2016 ESC Guidelines for the Diagnosis and treatment of on Acute - - PowerPoint PPT Presentation

2016 ESC Guidelines for the Diagnosis and treatment of

• n Acute & Chronic

Heart Failure Acute heart failure: Management of the early phase

John Parissis, MD

Heart Failure Unit Attikon University Hospital Athens, Greece

2

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Disclosures

• Research grants and honoraria for lectures from Pfizer,

Servier, Novartis International, Orion Pharma

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Goals of treatment in acute heart failure

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Goals of treatment in acute heart failure

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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

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Initial management

• f a patient

with acute HF

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Oxygen therapy and ventilatory support

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Pharmacologic treatment of AHF

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Pathophysiology of congestion in AHF

Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015

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Pathophysiology of congestion in AHF

Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015

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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

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Pharmacotherapy Diuretics

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Pathophysiology of congestion in AHF

Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015

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Pharmacotherapy Vasodilators

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Pharmacotherapy Vasodilators

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Pharmacotherapy Inotropes and vasopressors

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Inotropes and outcome in AHF

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 Cuffe MS, et al. JAMA 2002 O’Connor CM, et al. Am Heart J 1999

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Inotropes and outcome in AHF

Mebazaa A, et al. Intens Care Med 2011 Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002 Cuffe MS et al. JAMA 2002

ALARM-HF

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Pharmacotherapy Inotropes and vasopressors

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Pharmacotherapy TE prophylaxis and other drugs

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Management of cardiogenic shock

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Management of patients with acute heart failure based on clinical profile during an early phase

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Management of patients with AHF based on clinical profile during early phase

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Clinical profiles of patients with AHF based on the presence/absence of congestion and/or hypoperfusion

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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

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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