1、ESC Guidelines on Diagnosis and Treatment of CHFDiagnosis According to the Working Group in Heart Failure,Heart Failure is a syndrome where the diagnosis has the following essential components:A combination of:Symptoms,typically breathlessness or fatigue Cardiac dysfunction documented at rest The di
2、agnosis is supported by:Response to treatment directed towards heart failureESC Guidelines on Diagnosis and Treatment of CHFAssessments in all casesNecessarySupportsOpposes History with symptoms+If absent Objective evidence+If absent Response to treatment+Establish diagnosisESC Guidelines on Diagnos
3、is and Treatment of CHFTestNecessarySupportsOpposes Electrocardiogram+If normal Echocardiography+If normal Chest x-rayIf congestionIf normal Blood countIf normal Blood chemistryIf normalTests for DiagnosisESC Guidelines on Diagnosis and Treatment of CHFAdditional Tests for DiagnosisTestNecessarySupp
4、ortsOpposesExercise testIf normalNatriuretic peptide If elevated If normalCardiac cath.If normalESC Guidelines on Diagnosis and Treatment of CHFTest to Exclude Alternatives Chest x-ray(Lung disease)Pulmonary function Blood chemistry(Renal and hepatic disease)Blood count(Anaemia)Exercise tolerance(if
5、 impaired)ESC Guidelines on Diagnosis and Treatment of CHFElectrocardiography A normal ECG suggests that the diagnosis of heart failure should be carefully reviewed.The predictive value of a normal ECG to exclude LV systolic dysfunction exceeds 90%ESC Guidelines on Diagnosis and Treatment of CHFChes
6、t X-ray A high predictive value of X-ray findings is only achieved by interpreting them in the context of clinical findings and ECG anomalies.It is useful to detect cardiac enlargement and pulmonary congestion In chronic heart failure,increased cardiac size and pulmonary venous congestion are useful
7、 indicators of abnormal cardiac function with decreased ejection fraction and/or increased LV filling pressure However,cardiomegaly is frequently absent in acute heart failure and in cases with diastolic dysfunctionESC Guidelines on Diagnosis and Treatment of CHFPulmonary function tests Measurements
8、 of lung function are of little value in diagnosing chronic heart failure.However,they are useful in excluding respiratory causes of breathlessnessESC Guidelines on Diagnosis and Treatment of CHFExercise testing In clinical practice exercise testing is of limited value for the diagnosis of heart fai
9、lure.However,a normal maximal exercise test,in a patient not receiving heart failure treatment,excludes heart failure as a diagnosisESC Guidelines on Diagnosis and Treatment of CHFInvasive investigation Invasive investigation is generally not required to establish the presence of chronic heart failu
10、re,but may be important in elucidating the cause or to obtain prognostic informationESC Guidelines on Diagnosis and Treatment of CHFEchocardiography As objective evidence of cardiac dysfunction at rest is mandatory for the diagnosis of heart failure,echocardiography is the preferred method for this
11、documentation The most important parameter for identifying patients with systolic cardiac dysfunction and those with preserved systolic function is the LV ejection fraction When the diagnosis of heart failure is confirmed,echocardiography is also helpful in determining its aetiology ESC Guidelines o
12、n Diagnosis and Treatment of CHFNatriuretic PeptidesThese peptides may be most useful clinically as a“rule out”test due to a consistent and very high negative predictive values Especially in primary care patients suspected of having heart failure can be selected for further investigation by echocard
13、iography or other tests of cardiac function on the basis of having an elevated plasma concentration of a natriuretic peptideIn those in whom the concentrations are normal,other causes of dyspnoea and associated symptoms should be consideredThe added value of natriuretic peptides in this situation ha
14、s yet to be determinedESC Guidelines on Diagnosis and Treatment of CHFNatriuretic Peptides High levels of natriuretic peptides identify those at greatest risk of future serious cardiovascular events including death There is also recent evidence that adjusting heart failure therapy in order to reduce
15、 natriuretic peptides levels in individual patients may improve outcomeESC Guidelines on Diagnosis and Treatment of CHFOther neuroendocrine evaluations Other tests of neuroendocrine evaluation are not recommended for diagnostic or prognostic purposesESC Guidelines on Diagnosis and Treatment of CHFSu
16、spected Heart Failurebecause of symptoms and signsTests abnormalTests abnormalAssess presence of cardiac disease by ECG,X-Ray orNatriuretic peptides(where available)NormalHeart FailureunlikelyImaging by Echocardiography(Nuclear angiography orMRI where available)NormalHeart FailureunlikelyChoose ther
17、apyAssess etiology,degree,precipitatingfactors and type of cardiac dysfunctionAlgorithm for Diagnosis of Chronic HFAdditional diagnostic testswhere appropriate(e.g.coronary angiography)ESC Guidelines on Diagnosis and Treatment of CHFManagement OutlineEstablish that patient has heart failureIdentify
