ESC-51 COUNTRIESContentDefinition and diagnosisDiagnostic techniquesNon-pharmacological managementPharmacological therapyDevices and surgeryCo-morbidities and special populationsDefinition and diagnosis“The very essence of cardiovacular medicine is the recognition of early heart failure”Sir Thomas Lewis,1933Definition of HFImportantly,itwasemphasisedthatthediagnosisisnotdependentonacertainejectionfraction(EF),althoughithasimplicationsforprognosis.Common clinical manifestationsClinical manifestationsFatigueCoughBreathlessnessSwollenanklesDepressionWeightgainLossofappetiteNeedtourinateatnightPalpitationSwollenabdomenClassification of HFCommon causes of HFCoronary heart disease Many manifestationsHypertension Often associated with left ventricular hypertrophy and ejection fractionCardiomyopathies Familial/genetic or non-familial/non-genetic (including acquired, e.g. myocarditis) Hypertrophic (HCM), dilated (DCM), restrictive (RCM), arrhythmogenic right ventricular (ARVC), unclassifiedDrugs -Blockers, calcium antagonists, antiarrhythmics, cytotoxic agents Toxins Alcohol, medication, cocaine, trace elements (mercury, cobalt, arsenic) Endocrine Diabetes mellitus, hypo/hyperthyroidism, Cushing syndrome, adrenal insufficiency, excessive growth hormone, phaeochromocytomaNutritional Deficiency of thiamine, selenium, carnitine. Obesity, cachexiaInfiltrative Sarcoidosis, amyloidosis, haemochromatosis, connective tissue diseaseOthers Chagas disease, HIV infection, peripartum cardiomyopathy, end- stage renal failureClassification of HF New onset FirstpresentationAcuteorslowonsetTransient RecurrentorepisodicChronic PersistentStable,worsening,ordecompensatedTime is important for various types of heart failure.Diagnostic techniquesClinical examinationDiagnosis of HF with natriuretic peptidesAsregardsdiagnostictools,theimportanceofBNP/NT-proBNPwasstressed,anditisnowrecommendednotonlyforexcludingheartfailure,butalsoforconfirmationofthediagnosis.Diagnostic assessments supporting the presence of HF (BNP) in Differentiating between Dyspnea Alan S. Maisel, N Engl J Med 2002;347:161167. BNP among Patients in Each of the Four NYHA Classifications Alan S. Maisel, N Engl J Med 2002;347:161167. BNPBNP400pg/mL,NT-proBNP2000pg/m-Increasedventricularwallstress-HFlikely-Indicationforecho-ConsidertreatmentBNP100pg/mL,NT-proBNP40-50%.HFwithpreservedejectionfraction(HFPEF)ispresenthalfthepatientswithHF.”Epidemiologic studies Solomon SD,Circulation 112:3738- 3744, 2005Assessment of HFPEFPresenceofsignsand/orsymptomsofchronicHF.PresenceofnormaloronlymildlyabnormalLVsystolicfunction(LVEF45-50%).Evidenceofdiastolicdysfunction(abnormalLVrelaxationordiastolicstiffness).Speckle-tracking echocardiographyA 62-year-old man with a normal heartEF=60%A 78-year-old manDiastolic dysfunctionEF=55% Process underlying HFPEFNon-pharmacological managementAstrongrelationshipbetweenhealthcareprofessionalsandpatientsaswellassufficientsocialsupportfromanactivesocialnetworkhasbeenshowntoimproveadherencetotreatment.ItisrecommendedthatfamilymembersbeinvitedtoparticipateineducationprogrammesanddecisionsregardingtreatmentandcareSabate E. Adherence to Long-term Therapies. Evidence for Action. Geneva: WHO;2003.People involved in careThe PlayersPharmacological therapyPrognosis:Reduce mortalityMorbidity:Improve quality of life Prevention:Reduce hospitalizationACE inhibitorsUnlesscontraindicatedornottolerated,anACEIshouldbeusedinallpatientswithsymptomaticHFandaLVEF40%.TreatmentwithanACEIimprovesventricularfunctionandpatientwell-being,reduceshospitaladmissionforworseningHF,andincreasessurvival.Inhospitalizedpatients,treatmentwithanACEIshouldbeinitiatedbeforedischarge.Class of recommendation I, level of evidence ACONSENSUS(1987) and SOLVD-Treatment(1991)Mortality Reductions with ACEI051015202530Relative Risk Reduction (%)CONSENSUSSOLVDSAVEAIREHOPEn=253n=4228n=2231n=1986n=3577CONSENSUS: NEJM 1987;316:1429-435, SOLVD: NEJM 1991;325:293-302, SAVE: NEJM 1992;327:669-677AIRE: Lancet 1993;342:821-828, HOPE: Lancet 2000;355:253-259-BlockersUnlesscontraindicatedornottolerated,ab-blockershouldbeusedinallpatientswithsymptomaticHFandanLVEF40%.b-Blockadeimprovesventricularfunctionandpatientwell-being,reduceshospitaladmissionforworseningHF,andincreasessurvival.Wherepossible,inhospitalizedpatients,treatmentwithab-blockershouldbeinitiatedcautiouslybeforedischarge.Class of recommendation I, level of evidence ACIBIS II(1999), MERIT-HF(2000) and COPERNICUS(2002)Effect of -Blockers on outcomeAldosterone antagonistsUnlesscontraindicatedornottolerated,theadditionofalow-dose of an aldosterone antagonist should beconsideredinallpatientswithanLVEF35%andseveresymptomaticHF,i.e.currentlyNYHAfunctionalclassIIIorIV,intheabsenceofhyperkalaemiaandsignificantrenaldysfunction.Aldosterone