2016 ESC Guidelines for the Diagnosis and treatment of on Acute & Chronic Heart Failure Acute heart failure: Management of the early phase John Parissis, MD Heart Failure Unit Attikon University Hospital Athens, Greece
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Disclosures Research grants and honoraria for lectures from Pfizer, • Servier, Novartis International, Orion Pharma www.escardio.org/guidelines
Goals of treatment in acute heart failure www.escardio.org/guidelines
Goals of treatment in acute heart failure www.escardio.org/guidelines
Criteria for hospitalization in ICU/CCU High risk patients (persistent significant dyspnea, hemodynamic • instability, severe arrhythmias, AHF due to ACS) Need for intubation (or already intubated) • Signs/symptoms of hypoperfusion • SpO2 < 90% despite supplemental oxygen • Use of accessory muscles for breathing, RR > 25/min • Heart rate < 40 or > 130 bpm, SBP < 90 mmHg • www.escardio.org/guidelines
Initial management of a patient with acute HF www.escardio.org/guidelines
Oxygen therapy and ventilatory support www.escardio.org/guidelines
Pharmacologic treatment of AHF www.escardio.org/guidelines
Pathophysiology of congestion in AHF www.escardio.org/guidelines Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015
Pathophysiology of congestion in AHF www.escardio.org/guidelines Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015
Diuretics in AHF DOSE Trial • 308 pts with AHF • Bolus every 12h vs continuous infusion • Low dose (=oral) vs high dose (2.5 x oral) No significant differences: • in symptoms at 72h • in creatinine change at 72h • in death, rehospitalization or RF visits at 60 d Felker et al, N Engl J Med 2011 www.escardio.org/guidelines
Pharmacotherapy Diuretics www.escardio.org/guidelines
Pathophysiology of congestion in AHF www.escardio.org/guidelines Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015
Pharmacotherapy Vasodilators www.escardio.org/guidelines
Pharmacotherapy Vasodilators www.escardio.org/guidelines
Pharmacotherapy Inotropes and vasopressors www.escardio.org/guidelines
Inotropes and outcome in AHF O’Connor CM, et al. Am Heart J 1999 Cuffe MS, et al. JAMA 2002 www.escardio.org/guidelines Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002
Inotropes and outcome in AHF ALARM-HF Mebazaa A, et al. Intens Care Med 2011 www.escardio.org/guidelines Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002
Pharmacotherapy Inotropes and vasopressors www.escardio.org/guidelines
Pharmacotherapy TE prophylaxis and other drugs www.escardio.org/guidelines
Management of cardiogenic shock www.escardio.org/guidelines
Management of patients with acute heart failure based on clinical profile during an early phase www.escardio.org/guidelines
Management of patients with AHF based on clinical profile during early phase www.escardio.org/guidelines
Clinical profiles of patients with AHF based on the presence/absence of congestion and/or hypoperfusion www.escardio.org/guidelines
What’s new New treatment algorithm based mainly on clinical evaluation rather • than SBP levels only Definition of criteria for ICU/CCU admission • Specific guidance for diuretic use • Change in cut-off levels of SBP for vasodilator use • Change of recommendation class for inotropes • Change of recommendation class for opiates • www.escardio.org/guidelines
What’s missing Prospective evaluation of the ‘time-to-treatment’ concept • Role of inadequate phenotyping in treatments failure • Better definition and treatment of diuretic resistance • Role of new drugs • Treatments improving mortality and morbidity • www.escardio.org/guidelines
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