RECENT ADVANCES IN HYPERTENSION-3_8a962e0f-a3a6-4b76-add3-cb9570c046c8.pptx

Very important slides

1. MANAGEMENT & RECENT ADVANCES IN HYPERTENSION/ACS/HF PREPARED BY- Dr RAVI BAHADUR GURUNG MD(GP & EM) 3rd YEAR MODERATOR- Dr. ISHU GAJUREL FALGUN 2 , 2081 BS

2. Contents Guidelines updates Management of HTN/ACS/HF

3. NICE guidelines Hypertension in adults:diagnosis and management Published: 28 August 2019 Last updated: 21 November 2023

4. primary hypertension (high blood pressure) aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes Does not cover CKD, TYPE1DM, GDM

5. Measuring blood pressure blood pressure measurements have adequate initial training and periodic review of their performance. [2004] automated devices may not measure blood pressure accurately if there is pulse irregularity ( eg - AF) palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually [2011]

6. Standardise environment, provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. Use an appropriate cuff size for the person's arm. [2011, amended 2019] Postural hypotension: SBP falls by 20 mmHg or more, or DBP falls by 10 mmHg or more, after the person has been standing for at least 1 minute consider likely causes, including reviewing their current medication, referral to specialist care [2004, amended 2023]

7. Home-based blood pressure measurement 1 2 Use a validated BP device Measure BP in a quiet room after 5 min of rest with arm and back supported 3 Hypertension: average HBPM ≥ 135/85 mmHg Obtain two readings on each occasion, 1–2 min apart 5 4 Record and average all readings and present results to clinician Obtain readings twice a day (morning a and evening) for at least 3 and ideally 7 days https://doi.org/10.1093/eurheartj/ehae178

8. Ambulatory blood pressure measurement 1 2 3 Use a validated BP device Device usually records BP at 15–30 min intervals during the day and 30–60 min at night A minimum of 70% usable BP recordings is required Hypertension: ABPM ≥ 130/80 mmHg over 24 h or ≥ 135/85 mmHg for the daytime average or ≥ 120/70 mmHg for the night-time average 4 A diary of the patient's activities, intake of medications and sleep time should be completed https://doi.org/10.1093/eurheartj/ehae178

9. Diagnosing hypertension Check BP both arms If the difference in readings between arms is more than 15 mmHg, repeat the measurements. If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. [2019] If BP 140/90 mmHg or higher repeat twice again consider lower last two reading

10. If clinic BP between 140/90 mmHg- 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM), If unsuitable or unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. [2019] Assess for Target organ damage and cardiovascular risk assessment Confirm diagnosis if BP 140/90 mmHg or higher and ABPM daytime average or HBPM average of 135/85 mmHg or higher. [2019]

11. Assess for Target organ damage and cardiovascular risk assessment Urine RME -protein, estimation of the albumin:creatinine ratio, haematuria HbA1C, electrolytes, creatinine , estimated glomerular filtration rate, total cholesterol and HDL cholesterol examine the fundi -hypertensive retinopathy 12-lead electrocardiograph to be performed. [2011, amended 2019]

12. If BP more 180/120 (severe HTN) look for Red flag signs Retinal hemorrhage / papilloedema Angina symptoms- chest pain, pressure, SOB, palpitation Signs of HF/AKI -if so, send to ER immediately Also find out the secondary causes of HTN specially age <40years

13. Cause of secondary hypertension Screening test Primary aldosteronism Aldosterone -to- renin ratio Helpful information can also be provided by reviewing prior potassium levels ( hypokalaemia increases the likelihood of coexistent primary hyperaldosteronism ) Renovascular hypertension Renal doppler ultrasound Abdominal CT angiogram or MRI Phaeochromocytoma / paraganglioma 24 h urinary and/or plasma metanephrine and normetanephrine Obstructive sleep apnoea syndrome Overnight ambulatory polysomnography Renal parenchymal disease Plasma creatinine , sodium, and potassium eGFR Urine dipstick for blood and protein Urinary albumin-to- creatinine ratio Renal ultrasound Cushing’s syndrome 24 h urinary free cortisol Low-dose dexamethasone suppression test Thyroid disease (hyper- or hypothyroidism) TSH Hyperparathyroidism Parathyroid hormone Calcium and phosphate Coarctation of the aorta Echocardiogram Aortic CT angiogram

14. Treating and monitoring hypertension Encourage -dietary sodium intake low, either by reducing or substituting sodium salt Note that salt substitutes containing potassium chloride should not be used by older people, diabetes, pregnant women, kidney disease, taking ACE (-) and ARBs. Encourage salt reduction in these groups. [2004, amended 2019] Discourage coffee and other caffeine-rich products Stop alcohol (reduce if excessive consumption) & stop smoking.

15. Step 1 treatment Offer an ACE inhibitor or an ARB If Age <55 or T2DM Offer a calcium-channel blocker (CCB) If age >55 /no DM If a CCB is not tolerated, example - oedema , offer a thiazide -like diuretic

16. Step 2 treatment step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 + • a CCB or a thiazide -like diuretic. IF CCB add an ACE inhibitor or an ARB or a thiazide -like diuretic.

