Chronic Heart Failure powerpoint presentation.pdf

Chronic Heart Failure powerpoint presentation.pdf

1. Approach to CHF in an Outpatient Setting
SWAPNIL PARVE, MD
DEPT. OF PRIMARY CARE & GENERAL PRACTICE
KAZAN STATE MEDICAL UNIVERSITY

2. Outline
Case Vignette Definition of
Heart Failure
Epidemiology of
CHF
Etiopathogenesis
of CHF
Types of CHF
Clinical
Manifestations
and Diagnosis of
CHF
Management of
CHFPrevention

3. Definition of
Heart Failure
uClinical syndrome
uBreathlessness, ankle swelling, fatigue
u↑ JVP, pulmonary crackles, peripheral
edema
uDue to structural and functional
abnormality of the heart
uElevated intracardiac pressures &/or
inadequate cardiac output
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

4. Epidemiology
of Heart
Failure:
Burden
uRussia –~11.8 mln(~8,2% of population)
uIndia –1.3 –4.6* mln
uAfrica –No accurate data available
uUS –6mln(~1.8-1.9% of population)
* -No accurate data
1.Huffman MD, Prabhakaran D.Natl Med J India 2010;23(5):283–288.
2.Virani SS et al. Circulation. 2021; 143:e254–e743.28
3.Polyakov DSetal. Kardiologiia. 2021;61(4):4-14.

5. Heart Failure: Causes
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Causes of heart failure, common modes of presentation and specific
investigations (1)
ARVC = arrhythmogenicright ventricularcardiomyopathy; BP = bloodpressure; CAD= coronaryarterydisease; CMP = cardiomyopathy; CMR= cardiacmagneticresonance;
ECG = electrocardiogram; GGT= gamma-glutamyltransferase; LFT = liverfunctiontest.

6. Heart Failure: Causes
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Causes of heart failure, common modes of presentation and specific
investigations (2)
ACE = angiotensin-convertingenzyme; CMR= cardiacmagneticresonance; CK = creatininekinase; CT = computedtomography; ECG = electrocardiogram; Echo = echocardiography;
EMB = endomyocardialbiopsy; FDG = fluorodeoxyglucose; HIV = humanimmunodeficiencyvirus; h = hour; MEK =mitogen-activatedproteinkinase; PET = positron emission
tomography; VEGF = vascularendothelialgrowthfactor

7. Heart Failure: Causes
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Causes of heart failure, common modes of presentation and specific
investigations (3)
5-HIAA = 5-hydroxyindoleacetic acid; ANA = anti-nuclearantibody; ANCA = anti-nuclearcytoplasmicantibody; CK = creatininekinase; CMR = cardiacmagneticresonance;
CT = computedtomography; EMB = endomyocardialbiopsyTFT = thyroidfunctiontest.

8. Types of
Heart Failure
uLow output ( ↓ cardiac output) vs High
output(↑ stroke volume ±↑ cardiac output)
uLeft sided (pulmonary edema) vs Right sided
(↑ JVP, hepatomegaly, peripheral edema)
uBackward(↑ filling pressures, congestion) vs
Forward(impaired systemic perfusion)
uSystolic(inability to expel sufficient blood)vs
Diastolic(failure to relax and fill normally)
uAcutevs Chronic
BonowR et al.Braunwald'sHeart Disease. 10th ed. Saunders; 2014.

9. High Output
HF
u↑ CO and ↓ SVR
uⓃor ↑ EF
uDue to AV fistula, pregnancy,
hyperthyroidism, anemia, liver/renal
disease, Paget’s disease, Beriberi, VSD

10. Types of Heart
Failure
uHFrEF
uFormerly systolic HF
uHFpEF
uFormerly diastolic HF
uHFrEF–HF with mildly reduced EF
uFormerlyHF mid range EF

11. Etiopathogenesis of Heart Failure
CAD; Vascular disease, HTN; PE,
PPCM, Cardiotoxic agents,
EtOH/Substance abuse, Infiltrative
disease, Connective tissue
disease, Thyroid disease,
Myocarditis, Chronic tachycardia
Hypertension, Ischemia, Restrictive
diastolic dysfunction, Valvular
diseases, Pericardial diseases,
Congenital diseases,
aging, Fibrosis
Cardiomyopathy, Infiltrative
cardiomyopathy, Asymptomatic

