ciesDiagnosis - caveat! Difficulty in assigning evidence level to diagnostic tests - all given an arbitrary “Level C” recommendation. imal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869 .. elt syLinking diagnostic recommendations to value of tests Recommendations Class Level Investigations to consider in all patients Transthoracic echocardiography is recommended to evaluate cardiac structure and function, including diastolic function (Section 4.1.2), and to measure LVEF to make the diagnosis of HF, assist in planning and monitoring of treatment, and to obtain prognostic information A 12-lead ECG is recommended to determine heart rhythm, heart rate, QRS morphology, and QRS duration, and to detect other relevant abnormalities (Table 5). This information also assists in planning treatment and is of prognostic importance. A completely normal ECG makes systolic HF unlikely. Measurement of blood chemistry (including sodium, potassium, calcium, urea/blood urea nitrogen, creatinine/estimated glomerular filtration rate, liver enzymes and bilirubin, ferrtin/TIBC) and thyroid function is recommended to: (i) Evaluate patient suitability for diuretic, reninangiotensin-aldosterone antagonist, and anti-coagulant therapy (and monitor treatment) (i) Detect reversible/treatable causes of HF (e.g. hypocalcaemia, thyroid dysfunction) and co-morbidities (e.g. iron deficiency) (il) Obtain prognostic information. A complete blood countis recommended to: () Detect anaemia, which may be an alternative cause of the patient's symptoms and signs and may cause worsening of HF (ii) Obtain prognostic information. Heart Journal (2012) 33, 1787-1647 of Heart Failure (2012) 14, 803-869 Eee oTDiagnosis of heart failure 4, Symptoms typical of HF 2. Signs typical of HF# 3. Reduced LVEF 1. Symptoms typical of HF 2. Signs typical of HF® 3. Normal or only mildly reduced LVEF and LV notdilated 4, Relevant structural heart disease (LV hypertrophy/LA enlargement) and/or diastolic dysfunction (see Section 4.1.2) HF = heart failure; HF-PEF = heart failure with ‘preserved’ ejection fraction; HF-REF = heart failure and a reduced ejection fraction; LA = left atrial; LV = left ventricular; LVEF = left ventricular ejection fraction Signs may not be present in the early stages of HF (especially in HF-PEF) and in patients treated with diuretics (see Section 3.6). @ journal (2012) 33, 1787-1847 Eyrorean art Failure (2012) 14, 803-869 Socierr orSymptoms and signs typical of heart failure (1) Breathlessness Elevated jugular venous pressure Orthopnoea Hepatojugular reflux Paroxysmal noctumal dyspnoea Third heart sound (gallop rhythm) Reduced exercice tolerance Laterally displaced apical impulse Fatigue, tiredness, increased time to recover after exercise Cardiac murmur Ankle swelling Journal (2012) 33, 1787-1847 f Heart Failure (2012) 14, 803-869Symptoms and signs typical of heart failure (2) Symptoms Signs Less typical Less specific Nocturnal cough Peripheral oedema (ankle, sacral, scrotal) Wheezing Pulmonary crepitations Reduced air entry and dullness to percussion at Wiciahicain (CA KoseeN) lung bases (pleural effusion) Weight loss (in advanced heart failure) Tachycardia Bloated feeling Irregular pulse Loss of appetite Tachypnoea (>16 breaths/min) Confusion (especially in the elderly) Hepatomegaly Depression Ascites Palpitations Tissue wasting (cachexia) Syncope Journal (2012) 33, 1787-1847 a Failure (2012) 14, 803-869 corre) eoDiagnostic flowchart for patients with suspected heart failure-showing alternative ‘echocardiography first’ (blue) or ‘natriuretic peptide first’ (red) approaches. ECG Possibly chest X-1 —_ £ ~ Echocardiography BNPINT, a BNPY BNPINT-pro BNP. Echocardiography erate ECG oe and ECG ‘iondod ECG abnormal and ECG normal and Nr-proBNP 75 years), atrial arrhyhtmias, left ventricular hypertrophy, COPD, and chronic kidney disease. @ Journal (2012) 33, 1787-1847 Pa oe eee Ty Fallure (2012) 14, 803-869Clinical research NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients The International Collaborative of NT-pro-BNP Study Optimal NT-proBNP cut-points for the diagnosis or exclusion of acute HF among dyspnoeic patients ce oom ee a | LS Confirmatory (‘rule in’) cut-points < 50 years (r=184) 450 pail. oT 8 76 9 Cy 5075 years (9-537) 00paim | __90 2 83 8 S > 7B years (1-5) TOOpgiml | __ 8 a 92 5 we Rule in, overall 0 a 8 6 S Jenuzzi et al. EHJ 2006 Journal (2012) 33, 1787-1847 Pa oe eee Ty Fallure (2012) 14, 803-869BNP in 1872 patients suspected of non-acute HF Studies on the optimal exclusionary cut-point for BNP in patients suspected of non-acute new HF Zaphiriou et al Cowie et al Krishnaswamy et al. Yamamoto et al. Fuat et al. Kelder et al. ®To convert BNP poimL to pmol, multiply by 0.289 LV = left ventricular, HF = heart falure; NPV = negative predictive value; PPV = positive predictive value, journal (2012) 33, 1787-1847 somes jeart Failure (2012) 