acute and chronic heart failure (ESC Guidline)

2. 2016 ESC guidelines
for the diagnosis and treatment of acute
and chronic heart failure
PRESENTED BY
DR. MD. ROKUN UDDIN
MD (CARDIOLOGY)-3RD PART STUDENT
DEPT. OF CARDIOLOGY, SSMC & MH

4. What is Heart Failure?
 HF is a clinical syndrome characterized by
typical 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)
caused by a structural and/or functional cardiac
abnormality, resulting in a reduced cardiac
output and/or elevated intracardiac pressures at
rest or during stress.

5. HFrEF HFmrEF HFpEF
Symptoms±Signs Symptoms±Signs Symptoms±Signs
LVEF <40% LVEF 40-49% LVEF ≥50%
1. Elevated levels of
natriuretic peptides
2. At least one
a.structural heart
disease(LVH and/or
LAE)
b.diastolic dysfunction
1. Elevated levels of
natriuretic peptides
2. At least one
a.structural heart
disease(LVH and/or
LAE)
b.diastolic dysfunction

6. Symptoms and signs of heart
failure

7. Typical Symptoms
 Breathlessness
 Orthopnoea
 Paroxysmal nocturnal dyspnoea
 Reduced exercise tolerance
 Fatigue, tiredness,
 increased time to recover after exercise
 Ankle swelling

8. Less typical Symptoms
 Nocturnal cough
 Wheezing
 Bloated feeling
 Loss of appetite
 Confusion (especially in the elderly)
 Depression
 Palpitations
 Dizziness
 Syncope
 Bendopnea

9. Bendopnea

10. Specific Signs
 Elevated jugular venous pressure
 Hepatojugular reflux
 Third heart sound (gallop rhythm)
 Laterally displaced apical impulse

11.  Weight gain (>2
kg/week)
 Weight loss (in advanced
HF)
 Tissue wasting
 Cardiac murmur
 Peripheral oedema
(ankle, sacral, scrotal)
 Pulmonary crepitations
 Reduced air entry and
pleural effusion
 Tachycardia
 Irregular pulse
 Tachypnoea
 Cheyne Stokes
respiration
 Hepatomegaly
 Ascites
 Cold extremities
 Oliguria
 Narrow pulse pressure
Less specific signs

12. Investigation

13. Recommended investigation for initial
assessment HF/new HF
 Hb and WBC
 Sodium, potassium, urea, creatinine (with eGFR)
 Liver function tests (bilirubin, AST, ALT, GGTP)
 Glucose, HbA1c
 Lipid profile
 TSH
 Ferritin, TIBC
 Natriuretic peptides

14. ECG
 provide information on aetiology (e.g.
myocardial infarction.
 HF is unlikely in patients presenting with a
completely normal ECG (sensitivity 89%).
 the routine use of an ECG is mainly
recommended to rule out HF.

15. Chest X-ray
 show pulmonary venous congestion or
oedema in a patient with HF,
 probably most useful in identifying an
alternative diagosis

16. Natriuretic peptides (NPs)
 Patients with normal plasma NP concentrations
are unlikely to have HF.
 Upper limit of normal:
 Non acute setting
BNP is 35 pg/mL and NT-proBNP is 125 pg/mL
 Acute setting
BNP 100 pg/mL, NT-proBNP 300 pg/ml

17. Transthoracic echo
 myocardial structure and function
 diagnosis of either HFrEF, HFmrEF or HFpEF
 identify patients who would be suitable for
pharmacological and device (ICD, CRT)
 assessment of valve disease, right ventricular
function and pulmonary arterial pressure
 identify those suitable for correction of valve disease
 assessment of structure and function in subjects
exposed to treatment (chemotheraphy).

18. Transthoracic echo-cont.
 measurement of LVEF, the modified biplane
Simpson’s rule is recommended
 The Teichholz and Quinones methods as well as a
measurement of fractional shortening, are not
recommended, particularly with regional LV
dysfunction and/or LV remodelling.