12. Heart Failure: Definition
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Type of HFHFrEF HFmrEF HFpEF
CRITERIA
1Symptoms±Signs
a
Symptoms±Signs
a
Symptoms±Signs
a
2LVEF ≤40% LVEF 41–49%
b
LVEF ≥50%
3- - Objective evidenceof cardiacstructural
and/or functional
abnormalitiesconsistent withthe
presenceof LV diastolic
dysfunction/raisedLV fillingpressures,
includingraisednatriureticpeptides
c
Definitionof heartfailurewithreducedejectionfraction, mildlyreduced
ejectionfraction and preservedejectionfraction
HF = heartfailure; HFmrEF= heartfailurewithmildlyreducedejectionfraction; HFpEF= heartfailurewithpreservedejectionfraction; HFrEF= heartfailurewithreducedejection
fraction; LV = leftventricle; LVEF = leftventricularejectionfraction.
a
Signsmaynot bepresentin the earlystages of HF (especiallyin HFpEF) and in optimallytreatedpatients.
b
Forthe diagnosisof HFmrEF, the presenceof otherevidenceof structural heartdisease(e.g. increasedleftatrial size, LV hypertrophyor echocardiographicmeasuresof
impairedLV filling) makesthe diagnosismore likely.
c
Forthe diagnosisof HFpEF, the greaterthe numberof abnormalitiespresent, the higherthe likelihoodof HFpEF.

13. Clinical Manifestations of Heart Failure
Symptoms (Typical)Symptoms (Less typical)Signs (More specific)Signs (Less specific)
•Breathlessness
•Orthopnea
•Paroxysmal nocturnal
dyspnea
•↓ exercise tolerance
•Fatigue, tiredness,
increased time to recover
after exercise
•Ankle swelling
•Nocturnal cough
•Wheezing
•Bloated feeling
•Loss of appetite
•Confusion (especially
in elderly)
•Depression
•Palpitations
•Dizziness
•Syncope
•Bendopnea
•↑ JVP
•Hepatojugular reflux
•S3(Gallop rhythm)
•Laterally displaced apical
impulse
•Wt. gain (>2 kg/wk)
•Wt. loss (advanced HF)
•Tissue wasting (cachexia)
•Cardiac murmur
•Peripheral edema (ankle, sacral,
scrotal)
•Pulmonary crepitations
•↓ air entry & dullness to
percussion at lung bases (pl.
effusion)
•Tachycardia
•Irregular Ps
•Cheyne Stokes respiration
•Hepatomegaly
•Ascites
•Cold extremities
•Oliguria
•Narrow Ps press.
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

14. Bendopnea
•SOB on leaning forward
•Described by
Thibodeau et al in 2014
•Occurs in 8-30 secs. after bending
•Result of ↑ ventricular
filling pressures
Kathy Knorr from Santa Fe, USA. CC BY-SA.

15. Image by James Heilmann, MD. CC BY-SA

16. Image by James Heilmann, MD. CC BY-SA

17. King M et al.Am Fam Physician 2012;85(12):1161-1168.

18. Image by Mikael Häggström

19. radiologyassistant.nl

20. NYHA Heart Failure Classification

21. Diagnostic
Algorithm for
Heart Failure
www.escardio.org/guidelines
©ESC
28
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
The diagnostic algorithm for
heart failure
ECG = electrocardiogram; HFmrEF= heartfailurewithmildlyreducedejection
fraction;
HFpEF= heartfailurewithpreservedejectionfraction; HFrEF= heartfailurewith
reducedejectionfraction; LVEF = leftventricularejectionfraction; NT-proBNP= N-
terminal pro-B type natriureticpeptide.
The abnormalechocardiographicfindingsare describedin more detailin the
respective sections onHFrEF(section 5), HFmrEF(section 7), and HFpEF(section 8).
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

22. Recommended
Tests in all
Patientswith
SUSPECTEDCHF
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

23. Recommendations
for specialized
diagnostic tests
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

24. McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
Recommendations
for specialized
diagnostic tests
Was
IIa
Was
IIb

25. McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
Recommendations
for specialized
diagnostic tests

26. Formulating
the
Diagnosis
Main disease(the cause of
CHF)
Stage and functional class of
CHF
Presence of pulmonary
hypertension
Presence of ascites,
hydrothorax,
hydropericardium, anasarca

27. Management of Heart Failure
in an Outpatient Setting

28. McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
HFrEF–Treatment
algorithm

29. Management of HFrEF: ACE-I
uEnalapril 2.5mg BD | Lisinopril 2.5-5mg QD
u↑ survival in asymptomatic or symptomatic patients with EF ≤ 35%, NYHA
class II-IV
uTarget dose: Enalapril 10-20mg BD | Lisinopril 20-35mg QD
1.The SOLVD Investigators* . N EnglJ Med 1992;327:685-691.
2.The SOLVD Investigators* . N EnglJ Med 1991;325(5):293-302.
3.The Consensus Trial Study Group*. N EnglJ Med 1987;316(23):1429-1435.

