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.
27
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.
124
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
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