Petros Nihoyannopoulos MD, FRCP, FESC The new Guidelines: Focus Professor of Cardiology Imperial College London on Chronic Heart Failure and National & Kapodistrian University of Athens New Classification and Diagnosis
2 www.escardio.org/guidelines
3 New Classification and Diagnosis www.escardio.org/guidelines
4 New Classification and Diagnosis The principal changes from the 2012 guidelines relate to: (i) a new term for patients with HF and a LVEF that ranges from 40 to 49% — ‘HF with midrange EF ( HFmrEF )’; this may stimulate research into the underlying Characteristics, pathophysiology and treatment of this population (ii) clear recommendations on the diagnostic criteria for HF with reduced EF ( HFrEF ), HFmrEF and HF with preserved EF ( HFpEF ) (iii) a new algorithm for the diagnosis of HF in the non-acute setting based on the evaluation of HF probability (iv) a new algorithm for a combined diagnosis and treatment of acute HF based on the presence/absence of congestion/hypoperfusion www.escardio.org/guidelines
5 New Classification and Diagnosis The principal changes from the 2012 guidelines (continue): (v) recommendations aimed at prevention or delay of the development of overt HF or the prevention of death before the onset of symptoms; (vi) indications for the use of the new compound sacubitril/valsartan, the first in the class of angiotensin receptor neprilysin inhibitors (ARNIs); (vii) modified indications for cardiac resynchronization therapy ( CRT ); (viii) the concept of an early initiation of appropriate therapy going along with relevant investigations in acute HF that follows the ‘ time to therapy ’ approach already well established in acute coronary syndrome (ACS); www.escardio.org/guidelines
6 New Classification and Diagnosis Definition of heart failure HF is a clinical syndrome characterized by typical symptoms (e.g. SOB, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated JVP, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in: • a reduced cardiac output and/or • elevated intracardiac pressures at rest or during stress www.escardio.org/guidelines
7 New Classification and Diagnosis New Classification! • Heart failure with preserved, mid-range and reduced EF HF comprises a wide range of patients: • those with normal LVEF [typically considered as ≥50% or HF with preserved EF (HFpEF) to those with • Reduced LVEF - typically considered as ≤ 40% (HFrEF)] • Patients with an LVEF in the range of 40–49% represent a ‘grey area’, www.escardio.org/guidelines
8 New Classification and Diagnosis New Classification! • Heart failure with preserved, mid-range and reduced EF it is only in patients with HFrEF that therapies have been shown to reduce both morbidity and mortality www.escardio.org/guidelines
9 New Classification and Diagnosis New Classification! v The diagnosis of HFpEF is more challenging than that of HFrEF v Patients with HFpEF do not have a dilated LV, but often have: • increase in LV wall thickness and/or • increased LA size (sign of increased filling pressures) • most have additional ‘evidence’ of impaired LV filling or suction capacity, also classified as diastolic dysfunction www.escardio.org/guidelines
10 New Classification and Diagnosis New Classification! v Identifying HFmrEF as a separate group will stimulate research into the underlying characteristics and treatment of this group Patients with HFmrEF most probably have primarily mild systolic dysfunction, but with features of: • diastolic dysfunction • relevant structural heart disease (LVH, LA enlargement) • elevated BNP www.escardio.org/guidelines
11 New Classification and Diagnosis Diagnosis • Demonstration of an underlying cardiac cause is central to the diagnosis of HF. • This is usually a myocardial abnormality causing systolic and/or diastolic ventricular dysfunction • Abnormalities of the valves, pericardium, endocardium, heart rhythm and conduction can also cause HF • Identification of the underlying cardiac problem is crucial for therapeutic reasons www.escardio.org/guidelines
12 New Classification and Diagnosis Diagnosis – Symptoms & Signs • Non-specific, difficult to identify • Detailed clinical history www.escardio.org/guidelines
13 New Classification and Diagnosis Diagnosis – initial investigations BNP – ECG - Echo • Patients with normal plasma NP concentrations are unlikely to have HF • AF, age and renal failure are the most important factors impeding the interpretation of NP measurements • An abnormal electrocardiogram (ECG) increases the likelihood of the diagnosis of HF – but low specificity (rule out) • Echocardiography is the most useful, widely available test in patients with suspected HF to establish the diagnosis www.escardio.org/guidelines
