Le nuove Linee Guida

ESC-HF 2016: cosa è

cambiato

Scompenso cronico

Dr.Carlo Lombardi

Ricercatore

Cardiologia. Università e Spedali

Civili di Brescia

Nuove linee guida europee per lo scompenso

cardiaco: cosa c’è di nuovo

1. Algoritmo diagnostico

2. HF mr EF

3. Prevenzione: empaglifozin nei diabetici

4. Sacubitril/valsartan in sostituzione ACEi/ARB

5. CRT solo nei pazienti con QRS > 130 msec

6. Trattamento IC acuta

7. Indicazioni ai LVAD

3

ESC Heart Failure Guidelines: what’s new

1. Apply a novel algorithm for the diagnosis of heart

failure (HF) in the non-acute setting based on

clinical probability of the disease (derived from

medical history, physical examination and resting

ECG), the assessment of circulating natriuretic

peptides and transthoracic echocardiography.

8

Ponikowski, Voors et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Diagnostic algorithm for heart failure of non-acute onset

NPV:

0.94-0.98

PPV

0.44-0.57 (non acute)

0.66- 0.67 (acute)

ESC Heart Failure Guidelines: what’s new

2. 1. Use transthoracic echocardiography in patients

with suspected or established HF for the

assessment of myocardial structure and function

along with the measurement of LVEF to establish

the diagnosis of HF with reduced (HFrEF,

LVEF<40%), mid-range (HFmrEF, LVEF: 40-49%)

or preserved ejection fraction (HFpEF, LVEF≥50%).

10

Terminology of heart failure based

on ejection fraction

Ponikowski, Voors et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Multivariable adjusted incidence rate (per 100 patient-

years) of events by LVEF in TOPCAT

Scott D. Solomon et al. Eur Heart J 2016;37:455-462

P = 0.02 P = 0.79

P = 0.002 P = 0.004

Objective demonstration of structural and/or

functional alterations as the underlying

cause for the clinical presentation

Alterations Cut-off values

Structural

Left atrial volume index

Left ventricular mass index

> 34 mL/m2

> 115 g/m2 males

> 95 g/m2 females

Functional

E/e’

Mean e’ septal and lateral wall

> 13

< 9 cm/s

Others

Longitudinal strain

Tricuspid regurgitation velocity

(TVI)

Ponikowski et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

ESC Heart Failure Guidelines: what’s new

3. To prevent or delay onset of HF and prolong life,

treatment of arterial hypertension, use of statins in

patients with or at high risk of coronary artery

disease, use of ACE-I in patients with asymptomatic

left ventricular dysfunction and beta-blockers in

those with asymptomatic left ventricular

dysfunction and a history of myocardial infarction

are recommended.

18

Recommendations to prevent or delay the development of overt

heart failure or prevent death before the onset of symptoms

SGLT-2 inhibitors

Inhibit proximal tubular glucose reabsorption, cause

diuresis and natriuresis, lower BP and reduce weight.

Also renoprotective (in diabetes)?

Empaglifozin, cardiovascular outcomes and

mortality. EMPA-REG Outcome trial

Impact of glucose-lowering drugs on

HF hospitalizations

Fitchett, Udell, Inzucchi Eur J Heart Fail 2016. doi:10.1002/ejhf.633

Comparison of all-cause mortality reductions in

HF trials and in CV outcomes trials in diabetics

Fitchett, Udell, Inzucchi Eur J Heart Fail 2016. doi:10.1002/ejhf.633

ESC Heart Failure Guidelines: what’s new

4. Implement life-saving pharmacotherapy in patients

with symptomatic HFrEF, containing a combination

of an ACE-I (or ARB if ACE-I not tolerated), a β-

blocker and a MRA. If a patient still remains

symptomatic sacubitril/valsartan is recommended

to replace ACE-I. Use diuretics in order to improve

symptoms and exercise capacity in patients with

signs and/or symptoms of congestion.

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Therapeutic algorithm for a patient with symptomatic HFrEF

Ponikowski et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Therapeutic algorithm for a patient with symptomatic HFrEF

Ponikowski et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Therapeutic algorithm for a patient with symptomatic HFrEF

Ponikowski et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Estimated Mortality and Heart Rate at Dischargein Patients With Sinus Rhythm

Estimated One-Year Mortality by Heart Rate (Adjusted) (Patients With Normal Sinus Rhythm)

Esti

mat

ed M

ort

alit

y

Heart Rate (bpm)

AHA HF-Get With the Guidelines Program (n=26020)

Laskey WK, et al. J Am Heart Assoc. 2015;4:e001626.

Beta-Blocker Treatment in theESC-HF Long-Term Registry

Magggioni AP, et al. Eur J Heart Fail. 2013;15:1173-1184.

Patients at Target Doses of Beta-Blocker:ESC-HF Long-Term Registry

Not on target doses

n=5338 (83%)

On targetdoses

n=1130 (17%)

Magggioni AP, et al. Eur J Heart Fail. 2013;15(10):1173-1184.

Reasons for Not at Target Beta-Blocker Doses

Still in up-titration

35%

Symptomatic hypotension

17%

Bradycardia11%

Worsening HF3%

Bronchospasm3%

Worsening PAD1%

Sexual dysfunction

1%

Other/ unknown29%

Magggioni AP, et al. Eur J Heart Fail. 2013;15(10):1173-1184.

