Guideline directed medical therapy for “Chronic Heart Failure“
•Als PPTX, PDF herunterladen•
8 gefällt mir•2,003 views
Current guidelines for Heart Failure
Empfohlen
Weitere ähnliche Inhalte
Was ist angesagt?
Was ist angesagt? (20)
Ähnlich wie Guideline directed medical therapy for “Chronic Heart Failure“
Ähnlich wie Guideline directed medical therapy for “Chronic Heart Failure“ (20)
Mehr von Arindam Pande
Mehr von Arindam Pande (16)
Kürzlich hochgeladen
Kürzlich hochgeladen (20)
Guideline directed medical therapy for “Chronic Heart Failure“
- 1. Medica Lab is NABL accredited Guideline directed medical therapy for “Chronic Heart Failure“ Dr. Arindam Pande MBBS (Hons), MD, DM, FESC, FSCAI, FACC (USA), FRCP (Glasg) Consultant Interventional Cardiologist, Medica SuperSpeciality Hospital, Kolkata www.drarindampande.com
- 3. New Classification of Heart Failure 25
- 4. HOSPITAL 1 year ~20% mortality after 1 year‡†2,3 5 years ~50% mortality after 5 years†2 30 days 3.8% in-hospital mortality rate‡1 ~10% mortality after 30 days†2 HF=heart failure ‡Data from 1,892 European patients with acute heart failure in the European Society of Cardiology Heart Failure (ESC-HF) Pilot study †Analysis of HF data from 1,282 incident cases of heart failure in the Atherosclerosis Risk in Communities (ARIC) population-based study of n=15,792 individuals from four communities in the USA (1987–2002) 1. Maggioni et al. Eur J Heart Fail 2010;12:1076–84; 2. Loehr et al. Am J Cardiol 2008;101:1016–22; 3. Maggioni et al. Eur J Heart Fail 2013;15:808–17 HF is associated with significant mortality 4 TW1602431273
- 5. Heart failure is deadlier than many cancers 5 TW1602431273
- 6. Recent trends in Heart Failure treatment • Medical Management -- Emergence of Valsartan/Sacubitril -- Re-emphasizing importance of heart rate modulation -- Management of iron deficiency in HF • Device therapy -- ICD: Role of Primary prevention in Non-ischemic DCM -- CRT: Newer concepts to reduce non-responder rate
- 7. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure 2016 ESC Guideline on the Diagnosis and Treatment of Acute and Chronic Heart Failure Guidelines 2016- Improving Care of Patients with Heart Failure Yancy CW, et al. Journal of the American College of Cardiology (2016), doi: 10.1016/j.jacc.2016.05.011; Eur J Heart Fail. 2016 May 20. doi: 10.1002/ejhf.592. Concurrently developed recommendations
- 8. Algorithm for a Patient with Symptomatic Heart Failure with Reduced Ejection Fraction- ESC 2016 Eur J Heart Fail. 2016 May 20. doi: 10.1002/ejhf.592.
- 10. Diuretic Angiotensin Converting Enzyme Inhibitor Aldosterone Antagonist Angiotensin Receptor Antagonist Beta-adrenoreceptor Antagonists Digoxin Hydralazine/Nitrate Ivabradine Sacubutril-Valsartan The Potential Drugs for HF-REF
- 11. Beta blocker Mineralocorticoid receptor antagonist Drugs That Reduce Mortality in Heart Failure With Reduced Ejection Fraction ACE inhibitor Angiotensin receptor blocker Drugs that inhibit the renin- angiotensin system have modest effects on survival Based on results of SOLVD-Treatment, CHARM-Alternative, COPERNICUS, MERIT-HF, CIBIS II, RALES and EMPHASIS-HF 10% 20% 30% 40% 0% %DecreaseinMortality
- 12. Pharmacological treatments indicated in patients with symptomatic (NYHA Class II-IV) HFrEF
- 13. Pharmacological treatment of HFrEF • ACEIs, MRAs and beta-blockers have been shown to improve survival and are recommended for the treatment of every patient • The use of diuretics should be modulated according to the patient’s clinical status • Beta-blockers and ACEIs are complementary, and can be started together as soon as the diagnosis of HFrEF is made. • There is no evidence favouring the initiation of treatment with a beta-blocker before an ACEI has been started