30. Management of HFrEF: BB
uBisoprolol 1.25mg QD | Carvedilol 3.125mg BID | Metoprolol XL 12.5-25mg QD
u↑ overall & event-free survival in NYHA II-IV and EF ≤ 35-40%
uImprovement additive to ACE-I
uPatients should be stable to avoid worsening of symptoms
uCardioselectiveBB (eg.metoprolol) safe in mild—moderate reactive airway
disease (eg.COPD, asthma)
uTarget dose: Bisoprolol 10mg QD | Carvedilol 25mg BID | Metoprolol XL
200mg QD
1.HjalmarsonÅet al.JAMA 2000;283(10):1295.
2.Farrell M et al.JAMA 2002;287(7):890.
3.Foody J et al H.JAMA 2002;287(7):883.
4.CIBIS-II Investigators and Committees*. Lancet 1999;353(9146):9-13.
5.Packer M et al. N EnglJ Med 1996;334(21):1349-1355.

31. Management
of HF: ARB
uCandesartan 4mg QD | Losartan 50mg QD | Valsartan 20mg BID
uPatientsintolerant to ACE-I with symptomatic CHF and EF ≤ 35-40%
uARB ↑ survival
uPatients with NYHA II-IV, EF ≤ 40% & intolerant to ACE-I
u↑ survival with high dose losartan (150mg QD) vs low dose (50mg QD)
uCandesartan in NYHA II-IV patients
u↓ risk of CV death or nonfatal MI
uassociated with ↓ mortality risk as compared to Losartan
uACE-I + ARB
u↑ adverse effects
uCombo contraindicated in patients with symptomatic HF
uCaution in Hyperkalemia, Hypotension, or renal insufficiency due to ACE-I
uTarget dose: Candesartan 32mg QD | Losartan 150mg QD
1.Cohn J, TognoniG.N EnglJ Med 2001;345(23):1667-
1675.
2.Granger C et al. Lancet 2003;362(9386):772-776.
3.KonstamM et al. Lancet 2009;374(9704):1840-1848.
4.Demers C. JAMA 2005;294(14):1794.
5.Eklind-CervenkaM. JAMA 2011;305(2):175.
6.Phillips C et al.Arch Intern Med 2007;167(18):1930

32. Management of HFrEF: ARNI
uSacubitril/Valsartan fixed dose 49/51mg BID
uARNI:
uadded to inhibitor of neprilysin
u↓ composite of CV death or HF hospitalization by 20%
u↑ risk of hypotension, renal insufficiency, angioedema
ucan replace ACE-I/ARB in patients with persistently symptomatic HF to
further ↓ morbidity or mortality
uTarget dose: Sacubitril/Valsartan 97mg/103mg BID
McMurray J et al. N EnglJ Med 2014;371(11):993-1004.

33. Management
of HFrEF:
Aldosterone
Antagonists
uSpironolactone 25mg QD | Eplerenone
25mg QD (in patients with ⓃGFR)
u↑ survival in NYHA II-IV & EF ≤ 35%
uMonitor closely for ↑ K +
uAvoid if baseline
ucreatinine: ≥ 2.5 ♂; 2.0 ♀
uGFR ≤ 30
uK+ ≥ 5.0
uEplerenone
u↓ endocrine side effects (gynecomastia)
u↑ survival in NYHA II-IV & EF ≤ 35% or in EF
≤ 40% after MI
uTarget dose: Spironolactone 50mg QD |
Eplerenone 50mg QD
1.Pitt B et al. N EnglJ Med 1999;341(10):709-717.
2.ZannadF et al. N EnglJ Med 2011;364(1):11-21.
3.Pitt B et al.N EnglJ Med 2003;348(14):1309-1321.

34. McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
Management of
HFrEF: SGLT2-
inhibitors
uDapagliflozin 10mg QD | Empagliflozin 10mg QD
u↓ of 26% composite of worsening HF (hospitalization or an urgent visit resulting in i.v.therapy for HF) or CV death.
u↓ all-cause mortality
ualleviated HF symptoms, improved physical function and QOL
uEmpagliflozin
u↓ of 25% -CV death or HF hospitalization
uIn patients with NYHA II-IV, and
uLVEF ≤ 40% despite OMT
u↓ in decline in GFR
uimproved QOL
u↑Target dose: Dapagliflozin 10mg QD | Empagliflozin 10mg QD
Dapagliflozin or empagliflozin
are recommended, in addition
to OMT with an ACE-I/ARNI, a
beta-blocker and an MRA, for
patients with HFrEF
regardless of diabetes status.

35. Management of HFrEF: Loop Diuretics
uFurosemide 20mg QD | Bumetanide 0.5mg QD | Torsemide 5mg QD
uIdeally every 8 am, 1-2pm
uTitrate to weight ↓ by 1 kg/day until euvolemic
uMonitor for ↓ Mg2+/ K+
uIf lack of urine output after dose, ↑ dose rather than frequency
uPO Bumetanide 1mg ≈ Torsemide 20mg ≈ Furosemide 40mg

36. McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
HFrEF–Treatment
algorithm
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Recommendations ClassLevel
I
f-channel inhibitor
Ivabradineshouldbeconsideredin symptomaticpatients withLVEF ≤35%, in SR and a
restingheartrate ≥70 b.p.m. despitetreatmentwithan evidence-baseddose of beta-
blocker(or maximum tolerateddose belowthat), ACE-I/(or ARNI), and an MRA, to
reducethe riskof HF hospitalizationand CV death.
IIaB
Ivabradineshouldbeconsideredin symptomaticpatients withLVEF ≤35%, in SR and a
restingheartrate ≥70 b.p.m. whoare unableto tolerateor have contraindicationsfor a
beta-blockerto reducethe riskof HF hospitalizationand CV death. Patients shouldalso
receivean ACE-I (or ARNI) and an MRA.
IIaC
Otherpharmacologicaltreatmentsindicatedin selectedpatients with
NYHA class II-IV heartfailurewithreducedejectionfraction (LVEF ≤40%) (2)
ACE-I = angiotensin-convertingenzyme inhibitor; ARNI = angiotensinreceptor-neprilysininhibitor; b.p.m. = beats per minute; CV = cardiovascular; HF = heartfailure;
LVEF = leftventricularejectionfraction; MRA = mineralocorticoidreceptorantagonist; NYHA= New York Heart Association; SR = sinus rhythm.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Recommendations ClassLevel
Soluble guanylate cyclase stimulator
Vericiguatmaybeconsideredin patients in NYHA class II-IV whohave had worseningHF
despitetreatmentwithan ACE-I (or ARNI), a beta-blockerand an MRA to reducethe
riskof CV mortalityor HF hospitalization.
IIbB
Hydralazine and isosorbide dinitrate
Hydralazineand isosorbidedinitrate shouldbeconsideredin self-identifiedblack
patients withLVEF ≤35% or withan LVEF <45% combinedwitha dilatedleftventriclein
NYHA class III-IV despitetreatmentwithan ACE-I (or ARNI), a beta-blockerand an MRA
to reducethe riskof HF hospitalizationand death.
IIaB
Hydralazineand isosorbidedinitratemaybeconsideredin patients withsymptomatic
HFrEFwhocannottolerateanyof an ACE-I, an ARB, or ARNI (or theyare
contraindicated) to reducethe riskof death.
IIbB
Otherpharmacologicaltreatmentsindicatedin selectedpatients with
NYHA class II-IV heartfailurewithreducedejectionfraction (LVEF ≤40%) (3)
ACE-I = angiotensin-convertingenzyme inhibitor; ARNI = angiotensinreceptor-neprilysininhibitor; CV = cardiovascular; HF = heartfailure; LVEF = leftventricularejectionfraction;
MRA = mineralocorticoidreceptorantagonist; NYHA= New York Heart Association.