Therapeutic algorithm for a patient with symptomatic HFrEF

Ponikowski et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Combined AT1 Receptor Neprilysin Inhibition(ARNI) for the treatment of Heart Failure

LCZ696

Natriuretic peptides

BK, ADM, Subst.P,

VIP, CGRPAngiotensin II

sacubitril valsartan

Vasoconstriction

Sodium-water retention

Hypertrophy/ fibrosis

Vasodilation

Diuresis – natriuresis

Inhibition of hypertrophy

AT1 receptor

Degradation

products

Neprilysin

- -

Kaplan–Meier Curves for Key Study Outcomes, According to Study Group

McMurray JJV et al. N Engl J Med 2014;371:993-1004

McMurray et al. Eur J Heart Fail 2015

Effect of LCZ696 compared with enalapril

on mode of death in heart failure patients

Akshay S. Desai et al. Eur Heart J 2015;36:1990-1997

Sudden cardiac death Worsening HF death

Angiotensin Receptor Neprilysin Inhibition Compared With Enalapril in chronic heart failure. Effects on clinical progression in surviving patients with HF

Packer et al. Circulation. published online November 17, 2014;

Time to first HF hospitalization in the first

30 days after discharge

Cumulative number of HF hospitalizations

per 100 patients

Treatment effect of sacubitril/valsartan by tertileof LV EF for all outcomes

Scott D. Solomon et al. Circ Heart Fail. 2016;9:e002744

ESC Heart Failure Guidelines:

what remains the same

5. Ensure an ICD implantation in HF patients who either

have recovered from a ventricular arrhythmia causing

haemodynamic instability or in those with symptomatic

HF, LVEF ≤35% (despite at least 3 months of optimal

medical therapy), in order to reduce the risk of sudden

death and all-cause mortality. ICD implantation is not

recommended within 40 days of an MI as implantation

at this time does not improve prognosis.

97

Recommendations for implantable cardioverter-defibrillator in

patients with heart failure

Defibrillator Implantation in Patients with NonischemicSystolic Heart Failure. DANISH Trial

Køber L et al. N Engl J Med 2016;375:1221-1230

ESC Heart Failure Guidelines: what’s new

6. Implant a cardiac resynchronization therapy

in symptomatic patients with HF, LVEF ≤35%

(despite at least 3 months of optimal medical therapy),

in sinus rhythm with a QRS duration ≥130 msec and

LBBB QRS morphology, in order to improve symptoms

and reduce morbidity and mortality.

100

Recommendations for cardiac resynchronization therapy

implantation in patients with heart failure

*

Ruschitzka et al. NEJM 2013; 369: 1395-1405

Steffel et al. Eur Heart J 2015; 36:1983-9

Zusterzeel et al. JAMA Intern Med 2014; 174: 1340-8

ECHO-CRT: primary outcome of all-cause death or HF hospitalization or mortality alone

Ruschitzka F et al. N Engl J Med 2013;369:1395-1405

Recommendations for treatment of valvular diseases in

patients with heart failure

ESC Heart Failure Guidelines: what’s new

7. In the management of a patient with suspected acute

HF, try to shorten all diagnostic and therapeutic

decisions. During an initial phase, reassure that

circulatory or/and ventilatory support is provided in

case of either cardiogenic shock or/and ventilatory

failure, respectively.

106

ESC Guidelines. Treatment of acute heart failure

Ponikowski et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Treatment of Acute Heart Failure:

2016 ESC Guidelines

Ponikowski et al, Eur J Heart Fail 2016; 18: 891-975.

Mortality Rate Associated With Short-Term

Mechanical Circulatory Support (2004 to 2011)

Stretch et al. J Am Coll Cardiol. 2014;64(14):1407-1415

INTERMACS stages for patienst with

advanced heart failure

Ponikowski et al. Eur J Heart Fail 2016; 18 891-975

Comparative Effectiveness of LVAD and

Optimal Medical Management (OMM)

in Ambulatory HF Patients: ROADMAP Study

Estep et al. J Am Coll Cardiol. 2015;66(16):1747-1761

Comparative Effectiveness of LVAD and

Optimal Medical Management (OMM)

in Ambulatory HF Patients: ROADMAP Study

Estep et al. J Am Coll Cardiol. 2015;66(16):1747-1761

Recommendations for LVAD

implantation

Rose et al. N Engl J Med 2001; 345: 1435-43; Slaughter et al. N Engl J Med

2009; 361:2241-51; Estep et al. J Am Coll Cardiol 2015; 66:1747-61

Ponikowski et al. Eur J Heart Fail 2016; 18 891-975

ESC Heart Failure Guidelines: what’s new

10. Enrol the patients with HF in a multidisciplinary care

management program in order to reduce the risk of HF

hospitalization and mortality.

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Characteristics and components of management programmes for patients with heart failure

Characteristics

Components (I)

Components (II)

Ponikowski et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Recommendations for exercise, multidisciplinarymanagement and monitoring of patients with HF

Ponikowski et al. Eur J Heart Fail 20 MAY 2016 DOI: 10.1002/ejhf.592

Nuove linee guida europee per lo scompenso

cardiaco: cosa c’è di nuovo

1. Algoritmo diagnostico

2. HF mr EF

3. Prevenzione: empaglifozin nei diabetici

4. Sacubitril/valsartan in sostituzione ACEi/ARB

5. CRT solo nei pazienti con QRS > 130 msec

6. Trattamento IC acuta

7. Indicazioni ai LVAD

127