14, 803-869 S3eere er eoNT-proBNP in 1297 patients suspected of non-acute HF Studies on the optimal exclusion cut-point for NT-proBNP. in patients suspected of non-acute new HF Zaphiriou etal. Nielsen et a. Aes Gustafsson et al. 125 Fuatet a. 279 8 150 *To convert NT-proBNP pg/mL to pmol/L, multiply by 0.118, LV = left ventricular; HF = heert failure; NPV = negative predictive value; PPV = positive predictive velue journal (2012) 33, 1787-1847 ‘ jeart Failure (2012) 14, 803-869 S3eere er eoEchocardiography Recommendations Class | Level Transthoracic echocardiography is recommended to evaluate cardiac structure and function, including diastolic function (Section 4.1.2), and to measure LVEF to make the diagnosis of HF, assist in planning and monitoring of treatment, and to obtain prognostic information sart Journal (2012) 33, 1787-1847 x © art Failure (2012) 14, 803-869 Socierr or rd See cies\f heart failure confirmed, determine aetiology and start appropriate treatment Journal (2012) 33, 1787-184 ed 1867 Failure (2012) 14, 803-969 org/guidelines 2Functional or Structural Cardiac abnormalities related to HF-PEF e Abnormalities of the mitral inflow pattern, tissue velocities (e’), or the E/e’ ratio (Indicate degree of LV filling dysfunction and estimate filling pressures). e Left atrial volume index: increased (volume >34 mL/m*) Increased LV filling pressure (past or present) or mitral valve disease. e LV mass index: increased: >95 g/m? in women and >115 g/m? in men. imal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869Mitral Inflow Pattern san Heart Journal (2012) 33, 1787-1847 Soest See ee ansTissue Doppler ImagingWhat else is new in diagnosis? MR-pro ANP (BACH study). Echocardiography — 3D, strain imaging. CT coronary angiography. CMR. Genetic testing. imal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869Outline 3. Treatment - new evidence assessed rt Journal (2012) 33, 1787-1847 ‘seen art Failure (2012) 14, 803-869 Soeere st Pesce tei sieWhat new evidence did we have to assess e Drugs. e Non-surgical devices. e Surgery/surgical devices.. e Lifestyle/non-pharmacological. (2012) 33, 1787-1847 Failure (2012) 14, 803-869What’s new in treatment Drugs? (1) MRA EMPHASIS-HF — Systolic HF and mild symptoms (NYHA class Il). |, inhibitor SHIFT Role of |, inhibition in systolic HF. ARB HEAAL Comparison of 50 mg vs.150 mg losartan daily in systolic HF. Vitamin K antagonist WARCEF Role in systolic HF and sinus rhythm. Statin GISSI HF Role in ischaemic and non-ischaemic HF (and HF-REF and HF-PEF). n3-PUFA GISSI-HF Role in ischaemic and non-ischaemic HF (and HF-REF and HF-PEF). journal (2012) 33, 1787-1847 © art Failure (2012) 14, 803-869 Socierr orWhat’s new in treatment Drugs? (2) Class Ill ANDROMEDA Role of dronedrone in patients antiarrhythmic hospitalized with systolic HF. Role of dronedrone in patients with Glass at m EAELAS: persistent/permanent AF and High CV antiarrhythmic x Glitazones RECORD CV safety of rosiglitazone in T2DM. journal (2012) 33, 1787-1847 © art Failure (2012) 14, 803-069 seeerryWhat’s new in treatment HF-PEF? ARB PRESERVE Efficacy and safety of irbesartan in HF-PEF, sart Journal (2012) 33, 1787-1847 ‘i . Crete Heart allure (2012) 14, 803-869 Soeere stWhat’s new in treatment Non-surgical devices? CRT MADIT-CRT CRT in systolic HF and mild symptoms. CRT RAFT CRT in systolic HF and mild symptoms. TAVI PARTNER trials Role of transcatheter aortic valve implantation. sart Journal (2012) 33, 1787-1847 seanerii art Failure (2012) 14, 803-869 S3eere er See ciesWhat’s new in treatment Surgery/surgical devices? VAD Heart Mate || trial Continuous vs. pulsatile flow. CABG STICH Role in patients with systolic HF. imal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869 2What’s new in treatment Acute heart failure? Diuretic DOSE Dose and route of adiministration of diuretic. B type natriuretic ASCEND-HF Role of nesiritide as a treatment of peptide acute HF. Crete t Journal (2012) 33, 1787-1847 of Heart Fallure (2012) 14, 803-869What’s new in treatment Lifestyle/non-pharmacological or device therapy? Exercice training HF-ACTION Efficacy and safety of exercice training in HF-REF. Self management HART Self-management/adherence counselling counselling in HF-REFand HF-PEF. imal (2012) 33, 1787-1847 Pa oe eee Ty art Failure (2012) 14, 803-869Main changes from 2008 guidelines Treatment 1. An expanded indication for mineralocorticoid (aldosterone) receptor antagonists (MRAs). 2. A new indication for the sinus node inhibitor ivabradine. 3. An expanded indication for cardiac resynchronization therapy (CRT). 4. New information on the role of coronary revascularization in systolic HF. 5. Recognition of the growing use of ventricular assist devices (VADs). 