1、ESC Guidelines on Diagnosis and Treatment of CHFRelationship between cardiac dysfunction,HF and HF rendered asymptomaticNORMALCARDIAC DYSFUNCTIONCORRECTED OR RESOLVEDCARDIACDYSFUNCTIONSYMPTOMSHEARTFAILURETHERAPYTherapy CANbe withdrawn without recurrenceof symptomsSymptomsrelievedTherapy CANNOTbe wit
2、hdrawn without recurrenceof symptomsTransientHeartFailureNosymptomsAsymptomaticcardiacdysfunctionSystolicdysfunctionSymptomspersist1ESC 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 follow
3、ing essential components:A combination of:Symptoms,typically breathlessness or fatigue Cardiac dysfunction documented at rest The diagnosis is supported by:Response to treatment directed towards heart failure2ESC Guidelines on Diagnosis and Treatment of CHFAssessments in all casesNecessarySupportsOp
4、poses History with symptoms+If absent Objective evidence+If absent Response to treatment+Establish diagnosis3ESC Guidelines on Diagnosis and Treatment of CHFTestNecessarySupportsOpposes Electrocardiogram+If normal Echocardiography+If normal Chest x-rayIf congestion If normal Blood countIf normal Blo
5、od chemistryIf normalTests for Diagnosis4ESC Guidelines on Diagnosis and Treatment of CHFAdditional Tests for DiagnosisTestNecessarySupportsOpposesExercise testIf normalNatriuretic peptide If elevated If normalCardiac cath.If normal5ESC Guidelines on Diagnosis and Treatment of CHFTest to Exclude Alt
6、ernatives Chest x-ray(Lung disease)Pulmonary function Blood chemistry(Renal and hepatic disease)Blood count(Anaemia)Exercise tolerance(if impaired)6ESC Guidelines on Diagnosis and Treatment of CHFElectrocardiography A normal ECG suggests that the diagnosis of heart failure should be carefully review
7、ed.The predictive value of a normal ECG to exclude LV systolic dysfunction exceeds 90%7ESC Guidelines on Diagnosis and Treatment of CHFChest 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 det
8、ect cardiac enlargement and pulmonary congestion In chronic heart failure,increased cardiac size and pulmonary venous congestion are useful indicators of abnormal cardiac function with decreased ejection fraction and/or increased LV filling pressure However,cardiomegaly is frequently absent in acute
9、 heart failure and in cases with diastolic dysfunction8ESC Guidelines on Diagnosis and Treatment of CHFPulmonary function tests Measurements of lung function are of little value in diagnosing chronic heart failure.However,they are useful in excluding respiratory causes of breathlessness9ESC Guidelin
10、es on Diagnosis and Treatment of CHFExercise testing In clinical practice exercise testing is of limited value for the diagnosis of heart failure.However,a normal maximal exercise test,in a patient not receiving heart failure treatment,excludes heart failure as a diagnosis10ESC Guidelines on Diagnos
11、is and Treatment of CHFInvasive investigation Invasive investigation is generally not required to establish the presence of chronic heart failure,but may be important in elucidating the cause or to obtain prognostic information11ESC Guidelines on Diagnosis and Treatment of CHFEchocardiography As obj
12、ective evidence of cardiac dysfunction at rest is mandatory for the diagnosis of heart failure,echocardiography is the preferred method for this documentation The most important parameter for identifying patients with systolic cardiac dysfunction and those with preserved systolic function is the LV
13、ejection fraction When the diagnosis of heart failure is confirmed,echocardiography is also helpful in determining its aetiology 12ESC Guidelines on Diagnosis and Treatment of CHFNatriuretic PeptidesThese peptides may be most useful clinically as a“rule out”test due to a consistent and very high neg
14、ative predictive values Especially in primary care patients suspected of having heart failure can be selected for further investigation by echocardiography or other tests of cardiac function on the basis of having an elevated plasma concentration of a natriuretic peptideIn those in whom the concentr
15、ations are normal,other causes of dyspnoea and associated symptoms should be consideredThe added value of natriuretic peptides in this situation has yet to be determined13ESC Guidelines on Diagnosis and Treatment of CHFNatriuretic Peptides High levels of natriuretic peptides identify those at greate
16、st risk of future serious cardiovascular events including death There is also recent evidence that adjusting heart failure therapy in order to reduce natriuretic peptides levels in individual patients may improve outcome14ESC Guidelines on Diagnosis and Treatment of CHFOther neuroendocrine evaluatio