18、presenting symptomAssess severity of limitationDetermine etiologyExclude or confirm concomitant diseasesPredict prognosisChoose therapyMonitor progressESC Guidelines on Diagnosis and Treatment of CHFGuidelines Treatment-Contents General advice and measures Exercise and exercise training Pharmacologi
19、cal therapy Surgery and devices Special subsections(elderly,diastolic CHF)Care management programmesESC Guidelines on Diagnosis and Treatment of CHFESC Guidelines on Diagnosis and Treatment of CHFGeneral Measures and Advice Patient and family education explain heart failure symptoms what therapy doe
20、s self-weighing exercise vs rest ESC Guidelines on Diagnosis and Treatment of CHFGeneral measures and advice Diet-salt intake and fluid restriction Smoking-cessation Alcohol-moderate intake permitted Obesity-weight reduction Abnormal weight loss Travelling Sexual activity-counselling,reassurance pat
21、ients/partner Vaccinations-influenza,pneumococcalESC Guidelines on Diagnosis and Treatment of CHFGeneral measures and advice Drug counselling:Self-management(diuretics)Desired effects and side effects Duration treatment before effects become apparent Need for slow up-titration Interaction with other
22、 drugsESC Guidelines on Diagnosis and Treatment of CHFAce-inhibitors ACE inhibitors are recommended as first-line therapy in patients with a reduced LV systolic function (LVEF40-45%)(Level A)In the absence of fluid retention ACE inhibitors should be given first,in the presence of fluid retention tog
23、ether with diuretics (Level B)ACE inhibitors should be up-titrated to the dosages shown to be effective in large trials.They should not be titrated based on symptomatic improvementESC Guidelines on Diagnosis and Treatment of CHFThe recommended procedure for starting an ACE inhibitor1.Review the dose
24、 of diuretics2.Avoid excessive diuresis before treatment.3.Start with a low dose and build up to maintenance dosages4.If renal function deteriorates substantially,stop treatment.5.Avoid potassium-sparing diuretics during initiation of therapy.6.Avoid non-steroidal anti-inflammatory drugs(NSAIDs).7.C
25、heck blood pressure,renal function and electrolytes 1-2 weeks after each dose increment,at 3 months and subsequently at 6 monthly intervals(Level C)ESC Guidelines on Diagnosis and Treatment of CHFBeta-blockade in Heart Failure Beta-blocking agents are recommended for the treatment of all patients wi
26、th stable mild,moderate and severe heart failure from ischemic and non-ischemic origin on standard treatment including ACE inhibition and diuretics(level A)Beta-blocking agents are recommended in patients with LV dysfunction with/without heart failure post-MI for survival benefit (level B)ESC Guidel
27、ines on Diagnosis and Treatment of CHFInitiation and uptitration of beta-blockade in heart failure Patients should be on a background therapy of ACE inhibition and diuretics Stable condition Tirate slowly and carefully from low initial dose to target doses used in large RCT Patients may initially wo
28、rsen or experience adverse effects(hypotension)monitor and adapt other therapy first before changing dose beta-blocker.Consider PDE inhibitor when positive inotropic support is needed ESC Guidelines on Diagnosis and Treatment of CHF Spironolactone in Heart Failure Aldosterone antagonism is recommend
29、ed in advanced heart failure(NYHA III and IV)in addition to ACE inhibition to improve survival and morbidity (level B)ESC Guidelines on Diagnosis and Treatment of CHFAdministration and Dosing Considerations with Spironolactone To consider when a patient is in advanced CHF despite standard therapy Ch
30、eck serum potassium(5mmol/L)and creatinine(5-5.5mmol/L-reduce dose by 50%,stop if persists If after 1 month if symptoms are still severe-increase to 50 mg daily and check potassium and creatinine after 1 weekESC Guidelines on Diagnosis and Treatment of CHFLoop Diuretics,Thiazides and Metolazone Diur
31、etics are essential when fluid load is present and manifest as pulmonary congestion and pulmonary oedema(level A)The reduction of left ventricular filling pressures result in rapid improvement of dyspnea and improved exercise tolerance(level B)ESC Guidelines on Diagnosis and Treatment of CHFPotassiu
32、m-sparing Diuretics Potassium-sparing diuretics should only be prescribed if persisting hypokalemia despite ACE inhibitor therapy in mild heart failure(NYHA lII)and ACE inhibition+low-dose spironolactone in NYHA III/IV(level C)Potassium supplements are less effective in this situation Monitor creati
33、nine and potassium every 5-7 days until stable values ESC Guidelines on Diagnosis and Treatment of CHFAngiotensin Receptor Blockers(ARB)ARBs could be considered in patients who do not tolerate ACE inhibitors(level C)It has not been proven that they are as effective as ACE inhibitors in mortality red
