The new Guidelines: Focus Professor of Cardiology Imperial College - - PowerPoint PPT Presentation

The new Guidelines: Focus

• n Chronic Heart Failure

New Classification and Diagnosis Petros Nihoyannopoulos MD, FRCP, FESC Professor of Cardiology Imperial College London and National & Kapodistrian University of Athens

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New Classification and Diagnosis

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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

• f 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

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New Classification and Diagnosis

The principal changes from the 2012 guidelines (continue): (v) recommendations aimed at prevention or delay of the development

• f 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);

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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

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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’,

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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

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New Classification and Diagnosis

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

New Classification!

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New Classification and Diagnosis

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

New Classification!

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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

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New Classification and Diagnosis

Diagnosis – Symptoms & Signs

• Non-specific, difficult to identify
• Detailed clinical history

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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
• f 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

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• If no history, -ve examination & N ECG
• Normal BNP
• Normal echo

v Heart Failure unlikely: The probability of HF should first be evaluated

(History, HT, diuretic use, symptoms, examination, ECG)

v An Echo is indicated if NP level above the exclusion level

Algorithm for the diagnosis of HF

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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

New Classification and Diagnosis

Diagnosis of HFpEF

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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/m2, LVMI ≥115 g/m2 (M) / ≥95g/m2 (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

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New Classification and Diagnosis

Cardiac Imaging

• 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

• Imaging tests should only be performed when they have a

meaningful clinical consequence

• Reliability depends on the operator, centre experience and

imaging quality

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New Classification and Diagnosis

Chest X-ray

• Of limited use
• Pulmonary venous congestion
• Most useful in identifying

alternative, pulmonary explanation of symptoms

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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!

• 3D echocardiography of adequate quality improves the

quantification of LV volumes and LVEF and has the best accuracy compared with values obtained through CMR

• For LVEF, the modified biplane Simpson’s rule is recommended.

Contrast should be used in case of poor imaging!

• Doppler for calculating haemodynamic variables (Svi and CO)
• TDI (S wave) and deformation imaging (strain & strain rate)

are reproducible and feasible for clinical use

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New Classification and Diagnosis

Transthoracic Echocardiography

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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/m2, LVMI ≥115 g/m2 (M) / ≥95g/m2 (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

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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

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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

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New Classification and Diagnosis

Stress Echocardiography

v Exercise or pharmacological stress echocardiography may be used for the assessment of inducible ischaemia and/or viability v In valve disease, e.g. dynamic mitral regurgitation, low-flow–low-gradient aortic stenosis v For the detection of diastolic dysfunction in patients with exertional dyspnoea, preserved LVEF and inconclusive diastolic parameters at rest

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New Classification and Diagnosis

Cardiac magnetic resonance

v CMR is the gold standard for the measurements of volumes, mass and EF of both the left and right ventricles v The best alternative cardiac imaging modality for patients with non-diagnostic echocardiographic studies v The method of choice in patients with complex congenital heart diseases v CMR is the preferred imaging method to assess myocardial fibrosis using LGE along with T1 mapping and can be useful for establishing HF aetiology

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New Classification and Diagnosis

Cardiac magnetic resonance

v CMR may also be used for the assessment of myocardial ischaemia and viability in patients with HF and CAD § local expertise, lower availability and higher costs § uncertainty about safety in patients with metallic implants (devices) § less reliable measurements in patients with tachyarrhythmias § claustrophobia § contrast agents contraindicated in individuals with a GFR <30 mL/min/1.73m2 - nephrogenic systemic fibrosis (NSF) v Clinical limitations:

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New Classification and Diagnosis

Single-photon emission computed tomography and radionuclide ventriculography

v Single-photon emission CT (SPECT) may be useful in assessing ischaemia and myocardial viability v Gated SPECT can also yield information on ventricular volumes and function, but exposes the patient to ionizing radiation v PET useful in ishaemia and viability but limited availability, radiation exposure and cost are the main limitations

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New Classification and Diagnosis

Cardiac CT

v Cardiac CT may be considered in patients with HF and low to intermediate pre-test probability of CAD or those with equivocal non-invasive stress tests in order to rule out CAD (IIb C)

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New Classification and Diagnosis

Coronary angiography

v In concordance with the recommendations of other relevant ESC guidelines v Coronary angiography is recommended in patients with HF and angina pectoris recalcitrant to medical therapy, provided that are suitable for revascularisation (IC) v Coronary angiography recommended in patients with a history

• f symptomatic ventricular arrhythmia or aborted cardiac arrest

v Should be considered in patients with HF and intermediate to high pre-test probability of CAD and presence of ischaemia in non-invasive stress tests in order to establish CAD severity (IIa C)

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Recommendations IIa

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Thank you