antagonists reduce hospital admission forworsening HF and increase survival when added toexistingtherapy,includinganACEI.Inhospitalizedpatientssatisfyingthesecriteria,treatmentwithanaldosteroneantagonistshouldbeinitiatedbeforedischarge.Class of recommendation I, level of evidence BRALES(1999), EPHESUS(2003)Aldosterone antagonists in HFPitt B, N Engl J Med 1999;341:709717Pitt B, N Engl J Med 2003;348:13091321.ARBsUnlesscontraindicatedornottolerated,anARBis recommended in patients with HF and anLVEF 40% who remain symptomatic despiteoptimal treatment with an ACEI and b-blocker,unlessalsotakinganaldosteroneantagonist.Treatment with an ARB improves ventricularfunction and patient well-being, and reduceshospitaladmissionforworseningHF.Class of recommendation I, level of evidence AVal-HEFT(2001) and CHARMAdded(2003)CHARM-Alternative trialGranger et al. Lancet 2003;362:7726.Proportion with event(%)DigoxinIn patients with symptomatic HF and AF, digoxin may be used to slow a rapid ventricular rate. In patients with AF and an LVEF40% it should be used to control heart rate in addition to, or prior to a b-blocker.Class of recommendation I, level of evidence CThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart FailureN Eng1 Med,1997;336:525-533DIG TRAIL-All-cause mortalityPlaceboDigoxinThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533Hospital admission for worsening HF28%P0.01PlaceboDigoxinThe Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure N Eng1 Med,1997;336:525-533DiureticsDiuretics are recommended in patients with HF and clinical signs or symptoms of congestion.Class of recommendation I, level of evidence BInsymptomaticpatientswithanLVEF40%,thecombination of H-ISDN may be used as analternativeifthereisintolerancetobothanACEIandanARB.Adding the combination of H-ISDN should beconsideredinpatientswithpersistentsymptomsdespitetreatmentwithanACEI,b-blocker,andanARBoraldosteroneantagonist.Treatment with H-ISDN in these patients mayreducetheriskofdeath.Hydralazine and isosorbide dinitrate(H-ISDN)Class of recommendation IIa, level of evidence BV-HeFT-I(1991)and A-HeFT(2004)Other drugs-Statins“InelderlypatientswithsymptomaticchronicHFandsystolicdysfunctioncausedbyCAD,statintreatmentmaybeconsideredtoreducecardiovascularhospitalization.”Class of recommendation IIb, level of evidence BTrial design:Atotalof5011patientsatleast60yearsofagewithNewYorkHeartAssociationclassII,III,orIVischemic,systolicheartfailurewererandomlyassignedtoreceive10mgofrosuvastatinorplaceboperdayResults: -PrimaryOutcome:11.4%withrosuvastatinvs.12.3%withplacebo(p=0.12)-DeathfromAnyCause:11.6%vs.12.2%(p=0.31),respectively-AnycauseHospitalizations:2193vs.2564(p0.001),respectivelyRosuvastatin in Older Patientswith Systolic Heart FailureN Engl J Med 2007;357:22482261.Primary Outcome and Death from Any CauseN Engl J Med 2007;357:22482261.N Engl J Med 2007;357:22482261.Hospitalizations for cardiovascular causesP40daysofMI(ClassILevelA)-Non-ischaemicaetiology(ClassILevelB)CRT-NYHAClassIII/IVandQRS.120ms(ClassILevelA)-Toimprovesymptoms/reducehospitalization(ClassILevelA)-Toreducemortality(ClassILevelA)Class I recommendationsICDICDtherapyforprimarypreventionisrecommendedtoreducemortalityinpatientswithLVdysfunctionduetopriorMIwhoareatleast40dayspost-MI,haveanLVEF35%,inNYHAfunctionalclassIIorIII,receivingoptimalmedicaltherapy,andwhohaveareasonableexpectationofsurvivalwithgoodfunctionalstatusfor1year.(Class of recommendation I, level of evidence A)Meta-analysesofprimarypreventiontrialshaveshownthatthebenefitonsurvivalwithICDsishighestinthepost-MIpatientswithdepressedsystolicfunction(LVEF35%).Canadian Implantable DefibrillatorStudy. Eur Heart J 2000;21:20712078.Mortality of ICD23%Bardy GH, N Engl J Med 2005;352:225237.CRTThesurvivaladvantageofCRT-Dvs.CRT-Phasnotbeenadequatelyaddressed.IntheCARE-HFtrial,CRT-Pwasassociatedwithasignificantreductionof37%inthecompositeend-pointoftotaldeathandhospitalizationformajorcardiovascularevents(P0.001)andof36%intotalmortality(P0.002).COMPANION.N Engl J Med 2004;350:21402150.CARE-HF trial. N Engl J Med 2005;352:15391549.COMPANION All-Cause Death ResultsDays from RandomizationEvent-Free Survival (%)1009080706050OPTCRTCRT-D(CRT vs. OPT) P = 0.059 (CRT-D vs. OPT) P = 0.003 Bristow M. N Engl J Med. 2004;350:2140-2150.9090081072063054036027018009901080450Co-morbidities and special populationsManagement of arterial hypertension inpatients with HFConclusionthediagnosisofHFwithnatriureticpeptides(BNP)HFwithpreservedejectionfraction(HFPEF)RosuvastatininOlderPatientswithSystolicHeartFailure(statin)The Loop of Knowledge ResearchClinical TrialsGuidelinesEducation based on GuidelinesEvaluation of Practices by SurveysThanks For Your Attention!