6. The emergence of transcatheter valve interventions. journal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869Petrol symptoms/signs of congestion ‘ACE inhibitor (or ARB If not tolerated) Treatment options for patients ACCES with chronic HFrEF (NYHA class II-IV) COOUTT d the footnotes and : . <>—_————-| rn Sorry DrInitial pharmacological therapy Diuretics to relieve symptoms/signs of congestion + ACE inhibitor (or ARB if not tolerated ECs rs Add a MR antagonist st Journal (2012) 33, 1787-1847 fHeart Fallure (2012) 14, 803-869 eyPharmacological therapy indicated in potentially all patients with systolic HF Recommendations Class Level ACE inhibitor An ACE inhibitoris recommended, in addition to a beta-blocker, for all patients with an EF 340% to reduce the risk of HF hospitalization and the risk of premature death. Beta-blocker A beta-blocker is recommended, in addition to an ACE inhibitor (or ARB if ACE inhibitor not tolerated), for all patients with an EF <40% to reduce the risk of HF hospitalization and the risk of premature death. MRA An MRA\is recommended for all patients with persisting symptoms (NYHA class II- IV) and an EF 335%, despite treatment with an ACE inhibitor (or an ARB if an ACE inhibitor is not tolerated) and a beta-blocker, to reduce the risk of HF hospitalization and the risk of premature death Journal (2012) 33, 1787-1847 Pesce Ret ies) Failure (2012) 14, 803-869Pharmacological therapy — Next step | PNR Cleleteliits jeart Journal (2012) 33, 1787-1847 Heart Fallure (2012) 14, 803-869Ivabradine Recommendations Class | Level Should be considered to reduce the risk of HF hospitalization in patients in sinus rhythm with an EF $35 %, a heart rate remaining 270 beats per minute, and persisting symptoms (NYHA class II-IV) despite treatment with an evidence-based dose of beta-blocker (or maximum tolerated dose below that), ACE inhibitor (or ARB), and an MRA (or ARB). Caveat about EMA labelling: 275 b.p.m. st Journal (2012) 33, 1787-1847 Pa oe eee Ty Failure (2012) 14, 803-869Pharmacological therapy Other treatments with less certain benefits in systolic HF (1) Recommendations Class | Level ARB Recommended to reduce the risk of HF hospitalization and the risk of premature death in patients with an EF < 40 % and unable to tolerate an ACE inhibitor because of cough (patients should also receive a beta-blocker and an MRA) Recommended to reduce the risk of HF hospitalization in patients with an EF <40% and persisting symptoms (NYHA class II-IV) despite treatment with an ACE inhibitor and a beta-blocker who are unable to tolerate an MRA. Wabradine ‘Should be considered to reduce the risk of HF hospitalization in patients in sinus rhythm with an EF £35 %, a heart rate remaining>70 b.p.m., and persisting symptoms (NYHA class II-IV) despite treatment with an evidence-based dose of || Ila beta-blocker (or maximum tolerated dose below that), ACE inhibitor (or ARB), and an MRA (or ARB). May be considered to reduce the risk of HF hospitalization in patients in sinus rhythm with an EF <35 % anda heart rate 270 b.p.m. who are unable to tolerate a Ib beta-blocker, Patients should also receive an ACE inhibitor (or ARB) and an MRA | Tl (or ARB), Journal (2012) 33, 1787-1847 sanenesai Failure (2012) 14, 803-869 S3eere er Senet oes rdPharmacological therapy Other treatments with less certain benefits in systolic HF (2) Recommendations Class | Level Digoxin May be considered to reduce the risk of HF hospitalization in patients in sinus rhythm with an EF <45% who are unable to tolerate a beta-blocker (ivabradine is an alternative in patients with a heart rate 270 b.p.m.). Patients should also receive an ACE inhibitor (or ARB) and an MRA (or ARB). May be considered to reduce the risk of HF hospitalization in patients with an EF <45% and persisting symptoms (NYHA class I-IV) despite treatment with a beta- blocker, ACE inhibitor (or ARB), and an MRA (or ARB). HASDN May be considered as an alternative to an ACE inhibitor or ARB, if neither is tolerated, to reduce the risk of HF hospitalization and risk of premature death in patients with an EF <45% and dilated LV (or EF <35%). Patients should also receive a beta-blocker and an MRA May be considered to reduce the risk of HF hospitalization and risk of premature death in patients with an EF <45% and dilated LV (or EF < 35%) and persisting symptoms (NYHA class II-IV) despite treatment with a beta-blocker, ACE inhibitor (or ARB), and an MRA (or ARB). An n-3 PUFA preparation may be considered to reduce the risk of death and the risk of cardiovascular hospitalization in patients treated with an ACE inhibitor (or ARB), beta-blocker, and an MRA (or ARB). Journal (2012) 33, 1787-1847 Failure (2012) 14, 803-869 Senet oes www.Main changes from 2008 guidelines Treatment 1. An expanded indication for mineralocorticoid (aldosterone) receptor antagonists (MRAs). 2. A new indication for the sinus node inhibitor ivabradine. 3. An expanded indication for cardiac resynchronization therapy (CRT). 