Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK...
Transcript of Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK...
![Page 1: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/1.jpg)
Heart Failure Guidelines 2016
SGK 2016 Session: Postgraduate Course in
Heart Failure – Lausanne, 15. June 2016
Matthias Nägele, MD – University Hospital Zurich
![Page 2: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/2.jpg)
Disclosures
• I have nothing to disclose.
![Page 3: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/3.jpg)
The new guidelines
![Page 4: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/4.jpg)
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
![Page 5: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/5.jpg)
Definition of HF
![Page 6: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/6.jpg)
Type and diagnosis of HF
Type of HF HF with reduced
EF (HFrEF)
HF with mid-range
EF (HFmrEF)
HF with preserved EF
(HFpEF)
Necessary
Criteria
Symptoms ± signs Symptoms ± signs Symptoms ± signs
LVEF <40% LVEF 40-49% LVEF ≥ 50%
- NT-proBNP >125 pg/mL or BNP >35 pg/mL
At least one criteria:
1. Structural heart disease
• LA enlargement (LAVI >34 ml/m2)
and/or
• LV hypertrophy (LVMI >115/95 g/m2)
2. Diastolic dysfunction
• E/e′ ≥13 or septal/lateral e’ <9 cm/s
![Page 7: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/7.jpg)
Diagnostic algorithm (non-acute onset)
![Page 8: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/8.jpg)
Diagnostic algorithm (non-acute onset)
![Page 9: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/9.jpg)
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
![Page 10: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/10.jpg)
Treatment of HFrEF
Diu
retics
tore
lieve
sym
pto
ms
an
dsig
ns
ofco
ng
estio
n
![Page 11: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/11.jpg)
Treatment of HFrEFIC
D ifLV
EF
≤ 3
5%
de
sp
ite
Op
tim
al m
ed
ica
lth
era
py
or
his
tory
ofsym
pto
ma
tic
VT
/VF
![Page 12: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/12.jpg)
Background on valsartan/sacubitril
McMurray et al. NEJM 2014
PARADIGM-HF Trial
![Page 13: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/13.jpg)
Guidance on valsartan/sacubitril
• Contraindications:
– Angioedema
– eGFR <10ml/min/1.73m2
– 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/1.73m2
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
![Page 14: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/14.jpg)
Treatment of HFrEF
![Page 15: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/15.jpg)
Treatment of HFrEF
![Page 16: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/16.jpg)
Treatment of HFrEF
![Page 17: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/17.jpg)
Recommendations on ICD
![Page 18: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/18.jpg)
Recommendations on CRT
![Page 19: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/19.jpg)
Recommendations on CRT
Ruschitzka et al. NEJM 2013
EchoCRT Trial
All-cause mortality
HR 1.81 (1.11-2.93)
p= 0.02
Cleland et al. EHJ 2013
IPD meta-analysis of five RCTs
![Page 20: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/20.jpg)
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
![Page 21: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/21.jpg)
Comorbidities: Iron, Diabetes, CSA, Arthritis
![Page 22: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/22.jpg)
Comorbidities: CKD
![Page 23: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/23.jpg)
Comorbidities: COPD
![Page 24: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/24.jpg)
Comorbidities: Obesity
![Page 25: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/25.jpg)
Acute heart failure: Initial Assessment
No Yes
No Warm and Dry Warm and Wet
Yes Cold and Dry Cold and Wet
Hypoperfusion
(e.g. cold extremities,
oliguria, confusion,
dizziness, narrow
pulse pressure,
elevated lactate)
Congestion
(e.g. pulmonary congestion, orthopnea,
edema, jugular venous distension)
![Page 26: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/26.jpg)
Acute heart failure: Algorithms
![Page 27: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/27.jpg)
Acute heart failure: Algorithms
![Page 28: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/28.jpg)
Acute heart failure: Treatment
![Page 29: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/29.jpg)
Acute heart failure: Treatment
![Page 30: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/30.jpg)
Exercise and (tele-)monitoring programs
![Page 31: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/31.jpg)
Prevention of HF
![Page 32: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/32.jpg)
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
![Page 33: Heart Failure Guidelines 2016 - swisscardio.ch · 6/15/2016 · Heart Failure Guidelines 2016 SGK 2016 Session: Postgraduate Course in Heart Failure –Lausanne, 15. June 2016 Matthias](https://reader035.fdocuments.us/reader035/viewer/2022081517/5ecdc829ae8a0070877f0938/html5/thumbnails/33.jpg)
Heart Failure Specialists of Tomorrow
• Platform to connect young people
interested in heart failure
• Everyone under 40 and interested in
heart failure is invited to join
• Sign up: http://tinyurl.com/hotgrp