Heart Failure Guidelines 2016

SGK 2016 Session: Postgraduate Course in

Heart Failure – Lausanne, 15. June 2016

Matthias Nägele, MD – University Hospital Zurich

Disclosures

• I have nothing to disclose.

The new guidelines

New aspects

1. Definition

2. Types of HF: HFrEF, HFmrEF, HFpEF

3. Algorithms in chronic and acute heart failure

4. Valsartan/sacubitril

5. Modified CRT indications

6. Focus on comorbidities

Definition of HF

Type and diagnosis of HF

Type of HF HF with reduced

EF (HFrEF)

HF with mid-range

EF (HFmrEF)

HF with preserved EF

(HFpEF)

Necessary

Criteria

Symptoms ± signs Symptoms ± signs Symptoms ± signs

LVEF <40% LVEF 40-49% LVEF ≥ 50%

- NT-proBNP >125 pg/mL or BNP >35 pg/mL

At least one criteria:

1. Structural heart disease

• LA enlargement (LAVI >34 ml/m2)

and/or

• LV hypertrophy (LVMI >115/95 g/m2)

2. Diastolic dysfunction

• E/e′ ≥13 or septal/lateral e’ <9 cm/s

Diagnostic algorithm (non-acute onset)

Diagnostic algorithm (non-acute onset)

Initial work-up after diagnosis

In all patients

• TTE (LVEF, RV function, valves,

pulmonary hypertension)

• Laboratory

• Hb and leukocytes

• Na, K, urea, creatinine

• Bilirubin, AST, ALT, GT

• Glucose, HbA1c

• Lipid profile, TSH

• Ferritin, TF saturation

• Natriuretic peptides

• 12-lead ECG

• Chest X-Ray

In selected patients

• Cardiac MRI

• Non-invasive stress imaging

• Exercise testing

• Coronary angiography

• Cardiac CT

• Right heart catheterization

• Endomyocardial biopsy

Treatment of HFrEF

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Treatment of HFrEFIC

D ifLV

EF

≤ 3

5%

de

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ofsym

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VT

/VF

Background on valsartan/sacubitril

McMurray et al. NEJM 2014

PARADIGM-HF Trial

Guidance on valsartan/sacubitril

• Contraindications:

– Angioedema

– eGFR <10ml/min/1.73m2

– Pregnancy

• Titration:

– Low prior ACEI/ARB (i.e. <10mg lisinopril): 50mg b.i.d.

– Higher ACEI/ARB dose: 100mg b.i.d.

– Increase every 2-4 weeks to target dose: 200mg b.i.d

• Precautions:

– Discontinue ACEI at least 36h before starting

valsartan/sacubitril

– Do not combine with ACEI, aliskiren or ARB

– Hyperkalemia, Systolic blood pressure <100mmHg

– eGFR 10-30ml/min/1.73m2

Side effects more common

with valsartan/sacubitril

• Symptomatic hypotension

• SBP <90mmHg

• Angioedema*

Side effects more common

with enalapril

• Creatinine >2.5mg/dl

• Potassium >6mmol/l

• Cough

SwissMedic Fachinformation 25.09.2016

Treatment of HFrEF

Treatment of HFrEF

Treatment of HFrEF

Recommendations on ICD

Recommendations on CRT

Recommendations on CRT

Ruschitzka et al. NEJM 2013

EchoCRT Trial

All-cause mortality

HR 1.81 (1.11-2.93)

p= 0.02

Cleland et al. EHJ 2013

IPD meta-analysis of five RCTs

Treatment of HFmrEF and HFpEF

“No treatment has yet been shown, convincingly, to reduce morbidity or

mortality in patients with HFpEF or HFmrEF.”

Important comorbidities:

• Hypertension

• Atrial fibrillation

• Diabetes

• Ischemia

Exercise training

Comorbidities: Iron, Diabetes, CSA, Arthritis

Comorbidities: CKD

Comorbidities: COPD

Comorbidities: Obesity

Acute heart failure: Initial Assessment

No Yes

No Warm and Dry Warm and Wet

Yes Cold and Dry Cold and Wet

Hypoperfusion

(e.g. cold extremities,

oliguria, confusion,

dizziness, narrow

pulse pressure,

elevated lactate)

Congestion

(e.g. pulmonary congestion, orthopnea,

edema, jugular venous distension)

Acute heart failure: Algorithms

Acute heart failure: Algorithms

Acute heart failure: Treatment

Acute heart failure: Treatment

Exercise and (tele-)monitoring programs

Prevention of HF

Conclusions

• New guidelines: Consistent incorporation of last 4 year’s evidence

• HF with mid-range EF (40-49%) – New subtype to boost research efforts

• Valsartan/Sacubitril: Use when symptomatic on optimal ACEI, BB and MRA

• CRT: Contraindicated in QRS duration <130ms

• HFpEF/HFmrEF: Lack of treatments, focus on symptoms and comorbidities

• Acute HF: Congestion/perfusion assessment to triage treatment, effective

therapies still lacking

• New recommendations on comorbidities (i.e. iron, diabetes, ASV)

• Strong recommendations for exercise in HF patients

• Prevention of HF in diabetic patients: consider empagliflozin

Heart Failure Specialists of Tomorrow

• Platform to connect young people

interested in heart failure

• Everyone under 40 and interested in

heart failure is invited to join

• Sign up: http://tinyurl.com/hotgrp