19. Transoesophageal echo.
 valve disease
 suspected aortic dissection
 suspected endocarditis or congenital heart
disease
 ruling out intracavitary thrombi in AF patients

20. Coronary angiography
 recommended in patients with HF who suffer from
angina pectoris recalcitrant to medical therapy
 patients with a history of symptomatic ventricular
arrhythmia or aborted cardiac arrest
 patients with HF and intermediate to high pre-test
probability of CAD
 presence of ischaemia in non-invasive stress tests

21. Cardiac magnetic resonance
(CMR)
 assessment of myocardial structure and function
subjects with poor acoustic window and with
complex congenital heart diseases.
 suspected myocarditis, amyloidosis, sarcoidosis,
Chagas disease, haemochromatosis

22. Single-photon emission CT (SPECT)
&Positron emission tomography (PET):
 used to assess ischaemia and viability

23. Recommendations to prevent or delay the
development of overt heart failure
 Treatment of hypertension (class 1)
 Treatment with statins (class 1)
 smoking cessation and alcohol intake reduction
(class 1)
 ACE-I is recommended in patients with asymptomatic
LV systolic dysfunction and with/without history of MI
(class 1)
 ACE-I should be considered in patients with stable
CAD even if they do not have LV systolic dysfunction
(class IIa)

24.  Beta-blocker is recommended in patients with
asymptomatic LV systolic dysfunction and a
history of myocardial infarction (class1)
 Treating other risk factors of HF (e.g. obesity, DM)
(class IIa)
 ICD in recommended patient (class 1)

25. Algorithm for the diagnosis of heart
failure in the non-acute setting

28. Clinical profiles of patients with
acute heart failure

30. Management of patients with acute heart failure
based on clinical profile

32. Recommendations for the management of
patients with AHF: pharmacotherapy
 O2 therapy is recommended SpO2 <90% or PaO2 <60 mmHg
(8.0 kPa) to correct hypoxaemia
 Diuretics
 Vasodilators
 Inotropic agents – dobutamine, dopamine, PDE III
inhibitors
 Vasopressors
 Thrombo-embolism prophylaxis ( e.g. LMWH)
 Other drugs: digoxin, amiodarone
 Opiates

33. Therapeutic algorithm for a patient with
symptomatic HFrEF

36. Treatments recommended in
all symptomatic patients with HFrEF
 ACEi
 Beta-Blocker
 Mineralocorticoid receptor antagonist

37. Treatments recommended in selected
symptomatic patients with HFrEF
 Diuretics
 Angiotensin receptor neprolysin inhibitor(ARNI)
 If-chennel inhibitor- Ivabradine
 ARB
 Combination of Hydralazine and Isosorbde dinitrate

38. Treatments with less certain benefits in
symptomatic patients with HFrEF
 Digoxin
 N-3 polyunsaturated fatty acids
Treatments not recommended(unproven benefit)
Statins
Oral anticoagulants and antiplatelate.
Renin inhibitors

39. Treatments not recommended (believed to
cause harm) in symptomatic patients with
HFrEF
 Calcium chennel blocker-Diltiazem and Verapamil )
 There is only evidence on safety for amlodipine

40. Practical guidance on the use of
ACEi or ARB with HFrEF
WHY?
 To improve symptoms and exercise capacity, reduce the risk of
HF hospitalization and increase survival.
IN WHOM AND WHEN?
indications:
 1. Potentially all patients with HF and an LVEF <40%.
 2. First-line treatment (along with a beta-blockers and an MRA)
with NYHA Class II–IV, start as early as possible.
 3.ACEI also benefit asymptomatic HF (NYHA I)

41. Contra-indications:
 1. History of angioedema
 2. Known bilateral renal artery stenosis.
 3. Pregnancy/risk of pregnancy.
 4.Known allergic reaction/adverse reaction

42. WHICH ACE-INHIBITOR AND WHAT DOSE?
 Captopril: starting dose 6.25 mg t.i.d., target dose 50 mg t.i.d.
 Ramipril: starting dose 2.5 mg o.d., target dose 10 mg o.d
 Enalapril: starting dose 2.5 mg b.i.d. target dose 20 mg b.i.d.
 Lisinopril: starting dose 2.5–5.0 mg o.d., target dose 20–35 mg
o.d.
 Trandolapril: starting dose 0.5 mg o.d., target dose 4 mg o.d.

