Professor Dan Atar is a cardiologist who has authored and contributed to several heart failure and atrial fibrillation guidelines. He discusses key clinical aspects of heart failure management based on the ESC guidelines. First, inpatient treatment focuses on recompensation of acute heart failure, which carries a high mortality risk. Ensuring an uptitration plan and follow-up appointment at discharge is important. In the outpatient setting, adherence to therapies needs to be secured given the risk with multiple daily dosing, and comorbidities and polypharmacy must be adequately addressed.

1. Professor Dan Atar, MD, FESC
Dept. of Cardiology
Oslo University Hospital Ullevål
Norway
Vice-President of the ESC (2014-16)
Secretary/Treasurer of the ESC (2018-2020)
2.2.2019 – Mauritius
Heart Failure Guidelines of the ESC –
Clinical Aspects

2. • Co-author of the 2010, 2012 and 2016 ESC Guidelines on Atrial Fibrillation and
2012 ESC STEMI Guidelines, as well as the 2018 Universal Definition of AMI GL.
• Steering Committee member, National Coordinator for Norway, and Co-author
of ACTIVE, RELY, ARISTOTLE, AVERROES, APPRAISE, GARFIELD, ENGAGE-AF,
XANTUS, RE-ALIGN, RE-VERSE, ARTESIA, NOAH, ENTRUST-AF-PCI, REPORT-AF,
RE-SONANCE, REPORT-HF, PARAGON, VICTORIA.
• Adjudication Committee member for the AVRO and Roxadustat trials, DSMB for
the CHILL-MI, OPTIMUM, LUPUS, BETA-3 and HOMAGE trials. Chair of the FIRE
and MITOCARE trial (EU-FP7 fundet). Chair of the BETAMI-trial.
• Fees, honoraria from Boehringer- Ingelheim, Bayer, BMS/Pfizer, Cardiome,
Astra-Zeneca, MSD, Sanofi-Aventis, Amgen.
Prof. Dan Atar
Disclosures

9. The Inpatient Setting

10. Heart Failure
JVD EdemaJVD Edema

11. 11
All-cause mortality
(1892 pts with acute HF)
( 3226 pts with chronic HF)
Days from enrollment
Chronic HF: 6.8%
Acute HF: 16.8%
Courtesy Prof A.P.Maggioni
EORP
HF-Survey

12. ESC 2016 HF-Guideline. European Heart Journal (2016) 37, 2129–2200

13. 13

14. 1. Resitance to diuretic therapy
Clin Pharmacol Ther. 2013 Oct;94(4):490-8
11.13 Kidney dysfunction – need to increase dosages

15. Resitance to diuretic therapy
Clin Pharmacol Ther. 2013 Oct;94(4):490-8
PRACTICAL ADVICES:
• Continuous infusion of
loop diuretics
• Repeated iv-boluses of
loop diuretics
• Substitution of equipotent
doses of, e.g., Frusemide
vs. Bumetamide
• Combination of loop-
diuretics and thiazides
• Use of “super-thiazide”
Metolazone

16. 16

17. 2. The conundrum of inotropic therapy
Applying inotropic therapy – risk of inducing pro-arrhythmia
Concern of increased mortality
ESC 2016 HF-Guideline. European Heart Journal (2016) 37, 2129–2200

18. Risk reduction = 29 %
Effect of Nurse-driven HF Outpatient Clinic
N=282
Rich MW et al, NEJM, 1995;333:1190-5.
3. Discharging the patient from the ward

19. Nurse-driven HF Outpatient Clinic
N=282
Am Heart J. 2002 Aug;144(2):E2.
Discharge:

20. ESC 2016 HF-Guideline. European Heart Journal (2016) 37, 2129–2200

21. The Outpatient Setting

22. Amara W et al.: Eur Heart J Suppl. 2016;18(suppl_D):D1-D6. doi:10.1093/eurheartj/suv062
Results from a US study of >1 million cardiovascular patients in 2007:
Improved Adherence of Once-daily versus Twice-daily Therapy
MPR = medication possession ratio (no. of days for which medication supplied/365).
• In total 1.440.254 medication claims
• Once-daily (OD) dosing = 1.384.226
• Twice-daily (BID) dosing = 56.028
4. Ensuring Compliance to HF Therapies

23. … and how does it go with Four Times Daily Therapy ?

24. ESC 2016 HF-Guideline. European Heart Journal (2016) 37, 2129–2200

25. ESC 2016 HF-Guideline. European Heart Journal (2016) 37, 2129–2200

26. HF as One of Several Problems

27. ESC 2016 HF-Guideline. European Heart Journal (2016) 37, 2129–2200
5. Comorbidity
Many patients are elderly.
Frailty, cognitive impairment, immobility.

28. ESC 2016 HF-Guideline. European Heart Journal (2016) 37, 2129–2200
6. Polypharmacy
Need for adjustment of therapies to reduce polypharmacy due to comorbidities
and drug interactions. Example: arthritis and HF-therapy

29. ESC 2016 HF-Guideline. European Heart Journal (2016) 37, 2129–2200

30. Conclusions:
Heart Failure Guidelines – Clinical Aspects
• Inpatient setting - recompensation of AHF.
• Inpatient setting - AHF carries a high mortality.
• Discharge: is an uptitration plan in place?
• Discharge: is a follow-up appointment scheduled?
• Outpatient setting: Adherence to therapies secured?
• Outpatient setting: Co-morbidities and polypharmacy adequately
addressed?
• Are medications carrying class-III recommendations checked out?

31. 31
Thank you for your attention