37. Management of HFrEF: Ivabradine
uIvabradine 5mg BID
uBlocks If channel in SA node to ↓ HR
in patients with HR ≥ 70 bpm at rest
uCan ↓ HF hospitalization for stable,
chronic patients with EF ≤ 35% on
GDMT
uShould not be administered to
patients with MI in prior 2 months
uTarget dose: Ivabradine 7.5mg BID

38. McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
Management of
HFrEF: Vericiguat
uVericiguat 2.5mg QD
uMay beconsidered in patients with
NYHA II-IV who have worsening HF
despite total targeted dosing with
ACE (ARNI), a BB, and MRA
u↓riskofCVmortalityofHF
hospitalization
uTarget dose: Vericiguat 10mg QD

39. Management of HFrEF: Hydralazine
uHydralazine 37.5mg TID + Nitrate
(ISDN 20mg TID)
uConsider in all patients who
can’t tolerate ACE-I/ARB
uAssociated with lupus like
syndrome
uTarget: Hydralazine 75mg TID +
Nitrate (ISDN 40mg TID)
Taylor A et al. N EnglJ Med 2004;351(20):2049-2057.
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

40. Management of HFrEF: Digoxin
uDigoxin 62.5 !mg QD (in patients with ⓃGFR)
uSymptoms control in patients with EF ≤ 40% & NYHA II-IV despite OMT
u↓ hospitalization for heart failure but not mortality
uTitrate to goal serum digoxin 0.5-0.9 ng/ml
u↑ levels → ↑ toxicity and mortality
uCheck levels 6 hours after dose
uTarget: Digoxin 250 !mg QD
1.Digitalis Investigation Group* N EnglJ Med 1997;336(8):525-533.
2.Rathore S.JAMA 2003;289(7):871.

41. Management of HFrEF: ICD
uICD ↓ mortality by 23% in patients:
uwith persistent LVEF ≤ 35%,
uDCM & ischemic CMP, NYHA II-III
HF despite OMT for ≥ 3 months
(ischemic: >40 days post-MI)
uPatients should’ve >1 yr
expected survival with good
functional status
uClass IIaevidence of improvement
in mortality in non-ischemic CMP
Source: hcahamilton.com
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

42. Management of HFrEF: CRT
uCRT, Biventricular pacing:
u↑ NYHA functional status
u↓ symptoms
u↓ hospitalizations
u↓ all cause mortality in NYHA III & IV patients with ↓ EF and ↑
QRS
uRecommended in:
uQRS > 130 ms
uLVEF ≤ 35%
uSinus rhythm
uBest responders: LBBB+QRS >150ms, women
PonikowskiP et al.Eur Heart J. 2016;37(27):2129-2200.
Jarcho JA. N Engl J Med 2006;355:288-294.

43. Phenotype
overview of
management
of HFrEF
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

44. Tips for PCP:
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
1.New onset HFrEF: BB or ACE/ARNI?
uIfpatienteuvolemic,BBtoleratedbetter
uIf patient congested, ARNI
2.Uptitrationof doses -every 2 wks, not earlier
3.ACE/ARB/ARNI/MRA: KFT & electrolytes
u1-2wksafter initiation/uptitration
uf/uevery4months
4.Avoid NSAIDs
5.ARNI:
uWhen switching from ACE-I : washout 36 hours
uIf patients previously taking ACE/ARB
uEnalapril ≤ 10mg or valsartan ≤ 160mg
uStart ARNI with low dose: 24/26 bid
uUptitrateevery 2 wks.
6.Furosemide: if giving ≥ 80mg, switch to other loop or use combination eg.thiazides

45. HFpEF(Diastolic Dysfunction)

46. Heart Failure: Definition
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Type of HFHFrEF HFmrEF HFpEF
CRITERIA
1Symptoms±Signs
a
Symptoms±Signs
a
Symptoms±Signs
a
2LVEF ≤40% LVEF 41–49%
b
LVEF ≥50%
3- - Objective evidenceof cardiacstructural
and/or functional
abnormalitiesconsistent withthe
presenceof LV diastolic
dysfunction/raisedLV fillingpressures,
includingraisednatriureticpeptides
c
Definitionof heartfailurewithreducedejectionfraction, mildlyreduced
ejectionfraction and preservedejectionfraction
HF = heartfailure; HFmrEF= heartfailurewithmildlyreducedejectionfraction; HFpEF= heartfailurewithpreservedejectionfraction; HFrEF= heartfailurewithreducedejection
fraction; LV = leftventricle; LVEF = leftventricularejectionfraction.
a
Signsmaynot bepresentin the earlystages of HF (especiallyin HFpEF) and in optimallytreatedpatients.
b
Forthe diagnosisof HFmrEF, the presenceof otherevidenceof structural heartdisease(e.g. increasedleftatrial size, LV hypertrophyor echocardiographicmeasuresof
impairedLV filling) makesthe diagnosismore likely.
c
Forthe diagnosisof HFpEF, the greaterthe numberof abnormalitiespresent, the higherthe likelihoodof HFpEF.