43. WHERE?
 In the community in stable patients.
 In patients hospitalized with worsening HF – after
stabilizing, relieving congestion, and, if possible,
restoring ‘euvolaemia’ (but ideally before
discharge).

44. HOW TO USE ACEi ?
 Check renal function and electrolytes.
 Start with a low dose
 Double the dose at not less than 2-week intervals in
the community. More rapid dose up-titration in hospital
or closely monitored pt.
 Aim for target dose or the highest tolerated dose

45.  Monitor blood chemistry 4 monthly thereafter.
 It is very rarely necessary to stop an ACE-I (or ARB),
and clinical deterioration is likely if treatment is
withdrawn.

46.  Cautions/seek specialist advice:
 Significant hyperkalaemia (K >5 mmol/L)
 Significant renal dysfuction Cr >2.5 mg/dl) or eGFR
<30ml/min
 Symptomatic or severe asymptomatic hypotension
(systolic blood pressure <90 mmHg).

47. PROBLEM SOLVING (pt. With ACEi)
Asymptomatic low blood pressure:
 Does not usually require any change in therapy.
Symptomatic hypotension:
 Reconsider need for nitrates, calcium-channel
blockers and other vasodilators and reduce dose/stop,
if possible.
 If no signs or symptoms of congestion, consider
reducing diuretic dose.

48. Cough:
 ACE-I-induced cough does not always require
treatment discontinuation.
 When a troublesome cough does develop
substitution of an ARB is recommended.

49.  Worsening renal function and hyperkalaemia (pt
with ACEi with HF):
 creatinine of up to 50% above baseline
 or 3 mg/dL
 Or eGFR <25 mL/min/1.73 m2,
whichever is the smaller, is acceptable.
 potassium upto ≤5.5 mmol/L is acceptable.
 if no signs of congestion, reducing the dose of diuretic.

50.  If greater rise
the dose of the ACE-I (or ARB) should be halved
 ACE-I (or ARB) should be stopped
If potassium rises to >5.5 mmol/L or
creatinine increases by >100% or 3.5 mg/dL or
eGFR <20 mL/min/1.73 m2,
and specialist advice sought.

51. Practical guidance on the use of
β-blocker with HFrEF
WHY?
 To improve symptoms, reduce the risk of HF hospitalization and
increase survival.
IN WHOM AND WHEN?
Indications:
 1. Potentially all patients with stable mild or moderate systolic
HF (LVEF <40%) (NYHA Class II-III).
 2. Pts. With severe HF also benefit but treatment with caution
 3. First-line treatment, along with an ACE-I and an MRA, in
patients with stabilized HF; start as early as possible in the
course of disease.

52. Contra-indications of β-blocker :
 1. Second- or third-degree AV block
 2. Critical limb ischaemia.
 3. Asthma (relative contra-indication): if cardio-
selective beta-blockers are indicated, asthma is not
necessarily an absolute contra-indication
COPD is not a contra-indication

53. WHICH BETA-BLOCKER AND WHAT DOSE?
 Bisoprolol: starting dose 1.25 mg o.d., target dose 10
mg o.d.
 Carvedilol: starting dose 3.125 mg b.i.d., target dose
25 mg b.i.d.
 Metoprolol succinate (CR/XL): starting dose 12.5–25
mg o.d., target dose 200 mg o.d.
 Nebivolol: starting dose 1.25 mg o.d., target dose 10
mg o.d.

54. HOW TO USE BETA-BLOCKER?
 Start with a low dose in a stable condition (see Table
7.2).
 Double the dose at not less than 2-week intervals
 Aim for target dose or the highest tolerated dose
(remember: some beta-blocker is better than no beta-
blocker).
 Monitor heart rate, blood pressure, and clinical status
(symptoms, signs–especially signs of congestion,
body weight).