14 Algorithm for the diagnosis of HF The probability of HF should first be evaluated (History, HT, diuretic use, symptoms, examination, ECG) v Heart Failure unlikely: • If no history, -ve examination & N ECG • Normal BNP • Normal echo v An Echo is indicated if NP level above the exclusion level www.escardio.org/guidelines
15 New Classification and Diagnosis Diagnosis of HFpEF v The diagnosis of HFpEF requires the following: • The presence of symptoms and/or signs of HF • A ‘preserved’ EF (defined as LVEF ≥50% or 40–49% for HFmrEF) • Elevated levels of NPs (BNP >35 pg/mL and/or NT-proBNP >125 pg/mL) • An abnormal ECG increases the likelihood of HF • Objective evidence of other cardiac functional and structural alterations underlying HF – The pivotal role of Echo • In case of uncertainty, a stress test or invasively measured elevated LV filling pressure may be needed www.escardio.org/guidelines
16 New Classification and Diagnosis Diagnosis of HFpEF Clinical signs & symptoms the same as HFrEF, HFpEF, HFmrEF • ECG may be abnormal (LVH, AF, repol abnormalities) • Objective evidence of structural/functional cardiac alterations • LAVI >34 mL/m 2 , LVMI ≥115 g/m 2 (M) / ≥95g/m 2 (F) • E/e’ ≥13, mean e’ septal & lateral wall <9cm/s • GLS, TR velocities Diastolic stress test with echo (semi-supine bicycle ergometer) • LV E/e’, PAP, GLS, SV, CO Diagnosis difficult when AF • www.escardio.org/guidelines
17 New Classification and Diagnosis Cardiac Imaging Imaging tests should only be performed when they have a • meaningful clinical consequence Central role in the diagnosis of HF and in guiding treatment • Echocardiography is the method of choice in patients with • suspected HF (accuracy, availability, portability, safety and cost) Other modalities can be complimentary, chosen according to • their ability to answer specific clinical questions and taking account of contraindications to and risks of specific tests Reliability depends on the operator, centre experience and • imaging quality www.escardio.org/guidelines
18 New Classification and Diagnosis Chest X-ray • Of limited use • Pulmonary venous congestion • Most useful in identifying alternative, pulmonary explanation of symptoms www.escardio.org/guidelines
19 New Classification and Diagnosis Transthoracic Echocardiography The Teichholz and Quinones methods of calculating LVEF from • M-mode, as well as a measurement of FS, are not recommended! For LVEF, the modified biplane Simpson’s rule is recommended. • Contrast should be used in case of poor imaging! 3D echocardiography of adequate quality improves the • quantification of LV volumes and LVEF and has the best accuracy compared with values obtained through CMR Doppler for calculating haemodynamic variables (Svi and CO) • TDI (S wave) and deformation imaging (strain & strain rate) • are reproducible and feasible for clinical use www.escardio.org/guidelines
20 New Classification and Diagnosis Transthoracic Echocardiography www.escardio.org/guidelines
21 New Classification and Diagnosis Assessment of LV diastolic function v Diastolic dysfunction may be the underlying pathophysiological abnormality in patients with HFpEF and perhaps HFmrEF v Echocardiography is at present the only imaging technique that can allow for the diagnosis of diastolic dysfunction Objective evidence of structural/functional cardiac alterations • LAVI >34 mL/m 2 , LVMI ≥115 g/m 2 (M) / ≥95g/m 2 (F) • E/e’ ≥13, mean e’ septal & lateral wall <9cm/s • GLS, TR velocities Diastolic stress test with echo (semi-supine bicycle ergometer) • LV E/e’, PAP, GLS, SV, CO www.escardio.org/guidelines
22 New Classification and Diagnosis Assessment of RV function & PA Pressures An obligatory element of echocardiography examination! v RV structure & function v RA size v Estimate RV systolic function: TAPSE <17mm • S’ <9.5m/sec • PASP from TR velocity • 3D echo volumes is recommended • speckle tracking – specialised centres • www.escardio.org/guidelines
23 New Classification and Diagnosis Transoesophageal Echocardiography (TOE) v Not needed in the routine diagnostic assessment of HF But may be valuable in: valve disease and assessing severity • aortic dissection • suspected endocarditis • congenital heart disease • for ruling out thrombi in AF patients requiring cardioversion • www.escardio.org/guidelines
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