17、ns Other tests of neuroendocrine evaluation are not recommended for diagnostic or prognostic purposes15ESC Guidelines on Diagnosis and Treatment of CHFSuspected Heart Failurebecause of symptoms and signsTests abnormalTests abnormalAssess presence of cardiac disease by ECG,X-Ray orNatriuretic peptide
18、s(where available)NormalHeart FailureunlikelyImaging by Echocardiography(Nuclear angiography orMRI where available)NormalHeart FailureunlikelyChoose therapyAssess etiology,degree,precipitatingfactors and type of cardiac dysfunctionAlgorithm for Diagnosis of Chronic HFAdditional diagnostic testswhere
19、 appropriate(e.g.coronary angiography)16ESC Guidelines on Diagnosis and Treatment of CHFManagement OutlineEstablish that patient has heart failureIdentify presenting symptomAssess severity of limitationDetermine etiologyExclude or confirm concomitant diseasesPredict prognosisChoose therapyMonitor pr
20、ogress17ESC Guidelines on Diagnosis and Treatment of CHFGuidelines Treatment-Contents General advice and measures Exercise and exercise training Pharmacological therapy Surgery and devices Special subsections(elderly,diastolic CHF)Care management programmes18ESC Guidelines on Diagnosis and Treatment
21、 of CHF19ESC Guidelines on Diagnosis and Treatment of CHFGeneral Measures and Advice Patient and family education explain heart failure symptoms what therapy does self-weighing exercise vs rest 20ESC Guidelines on Diagnosis and Treatment of CHFGeneral measures and advice Diet-salt intake and fluid r
22、estriction Smoking-cessation Alcohol-moderate intake permitted Obesity-weight reduction Abnormal weight loss Travelling Sexual activity-counselling,reassurance patients/partner Vaccinations-influenza,pneumococcal21ESC Guidelines on Diagnosis and Treatment of CHFGeneral measures and advice Drug couns
23、elling:Self-management(diuretics)Desired effects and side effects Duration treatment before effects become apparent Need for slow up-titration Interaction with other drugs22ESC Guidelines on Diagnosis and Treatment of CHFAce-inhibitors ACE inhibitors are recommended as first-line therapy in patients
24、 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 together with diuretics (Level B)ACE inhibitors should be up-titrated to the dosages shown to be effective in large trials.They should n
25、ot be titrated based on symptomatic improvement23ESC Guidelines on Diagnosis and Treatment of CHFThe recommended procedure for starting an ACE inhibitor1.Review the dose of diuretics2.Avoid excessive diuresis before treatment.3.Start with a low dose and build up to maintenance dosages4.If renal func
26、tion deteriorates substantially,stop treatment.5.Avoid potassium-sparing diuretics during initiation of therapy.6.Avoid non-steroidal anti-inflammatory drugs(NSAIDs).7.Check blood pressure,renal function and electrolytes 1-2 weeks after each dose increment,at 3 months and subsequently at 6 monthly i
27、ntervals(Level C)24ESC Guidelines on Diagnosis and Treatment of CHFBeta-blockade in Heart Failure Beta-blocking agents are recommended for the treatment of all patients with stable mild,moderate and severe heart failure from ischemic and non-ischemic origin on standard treatment including ACE inhibi
28、tion 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)25ESC Guidelines on Diagnosis and Treatment of CHFInitiation and uptitration of beta-blockade in heart failure Patients should be on a back
29、ground 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 worsen or experience adverse effects(hypotension)monitor and adapt other therapy first before changing dose beta-blocker.Consider
30、 PDE inhibitor when positive inotropic support is needed 26ESC Guidelines on Diagnosis and Treatment of CHF Spironolactone in Heart Failure Aldosterone antagonism is recommended in advanced heart failure(NYHA III and IV)in addition to ACE inhibition to improve survival and morbidity (level B)27ESC G
31、uidelines on Diagnosis and Treatment of CHFAdministration and Dosing Considerations with Spironolactone To consider when a patient is in advanced CHF despite standard therapy Check serum potassium(5mmol/L)and creatinine(5-5.5mmol/L-reduce dose by 50%,stop if persists If after 1 month if symptoms are
32、 still severe-increase to 50 mg daily and check potassium and creatinine after 1 week28ESC Guidelines on Diagnosis and Treatment of CHFLoop Diuretics,Thiazides and Metolazone Diuretics are essential when fluid load is present and manifest as pulmonary congestion and pulmonary oedema(level A)The redu
