Presentation on 2021 ESC Guidelines for Heart Failure

1. 2021 ESC Guidelines for Heart Failure:
What’s New & How much to adapt
Speaker:
Dr. Md. Samiul Haque, MBBS
HMO & FCPS P-2 Trainee
MU-2, MMCH

2. What’s New in the Guidelines?
❑ A change of the term ‘heart failure with mid-range ejection fraction’ to
‘heart failure with mildly reduced ejection fraction’ (HFmrEF).
❑ A new simplified treatment algorithm for HFrEF.
❑ The addition of a treatment algorithm for HFrEF according to
phenotypes.
❑ Modified classification for acute HF.
❑ Updated treatments for most non-cardiovascular comorbidities including
diabetes, hyperkalaemia, iron deficiency, and cancer.
❑ The addition of key quality indicators.
•

3. Heart Failure: A Global Burden
✔ 26 million Number of heart
failure patients worldwide.
✔ 74% Heart failure patients
suffering from at least 1
comorbidity.

4. Definition of Heart Failure
According to ESC
✔ Heart failure is not a single pathological diagnosis, but a clinical syndrome
consisting of
✔ Cardinal symptoms(e.g. breathlessness, ankle swelling, and fatigue) that may
be accompanied by
✔ Signs (e.g. elevated jugular venous pressure, pulmonary crackles, and
peripheral oedema).
✔ It is due to a structural and/or functional abnormality of the heart that results in
elevated intracardiac pressures and/or inadequate cardiac output at rest and/or
during exercise.

5. Cont...d
Universal Definition
HF is clinical syndrome with symptoms and/or
signs caused by a structural and/or functional
cardiac abnormality and corroborated by
elevated natriuretic peptide levels and/or
objective evidence of pulmonary or systemic
congestion.

6. Terminology
✔Definition of heart failure with reduced ejection fraction, mildly
reduced ejection fraction and preserved ejection fraction.

7. Cont...d
Terminology related to symptomatic severity of HF

8. Diagnostic algorithm for heart failure

9. Classes of Recommendations

10. Levels of Evidence

11. Recommended diagnostic tests in all patients with
suspected chronic heart failure

12. General Measures in HF Management
✔ Education: explanation of nature of disease, treatment and self-help strategies
✔ Diet: good general nutrition, salt and fluid restriction & weight reduction for the
obese
✔ Smoking: cessation
✔ Alcohol: elimination of alcohol consumption specially in alcohol-induced
cardiomyopathy
✔ Exercise: regular moderate aerobic exercise within limit of symptoms
✔ Vaccination: consideration of influenza and pneumococcal vaccination

13. Pharmacotherapy for HFrEF
There are three major goals of treatment for patients with HFrEF:
✔ reduction in mortality,
✔ prevention of recurrent hospitalizations due to worsening HF,
and
✔ improvement in clinical status, functional capacity, and quality
of life.

14. Cont...d
The Five Pillars of Heart Failure
Pharmacotherapy

16. Cont...d

18. ✔ In the PARADIGM-HF trial, sacubitril/valsartan, an ARNI, was shown to be
superior to enalapril in reducing hospitalizations for worsening HF, CV mortality,
and all-cause mortality in patients with ambulatory HFrEF with LVEF ≤40%
✔ Additional benefits of sacubitril/valsartan includes
• improvement in symptoms and QOL
• reduction in the incidence of diabetes requiring insulin treatment
• reduction in the decline in eGFR
• reduced rate of hyperkalaemia.
ARNI
(Sacubitril/valsartan)

19. ❖ Patients being commenced on sacubitril/valsartan should have
⮚ adequate blood pressure (SBP>90 mmHg)
⮚ eGFR ≥30 mL/min/1.73 m2
⮚ A washout period of at least 36 h after ACE-I therapy is required in
order to minimize the risk of angioedema
Cont...d

20. ✔ The DAPA-HF trial & EMPEROR-Reduced trial found that dapagliflozin and
empagliflozin reduced the combined primary endpoint of CV death or HF
hospitalization by 26% & 25% respectively in patients with NYHA class II–IV
symptoms, and an LVEF ≤40% despite OMT
✔ Therefore, dapagliflozin or empagliflozin is recommended, in addition to OMT
with an ACE-I/ARNI, a beta-blocker and an MRA, for patients with HFrEF
regardless of diabetes status.
SGLT2
inhibitors

21. ❖ Contraindicated in
⮚ Pregnancy/risk of pregnancy and breastfeeding period
⮚ eGFR <20 mL/min/1.73 m2
❖ Type 1 diabetes mellitus is not an absolute contraindication, but an individual
risk of ketoacidosis should be taken into account when starting this therapy.
❖ Glycosuria may predispose to fungal genito-urinary infections.
Cont...d

22. Dosage of the drugs

23. HFmrEF Management

24. HFpEF differs from HFrEF and HFmrEF in that HFpEF patients are older and
more often female. AF, CKD, and non-CV comorbidities are more common in
patients with HFpEF than in those with HFrEF. To date, no treatment has been
shown to convincingly reduce mortality and morbidity in patients with HFpEF
HFpEF
Management

25. ✔AHF refers to rapid or gradual onset of symptoms and/or signs of HF, severe
enough for the patient to seek urgent medical attention, leading to an unplanned
hospital admission or an emergency department visit.
✔Four major clinical presentations-
i. Acute decompensated heart failure
ii. Acute pulmonary edema
iii. Isolated right ventricular failure
iv. Cardiogenic shock
Acute Heart Failure