- 14. 14 Neprilysin inhibitors: natriuretic and other vasoactive peptides enhancement Evolution of pharmacologic approaches in HF: Neprilysin inhibition as a new therapeutic strategy1 ACEI=angiotensin-converting enzyme inhibitor; Ang=angiotensin; ARB=angiotensin receptor blocker; AT1R= angiotensin II type 1 receptor; HF=heart failure; MRA=mineralocorticoid receptor antagonist; NP=natriuretic peptide; NPRs=natriuretic peptide receptors; RAAS=renin-angiotensin- aldosterone system; SNS=sympathetic nervous system 1. McMurrayet al. Eur J Heart Fail. 2013;15:1062–73; Figure references: Levin et al. N Engl J Med 1998;339:321–8; Nathisuwan & Talbert. Pharmacotherapy2002;22:27–42; Kemp & Conte. Cardiovascular Pathology 2012;365–71; Schrier & Abraham N Engl J Med 2009;341:577–85 SNS RAAS Vasoconstriction Blood pressure Sympathetic tone Aldosterone Hypertrophy Fibrosis Ang II AT1R HF SYMPTOMS & PROGRESSION INACTIVE FRAGMENTS NP system Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy NPRs NPs Epinephrine Norepinephrine α1, β1, β2 receptors Vasoconstriction RAAS activity Vasopressin Heart rate Contractility Neprilysin inhibitors RAAS inhibitors (ACEI, ARB, MRA) β-blockers
- 15. Angiotensin receptor neprilysin inhibitor (Sacubitril/Valsartan) • Based on PARADIGM-HF, LCZ 696 should be used in patients with: • ambulatory, symptomatic HFrEF • treated with ACEi/ARB, BB and MRA • elevated plasma NP levels (BNP ≥150 pg/mL or NT-proBNP ≥600 pg/mL) • estimated GFR (eGFR) ≥30 mL/min/1.73 m2 of body surface area • who are able to tolerate treatment with enalapril (see run-in period in trial) • Some relevant issues for clinical practice: • symptomatic hypotension in some cases &risk of angioedema (Note: ACEI should be withheld for at least 36 h before initiating LCZ696) • NP–assessment: BNP biomarker cannot be used, valid are only NT-BNP or MR-proANP
- 16. Heart rate modulation in HF: background
- 17. Atherosclerosis Endothelial dysfunction↑ Oxidative stress↑ Plaque stability↓ Arterial stiffness↑ Ischemia Oxygen consumption↑ Duration of diastole↓ Coronary perfusion↓ Remodeling Cardiac hypertrophy↑ Chronic heart failure Oxygen demand↑ Ventricular efficiency ↓ Ventricular relaxation↑ Elevated heart rate + + + + The pivotal role of heart rate in cardiovascular disease
- 18. Limitations of beta blockers Patients with CHF (Chronic Heart Failure) who are on beta- blockers have inadequately controlled heart rate (HR) 1 Patients do not tolerate the target doses of beta-blockers used in the large clinical trials 2 1. Clin Res Cardiol 2013;102:23–31 2. Br J Cardiol 2012;19:21–3.
- 21. If-channel inhibitor • Ivabradine is indicated in HF patients with: • symptomatic patients with HFrEF • in sinus rhythm and with a heart rate ≥70 bpm • who had been hospitalized for HF within the previous 12 months • Note: The European Medicines Agency (EMA) approved ivabradine for use in Europe in patients with HFrEF with LVEF ≤35% and in sinus rhythm with a resting heart rate ≥75 bpm, because in this group ivabradine conferred a survival benefit.
- 22. Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) HFrEF
- 23. Other treatments with less certain benefit in symptomatic patients with HFrEF Digoxin and other digitalis glycosides • Digoxin may be considered in patients in sinus rhythm to reduce the risk of hospitalisation in symptomatic patients with HFrEF • It is only recommended for the treatment of patients with HFrEF and AF with rapid ventricular rate when other therapeutic options cannot be pursued • A resting ventricular rate in the range of 70–90 bpm is recommended, although a resting ventricular rate of up to 110 bpm might still be acceptable • Digitalis should always be prescribed under specialist supervision. Caution should be exerted in females, in the elderly and in patients with reduced renal function.
- 24. Other treatments with less certain benefit in symptomatic patients with HFrEF 3 polyunsaturated fatty acids • n-3 PUFA preparations may be considered as an adjunctive therapy in patients with symptomatic HFrEF who are already receiving optimized recommended therapy with an ACEI (or ARB), a beta-blocker and an MRA.