4. New information on the role of coronary revascularization in systolic HF. 5. Recognition of the growing use of ventricular assist devices (VADs). 6. The emergence of transcatheter valve interventions. smal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869When to consider CRT and ICD Still NYHA class IIIV and LVEF <35%? QRS duration 2120 ms? ees Uez eae) ee Ca e2) Still NYHA class II. Pome 1 year with good functional status, to reduce the risk of HF hospitalization and the risk of premature death. 2 trials: MADIT-CRT and RAFT Pesce Ret ies) Journal (2012) 33, 1787-1847 | Heart Failure (2012) 14, 803-869 @What to do about non-LBBB? Risk Lower Upper Study name Ratio Limit Limit Z-Value P-Value Risk ratio and 95% Cl COMPANION -Non-LBBB 086 063 147 0.96 0.34 CARE-HF - RBBB 081 054 1.22 0.99 0.32 CARE-HF -TVCD 075 024 233 0.50 0.62 MADIT-CRT- RBBB 099 055 179 0.03 097 MADIT-CRT - IVCD. 144 088 2.36 145 0.15 RAFT - RBBB 100 062 162 0.00 1.00 RAFT - VCD 110 071 169 043 067 Meta Analysis 0.97 082 115 0.32 0.75 Am Heart J 2012;163:260-267 23. 5 FavorsCRT 1 Favors Control journal (2012) 33, 1787-1847 jeart Failure (2012) 14, 803-869 @ 2What to do about non-LBBB? Risk Lower Upper Study name Ratio Limit Limit Z-Value P-Value Risk ratio and 95% Cl COMPANION-Non-LBBB «086-063 «1.17 «0.96 0.34 CARE-HF - RBBB 081 054 1.22 0.99 0.32 CARE-HF -TVCD O75 024 233 0.50 062 MADIT-CRT- RBBB 0.99 0.55 1.79 0.03 0.97 MADIT-CRT-IVCD 144 088 236 145 0.45 RAFT - RBBB 1.00 0.62 1.62 0.00 1.00 RAFT -IVCD 110 071 1.69 0.43 0.67 Meta Analysis 097 082 145 0.32 0.75 Am Heart J 2012;163:260-267 23. rd See cies °5 Favors CRT 1 Favors Control 4] rt Journal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869 @QRS morphology, duration and effect of CRT CRT-D vs. ICD only HR for primary endpoint All 0.75 (0.64, 0.87) 0.66 (0.52, 0.84) ne QRS<150 | 0.89(0.60, 1.32) 0.55 (0.35, 0.86) QRS 2 150 0.51 (0.37, 0.69) 0.41 (0.30. 0.56) QRS < 150 1.24 (0.70, 2.19) 1.41 (0.85, 2.32) Non-LBBB QRS 2 150 0.83 (0.47, 1.47) 0.92 (0.52, 1.64) imal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869An expanded indication for cardiac resynchronization therapy (CRT) Recommendations for the use CRT where the evidence is strong—patients in sinus rhythm with NYHA functional class II heart failure and a persistently reduced ejection fraction, despite optimal pharmacological therapy. Recommendations Class | Level LBBB QRS morphology CRT-PICRT-D is recommended in patients in sinus rhythm with a QRS duration of 2 130 ms, LBBB QRS morphology, and an EF < 30%, who are expected fo survive > 1 year with good functional status, to reduce the risk of HF hospitalization and the risk of premature death Non-LBBB QRS morphology CRT preferably CRT-D should be considered in patients in sinus rhythm with a QRS duration of 2 150 ms, irrespective of QRS morphology, and an EF $ 30%, who are expected to survive > 1 year |) Mla with good functional status to reduce the risk of HF hospitalization and the risk of premature death. Journal (2012) 33, 1787-1847 ‘ 7 |Heart Fallure (2012) 14, 803-869 aes eectsMain changes from 2008 guidelines . An expanded indication for mineralocorticoid (aldosterone) receptor antagonists (MRAs). 2. A new indication for the sinus node inhibitor ivabradine. 3. An expanded indication for cardiac resynchronization therapy (CRT). . New information on the role of coronary revascularization in systolic HF. . Recognition of the growing use of ventricular assist devices (VADs). . The emergence of transcatheter valve interventions. Journal (2012) 33, 1787-1847 Pe art Failure (2012) 14, 803-869 S3eere erIndications for myocardial revascularization e CABG indicated in symptomatic patients with left main or multivessel disease. e No indication for revascularization in asymptomatic patients without viable myocardium (scar). Recommendations Class | Level CABG is recommended for patients with angina and significant left main stenosis, who are otherwise suitable for surgery and expected to survive >1 year with good functional status, to reduce the risk of premature death. CABG is recommended for patients with angina and two- or three-vessel coronary disease, including a left anterior descending stenosis, who are otherwise suitable for surgery and expected to survive >1 year with good functional status, to reduce the ‘isk of hospitalization for cardiovascular causes and the risk of premature death from cardiovascular causes. Altemative to CABG: PC/ may be considered as an alternative to CABG in the above categories of patients unsuitable for surgery. CABG and PCI are NOT recommended in patients without angina AND without viable myocardium. st Journal (2012) 33, 1787-1847 allure (2012) 14, 803-869 eoMain changes from 2008 guidelines . An expanded indication for mineralocorticoid (aldosterone) receptor antagonists (MRAs). 2. A new indication for the sinus node inhibitor ivabradine. 