Insuffisance cardiaque en 2017 Traitement : guidelines ESC 2016 - PowerPoint PPT Presentation

Insuffisance cardiaque en 2017 Traitement : guidelines ESC 2016 Prof. O. Gurné Cardiologie Cliniques Universitaires St Luc – UCL Bruxelles

2012 2016

Algorythme prise en charge HF HF p EF FE HF FE < 40 % HF r EF

HFp(m)EF : Classify the patient – Etiology and stratification

Algorythme prise en charge HF Contrôle des FDR tabagisme, diabète Causes déclenchantes sédentarité, obésité Mauvaise observance Ajout récent de médicaments dépresseurs cardiaque HF p EF Abus d’alcool Anémie, dénutrition Infection pulmonaire Insuffisance rénale Dysfonction thyroïdienne FE HF Maladie générale connue Cardiopathie sous-jacente Insuffisance coronarienne Fibrillation atriale, TRV HTA Atteinte valvulaire FE < 40 % Antécédent de chimio/radiothérapie HF r EF

Algorythme prise en charge HF Contrôle des FDR tabagisme, diabète Causes déclenchantes sédentarité, obésité Mauvaise observance Ajout récent de médicaments dépresseurs cardiaque HF p EF Abus d’alcool Anémie, dénutrition Infection pulmonaire Insuffisance rénale Dysfonction thyroïdienne FE HF Maladie générale connue Cardiopathie sous-jacente Insuffisance coronarienne Fibrillation atriale, TRV HTA Atteinte valvulaire FE < 40 % Antécédent de chimio/radiothérapie HF r EF Prise en charge « EBM »

Le traitement médicamenteux HF (HFrEF) évolue… SOLVD, CONSENSUS BB RALES,EPHESUS SHIFT PARADIGM

ACEI/ARB

ARNI : Angiotensin II Receptor inhibitor Neprilisyin Inhibitor

LCZ696 simultaneously - inhibits NEP (via sacubitril) - blocks the AT 1 receptor (via valsartan) LCZ696 Natriuretic and other Natriuretic and other RAAS RAAS vasoactive peptides* vasoactive peptides* Angiotensinogen (liver secretion) – Sacubitril (AHU377; pro-drug) Ang I Sacubitrilat Inactive Ang II Valsartan fragments (NEP inhibitor) – O AT 1 Receptor O Enhancing N OH Inhibiting Vasorelaxation O HN OH N Vasoconstriction  Blood pressure O N NH HO N  Blood pressure  Sympathetic tone O  Sympathetic tone  Aldosterone levels  Aldosterone  Fibrosis  Fibrosis  Hypertrophy  Hypertrophy  Natriuresis/diuresis * Neprilysin substrates listed in order of relative affinity for NEP: ANP, CNP, Ang II, Ang I, adrenomedullin, substance P, bradykinin, endothelin-1, BNP

A paradigm-shift in treatment Not adding but replacing • Replace a current gold standard with something better? • An ARNI instead of an ACE inhibitor?

Patients – main inclusion criteria • CHF NYHA Class II–IV and LVEF ≤ 40% – BNP ≥ 150 pg/ml (NT-proBNP ≥600 pg/ml) OR – BNP ≥ 100 pg/ml (NT-proBNP ≥400 pg/ml) and a hospitalization for HF within the last 12 months • Must be taking ACEI or ARB: i) dose equivalent to enalapril ≥10 mg/d ii) stable dose for at least 4 weeks • Must be taking a β-blocker: unless contraindicated or not tolerated; stable dose for at least 4 weeks • MRA (a ldosterone antagonist) where indicated: e.g. RALES type patient • Individually optimized dosing of background HF medications

Titration algorithm 25

Ivabradine

2012 2016

SHIFT – HR > 75 bpm Effect of ivabradine Effect of ivabradine on on cardiovascular death hospitalization for heart failure 30 Hazard ratio=0.70 Hazard ratio=0.83 30 P <0.0001 P =0.0166 Placebo Placebo 20 20 Ivabradine 10 10 Ivabradine 0 0 0 6 12 18 24 30 0 6 12 18 24 30 Time (months)

Acute Heart Failure

Management of a patient with acute HF based on clinical profile durring an early phase