The New ESC Guidelines: HFrEF: Devices & Interventions. John - - PowerPoint PPT Presentation

The New ESC Guidelines: HFrEF: Devices & Interventions.

John GF Cleland Imperial College London

8:30am: 9.15-9.30

www.escardio.org/guidelines

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www.escardio.org/guidelines

ESC Guidelines on Heart Failure

• Professional (Expert) Guidelines

– No patient involvement (yet)

• Evolved from 2012 Guideline

– Discouraged from re-interpreting old evidence – Encouraged to respond to new evidence (trials or meta-/re-analyses)

• Interpret & Apply Results (Not a Textbook!)

– Rather than long summaries

• Coordinated with Other ESC Guidelines

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New (Published) Landmark Trials Since 2012

BIOPACE not yet published

Echo-CRT BLOCK-HF

Mortality Inappropriate Activation

2013

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New Published Meta-Analyses Since 2012

Only QRS duration

predicts CRT prognostic benefit

Independent predictors of Benefit of CRT

• Younger patients
• Women
• QRS Duration
• Not LVEF
• Not Aetiology
• Not QRS Morphology

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2012 2016

The ‘Rise’ of Rhythm in Heart Failure

www.escardio.org/guidelines

Recommendations for implantable cardioverter- defibrillator in patients with heart failure

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2012

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‘New’ Issues: >30% of ICD Implants are for Generator Exchange

EHRA: units pa ~4,000 (32%) Italy, ~2,000 (27%) UK; ~20,000 (39%) Germany (includes CRT-D)

Of patients who required exchange 68% had received no ATP/shock of whom 11% received ATP/shock (FU ~30m) 24% of whom died anyway

ATP/Shock Shock

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2012 2016

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Recommendations for cardiac resynchronization therapy implantation in patients with heart failure

www.escardio.org/guidelines

QRS Duration / Morphology Debate

• Longer QRS Duration
• Consistently associated with

benefit

• Threshold 130-140ms
• Planned trial inclusion criterion
• Prospective subgroup analyses
• LBBB QRS Morphology
• Most of the data is LBBB

But

• Not used for inclusion
• Mainly retrospective subgroup analyses
• Most reports conflate RBBB/IVCD
• IVCD have shorter QRS
• RBBB more IHD; often sicker
• LBBB is a surrogate for longer QRS,

DCM and less sick patients

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Is LBBB is just a surrogate for QRS duration?

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Conclusions: CRT

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QRS >150ms (+/- LBBB) (+/- AF) NYHA III LVEF <35% QRS 120(130 if NYHA II)-150ms

• Only LBBB
• Only AF if NYHA III

NYHA II LVEF <30%

2016

• QRS >130ms
• LVEF <35%
• If SR - NYHA II-IV
• If AF - NYHA III-IV
• Longer QRS  Greater Benefit
• Does QRS Morphology Matter?

2012

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Coronary Revascularization

• Two RCTs:- HEART-UK & STICH – both neutral
• If revascularization does not improve outcome – why do a

coronary angiogram?

• Revascularization improved neither cardiac function nor HF symptoms
• Neither the presence of viability, ischaemia nor angina identify those

who had a greater benefit from CABG on mortality.

• CABG does improve angina

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Other Interventions

• Other Implantable Devices
• Vagal Stimulation
• Baroreceptor Stimulation
• Cardiac Contractility Modulation
• Circulatory Support
• Other Interventions
• Valves
• Ablation (AV / PV / Renal)
• Transplantation
• Ultrafiltration
• Algisyl LVR
• Other