3. An expanded indication for cardiac resynchronization therapy (CRT). . New information on the role of coronary revascularization in systolic HF. . Recognition of the growing use of ventricular assist devices (VADs). . The emergence of transcatheter valve interventions. Journal (2012) 33, 1787-1847 Pe art Failure (2012) 14, 803-869 S3eere erIndications for MCS e Increasing waiting lists for heart transplantation. e Limited organ availability. e Improvements of LVAD technology. Continuous-flow (2003) LVAD (2008) Pulsatileflow LVAD (2008) Percent Survival ma Pulsatileflow a LVAD (2001) at Medical therapy (2001) 12 Percent Survival 1 (2012) 33, 1787-1047 e Failure (2012) 14, 603-869 Soserot_Indications for MCS Upgrade of LVAD indication for destination therapy Patients eligible for LVAD or BiVAD implantation Recommendations Ref ‘An LVAD or BIVAD is recommended in selected patients with end-stage HF despite optimal pharmacological and device treatment and who are — otherwise suitable for heart trans- ie plantation, to improve symptoms and aa reduce the risk of HF hospitalization for worsening HF and to reduce the risk of premature death while awaiting transplantation Patients with >2 months of severe symptoms despite optimal medical and device therapy and more than one of the following: + LVEF <25% and, if measured, peak VO, <12 mLikg/min. +23 HF hospitalizations in previous 12 months without an obvious precipitating cause. ‘An LVAD should be considered in highly selected patients who have end-stage HF despite optimal pharmacological and device therapy and who are not suitable for heart transplantation, but are expected to survive >1 year with good functional status, to improve symptoms, and reduce the risk of HF hospitalization and of premature death 254 + Dependence on i.v. inotropic therapy * Progressive end-organ dysfunction (worsening renal and/or hepatic function) due to reduced perfusion and not to inadequate ventricular filing pressure (PCWP 220 mmHg and SBP <80-90 mmHg or Cl s2 Limin/m?). + Deteriorating right ventricular function, Pesce Ret ies) st Journal (2012) 33, 1787-1847 @ Failure (2012) 14, 803-869Recognition of the growing use of ventricular assist devices (VADs) - Bridge to transplantation Recommendations Class | Level An LVAD or BiVAD is recommended in selected patients with end-stage HF despite optimal pharmacological and device treatment and who are otherwise suitable for heart transplantation, to improve symptoms and reduce the risk of HF hospitalization for worsening HF and to reduce the risk of premature death while awaiting transplantation. st Journal (2012) 33, 1787-1847 Eee oI Failure (2012) 14, 803-869Recognition of the growing use of ventricular assist devices (VADs) — Destination therapy Recommendations Class| Level ‘An LVAD should be considered in highly selected patients who have end-stage HF despite optimal pharmacological and device therapy and who are not suitable for heart transplantation, but are expected to survive >1 year with good functional status, to improve symptoms, and reduce the risk of HF hospitalization and of premature death. art Journal (2012) 33, 1787-1847 Eee oI Fallure (2012) 14, 803-869 RaMain changes from 2008 guidelines . An expanded indication for mineralocorticoid (aldosterone) receptor antagonists (MRAs). 2. A new indication for the sinus node inhibitor ivabradine. 3. An expanded indication for cardiac resynchronization therapy (CRT). . New information on the role of coronary revascularization in systolic HF. . Recognition of the growing use of ventricular assist devices (VADs). . The emergence of transcatheter valve interventions. Journal (2012) 33, 1787-1847 Pe art Fallure (2012) 14, 803-869 S3eere erIndications for Valve Surgery e Aortic stenosis — If mean gradient is >40 mmHg, there is no lower EF limit for AVR in symptomatic patients. — Optimization of treatment should not delay surgical decision-making. — In patients who are not medically fit for surgery TAVI should be considered. ‘AVR should be considered in symptomatic patients with low flow, low gradient (<40 mmHg) AS with normal EF only after carreful confirmation of severe AS. AVR should be considered in symptomatic patients with severe AS, low flow, low gradient with reduced EF, and evidence of flow reserve. ‘AVR may be considered in symptomatic patients with severe AS low flow, low gradient, and LV dysfunction with out flow reserve. Table taken from ESC GL on VHD 2012 st Journal (2012) 33, 1787-1847 allure (2012) 14, 803-869 Pesce Ret ies) Recommendations Class | LevelIndications for Valve Surgery e Secondary mitral insufficiency — The role of isolated MVR in patients with severe functional MI and severe LV systolic dysfunction who cannot be revascularized or have non-ischaemic cardiomyopathy is questionable. - Inselected cases, repair may be considered in order to avoid or postpone transplantation. Recommendations Class | Level Surgery is indicated in patients with severe MR