novedades en el tratamiento no farmacológico
TRANSCRIPT
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Novedades en el tratamiento no farmacológico
Marisa Crespo Leiro
Complejo Hospitalario Universitario A Coruña
HF 2016
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Declaración de Intereses
• Ninguna
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Tratamiento no farmacológico
• Desfibrilador Implantable (ICD)
• Resincronización (CRT)
• Trasplante cardiaco (TC)
• Asistencia mecánica circulatoria (MCS)
• Otras novedades
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
ESC GUIDELINES
2016 ESC Guidelines for the diagnosis and
treatment of acute and chronic heart failure
The Task Force for the diagnosis and t reatment of acute and chronic
heart failure of the European Society of Cardiology (ESC)
Developed with the special cont r ibut ion of the Heart Failure
Associat ion (HFA) of the ESC
Authors/Task Force Members: Piot r Ponikowski* (Chairperson) (Poland),
Adr iaan A. Voors* (Co-Chairperson) (The Nether lands), Stefan D. Anker (Germany),
Hector Bueno (Spain), John G. F. Cleland (UK), Andrew J. S. Coats (UK),
Volkmar Falk (Germany), Jose Ramon Gonzalez-Juanatey (Spain), Veli-Pekka Har jola
(Finland), Ewa A. Jankowska (Poland), Mar iell Jessup (USA), Cecilia Linde (Sweden),
Pet ros Nihoyannopoulos (UK), John T. Par issis (Greece), Burker t Pieske (Germany),
Jillian P. Riley (UK), Giuseppe M. C. Rosano (UK/Italy), Luis M. Ruilope (Spain),
Frank Ruschitzka (Switzer land), Frans H. Rut ten (The Nether lands),
Peter van der Meer (The Nether lands)
Document Reviewers: Gerasimos Filippatos (CPG Review Coordinator) (Greece), John J. V. McMurray (CPG Review
Coordinator) (UK), Vict or Aboyans (France), Stephan Achenbach (Germany), Stefan Agewall (Norway),
Nawwar Al-A t tar (UK), John James Athert on (Aust ralia), Johann Bauersachs (Germany), A. John Camm (UK),
Scipione Carer j (Italy), Claudio Ceconi (Italy), Antonio Coca (Spain), Perry Elliot t (UK), Çet in Erol (Turkey),
Just in Ezekowit z (Canada), Covadonga Fernandez-Gol fın (Spain), Donna Fitzsimons (UK), Marco Guazzi (Italy),
* Correspondingauthors: Piotr Ponikowski, Department of Heart Diseases, Wroclaw Medical University, Centre for Heart Diseases, Military Hospital, ul. Weigla5, 50-981 Wroclaw,
Poland, Tel: + 48 261 660 279, Tel/Fax: + 48 261 660 237, E-mail: [email protected] .
Adriaan Voors, Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1,PO Box 30.001, 9700 RBGroningen, TheNetherlands, Tel: + 31503612355,
Fax: + 31 50 3614391, E-mail: [email protected] .
ESC Commit tee for Pract ice Guidelines (CPG) and Nat ional Cardiac Societ ies document reviewers: listed in the Appendix.
ESC ent it ies having part icipated in the development of this document:
Associat ions: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of
Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA).
Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.
W orking Groups: Cardiovascular Pharmacotherapy,Cardiovascular Surgery, Myocardial and Pericardial Diseases, Myocardial Function, Pulmonary Circulation and Right Ventricular
Function, Valvular Heart Disease.
Thecontent of these European Society of Cardiology (ESC) Guidelines hasbeen published for personal and educational use only.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford
University Press, the publisher of the European Heart Journal and the party authorized to handle such permissionson behalf of the ESC ([email protected]).
Disclaimer . The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelinesexempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by thecompetent
public health authorities, in order to manage each patient’s case in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
The article hasbeen co-published with permission in European Heart Journal and European Journal of Heart Failure. All rights reserved in respect of European Heart Journal.
& European Society of Cardiology 2016. All rights reserved. For permissions please email: [email protected].