- 25. RCT Evidence for Intra Venous Fe
- 26. Iron deficiency in HF: guidelines recommendations • tinine Diagnostic tests for newly diagnosed HF (Ic): -Hb and WBC -sodium, potassium, urea, crea (with eGFR) -LFTs glucose, HbA1c -lipid profile -TSH -Ferritin, TSAT = TIBC Diagnostic criteria: Ferritin<100ug/ml OR Ferritin 100-300ug/ml and TSAT<20%
- 27. Recommendations for the treatment of other co- morbidities in patients with HF => should be treatment of choice, except in severe renal or hepatic impairment
- 28. 2016 ESC Guidelines for the Diagnosis and treatment of Acute & Chronic Heart Failure ESC Recommendations: Empagliflozin for Prevention of Heart Failure or Death
- 29. EMPEROR-Reduced and EMPEROR-Preserved Heart Failure Outcome Trials HF with Reduced Ejection Fraction (HFrEF) • T2D and non-T2D • Event driven trial • 2850 pts HF with Preserved Ejection Fraction (HFpEF) • T2D and non-T2D • Event driven trial • 4126 pts + EMPEROR-Reduced1 EMPEROR-Preserved2 1. NCT03057977 2. NCT03057951 www.clinicaltrials.gov 2850 randomized patients (can be increased up to 4000 patients) globally 4126 randomized patients (can be increased up to 6000 patients) globally
Hinweis der Redaktion
- 心臟衰竭是一種高死亡率的疾病 住院死亡率約3.8% 出院後一個月死往率約10% 一年後死亡率約20% 五年後死亡率約40% 這樣的致死率，甚至比某些癌症還來的高
- Therapeutic algorithm for a patient with symptomatic heart failure with reduced ejection fraction. Green indicates a class I recommendation; yellow indicates a class IIa recommendation. ACEI ¼ angiotensin-converting enzyme inhibitor; ARB ¼ angiotensin receptor blocker; ARNI ¼ angiotensin receptor neprilysin inhibitor; BNP ¼ B-type natriuretic peptide; CRT ¼ cardiac resynchronization therapy; HF ¼ heart failure; HFrEF ¼ heart failure with reduced ejection fraction; H-ISDN ¼ hydralazine and isosorbide dinitrate; HR ¼ heart rate; ICD ¼ implantable cardioverter defibrillator; LBBB ¼ left bundle branch block; LVAD ¼ left ventricular assist device; LVEF ¼ left ventricular ejection fraction; MR ¼ mineralocorticoid receptor; NT-proBNP ¼ N-terminal pro-B type natriuretic peptide; NYHA ¼ New York Heart Association; OMT ¼ optimal medical therapy; VF ¼ ventricular fibrillation; VT ¼ ventricular tachycardia. aSymptomatic ¼ NYHA Class II-IV. bHFrEF ¼ LVEF ,40%. cIf ACE inhibitor not tolerated/contra-indicated, use ARB. dIf MR antagonist not tolerated/contra-indicated, use ARB. eWith a hospital admission for HF within the last 6 months or with elevated natriuretic peptides (BNP . 250 pg/ml or NTproBNP . 500 pg/ml in men and 750 pg/ml in women). fWith an elevated plasma natriuretic peptide level (BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL, or if HF hospitalization within recent 12 months plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL). gIn doses equivalent to enalapril 10 mg b.i.d. hWith a hospital admission for HF within the previous year. iCRT is recommended if QRS ≥ 130 msec and LBBB (in sinus rhythm). jCRT should/may be considered if QRS ≥ 130 msec with non-LBBB (in a sinus rhythm) or for patients in AF provided a strategy to ensure bi-ventricular capture in place (individualized decision). For further details, see Sections 7 and 8 and corresponding web pages. ESC Guidelines Page 21 of 85 NOT FOR PUBLIC RELEASE 2285 2290 2295 2300 2305 2310 2315 2320 2325 2330 2335 2340 2345 2350 2355 2360 2365 2370 2375 2380 2385
- Evolution of pharmacologic approaches in HF: Neprilysin inhibition as a new therapeutic strategy A decline in left ventricular systolic function leads to activation of three major compensatory neurohormonal systems in an attempt to increase cardiac output (CO):1 Sympathetic nervous system (SNS) Renin-angiotensin-aldosterone system (RAAS) Natriuretic peptide (NP) system SNS and RAAS suppression Long-term over-activation of the SNS and RAAS in HF are thought to be harmful and blockade of these pathways has been the focus of current HF therapies. The SNS can be inhibited using β-blockers and the RAAS using RAAS inhibitors such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor antagonists (ARBs), and mineralocorticoid receptor antagonists (MRAs).2 Natriuretic peptide system enhancement In contrast to the RAAS and SNS, the natriuretic peptide system is a potentially beneficial counter-regulatory system in HF.2 Augmentation of this system is a new therapeutic strategy being considered for HF. This can be achieved by blocking the enzyme neprilysin which is responsible for the breakdown of NPs. Neprilysin inhibition may enhance the effects of natriuretic and other vasoactive peptides, which include vasodilation, diuresis and natriuresis, reduced sympathetic tone, reduced aldosterone, and antifibrotic and hypertrophic effects.2–4 Abbreviations ACEI=angiotensin-converting enzyme inhibitor; ARB=angiotensin receptor blocker; CO=cardiac output; HF=heart failure; MRA=mineralocorticoid receptor antagonist; NP=natriuretic peptide; RAAS=renin-angiotensin-aldosterone system; SNS=sympathetic nervous system References Kemp & Conte. Cardiovascular Pathology 2012;365–71 McMurray et al. Eur J Heart Fail 2013;15:1062–73 Levin et al. N Engl J Med 1998;339:321–8 Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42
- ACEI ¼ angiotensin-converting enzyme inhibitor; CAD ¼ coronary artery disease; HF ¼ heart failure; ICD ¼ implantable cardioverter-defibrillator; LV ¼ left ventricular; LVEF ¼ left ventricular ejection fraction; OMT ¼ optimal medical therapy aClass of recommendation. bLevel of evidence.