undergoing CABG, and LVEF >30%. Surgery should be considered in patients with moderate MR undergoing CABG. Surgery should be considered in symptomatic patients with severe MR, LVEF <30%, option for revascularisation, and evidence of viability. Surgery may be considered in patients with severe MR, LVEF >30%, who remain symptomatic despite optimal medical management (including CRT if indicated) and have low co-morbidity, when revascularization is not indicated. Table taken from ESC GL on VHD 2012 st Journal (2012) 33, 1787-1847 Pa oe eee Ty Failure (2012) 14, 803-869Other areas covered Arrhythmias Co-morbidities art, Baie ets) 30 4787-1067 allure (2012) 14, 803-869 =Ventricular rate-control in persistent/permanent atrial fibrillation HF-REF HF-PEF Ratesimiting CCB Betloctet Certs Rr Binoeece cn (or rate-limiting CCB) ea Se Cru ciency eee cue ery DC Seek specialist advice, including consideration DT Ce oD Cec cay ey “Thrombo-ombolism prophyais should also be considered in paralol AV = atioventrcular; CCB = caleium-channel blocker, {{ Bolo-bocke ireaiment ean cause worseningin acutely decor pencatedpationts wih HE-REF — HF-PEF = hear ialurewith preserved ejecten fraction, (see section on acute heat! faiuce) -* Rate-imiing CCBs shouldbe avoided in HF-REF HF-REF = het failure with reduced ejecion factionThromoembolism prophylaxis in atrial fibrillation Recommendations Class | Level ‘The CHA,DS,-VASc and HAS-BLED scores (Tables 17 and 18) are recommended to determine the likely risk=benefit (thrombo-embolism prevention vs. risk of bleeding) of oral anticoagulation ‘An oral anticoagulant s recommended for all patents with paroxysmal or persistent/ permanent AF and e CHA,DS,-VASc score 21, without contrandications, and irrespective of whether a tate- or rhythm-management strategy is used (including after successful cardioversion). In patients with AF of 248 h duration, or when the known duration of AF is unknown, an oral anticoagulant is recommended at a therapeutic dose for 23 weeks prior to electrical or pharmacological cardioversion intravenous hepann or LMWH is recommendad for patients who have not been treated with an anticoagulant end require urgent electrical or pharmacological cardioversion. ‘Alie mative to iv hepann or LMWH ATOE-guided strategy may be considered for patients who have not been treated with an anticoagulant and require urgent electrical or pharmacological cardioversion, Combination of an oral anticoagulant and an antiplatelet agent is not recommended in patients with chronic 12 months efter an acute event) coronary or other arterial disease, because of a high risk of serous bleeding. Single therepy with an oral anticoagulant is preferred after 12 months. {AF = atta fibrilation; CHA,DS,-VASe = Cardiac failure, Hypertension Age »75 (Doubled), Diabetes, Stroke (Doubled) Vascular disease, Age 65-74 and Sex category (Female); EF = ejection fraction; HAS-BLED = Hype tension, Abnormal renalliver function (1 point each), Stroke, Bleeding history or predisposttion, Labile international nomalized ratio, Elderly (65), Drugs/aleohol concomitantly (1 point each), HF = heart failure; iv. = intravenous; LMWH =low molecular weight heparin, LV = lef ventricular, NYHA = New York Heart Association, TOE = transoesophageal echocardiography: Class of recommendation — » Level of evidence — 5) Journal (2012) 33, 1787-1847 eect i allure (2012) 14, 803-869 sseer st reser ers)Management of ventricular arrhythmias [Recommendations Class | Level itis recommended that potential aagravatina/precipitating factors (@ a. electrolyte disorders, use of proarhythmic drugs, myocardial ischaemia) should be sought and corrected in patients with 1 ventricular arrhythmias. ils recommended thal treatment wih an ACE inhibitor (or ARB), bota-blocker, and MRA should , A be optimized in patients with ventricular armythmies, its recommended that coronary revascularization is considered in patienis with vantricular i arthythmias and coronary altery disease (see Section 13.2) Ils recommended that an [CD is implanted in a patient with symptomatic or sustained ventricular arthythmia (ventricular tachycardia or ventricular fibrilation), reasonable functional status, and in | whom a goal of treatment s to improve survival ‘Amiodarone is recommended in pationts with an ICD, who continue to have symptomatic . ventricular armythmias or recurrent shocks despite optimal treatment and device re-Programming. Caiheter ablation is recommended in patienis with an ICD who continue to have ventricular armhythmias causing recurrent shocks not preventable by optimal treatment device re- 1 programming and amioderone. ‘Amniodarone may be considered as a treatment to prevent recurrence of sustained symptomatic ventricular arrhythmias in otherwise optimally treated patients in whom an ICD isnot considered | IIb appropriate Routine use of amiadarone is not recommended in patients