Diagnosis and new classification Prof. Dr. Adriaan Voors - - PowerPoint PPT Presentation

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Diagnosis and new classification Prof. Dr. Adriaan Voors - - PowerPoint PPT Presentation

Nov 05, 2022 187 likes •444 views

Diagnosis and new classification Prof. Dr. Adriaan Voors University Medical Center Groningen the Netherlands Treatment of Diabetes in HF Disclosures AAV received consultancy fees and/or research grants from: Alere, AstraZeneca, Bayer,

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Diagnosis and new classification

  • Prof. Dr. Adriaan Voors

University Medical Center Groningen the Netherlands

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Treatment of Diabetes in HF

University Medical Center Groningen

Disclosures

  • AAV received consultancy fees and/or research grants from: Alere,

AstraZeneca, Bayer, BMS, Boehringer, Cardio3Biosciences, Merck/MSD, Novartis, Servier, Singulex, Sphingotec, Stealth, Trevena, Vifor.

  • AAV is supported by a grant from the European Commission: FP7-

242209-BIOSTAT-CHF

  • AAV is Clinical Established Investigator and supported by other

grants of the Dutch Heart Foundation

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www.escardio.org/guidelines

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www.escardio.org/guidelines

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Now online available

http://www.escardio.org/Guidelines-&-Education/Clinical-Practice- Guidelines/Acute-and-Chronic-Heart-Failure

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www.escardio.org/guidelines

Key Points

  • Definition
  • New Classification HFrEF/HFpEF
  • Diagnosis of Heart Failure (general)
  • (NT-pro)BNP cut-offs
  • Diagnosis of HFpEF
  • Assessment of Diastolic Dysfunction

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www.escardio.org/guidelines

Definition

  • HF is a clinical syndrome characterized by typical

symptoms (e.g. breathlessness, ankle swelling and

fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, 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

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www.escardio.org/guidelines

Key Points

  • Definition
  • New Classification HFrEF/HFpEF
  • Diagnosis of Heart Failure (general)
  • (NT-pro)BNP cut-offs
  • Diagnosis of HFpEF
  • Assessment of Diastolic Dysfunction

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www.escardio.org/guidelines

Hands-up Question 1

  • Which LVEF cut-off to use for HFrEF?
  • A) ≤ 35%
  • B) ≤ 40%
  • C) ≤ 45%
  • D) ≤ 50%

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www.escardio.org/guidelines

Hands-up Question 2

  • Which LVEF cut-off to use for HFpEF?
  • A) ≥ 35%
  • B) ≥ 40%
  • C) ≥ 45%
  • C) ≥ 50%

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www.escardio.org/guidelines

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“The middle child of HF deserves attention: available data suggest that it constitutes a sizeable proportion (10–20%) of the HF population, has a unique clinical, echocardiographic, haemodynamic, and biomarker profile compared with HFrEF and HFpEF, and carries a poor prognosis. Large gaps in evidence regarding its treatment warrant further study.”

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www.escardio.org/guidelines

  • TOPCAT:n=3444; EF≥45%;
  • spironolactone vs. placebo
  • Primary outcome: neutral
  • HFmrEF greater treatment

effect than HFpEF

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Solomon et a;. EHJ 2016

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www.escardio.org/guidelines

Heart Failure with mid-range Ejection Fraction (HFmrEF)

Justification for the introduction of HFmrEF

  • Grey area between 40-50 %; HFpEF or HFrEF?
  • EF 40-49% different phenotype compared with EF>50%
  • Potentially differential treatment effects
  • “ Identifying HFmrEF as a separate group will stimulate

research into the underlying characteristics, pathophysiology and treatment of this group of patients”

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www.escardio.org/guidelines

New Classification of Heart Failure

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www.escardio.org/guidelines

Key Points

  • Definition
  • New Classification HFrEF/HFpEF
  • Diagnosis of Heart Failure (general)
  • (NT-pro)BNP cut-offs
  • Diagnosis of HFpEF
  • Assessment of Diastolic Dysfunction

