Ten commandments on optimal management of heart failure
At the presentation of the new ESC Heart Failure Guidelines, Professor Ponikowski (Wroclaw, Poland), Chairperson of the guidelines Task Force, formulated the take home summary of the new HF guidelines in the form of ten commandments.
- Apply a novel algorithm for the diagnosis of HF in non-acute setting based on clinical probability of the disease (derived from medical history, physical examination and resting ECG), the assessment of circulating natriuretic peptides and transthoracic echocardiography.
- Use transthoracic echocardiography in patients with suspected or established HF for the assessment of myocardial structure and function along with the measurement of LVEF to establish the diagnosis of HF with reduced (HFrEF, LVEF<40%), mid-range (HFmrEF, LVEF: 40-49%) or preserved ejection fraction (HFpEF, LVF>50%).
- To prevent or delay onset of HF and prolong life, treatment of arterial hypertension, use of statins in patients with or at high risk of coronary artery disease, use of ACE-I in patients with a symptomatic left ventricular dysfunction and beta-blockers in those with asymptomatic left ventricular dysfunction and a history of myocardial infarction are recommended.
- Implement life-saving pharmacotherapy in patiens with symptomatic HFrEF, containing a combination of an ACE-I (or ARB if ACE-I not tolerated), a beta-blocker and an MRA. If a patient still remains symptomatic, sacubitril-valsartan is recommended to replace ACE-I. Use diuretics in order to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion.
- Ensure an ICD implantation in HF patients who either have recovered from a ventricular arrhythmia causing haemodynamic instability or in those with symptomatic HF, LVEF<35% (despite at least 3 months of OMT), in order to reduce the risk of sudden death and all-cause mortality. ICD implantation is not recommended within 40 days of an MI as implantation at this time does not improve prognosis.
- Implant a cardiac resynchronisation therapy in symptomatic patients with HF, LVEF<35% (despite at least 3 months of OMT), in sinus rhythm with a QRS duration >130 msec and LBBB QRS morphology, in order to improve symptoms and reduce morbidity and mortality. CRT is contra-indicated in patients with a QRS duration < 130 msec.
- In the management of a patient with suspected acute HF, try to shorten all diagnostic and therapeutic decisions. During an initial phase, reassure that circulatory or/and ventilator support is provided in case of either cardiogenic shock or/and ventilatory failure, respectively.
- In parallel, identify immediately coexisting life-threatening clinical conditions and/or precipitants (according to the CHAMP acronym: acute Coronary syndrome, Hypertension emergency, Arrhythmia, acute Mechanical cause, Pulmonary embolism) and introduce a guideline-recommended specific management.
- During an early phase of AHF for an optimal management apply the algorithm based on clinical profiles evaluating the presence of congestion and peripheral hypoperfusion. Remember that hypoperfusion is not synonym with hypotension, but often hypoperfusion is accompanied by hypotension.
- Enrol patients with HF in a multidisciplinary care management programme in order to reduce the risk of HF hospitalisation and mortality.