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Heart Failure Guidelines 2016
SGK 2016 Session: Postgraduate Course in
Heart Failure – Lausanne, 15. June 2016
Matthias Nägele, MD – University Hospital Zurich
Disclosures
• I have nothing to disclose.
The new guidelines
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
Definition of HF
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
Diagnostic algorithm (non-acute onset)
Diagnostic algorithm (non-acute onset)
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
Treatment of HFrEF
Diu
retics
tore
lieve
sym
pto
ms
an
dsig
ns
ofco
ng
estio
n
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
Background on valsartan/sacubitril
McMurray et al. NEJM 2014
PARADIGM-HF Trial
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
Treatment of HFrEF
Treatment of HFrEF
Treatment of HFrEF
Recommendations on ICD
Recommendations on CRT
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
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
Comorbidities: Iron, Diabetes, CSA, Arthritis
Comorbidities: CKD
Comorbidities: COPD
Comorbidities: Obesity
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)
Acute heart failure: Algorithms
Acute heart failure: Algorithms
Acute heart failure: Treatment
Acute heart failure: Treatment
Exercise and (tele-)monitoring programs
Prevention of HF
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
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