with non-sustained ventricular arthythmias because of lack of benefit and potential drug toxicity. Other antiarrhythmic drugs (particularly class IC agents and dronedarone) should not be used in patients with systolic HF because of safely concems (worsening HF, proamthythmia, and death), ACE = antes converting erayme ARB =angtensh rece. Blcke. HE heat faett/= Faria carove dation Level of evidence - © Journal (2012) 33, 1787-1847 sanenesai Heart Failure (2012) 14, 803-869 Sober ot Tne exer]Management of co-morbidities e Anaemia e Hyperlipidaemia e Angina e Hypertension e Asthma/COPD e lron deficiency e Cachexia e Kidney dysfunction e Cancer e Obesity e Depression e Prostatic obstruction e Diabetes mellitus e Sleepdisturbance/ sleep disordered breathing e Erectile dysfunction imal (2012) 33, 1787-1847 art Failure (2012) 14, 803-869Outline 5. Acute heart failure rt Journal (2012) 33, 1787-1847 Pesce Ret ies) eart Failure (2012) 14, 803-869Initial assessment of patient with suspected acute heart failure History / examination (including blood pressure and respiratory rate) ChestX-ray ECG Echocardiogramm or NP (or both) Oxygen saturation Blood chemistry Full blood count 7 Blood pressure ‘ute ‘eute Simultaneously systemic 25 mmig coronary mechanical xygenation arshock syndrome eause/seveie assesstar—s| liga vahitar dacase + Oxygen tia *Eshe cohy ar cardioversion cardio grapl Urgent action “errang +Pachg c + Surgical’ if present : pes Faure (2012) 14, 603-069Algorithm for management of acute pulmonary oedema/congestion Intravenous bolus of loop dluretie eae. Yes Hypoxaemia es Oxygen) Yes a Consider iv. opiate Wo systolic blood pressure [SBP GS mmbigorshock | SBPEE-NO mmHg ar f tng matrpe) (> Severe yIdistre 0 mm ‘onsider vascullator (e.g. NTG) Yes equate fespens® >! Continue prevent treatment [Re-evaluation of palin’ linia statue Ba 6 rmihg 890, 0 pT output ad Ye a (Stop varodiatr + Sop beta-blocker it hypopertused sider non-asodiating inetrope Vow * Blader catheterization to confirm of dluretle of use + Consider ETT and invasive ventilation ight-heart cathete ler mechanical eireulstoryAlgorithm for management of acute pulmonary oedema/congestion Intravenous bolus of loop diuretic Severe anxietyldistress No Measure systolic blood pressure SBP 110 mmHg Consider vasodilator (e.g. NTG)Outline 6. Non-pharmacological, non-device/surgery recommendations journal (2012) 33, 1787-1847 Pa oe eee Ty art Failure (2012) 14, 803-869Lifestyle and non-pharmacological / device / surgical interventions Lack of robust evidence for most lifestyle, non-pharmacological interventions, e.g. sodium restriction. journal (2012) 33, 1787-1847 Failure (2012) 14, 803-869RCT of “low” vs. “normal” sodium diet in chronic systolic HF Clinica Scene (2008) 114, 221-230 (Prod in Great Briain) dot.1042/C520070193 Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend? Randomised comparison of normal (120 mmol/d) and low sodium (80 mmoll/d) diet in 232 patients with chronic systolic HF followed for 6 months. Primary endpoint - HF hospitalisation. | Heart Journal (2012) 33, 1787-1847 [of Heart Failure (2012) 14, 803-869RCT of “low” vs. “normal” sodium diet in chronic systolic HF 2 = 6 deaths 2 ie 9 hospitalisations 3 & 15 deaths = 04 80 mmol Na 30 hospitalisations 8 € S02 LogRank = 0.001 30 60 90 120 Time (Days) 150 = 180 st Journal (2012) 33, 1787-1847 Poet TS art Failure (2012) 14, 803-869Lifestyle and non-pharmacological / device / surgical interventions Recommendations Class | Level It is recommended that regular aerobic exercise is encouraged in patients with heart failure to improve functional capacity and symptoms. itis recommended that patients with heart failure are enrolled in @ multidisciplinary-care management programme to reduce the risk of heart failure hospitalization. O'Connor CM, Mellon D4, Lee KL, Ketoyian SJ, Cooper LS Els SJ, Leifer ES Kraus WE, Kitzman DW, Blumenthal 1A, Rendall DS, Miler NH Fleg JL, Schulman KA, McKeWvie RS, Zannad F, Pia IL: HE-ACTION Investigators. Eficacy and safety of exercise traning inpatients ath ‘chienic heart fluro: HEACTION randomized cont olld al. JANA 2008;201:1439 1450, Piepoli MF, Conraads V, CorraU, Dickstein K, Francés DP, Jaarsma T, McMurray J, PieskeB, PiotrowiczE, Schmid JP, Anker SD, Solal AC, Flippates G5, Hoes AW, Gielen 5, Giannuzzi, Ponikowski PP. Exercise training in hea falure: from theory to practice, A consensus ‘document ofthe Heart FallireAesociation and the European Association for Cardiovascular Prevention and Rehebiltaton. Eur) Heart Fail DON tS MT-207. Journal (2012) 33, 1787-1847 PeeleOutline 7. Uncertainties rt Journal (2012) 33, 1787-1847 Pesce Ret ies) eart Failure (2012) 14, 803-869Still uncertain Key examples e Remote monitoring: - Using implanted device. - No implanted device. e Serial monitoring of natriuretic peptides. st Journal (2012) 33, 1787-1847 fHeart Failure (2012) 14, 803-869European