European Heart Journal
doi:10.1093/eurheartj/ehw128
European Heart Journal Advance Access published May 20, 2016 b
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Heart Failure: state of the art
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
2016 ESC Guidelines HF www.escardio.org
ICD
2012 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
2016 ESC Guidelines HF www.escardio.org
CRT
2012 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Desfibrilador Implantable (ICD) Prevención secundaria
2016 ESC Guidelines HF www.escardio.org
2012 ESC Guidelines HF www.escardio.org
No cambios I-A
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Desfibrilador Implantable (ICD) Prevención primaria
2016 ESC Guidelines HF www.escardio.org
2012 ESC Guidelines HF www.escardio.org
Síntomas (NYHA II-III) ≥ 3 meses tratamiento médico óptimo FEVI ≤ 35% Supervivencia esperada “sustancialmente” > 1 año Buen estado funcional
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Comorbidities
Steinberg, JACC HF 2014; 2: 623-29
• Smoking • Pulmonary disease • Diabetes • Peripheral vascular disease • Atrial fibrillation • Ischemic heart disease • Chronic kidney disease
MADIT I, MADIT II, DEFINITE, SCD-HeFT
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
No recomendado si: - IAM 40 días antes - NYHA IV (salvo candidatos a CRT, TC o VADs)
Desfibrilador Implantable (ICD) Prevención primaria
Recambios de generador
• Cuando el generador se agota…., no debe de ser “automaticamente” reemplazado • Es controvertido si pacientes con mejoría clara de la FEVI que no han necesitado
terapias ICD... se benefician de un nuevo implante... • Desactivacion en fase terminal
2016 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Wearable ICD
Desfibrilador Implantable (ICD) Prevención primaria
Riesgo de MS durante un periodo de tiempo limitado - FEVI reducida post-IAM - Lista de espera TC
http://lifevest.zoll.com/medical-professionals
2016 ESC Guidelines HF www.escardio.org
Limitaciones: No ATP ni CRT No ensayos clínicos
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Resincronizacion cardiaca (CRT)
• Duración QRS ≥ 150 ms • Ritmo sinusal vs FA • BRI • Necesidad Estimulación
2016 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
CRT. Ensayos clínicos relevantes desde 2012
NEJM 2013; 368:1585-93
Biventricular pacing superior to conventional RV pacing in HFrEF, NYHA I-III.
NEJM 2013; 369: 1395-1405
BLOCK-HF
Echo-CRT
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
CRT. Meta-análisis
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CLIN ICAL RESEARCH
An individual pat ient meta-analysisof five
randomized tr ialsassessing the effectsof cardiac
resynchronizat ion therapy on morbidity and
mortality in pat ientswith symptomat ic heart
failure
John G. Cleland1*, W illiam T. Abraham 2, Cecilia Linde3, Michael R. Gold4,
James B. Young5, J. Claude Dauber t 6, Lou Sher fesee7, George A. W ells8,
and Anthony S.L. Tang9
1National Heart and LungInstitute, Imperial College London (Royal Brompton &Harefield Hospitals) and Department of Cardiology, Castle Hill Hospital,University of Hull, Kingston-
upon-Hull, UK; 2Division of Cardiovascular Medicine and the DavisHeart and LungResearch Institute, The Ohio State University, Columbus, OH, USA; 3Department of Cardiology,
Karolinska University Hospital, Stockholm, Sweden; 4Medical University of South Carolina, Charleston, SC, USA; 5Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA;6Departement de Cardiologie, CHU, Rennes, France; 7Medtronic, Inc., Minneapolis, MN, USA; 8The University of OttawaHeart Institute, Ottawa, Canada; and 9The Island Medical
Program, University of British Columbia, Vancouver, Canada
Received 15 May2013; revised 24 June 2013; accepted 4 July2013;online publish-ahead-of-print 29 July2013
A im s Cardiac resynchronization therapy (CRT) with or without adefibrillator reduces morbidity and mortality in selected
patients with heart failure (HF) but response can be variable. We sought to identify pre-implantation variables that
predict the response to CRT in ameta-analysisusing individual patient-data.
Met hods
and r esult s
An individual patient meta-analysisof five randomized trials, funded byMedtronic, comparingCRT either with no active
device or with a defibrillator was conducted, including the following baseline variables: age, sex, New York Heart
Association class, aetiology, QRS morphology, QRS duration, left ventricular ejection fraction (LVEF), and systolic
blood pressure. Outcomes were all-cause mortality and first hospitalization for HFor death. Of 3782 patients in sinus
rhythm, median (inter-quartile range) age was 66 (58–73) years, QRSduration was 160 (146–176) ms, LVEFwas 24
(20–28)%, and 78%had left bundle branch block. A multivariable model suggested that only QRSduration predicted
the magnitude of the effect of CRT on outcomes. Further analysis produced estimated hazard ratios for the effect of
CRT on all-cause mortality and on the composite of first hospitalization for HF or death that suggested increasing
benefitwithincreasingQRSduration,the95%confidenceboundsexcluding1.0at 140 msfor eachendpoint,suggesting
ahigh probability of substantial benefit from CRT when QRSduration exceedsthisvalue.
Conclusion QRSduration isapowerful predictor of theeffectsof CRT on morbidity and mortality in patientswith symptomatic HF
and left ventricular systolicdysfunction who areinsinusrhythm.QRSmorphologydidnot provideadditional information
about clinical response.
