What can we do after Entresto, ICD, CRT… · 2017. 10. 3. · e p-value=0.011 383 372 354 308 241...

What can we do after Entresto, ICD, CRT… and before LVAD?The HF Guidelines

Stefan D. Anker, MD, PhD

Berlin, Germany

ESC Heart Failure GuidelinesTHE 1ST COMMANDMENT

Apply a novel algorithm for the diagnosis of heart failure in the non-acute setting based on:

i. clinical probability of the disease (derived from medical history, physical examination and resting ECG),

ii. the assessment of circulating natriuretic peptides, and

iii. transthoracic echocardiography.

PATIENT WITH SUSPECTED HF(non-acute onset)

ASSESSMENT OF HF PROBABILITY1. Clinical history:- History of CAD (MI, revascularization)- History of arterial hypertension- Exposition to cardiotoxic drug/radiation- Use of diuretics- Orthopnoea / paroxysmal nocturnal dyspnoea

2. Physical examination:- Rales- Bilateral ankle oedema - Heart murmur- Jugular venous dilatation - Laterally displaced/broadened apical beat

3. ECG:- Any abnormality

Assessment of HF probability

ESC Heart Failure GuidelinesTHE 2ND COMMANDMENT

Use transthoracic echocardiography in patients with suspected or established HF for the

assessment of myocardial structure and function along with the measurement of LVEF to establish

the diagnosis of HF with:REDUCED EJECTION FRACTION

MID-RANGE EJECTION FRACTION PRESERVED EJECTION FRACTION

ESC Heart Failure GuidelinesTHE 3RD COMMANDMENT

To prevent or delay onset of HF and prolong life, treatment of arterial hypertension, use of statins in

patients with or at high risk of coronary artery disease, use of ACE-I in patients with asymptomatic left

ventricular dysfunction and beta-blockers in those with asymptomatic left ventricular dysfunction and a

history of myocardial infarction are recommended.

ESC Heart Failure GuidelinesTHE 4TH COMMANDMENT

Implement life-saving pharmacotherapy in patients with symptomatic

HFrEF, containing a combination of an ACE-I (or ARB if ACE-I not tolerated),

a β-blocker and a MRA.

• If a patient still remains symptomatic, sacubitril/valsartan is

recommended to replace ACE-I.

• Use diuretics in order to improve symptoms and exercise capacity in

patients with signs and/or symptoms of congestion.

Therapeutic algorithm for HF patient with reduced LVEF (Part 1)

Ponikowski P, et al. Eur J Heart Fail 2016 & EHJ 2016

Therapeutic algorithm for HF patient with reduced LVEF (Part 2)


Other pharmacological treatments recommended in patients with symptomatic HFrEF (NYHA II-IV)

Based on PARADIGM-HF, LCZ 696 should be used in patients with:

• ambulatory, symptomatic HFrEF

• treated with ACEi/ARB, BB and MRA

• elevated plasma NP levels (BNP ≥150 pg/mL or NT-proBNP ≥600 pg/mL)

• estimated GFR (eGFR) ≥30 mL/min/1.73 m2 of body surface area

• who are able to tolerate treatment with enalapril (see run-in period in trial)

Some relevant issues for clinical practice:

• symptomatic hypotension in some cases & risk of angioedema (Note: ACEI should be withheld for at least 36 h before initiating LCZ696)

• NP–assessment: BNP biomarker cannot be used, valid are only NT-BNP or MR-proANP

What drugs or combinations of drugs not to give in HFrEF patients in NYHA class II-IV ?


Ensure an ICD implantation in HF patients who either have

recovered from a ventricular arrhythmia causing haemodynamic

instability or in those with symptomatic HF, LVEF ≤35% (despite at

least 3 months of OMT), in order to reduce the risk of sudden death

and all-cause mortality. ICD implantation is not recommended within

40 days of an MI as implantation at this time does not improve

prognosis.


Implant a cardiac resynchronization therapy in symptomatic

patients with HF, LVEF ≤35% (despite at least 3 months of OMT), in

sinus rhythm with a QRS duration ≥130 msec and LBBB QRS

morphology, and in patients with a QRS duration ≥150 msec in

order to improve symptoms and reduce morbidity and mortality.

CRT is contra-indicated in patients with a QRS duration < 130 msec.

UNMET NEED:

Patients who are not yet indicated for

LVAD or heart transplantation and

are still symptomatic.

Unmet need in HFrEF

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The goals of treatment in patients with HF:• Reduce mortality• Prevent hospital admission• Improve clinical status, functional capacity and quality of life

“…preventing HF hospitalization and improving functional capacity are important benefits to be considered if a mortality excess is ruled out…”

What can we do for patients with HFrEF, under optimal medical treatment, who do not tolerate or are not improved enough by ARNI, and who are not

indicated for Cardiac Resynchronisation Therapy?

ConsiderBAROSTIM THERAPY


Primary prophylactic ICDs in dilated cardiomyopathy - the DANISH study.

Aim: to study if PP ICD reduces total mortality

in HF pts with DCM

Method: RCT to ICD +/- CRT or no ICD +/- CRT

Primary endpoint: total mortality , others : CV mortality

and sudden cardiac death

Patients: ICD (n=556) Control (N=560), 64 years,

NYHA II/III , LVEF 25%

Kober L, et al. NEJM 2016

Sudden cardiac death

Hazard Ratio = 0.50 (0.31 – 0.82)p=0.005

Cum

ula

tive e

vent

rate

Controls 560 540 517 438 344 248 169 88 12ICD 556 540 526 451 358 272 186 107 17

PE: Total mortality

Hazard Ratio = 0.87 (0.68 – 1.12)p=0.28

Cum

ula

tive e

vent

rate

Years

Note:- All on OMT and 60 % had CRT.- Follow up 5.6 years

Primary prophylactic ICDs in dilated cardiomyopathy - the DANISH study.

RRR 36% with ICD

Younger two tertiles < 68 years

Hazard Ratio 0.64 (0.46–0.91)p-value=0.011

Cum

ula

tive e

vent

rate

383 372 354 308 241 176 123 64 10 Controls

340 336 330 294 237 179 132 82 15 ICD

Oldest tertile≥ 68 years

Hazard Ratio 1.2 (0.81– 1.72)p-value=0.38

Cum

ula

tive e

vent

rate

177 168 163 130 103

Controls216 204 196 157 121 93 54 25

2 ICD

Kober L, et al. NEJM 2016


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Manage HF co-morbidities in all heart failure patients. In HFpEF, this is the only

evidence-based treatment approach.


In the management of a patient with suspected acute HF, try to shorten all

diagnostic and therapeutic decisions. During an initial phase, reassure that

circulatory or/and ventilatory support is provided in case of either

cardiogenic shock or/and ventilatory failure, respectively.

Apply the algorithm based on clinical profiles evaluating the presence of

congestion & peripheral hypoperfusion. Hypoperfusion is not synonymous

with hypotension, but often hypoperfusion is accompanied by hypotension.


In parallel, identify immediately coexisting life-threatening clinical

conditions and/or precipitants (according to the CHAMP acronym -

acute Coronary syndrome, Hypertension emergency, Arrhythmia,

acute Mechanical cause, Pulmonary embolism) and introduce a

guideline-recommended specific management.


Enrol the patients with HF in a

multidisciplinary care

management program in order

to reduce the risk of HF

hospitalization and mortality.

Specific recommendations regardingmonitoring & follow-up of older adults with HF

Thank you.

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What can we do after Entresto, ICD, CRT… · 2017. 10. 3. · e p-value=0.011 383 372 354 308 241...

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