journal of heart failure and pocket version ® european Heart Joumal (2012) 14, 203-269 ESC GUIDELINES dol:10.1083/eurheart/ehs105 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 ‘The Task Force for the Diagnosis and Treatment of Acute and Chroni Heart Failure 2012 of the European Society of Cardiology. Developet collaboration with the Heart Failure Association (HFA) of the ESC Authors/Task Force Members: John J.V. McMurray (Chairperson) (UK), ESC GUIDELINES Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Angelo Auricchio ume ins (Switzerland), Michael B&hm (Germany), Kenneth Dickstein (Norway), Volkmar sey ca patee ncn cae nace | Falk (Switzerland), Gerasimos Filippatos (Greece), Candida Fonseca wy (Portugal), Miguel Angel Gomez-Sanchez (Spain), Tiny Jaarsma (Sweden), Lars Keber (Denmark), Gregory Y.H. Lip (UK), Aldo Pietro Maggioni (Italy), HEART FAILURE | Alexander Parkhomenko (Ukraine), Burkert M. Pieske (Austria), Bogdan A. ogame ton ne Popescu (Romania), Per K. Ronnevik (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). OF ACUTE tS as Nea Ra elt sy ‘Heart Failure (2012) 14, 803-869 ea SInternet links and references hse rernc online revurce for pret, careers and professionals seoecscarti orgies De rhvemesterson3 12012 ESE Guidelines on Heart Failure Adgenda: ‘pang! bes (210-13 ad 5) ar rable om the EXC Webs in the Full Tet coment ae othe Ades 3° crrerbrpiadrines survey esd Peesarae ron alr Reiavane additional rsading: pase bonagh TA, Ewe Lak AL, Dahir U, Euan | Laima M, MeDonald Xipuer une A arama T Europe Sct of Cardogy Heer Fare Rarccion Commuter on Patent Care. Furopean Soucy of Cardlogy Heart Paton Associaton Sandra Cr dalveing heat eure care Ear J Hear 2011 Mae 130) 255-41 2 Lay ak Me Ble L, Clark AL, Debt U, Dich iem Ky Elan 1 MeDonah T Febery Ryder MH Stoner 5 Smee & are 7 Stbeare mangement of eee arc pracuclreemanencanons Wom the Palen Care Comatre ot tt rab Bere Assocation cl the Earpean Soc of Cardufgy Bur] Hear Ft 201) FIGS 26 3. Pepa ME CorenadsV. Cored U, Dicks K Francis OF parame T MMe ay jt Poke B Potro, Slra JP Aker $D, Sol AC, Fiypatos GS, Hom AW ered Gurr! ® Ponkowal PP Gears ring inertial fom theory > cr: cance rumen ol the Heat lie Astacaion an the BoP Fearetion fr Cardovouafar Pevanion amd Rehaidation, Eur J Hear at 2011 apr OMT 7 4 JarsnaT, Beatle JM. Ryder, Rutten FH, MMeDonagh T, Hobe ‘a Grocei T, erp | Metra M, Ean , Argan C, Leventhal. Pe Fa orca Gaerza A Pore, Dihstcn K, Debretre Blue, Strmser & Pe Monay):Adranced Heart Fate Study Group ofthe HFA of te BSC. Polar eae cc tanre:apeson statement from the pate rare warkahvp of he are Felure Assoricton of the Eocpszn Sock of Cardtolgy, Ge] Heart Fal. 2005 May 16)43-8 www. eT oes Pocket Guideline Web address for Heartfailurematters.org References to key HFA position statements / consensus documents * Standards of care Self-care management Exercise training Palliative care @ Journal (2012) 33, 1787-1847 Failure (2012) 14, 803-869Practical guidance on use of key disease modifying drugs and diuretics in HF ‘Appendix E: Practical guidance on the use of mineralocorticoid receptor antagonists in patients with systolic heart failure™ WHY? To improve symptoms, reduce the risk of HF hospitalization, and increase survival IN WHOM AND WHEN? Indications Potential all patients with persisting sympcams (NYHA Class ILIV) and an EF <35% despice treatment with an ACE inhibitor (or ARB) and bets-blocker [Cautionslscek speciliet advice Signifieane hyperkalnemia (K* 25.0 mmol? Significane renal dysfunction (creachine >221 moVL [>2.5 mgldL] or eGFR <30 mLimin/.73 m9 rug itersetions to look out for IK: supplements! I°-spartng isratic (3g: vdlocde ahd timers bows combhetion preparers wih firemen) [ACE InhibiorvJARBs/renin ilbicors® NSAIDs? ‘Tamechoprim/trimethoprim sulfamethoxazole Low-zalt aubsukutes with a high K° conten |Coneraindication Eplerenone-strang CYP3A4 inhibitors. e.g kecoconazale.itraconzole,nefarodone, teithromyein, canthromycn. ntonavr.and nelfinavie WHERE? In she community oF inthe hospital Exceptions see Caucions/seek specialat advice WHICH MRA AND WHAT DOSE! - see Table 14" HOW To USE? ‘Check renal function and electrotytes (particularly K) Start with a low dose (see above) Consider dose up-ttation after 4-8 woeks (Check blood chemistry at | and 4 weeks after starting/increasing dose and at 8 and 12 weeks; 6,9,and 12 months 4-monthly thereafter INK rises above 55 mol/L or creatine rises to 221 jmolil (25 mg/dL)/&GFR <30 mLimin! 73 my halve dose and monitor blood chemistry closely WK: ree €0 26.0 mmol oF creatinine to >310 jmol (35 mgldl) GFR <20 mLUmin!l 73 mv, stop MRA immediately and soak specialist advice ‘A specialist HE nurse may assist with educaton of tha patient, follow-up (in person ar by talephone). biochemical monitoring. and dose up-titration Journal (2012) 33, 1787-1847 Eyrorean allure (2012) 14, 203-869 Soeere st Peele