55. PROBLEM SOLVING
 Worsening symptoms or signs (dyspnoea, fatigue,
oedema):
 If increasing congestion, increase dose of diuretic or
halve dose of beta-blocker
 If marked fatigue (bradycardia) halve dose of beta-
blocker (rarely necessary)
 If serious deterioration, halve dose of beta-blocker or
stop this treatment (rarely necessary)

56. Asymptomatic low blood pressure:
 Does not usually require any change in therapy
Low heart rate:
 If <50 bpm and worsening symptoms, halve dose of
beta-blocker, or, if severe deterioration, stop beta-
blocker (rarely necessary).
 Review need for other heart rate-slowing drugs
(digoxin, amiodarone, diltiazem, or verapamil)

57. Practical guidance on the use
of MRA with HFrEF
WHY?
 To improve symptoms, reduce the risk of HF
hospitalization and increase survival.
Indications:
 Potentially all patients with persisting symptoms
(NYHA Class II–IV) and an LVEF ≤35% despite
treatment with an ACE-I (or ARB) and a beta-blocker

58. WHICH MRA AND WHAT DOSE?
 Eplerenone: starting dose 25 mg o.d., target dose 50
mg o.d.
 Spironolactone: starting dose 25 mg o.d., target dose
50 mg o.d.

59. HOW TO USE?
 Consider dose up-titration after 4–8 weeks.
 halve dose
If K+ rises above 5.5 mmol/L or creatinine rises to 2.5 mg/dL or
eGFR <30 mL/min/1.73 m2, and monitor blood chemistry
closely.
 stop MRA immediately
If K+ rises to >6.0 mmol/L or creatinine to >3.5 mg/dL) eGFR
<20 mL/min/1.73 m2, and seek specialist advice.

60. Practical guidance on the use
of Diuretics with HFrEF
WHY?
 To relieve breathlessness and oedema in patients with
symptoms and signs of congestion.
Indications:
 Potentially all patients with symptoms and signs of congestion,
irrespective of LVEF.
 always be used in combination with an ACE-I (or ARB), a beta-
blocker, and an MRA in patients with HFrEF (unless contra-
indicated)
 Thaizde diuretics can be used in patients with preserved renal
function and mild symptoms of congestion

61.  WHICH DIURETIC AND WHAT DAILY DOSE?
 Furosemide: starting dose 20–40 mg, usual dose 40–240 mg
 Hydrochlorothiazide: starting dose 25 mg, usual dose 12.5–100
mg
 Indapamide: starting dose 2.5 mg, usual dose 2.5–5 mg

62. Contra-indications:
 Not indicated if the patient has never had symptoms or signs of
congestion.
 Known allergic reaction
HOW TO USE?
 Start with a low dose
 Use minimum dose necessary to maintain euvolaemia
 Dose may need to be increased or decreased according to the
patient’s volume status

63. Non-surgical device treatment of heart
failure with HFrEF

64. Implantable cardioverter-defibrillator (ICD)
(Recommendations)
Primary prevention
An ICD is recommended
o to reduce the risk of sudden death and all-cause mortality
o in patients with symptomatic HF (NYHA Class II–III), and
o an LVEF ≤35% despite ≥3 months of OMT,
o provided they are expected to survive substantially longer
than one year with good functional status, and they have:
1. IHD (unless they have had an MI in the prior 40 days
2. DCM.

65. Secondary prevention
 An ICD is recommended to reduce the risk of sudden
death and all-cause mortality in patients who have
 recovered from a ventricular arrhythmia causing
haemodynamic instability,
 and who are expected to survive for >1 year with
good functional status

66. Recommendations for cardiac resynchronization
therapy(CRT) implantation
 CRT is recommended for symptomatic patients
 With HF in sinus rhythm with a QRS duration ≥150
msec/130–149 msec and LBBB QRS morphology and
 with LVEF ≤35% despite OMT
 in order to improve symptoms and reduce morbidity
and mortality. (Class I)