ClinicalT r ials.
gov num ber s
NCT00170300, NCT00271154, NCT00251251.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Keywor ds Cardiac resynchronization therapy † Morbidity † Mortality † Heart failure
* Correspondingauthor. Tel: + 44 1482 46 1780; fax: + 44 1482 46 1779, Email: [email protected]
& The Author 2013. Published by Oxford University Presson behalf of the European Society of Cardiology. This isan Open Accessarticle distributed under the termsof the Creative
CommonsAttributionNon-Commercial License(http://creativecommons.org/licenses/by-nc/3.0/),whichpermitsnon-commercial re-use,distribution,andreproductioninanymedium,
provided the original work isproperly cited. For commercial re-use, please contact [email protected]
European Heart Journal (2013) 34, 3547–3556
doi:10.1093/eurheartj/eht290
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EHJ 2013; 34: 3547-3556
Solo duración QRS predice beneficio
pronostico
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Resincronización cardiaca (CRT)
2016 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Resincronización cardiaca (CRT)
Síntomas, FEVI ≤ 35%, RS, QRS ≥ 150 y BRI
Síntomas, FEVI ≤ 35%, RS, QRS 130-149 y BRI
Necesidad de estimulación ventricular, FE reducida, Independiente de NYHA (reduce morbilidad)
2016 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Resincronización cardiaca (CRT)
Síntomas, FEVI ≤ 35%, RS, QRS ≥ 150 y no-BRI
Síntomas, FEVI ≤ 35%, RS, QRS ≥ 130-149 y no-BRI
Síntomas III-IV, FEVI ≤ 35%, FA, QRS ≥ 130 y no-BRI
Upgrading si Mp / ICD FEVI reducida y Empeoramiento IC a pesar de TMO
2016 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Muerte cualquier causa u hospitalización IC
Muerte cualquier causa
NEJM 2013; 369: 1395-1405
Contraindicado si QRS < 130 ms
2016 ESC Guidelines HF www.escardio.org
EchoCRT
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Trasplante Cardiaco
Mehra M, et al J Heart Lung Transplant 2016
Mehra M, et al J Heart Lung Transplant 2006
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
No limite de edad como contraindicación absoluta
No intervalo de tiempo definido tras historia de cáncer
BMI < 35 kg/m2
Trasplante Cardiaco
IC terminal sin otras opciones y mal px Motivación, Información
Adherencia al tratamiento
Soporte social
LVAD* si HTP irreversible
*LVAD si otras co-morbilidades potencialmente reversibles: cáncer, obesidad, tabaquismo o IR y reevaluación posterior
2016 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Trasplante Cardiaco
Limitaciones y Consecuencias de la
Inmunosupresión
Supervivencia a largo plazo
Adult and Pediatric Heart Transplants Median Donor Age by Location
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Europe North America Other
JHLT. 2014 Oct; 33(10): 996-1008
2015 JHLT. 2015 Oct; 34(10): 1244-1254
Donantes MCS como puente al TC
Lund J Heart Lung Transplant 2015
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
MCS. Terminología
BTD / BTB
BTC
BTT
BTR
DT
2016 ESC Guidelines HF www.escardio.org
Protocolo Heartware CHUAC- Octubre 2014 | PRÓLOGO 1
DISPOSITI VO DE ASISTENCI A
VENTRI CULAR I ZQUIERDA
MANUAL DE USO
PROTOCOLO DE I MPLANTE Y MANEJO
SERVICIO DE UCI
Short-term
Long-term
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Asistencia mecánica circulatoria (MCS)
Inotrópicos
Daño orgánico (riñón/hígado)
VD + IT
Hospitalizaciones
FEVI < 25%, VO2 < 12
Pacientes potencialmente elegibles para MCS izda ( LVAD)
2016 ESC Guidelines HF www.escardio.org
Protocolo Heartware CHUAC- Octubre 2014 | PRÓLOGO 1
DISPOSITI VO DE ASISTENCI A
VENTRI CULAR I ZQUIERDA
MANUAL DE USO
PROTOCOLO DE I MPLANTE Y MANEJO
SERVICIO DE UCI
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Perfiles INTERMACS Interagency Registry for Mechanically Asisted Circulatory Support
Kirklin J JHLT 2015; 34; 1498-1504 INTERMACS Registry: > 15.000 patients
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Fracaso VD severo post LVAD
Kirklin J JHLT 2015; 34; 1498-1504
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Recomendaciones MCS
BTT
DT
2016 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Dispositivos monitorización IC
Monitorización presión AP (CardioMems)
ICD
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
IC aguda. Ultrafiltración
Ultrafiltración
Terapia sustitución renal
2016 ESC Guidelines HF www.escardio.org
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Tratamiento no farmacológico IC ¿Qué hay de nuevo (vs 2012)?
• DAI
– prevención secundaria: No cambios
– prevención primaria: Pocos cambios • Comorbilidad / Recambios generador / Desactivación en fase
terminal
• CRT: Duración QRS
• TC: Actualización criterios selección
• MCS: El futuro que ya está aquí
• Monitorización hemodinámica “ a distancia”:
– prometedor
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
Nos vemos en Oviedo, 16-19 Junio
Muchas gracias!
Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016
4 days of scientific exchange
+100 scientific sessions
+6 100 healthcare professionals
+100 countries represented
+ 2010 abstracts and cases submitted
+ 300 expert faculty members
+ 2000m2 exhibition space
+ 40 industry sessions and workshops
Heart Failure 2017 29 April – 2 May 2017
Call for abstracts: November 3
www.escardio.org/heartfailure