47. HFpEF
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

48. HFpEF
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
uPost guideline published,
uEmpagliflozin 10mg, QD in LVEF ≥ 40%
u↓ compositeofCVdeathandHF
hospitalization

49. Management
of HF: HFpEF
(Diastolic
Dysfunction)
uTreat underlying condition
uSalt restriction
uCautious use of diuretics
uBP control in Hypertensive
patients
uRate control in AF

50. Management
of HFpEF:
Treatment of
Reversible
conditions
uThyroid disease
uTachycardia
uAnemia
uHemochromatosis
uHypertension
uRenovascular disease
uCAD
uValvular Disease
uEtOH/Substance abuse
uMalnutrition
uSLE
uSarcoidosis
uCPAP in Obstructive sleep apnea & HF

51. HFmrEF
HF with Mildly Reduced EF

52. Heart Failure: Definition
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Type of HFHFrEF HFmrEF HFpEF
CRITERIA
1Symptoms±Signs
a
Symptoms±Signs
a
Symptoms±Signs
a
2LVEF ≤40% LVEF 41–49%
b
LVEF ≥50%
3- - Objective evidenceof cardiacstructural
and/or functional
abnormalitiesconsistent withthe
presenceof LV diastolic
dysfunction/raisedLV fillingpressures,
includingraisednatriureticpeptides
c
Definitionof heartfailurewithreducedejectionfraction, mildlyreduced
ejectionfraction and preservedejectionfraction
HF = heartfailure; HFmrEF= heartfailurewithmildlyreducedejectionfraction; HFpEF= heartfailurewithpreservedejectionfraction; HFrEF= heartfailurewithreducedejection
fraction; LV = leftventricle; LVEF = leftventricularejectionfraction.
a
Signsmaynot bepresentin the earlystages of HF (especiallyin HFpEF) and in optimallytreatedpatients.
b
Forthe diagnosisof HFmrEF, the presenceof otherevidenceof structural heartdisease(e.g. increasedleftatrial size, LV hypertrophyor echocardiographicmeasuresof
impairedLV filling) makesthe diagnosismore likely.
c
Forthe diagnosisof HFpEF, the greaterthe numberof abnormalitiespresent, the higherthe likelihoodof HFpEF.

53. HFmrEF:
Management
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
+ Empagliflozin
regardless of diabetes status

54. Management
of HF: Lifestyle
Modifications
uSmoking/EtOH cessation
uSalt intake < 2 grams per day
uFluid restrictions (1.5-2 L/day)
uWeight loss
uNutrition referral
uCardiac rehabilitation and
supervised exercise
uImmunizations: Influenza and
pneumococcal
1.O'Connor CM et al.JAMA 2009;301(14):1439–1450.
2.Flynn et al.JAMA 2009;301(14):1451–1459

55. Management
of HF: Care
Coordination/
Self
Management
uDaily weight
uEdema Check
uSymptom log
uFollow-up appointment
uFrequent patient education & clinician
contact
uInvolvement of cardiologists
Hernandez AF et al.JAMA2010;303(17):1716–1722.

56. Management
of HF:
Medications to
avoid/use with
caution
uNSAID’s
uCorticosteroids
uCCB (except amlodipine, Felodipine)
uThiazolidinediones
uMetformin (can ↑ HF symptoms)
uCilostazol
uClass I & III antiarrhythmics (except amiodarone)
uAnagrelide
uAmphetamines
uCarbamazepine
uDronedarone
uClozapine
uErgots
uβ-2 agonists (eg: albuterol)
uHerbal agents
1.Littler WA, Sheridan DJ.Br Heart J 1995;73(5):428–
433.
2.Packer MA et al. N EnglJ Med 1996;335:1107-1114.
3.MasoudiFA et al. JAMA2003;290(1):81–85.
4.Amabile CM. Arch Intern Med 2004;164(7):709–
720.