34、uction(level B)In addition to ACE inhibition ARBs improve symptoms and reduce hospitalisations for heart failure(level B)The addition of ARBs to ACE inhibition and beta-blockade cannot be recommended at present-needs further investigation(level C)ESC Guidelines on Diagnosis and Treatment of CHFDigit
35、alis Glycosides Cardiac glycosides are recommended in atrial fibrillation and symptomatic CHF in order to improve cardiac function and symptoms(level B)A combination of digitalis and beta-blockade appears superior to either agent alone(level C)In sinus rhythm digoxin may improve the clinical status
36、in persisting heart failure symptoms due to LV systolic dysfunction(level B).ESC Guidelines on Diagnosis and Treatment of CHFVasodilators Vasodilators may be used as adjunctive therapy in heart failure for the relief of angina or acute dyspnoe(nitrates)or concomitant hypertension(DHP calcium antagon
37、ists)ARBs better choice than nitrates/hydralazine when intolerance to ACE inhibitors(level B)Alpha-blockers are not recommended for heart failure(level B)DHP calcium antagonists have no effect on survival in CHF due to LV systolic dysfunction(level A)ESC Guidelines on Diagnosis and Treatment of CHFP
38、ositive Inotropes Inotropic agents are commonly used to limit severe episodes of CHF or as a bridge to transplantation(level C).Use of dobutamine insufficiently documented-prognosis unclear.Higher incidence of treatment-related complications with milrinone.Prolonged or repeated oral therapy with ava
39、ilable agents(cAMP dependent)increases mortality(level A)Short-term levosimendan(calcium sensitiser)appears to be safer than dobutamine.Its long term effect on mortality needs to be confirmed(level C)ESC Guidelines on Diagnosis and Treatment of CHFAntiarrhythmics in Heart FailureIn general there is
40、no indication for the use of anti-arrhythmics in CHF.Specific indications:atrial fibrillation,non-sustained or sustained VTClass I agents should be avoided(level C)Beta-blockers reduce sudden death in CHF(level A)Amiodarone is effective against most common supra-and ventricular arrhythmias(level B),
41、but routine administration in CHF is not justified(level B)There is no specifically defined role for ICD in CHF(level C),but it improves survival in cardiac arrest or sustained VT associated with LV dysfunction(level A)ESC Guidelines on Diagnosis and Treatment of CHFAntiarrhythmics in heart failure(
42、cont d)Amiodarone is effective against most common supra-and ventricular arrhythmias(level B),but routine administration in CHF is not justified (level B)There is no specifically defined role for ICD in CHF(level C),but it improves survival in cardiac arrest or sustained VT associated with LV dysfun
43、ction(level A)ESC Guidelines on Diagnosis and Treatment of CHFAnti-thrombotic Therapy Little evidence that anti-thrombotic therapy modifies the risk of death or vascular events other than in atrial fibrillation where anticoagulants are firmly indicated(level C)Lack of evidence to support anti-thromb
44、otic agents in sinus rhythm There is controversy about the role of a potential interaction between aspirin and ACE inhibitorsESC Guidelines on Diagnosis and Treatment of CHFPacemakers Pacemakers have had no specific role other than convential bradycardia indication.When needed,AV-synchronous pacing
45、should be preferred Resynchronization therapy using bi-ventricular pacing may improve symptoms and sub-maximal exercise capacity(level B)but the effect on mortality and morbidity is as yet unknownESC Guidelines on Diagnosis and Treatment of CHFSurgery for Heart Failure No controlled data to support
46、revascularisation in general.In individuals with heart failure due to ischemic cardiomyopathy revascularisation may lead to improvement of symptoms(level C)Mitral valve surgery in advanced heart failure and severe MI may improve symptoms(level C)Cardiomyoplasty not recommended(level C)Partial left v
47、entriculotomy(Batista)not recommended(level C)ESC Guidelines on Diagnosis and Treatment of CHFChoice of Pharmacological Therapy IndicatedIndicated(under specialist care)Indicated(combination of diuretics)IndicatedEnd-stage heart failure(NYHA IV)IndicatedIndicated(under specialist care)Indicated(comb
48、ination of diuretics)IndicatedWorsening heart failure(NYHA III)Not indicatedIndicatedIndicated if fluid retentionIndicatedSymptomatic heart failure(NYHAII)Not indicatedPost-MINot indicatedIndicatedAsymptomatic LVdysfunctionAldosterone antagonistBeta-blockerDiureticACE inhibitorESC Guidelines on Diag
49、nosis and Treatment of CHFChoice of Pharmacological Therapy If persisting hypokalemia If ACE inhibitors and ARBs not tolerated Possibly for symptoms in sinus rhythmIf ACE inhibitors or beta-blockers not toleratedEnd-stage heart failure(NYHA IV)If persisting hypokalemia If ACE inhibitors and ARBs not
50、 tolerated For symptoms in sinus rhythmIf ACE inhibitors or beta-blockers not tolerated Worsening heart failure(NYHA III)If persisting hypokalemiaIf ACE inhibitors and ARBs not toleratedFor symptoms in sinus rhythmIf ACE inhibitors or beta-blockers not tolerated Symptomatic heart failure(NYHAII)Not