33、ction of left ventricular filling pressures result in rapid improvement of dyspnea and improved exercise tolerance(level B)29ESC Guidelines on Diagnosis and Treatment of CHFPotassium-sparing Diuretics Potassium-sparing diuretics should only be prescribed if persisting hypokalemia despite ACE inhibit
34、or 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 creatinine and potassium every 5-7 days until stable values 30ESC Guidelines on Diagnosis and Treatment of CHFAngiotensin Rec
35、eptor 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 reduction(level B)In addition to ACE inhibition ARBs improve symptoms and reduce hospitalisations for heart failure(leve
36、l B)The addition of ARBs to ACE inhibition and beta-blockade cannot be recommended at present-needs further investigation(level C)31ESC Guidelines on Diagnosis and Treatment of CHFDigitalis Glycosides Cardiac glycosides are recommended in atrial fibrillation and symptomatic CHF in order to improve c
37、ardiac 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 in persisting heart failure symptoms due to LV systolic dysfunction(level B).32ESC Guidelines on Diagnosis and Trea
38、tment 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 antagonists)ARBs better choice than nitrates/hydralazine when intolerance to ACE inhibitors(level B)Alpha-blockers are n
39、ot recommended for heart failure(level B)DHP calcium antagonists have no effect on survival in CHF due to LV systolic dysfunction(level A)33ESC Guidelines on Diagnosis and Treatment of CHFPositive Inotropes Inotropic agents are commonly used to limit severe episodes of CHF or as a bridge to transpla
40、ntation(level C).Use of dobutamine insufficiently documented-prognosis unclear.Higher incidence of treatment-related complications with milrinone.Prolonged or repeated oral therapy with available agents(cAMP dependent)increases mortality(level A)Short-term levosimendan(calcium sensitiser)appears to
41、be safer than dobutamine.Its long term effect on mortality needs to be confirmed(level C)34ESC Guidelines on Diagnosis and Treatment of CHFAntiarrhythmics in Heart FailureIn general there is no indication for the use of anti-arrhythmics in CHF.Specific indications:atrial fibrillation,non-sustained o
42、r 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),but routine administration in CHF is not justified(level B)There is no specifically defined role for ICD in C
43、HF(level C),but it improves survival in cardiac arrest or sustained VT associated with LV dysfunction(level A)35ESC Guidelines on Diagnosis and Treatment of CHFAntiarrhythmics in heart failure(cont d)Amiodarone is effective against most common supra-and ventricular arrhythmias(level B),but routine a
44、dministration 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)36ESC Guidelines on Diagnosis and Treatment of CHFAnti-thrombotic Therapy Little evidence tha
45、t 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-thrombotic agents in sinus rhythm There is controversy about the role of a potential interaction between aspiri
46、n and ACE inhibitors37ESC Guidelines on Diagnosis and Treatment of CHFPacemakers Pacemakers have had no specific role other than convential bradycardia indication.When needed,AV-synchronous pacing should be preferred Resynchronization therapy using bi-ventricular pacing may improve symptoms and sub-
47、maximal exercise capacity(level B)but the effect on mortality and morbidity is as yet unknown38ESC Guidelines on Diagnosis and Treatment of CHFSurgery for Heart Failure No controlled data to support revascularisation in general.In individuals with heart failure due to ischemic cardiomyopathy revascu
48、larisation 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 ventriculotomy(Batista)not recommended(level C)39ESC Guidelines on Diagnosis and Treatment of CHFChoic
49、e of Pharmacological Therapy IndicatedIndicated(under specialist care)Indicated(combination of diuretics)IndicatedEnd-stage heart failure(NYHA IV)IndicatedIndicated(under specialist care)Indicated(combination of diuretics)IndicatedWorsening heart failure(NYHA III)Not indicatedIndicatedIndicated if f
50、luid retentionIndicatedSymptomatic heart failure(NYHAII)Not indicatedPost-MINot indicatedIndicatedAsymptomatic LVdysfunctionAldosterone antagonistBeta-blockerDiureticACE inhibitor40ESC Guidelines on Diagnosis and Treatment of CHFChoice of Pharmacological Therapy If persisting hypokalemia If ACE inhi