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www.escardio.org/guidelines

Diagnostic algorithm for a diagnosis of heart failure of non- acute onset

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www.escardio.org/guidelines

Diagnostic algorithm for a diagnosis of heart failure of non-acute onset

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www.escardio.org/guidelines

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Natriuretic Peptides: cut-offs for EXCLUSION

Roberts E, et al.. BMJ 2015; Zaphiriou A, et al. Eur J Heart Fail 2005; Fuat A, et al. Br J Gen Pract 2006;Yamamoto K, et al. J Card Fail 2000; Cowie MR, et al. Lancet 1997; Krishnaswamy P, et al. Am J Med 2001; Kelder JC, et al. J Card Fail 2011.

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www.escardio.org/guidelines

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NT-proBNP cut-off in Non- Acute Setting

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www.escardio.org/guidelines

Natriuretic Peptides: cut-offs for EXCLUSION

  • “ At the mentioned exclusionary cut-points, the negative

predictive values are very similar and high (0.94–0.98) in both the non-acute and acute setting, but the positive predictive values are lower both in the non-acute setting (0.44–0.57) and in the acute setting (0.66–0.67).54,56 – 61

Therefore, the use of NPs is recommended for ruling-out HF, but not to establish the diagnosis.”

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www.escardio.org/guidelines

Key Points

  • Definition
  • New Classification HFrEF/HFpEF
  • Diagnosis of Heart Failure (general)
  • (NT-pro)BNP cut-offs
  • Diagnosis of HFpEF
  • Assessment of Diastolic Dysfunction

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www.escardio.org/guidelines

Definition

  • HF is a clinical syndrome characterized by typical symptoms

(e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema)

caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac

  • utput and/or elevated intracardiac pressures at rest or

during stress.

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www.escardio.org/guidelines

New Classification of Heart Failure

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www.escardio.org/guidelines

Echocardiographic HFpEF/HFmrEF criteria for “structural and/or functional cardiac abnormality”

  • How? Which parameters? Which cut-offs?

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Paulus WJ, et al. Eur Heart J 2007; Dokainish H, et al. Eur J Echocardiogr 2011; Caballero L, et al. Eur Heart J Cardiovasc Imaging 2015. Lang RM, et

  • al. Eur Heart J Cardiovasc Imaging 2015; Cohen GI, et al. J Am Coll Cardiol

1996; Gilman G, et al. J Am Soc Echocardiogr 2007; Nagueh SF, et al. Eur J Echocardiogr 2009; Nishimura RA, et al. J Am Coll Cardiol 1996; Ommen SR, et al. Circulation 2000;102:1788–1794.

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www.escardio.org/guidelines

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Diagnosis of HFpEF/HFmrEF

  • Limited data (Unmet Need!)
  • Cut-offs arbitrary
  • More criteria; greater

certainty of diagnosis

  • Diastolic stress test?
  • Invasive hemodynamic

measurements? HFpEF: EF≥50% HFmrEF: EF 40-49%

Signs (± symptoms) of HF

Structural abnormalities Functional abnormalities

LAVI >34ml/m2 LVMI >115g/m2 (m) >95 g/m2 ( f ) E/e‘avg ≥ 13 e‘ average (lateral-septal) < 9 cm/s

+ +

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www.escardio.org/guidelines

Conclusions: Diagnosis and new classification

  • Definition: No symptoms, no heart failure
  • New Classification: Addition of HFmrEF
  • Diagnosis of Heart Failure: New diagnostic algorithm
  • (NT-pro)BNP cut-offs for exclusion
  • Diagnosis of HFpEF: structural (LAVI>34 mL/m2 or LVMI ≥115

g/m2 (m) ≥95 g/m2 (f) ) of functional (E/e′ ≥13 mean e’ < 9 cm/s) abnormalities

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