ESC慢性心衰指南
Relationship between cardiac dysfunction, HF and HF rendered asymptomatic
NORMAL
CARDIAC DYSFUNCTION CORRECTED OR RESOLVED
CARDIAC DYSFUNCTION
SYMPTOMS
HEART FAILURE
THERAPY
Therapy CAN be withdrawn without recurrence of symptoms
Symptoms relieved
Therapy CANNOT be withdrawn without recurrence of symptoms
Transient Heart Failure
No symptoms
Asymptomatic cardiac dysfunction
Systolic dysfunction
Symptoms persist
Diagnosis
According to the Working Group in Heart Failure, Heart Failure is a syndrome where the diagnosis has the following essential components:
A combination of:
Symptoms, typically breathlessness or fatigue
Cardiac dysfunction documented at rest
The diagnosis is supported by:
Response to treatment directed towards heart failure
Assessments in all cases
Necessary Supports Opposes
History with symptoms +++ If absent
Objective evidence +++ If absent
Response to treatment ++
Establish diagnosis
Test
Necessary Supports Opposes
Electrocardiogram ++ If normal
Echocardiography +++ If normal
Chest x-ray If congestion If normal
Blood count If normal
Blood chemistry If normal
Tests for Diagnosis
Additional Tests for Diagnosis
Test
Necessary Supports Opposes
Exercise test If normal
Natriuretic peptide If elevated If normal
Cardiac cath. If normal
Test to Exclude Alternatives
Chest x-ray (Lung disease)
Pulmonary function
Blood chemistry (Renal and hepatic disease)
Blood count (Anaemia)
Exercise tolerance (if impaired)
Electrocardiography
A normal ECG suggests that the diagnosis of heart failure should be carefully reviewed.
The predictive value of a normal ECG to exclude LV systolic dysfunction exceeds 90%
Chest X-ray
A high predictive value of X-ray findings is only achieved by interpreting them in the context of clinical findings and ECG anomalies.
It is useful to detect cardiac enlargement and pulmonary congestion
In chronic heart failure, increased cardiac size and pulmonary venous congestion are useful indicators of abnormal cardiac function with decreased ejection fraction and/or increased LV filling pressure
However, cardiomegaly is frequently absent in acute heart failure and in cases with diastolic dysfunction
Pulmonary function tests
Measurements of lung function are of little value in diagnosing chronic heart failure.
However, they are useful in excluding respiratory causes of breathlessness
Exercise testing
In clinical practice exercise testing is of limited value for the diagnosis of heart failure.
However, a normal maximal exercise test, in a patient not receiving heart failure treatment, excludes heart failure as a diagnosis
Invasive investigation
Invasive investigation is generally not required to establish the presence of chronic heart failure, but may be important in elucidating the cause or to obtain prognostic information
Echocardiography
As objective evidence of cardiac dysfunction at rest is mandatory for the diagnosis of heart failure, echocardiography is the preferred method for this documentation
The most important parameter for identifying patients with systolic cardiac dysfunction and those with preserved systolic function is the LV ejection fraction
When the diagnosis of heart failure is confirmed, echocardiography is also helpful in determining its aetiology
Natriuretic Peptides
These peptides may be most useful clinically as a “rule out” test due to a consistent and very high negative predictive values
Especially in primary care patients suspected of having heart failure can be selected for further investigation by echocardiography or other tests of cardiac function on the basis of having an elevated plasma concentration of a natriuretic peptide
In those in whom the concentrations are normal, other causes of dyspnoea and associated symptoms should be considered
The added value of natriuretic peptides in this situation has yet to be determined
Natriuretic Peptides
High levels of natriuretic peptides identify those at greatest risk of future serious cardiovascular events including death
There is also recent evidence that adjusting heart failure therapy in order to reduce natriuretic peptides levels in individual patients may improve outcome
Other neuroendocrine evaluations
Other tests of neuroendocrine evaluation are not recommended for diagnostic or prognostic purposes
Suspected Heart Failure
because of symptoms and signs
Tests abnormal
Tests abnormal
Assess presence of cardiac disease by ECG, X-Ray or
Natriuretic peptides (where available)
Normal
Heart Failure unlikely
Imaging by Echocardiography
(Nuclear angiography or MRI where available)
Normal
Heart Failure unlikely
Algorithm for Diagnosis of Chronic HF
Additional diagnostic tests where appropriate
(e.g. coronary angiography)
Management Outline
Establish that patient has heart failure
Identify presenting symptom
Assess severity of limitation
Determine etiology
Exclude or confirm concomitant diseases
Predict prognosis
Choose therapy
Monitor progress
Guidelines Treatment - Contents
General advice and measures
Exercise and exercise training
Pharmacological therapy
Surgery and devices
Special subsections (elderly, diastolic CHF)
Care management programmes
General Measures and Advice
Patient and family education
explain heart failure
symptoms –what therapy does
self-weighing
exercise vs rest
General measures and advice
Diet-salt intake and fluid restriction
Smoking-cessation
Alcohol-moderate intake permitted
Obesity-weight reduction
Abnormal weight loss
Travelling
Sexual activity-counselling, reassurance patients/partner
Vaccinations-influenza, pneumococcal
General measures and advice
Drug counselling :
Self-management (diuretics)
Desired effects and side effects
Duration treatment before effects become apparent
Need for slow up-titration
Interaction with other drugs
Ace-inhibitors
ACE inhibitors are recommended as first-line therapy in patients with a reduced LV systolic function
(LVEF<40-45%) (Level A)
In the absence of fluid retention ACE inhibitors should be given first, in the presence of fluid retention together with diuretics (Level B)
ACE inhibitors should be up-titrated to the dosages shown to be effective in large trials .
They should not be titrated based on symptomatic improvement
The recommended procedure for starting an ACE inhibitor
1. Review the dose of diuretics
2. Avoid excessive diuresis before treatment.
3. Start with a low dose and build up to maintenance dosages
4. If renal function deteriorates substantially, stop treatment.
5. Avoid potassium-sparing diuretics during initiation of therapy.
6. Avoid non-steroidal anti-inflammatory drugs (NSAIDs).
7. Check blood pressure, renal function and electrolytes 1-2 weeks after each dose increment, at 3 months and subsequently at 6 monthly intervals (Level C)
Beta-blockade in Heart Failure
Beta-blocking agents are recommended for the treatment of all patients with stable mild, moderate and severe heart failure from ischemic and non-ischemi