57. Advanced HF

58. Advanced HF:Diagnostic criteria
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
All the followingcriteriamust bepresentdespiteOMT:
1.Severe and persistent symptoms of heart failure [NYHA class III (advanced) or IV].
2.Severecardiacdysfunctiondefinedby (at least one of the following):
•LVEF (≤30%)
•IsolatedRV failure(e.g., ARVC)
•Non-operableseverevalve abnormalitiesor congenitalabnormalities
•Persistentlyhigh (or increasing) BNP or NT-proBNPvalues and severediastolic
dysfunctionor LV structural abnormalities(accordingto the definitionsof HFpEF)
3.Episodes of pulmonaryor systemiccongestion requiringhigh-dose i.v. diuretics(or diuretic
combinations) or episodesof lowoutput requiringinotropes or vasoactive drugsor
malignantarrhythmiascausing>1 unplannedvisitor hospitalizationin the last 12 months.
4.Severe impairment of exercise capacity with inability to exercise or low 6MW (<300 m) or
pVO2 <12 mL/kg/min or <50% predicted value, estimated to be of cardiac origin.
Criteriafor definitionof advancedheartfailure
6MWT= 6-minute walktest; ARVC = arrhythmogenicright ventricularcardiomyopathy; BNP = B-type natriureticpeptide; HFpEF= heartfailurewithpreservedéjection fraction; i.v. =
intravenous; LV = leftventricular; LVEF = leftventricularejectionfraction; NT-proBNP= N-terminal pro-B-type natriureticpeptide; NYHA =New York Heart Association; pVO2 = peakoxygen
consumption; RV = right ventricular.

59. uRefer
Advanced HF:Management

60. HF + Comorbidities

61. Management
of HF: HFrEF+
AF
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
92
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Management of atrial fibrillation
in patients with heart failure with
reduced ejection fraction
AF = atrial fibrillation; AVN = atrioventricularnode; ECV = electricalcardioversion;
HF = heartfailure; i.v. = intravenous; PV = pulmonaryvein.
Colourcode for classes of recommendation: Green for Class of recommendationI;
Yellow for Class of recommendationIIa; Orange for Class of recommendationIIb; Red
for Class of recommendationIII (seeTable 1 for furtherdetailson classes of
recommendation).

62. Management of HF: HFrEF+ AF
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Recommendations ClassLevel
Anticoagulation
Long-termtreatmentwithan oral anticoagulant isrecommendedin all patients
withAF, HF, and CHA
2DS
2-VASc score ≥2 in men or ≥3 in women.
IA
DOACsare recommendedin preferenceto VKAsin patients withHF, exceptin
thosewithmoderateor severemitral stenosisor mechanicalprostheticheart
valves.
IA
Long-termtreatmentwithan oral anticoagulant shouldbeconsideredfor stroke
preventionin AF patients witha CHA
2DS
2-VASc score of 1 in men or 2 in women.
IIaB
Rate control
Beta-blockersshouldbeconsideredfor short and long-termrate control in
patients withHF and AF.
IIaB
Digoxinshouldbeconsideredwhenthe ventricularrate remainshigh, despite
beta-blockers, or whenbeta-blockersare contraindicatedor not tolerated.
IIaC
Recommendationsfor the treatmentof atrial fibrillation in patients
withheartfailure(1)
AF = atrial fibrillation; CHA
2DS
2-VASc = congestive heartfailureor leftventriculardysfunction, Hypertension, Age ≥7 (doubled), Diabetes, Stroke (doubled)-Vasculardisease, Age 65–74, Sex
category(female) (score); DOAC= directactingoral anticoagulant; HF = heartfailure; MT = medicaltherapy; VKA = vitaminK antagonist.

63. Management of HF: HFrEF+ AF
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

64. Management
of HF: AF
uNo survival benefit for rate vs rhythm
control in HF patients
uRhythm control ↓ symptoms
uAmiodarone & Dofetilidepreferred
uDronedarone associated with ↑
mortality in severe systolic HF
uIf rate control used:
uBB considered if ⊖
contraindications
uVerapamil, diltiazem in HFpEF
1.Roy D et al. N EnglJ Med 2008;358(25):2667-2677.
2.Torp-Pedersen C et al.N EnglJ Med 1999;341(12):857-865.
3.KøberL et al. N EnglJ Med. 2008;358(25):2678-2687.