27. ⮚ Troponin
⮚ Serum creatinine
⮚ Electrolytes
⮚ Blood urea nitrogen or urea
⮚ TSH
⮚ Liver function tests
⮚ D-dimer and procalcitonin when
pulmonary embolism or infection are
suspected
⮚ Arterial blood gas analysis in case of
respiratory distress and
⮚ Lactate in case of hypoperfusion
Initial laboratory exams in AHF

29. ✔Propped up position
✔Oxygen &/ Mechanical ventilation: Oxygen therapy is recommended in
patients with AHF and SpO2 <90% or PaO2 <60 mmHg to correct hypoxaemia.
(l)
✔Diuretics (l)
✔Vasodilators: Intravenous vasodilators may be considered to relieve AHF
symptoms when SBP is >110 mmHg (llb)
✔Ionotropes: They should be reserved for patients with LV systolic
dysfunction, low cardiac output and low SBP (e.g. <90 mmHg) resulting in poor
vital organ perfusion. (llb)
Management of
AHF

30. ✔Vasopressors: Norepinephrine may be preferred in patients with severe
hypotension. The aim is to increase perfusion to the vital organs. Some
studies, support the use of norepinephrine as first choice, compared with
dopamine or epinephrine. (llb)
✔Opiates: Routine use of opiates in AHF is not recommended although they
may be considered in selected patients, particularly in case of
severe/intractable pain or anxiety or in the setting of palliation. (lll)
✔Thromboembolism prophylaxis: with heparin (e.g. low-molecular-weight
heparin) or another anticoagulant is recommended, unless contraindicated or
unnecessary (because of existing treatment with oral anticoagulants). (l)
Cont...d

32. Cardiovascular comorbidities
Atrial Fibrillation:
❑ The management of patients with concomitant HF and AF includes:
✔ Identification and treatment of possible causes or triggers of AF
✔ Management of HF
✔ Prevention of embolic events by anticoagulation (l)
✔ Rate control if hemodynamically stable
✔ Rhythm control if hemodynamically unstable

35. Non-cardiovascular comorbidities
Diabetes:
Treatment of HF is similar in patients with and without diabetes. Conversely,
antidiabetic drugs differ in their effects in patients with HF and preference
must be given to drugs that are both safe and reduce HF-related events.

36. ✔ Iron deficiency, which can be present independently of anaemia, is present
in up to 55% of chronic HF patients and in up to 80% of those with AHF.
✔ It may be caused by increased loss, reduced intake or absorption (i.e.
malnutrition, gut congestion) and/or impaired iron metabolism caused by the
chronic inflammatory activation of HF.
✔ It is recommended that all patients with HF are regularly screened for
anaemia and iron deficiency with full blood count, serum ferritin
concentration, and TSAT
Iron deficiency & anaemia:

37. ✔ Iron supplementation with i.v. ferric carboxymaltose is safe and improves
symptoms, exercise capacity, and QOL of patients with HFrEF and iron
deficiency.
✔ Oral iron therapy is not effective in iron repletion and did not improve exercise
capacity in patients with HFrEF and iron deficiency
✔ Erythropoietin stimulating agents are not indicated for the treatment of anaemia
in HF

38. ✔ CKD and HF frequently coexist. They share common risk factors, such as
diabetes or hypertension.
✔ When RAAS inhibitors, ARNI or SGLT2 inhibitors are started, the initial
decrease in the glomerular filtration pressure may decrease GFR and increase
serum creatinine. However, these changes are generally transient.
✔ There is little direct evidence to support any recommendations for treatment of
HF patients with severe CKD as to date.
CK
D

39. ❑ COPD affects about 20% of patients with HF and has a major impact on
symptoms and outcomes
❑ Due to the overlap in symptoms and signs, the differentiation between HF and
COPD may be difficult
❑ Treatment of HF is generally well tolerated in COPD.
❑ Beta-blockers can worsen pulmonary function in individual patients but are not
contraindicated in either COPD or asthma, as stated in GOLD and GINA,
respectively. Use cardio-selective beta blockers.
COP
D

40. ✔ Patients with HF are classified based on their LVEF. Those with a LVEF between
41% and 49% are defined as ‘mildly reduced LVEF’ (HFmrEF).
✔ Measurement of NPs and echocardiography have key roles in the diagnosis of
HF.
✔ ACE-I or ARNI, beta-blockers, MRA, and SGLT2 inhibitors are recommended as
cornerstone therapies for patients with HFrEF.
✔ ACE-I/ARNI, beta-blockers, and MRA may be considered in patients with
HFmrEF.
Key Messages

41. ✔ Exercise is recommended for all patients who are able, to improve
exercise capacity and QOL, and reduce HF hospitalization.
✔ Four major clinical presentations of acute HF may occur: ADHF, acute
pulmonary oedema, RV failure, and cardiogenic shock.
✔ Treatment of acute HF is based on diuretics for congestion, inotropes,
and short- term MCS for peripheral hypoperfusion.

42. ✔ It is recommended that patients with type II diabetes are treated with SGLT2
inhibitors.
✔ Patients should be periodically screened for anaemia and iron deficiency and
i.v. iron supplementation with ferric carboxymaltose should be considered in
symptomatic patients with LVEF <45% and iron deficiency, and in patients
recently hospitalized for HF and with LVEF ≤50% and iron deficiency.