65. Management
of HF: HFrEF+
CCS
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
95
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Algorithm for the medical
treatment of chronic
coronary syndrome in
patients with heart failure
with reduced ejection
fraction
CCS = chroniccoronarysyndrome; HFrEF= heartfailurewith
reducedejectionfraction; HR = heartrate.
Colourcode for classes of recommendation: Green for Class of
recommendationI; Yellow for Class of recommendationIIa;
Orange for Class of recommendationIIb; Redfor Class of
recommendationIII (seeTable 1 for furtherdetailson classes of
recommendation).

66. Management of HF: HFrEF+ CCS
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Recommendations ClassLevel
Coronaryrevascularizationshouldbeconsideredto relievepersistent symptoms
of angina(or an angina-equivalent) in patients withHFrEF, CCS, and coronary
anatomysuitablefor revascularization, despiteOMT includinganti-anginaldrugs.
IIaC
Coronaryrevascularizationmaybeconsideredto improveoutcomesin patients
withHFrEF, CCS, and coronaryanatomysuitablefor revascularization, aftercareful
evaluationof the individualriskto benefitratio, includingcoronaryanatomy(i.e.
proximal stenosis>90% of large vessels, stenosisof leftmain or proximal LAD),
comorbidities, life expectancy, and patient’sperspectives.
IIbC
In LVAD candidates needingcoronaryrevascularization, CABG shouldbeavoided,
if possible.
IIaC
Recommendationsfor myocardialrevascularizationin patients with
heartfailurewithreducedejectionfraction (1)
CABG = coronaryarterybypass graft; CCS = chroniccoronarysyndrome; HFrEF= heartfailurewithreducedejectionfraction; LAD = leftanteriordescendingartery; LVAD = leftventricular
assist device; OMT= optimal medicaltherapy

67. Management of HF: HFrEF+ CCS
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.
www.escardio.org/guidelines
©ESC
2021 ESC Guidelines for the diagnosisand treatmentof acute and chronicheartfailure
(EuropeanHeartJournal 2021 –doi:10.1093/eurheartj/ehab368)
Recommendations ClassLevel
CABG shouldbeconsideredas the first-choicerevascularizationstrategy, in
patients suitablefor surgery, especiallyif theyhave diabetesand for thosewith
multivesseldisease.
IIaB
PCI maybeconsideredas an alternative to CABG, basedon HeartTeam
evaluation, consideringcoronaryanatomy, comorbidities, and surgicalrisk.
IIbC
Recommendationsfor myocardialrevascularizationin patients with
heartfailurewithreducedejectionfraction (2)
CABG = coronaryarterybypass graft; PCI = percutaneouscoronaryintervention.

68. Management of HF: HFrEF+ T2DM
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

69. Management
of HF:
Fe Deficiency
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

70. CHF:
Prevention
McDonagh TA et al.Eur Heart J 2021;42(36):3599-3726.

71. Evaluation of
Heart failure
at Follow-up
(Routine)
uEvaluate CHF symptoms if any
uReview of logs
uDaily weight, diet, medications, and
exercise regimen adherence
uPhysical Exam for CHF
uCan patient afford medications + healthy
food?

72. Evaluation of
Heart failure
at Follow-up
(Routine)
uElectrolytes, BUN, Creatinine when
titrating medications
uEstablish BNP/NT-proBNPat dry
weight
uEKG
uTTE per guidelines

73. Evaluation of
Heart failure
at Follow-up
(New
Symptom or
Worsening)
uEvaluate change in symptoms
uTrigger Identification:
uInfection
uMedication/diet adherence
uArrhythmias (AF)
uAnemia
uEtOH
uRenal dysfunction
uIschemia
uLabs for above mentioned triggers + as
discussed previously

74. Management
of HF: Referral
uReferral to a cardiologist:
uFor new diagnosis
uFor work-up, periodic evaluation
uReferral to a HF specialist/transplant surgeon:
uSevere disease
uReferral to Advanced center, if:
1.severe symptoms of HF with dyspnea at rest
or minimal exertion
2.episodes of fluid retention or evidence of
peripheral hypoperfusion at rest
3.inability to exercise, 6-min walk test ≤ 300
min., peak VO2 <12-14 mL/kg/min (as
determined by cardiopulmonary exercise
testing)
4.≥ 1 HF hospitalization in past 6 months

75. Thank You!