17. Step 3 treatment an ACE inhibitor/ ARB and a CCB and a thiazide -like diuretic.

18. Step 4 treatment ACE inhibitor/ARB + CCB + thiazide -like diuretic in optimal tolerated doses regard- resistant hypertension. Referral specialist OR If K<4.5 add Low dose Spironolactone If K>4.5 add ALPHA/BETA blocker If again not controlled seek referral

19. When to referral Bp >220/120 severe HTN Features of Target organ damage Associated with other comorbodities Drugs adverse reaction Resistant HTN Suspected Secondary HTN HTN with HF, arrythmia , pregnancy, CKD,

20. ACS UPDATED 2023 ESC Guidelines for the management of acute coronary syndromes European Heart Journal (2023) 44, 3720–3826 https://doi.org/10.1093/eurheartj/ehad191

21. Definition Wording to use Is not recommended Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. Class III May be considered Usefulness/efficacy is less well established by evidence/opinion. Class IIb Should be considered Weight of evidence/opinion is in favour ofusefulness /efficacy. Class IIa Conflicting evidence and/or a divergence of opinion about the usefulness/ efficacy of the given treatment or procedure. Class II Is recommended or is indicated Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective. Class I Level of evidence A Data derived from multiple randomized clinical trials or meta-analyses. Level of evidence B Data derived from a single randomized clinical trial or large non-randomized studies. Level of evidence C Consensus of opinion of the experts and/or small studies, retrospective studies, registries.

22. ACS encompasses a spectrum Unstable angina NSTEMI STEMI 1 Think ‘A.C.S.’ at initial assessment Abnormal ECG? Clinical context? Stable patient? 2 STEMI Think invasive management Very high-risk NSTE-ACS High-risk NSTE-ACS OR Primary PCI Fibrinolysis (If timely primary PCI not feasible) Immediate angiography ± PCI Early (<24 h) angiography should be considered 3 Think antithrombotic therapy Antiplatelet therapy AND Anticoagulant therapy + OR OR OR Aspirin P2Y 12 inhibitor UFH LMWH Bivalirudin Fondaparinux 4 Think revascularization Based on clinical status, co-morbidities, Aim for complete and disease complexity revascularization Consider adjunctive tests to guide revascularization OR PCI CABG Intravascular imaging Intravascular physiology 5 Think secondary prevention Antithrombotic Lipid lowering therapy therapy Smoking cessation Cardiac rehabilitation Risk factor management Psychosocial considerations

23. ECG CRITERIA New ST elevation at the J-point in at least two contiguous leads: ≥2.5 mm in men <40 years, ≥2 mm in men ≥40 years, or ≥1.5 mm in women regardless of age in leads V2–V3 and/or ≥1 mm in the other leads (in the absence of left ventricular hypertrophy or left bundle branch block [LBBB]). it is recommended to record right precordial leads (V3R and V4R ) to assess for ST-segment elevation. 6 Posterior leads (V7–V9) can also be recorded to investigate for posterior STEMI,

24. Recommendations Class a Level b It is recommended to base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and hs- cTn. 1 , 17 , 18 I B ECG Twelve-lead ECG recording and interpretation is recommended as soon as possible at the point of FMC, with a target of < 10 min. 5 , 19 I B Continuous ECG monitoring and the availability of defibrillator capacity is recommended as soon as possible in all patients with suspected STEMI, in suspected ACS with other ECG changes or ongoing chest pain, and once the diagnosis of MI is made. 20 , 21 I B The use of additional ECG leads (V3R, V4R, and V7– V9) is recommended in cases of inferior STEMI or if total vessel occlusion is suspected and standard leads are inconclusive. 22 – 24 I B An additional 12-lead ECG is recommended in cases with recurrent symptoms or diagnostic uncertainty. I C

25. Blood sampling It is recommended to measure cardiac troponins with high-sensitivity assays immediately after presentation and to obtain the results within 60 min of blood sampling. 15 , 25 – 27 I B It is recommended to use an ESC algorithmic approach with serial hs - cTn measurements (0 h/1 h or h/2 h) to rule in and rule out NSTEMI. 28 – 44 I B Additional testing after 3 h is recommended if the first two hs - cTn measurements of the h/1 h algorithm are inconclusive and no alternative diagnoses explaining the condition have been made. 45 , 46 I B The use of established risk scores (e.g. GRACE risk score) for prognosis estimation should be considered. 47 – 49 IIa B Triage for emergency reperfusion strategy It is recommended that patients with suspected STEMI are immediately triaged for an emergency reperfusion strategy. 50 – 52 I A

26. Recommendations Class a Level b Emergency TTE is recommended in patients with suspected ACS presenting with cardiogenic shock or suspected mechanical complications. I C In patients with suspected ACS, non-elevated (or uncertain) hs-cTn levels, no ECG changes and no recurrence of pain, incorporating CCTA or a non-invasive stress imaging test as part of the initial workup should be considered. 116 , 122 – 127 IIa A Emergency TTE should be considered at triage in cases of diagnostic uncertainty but this should not result in delays in transfer to the cardiac catheterization laboratory if there is suspicion of an acute coronary artery occlusion. IIa C Routine, early CCTA in patients with suspected ACS is not recommended. 117 III B Recommendation Table 2 — Recommendations for non-invasive imaging in the initial assessment of patients with suspected acute coronary syndrome

27. Emergency care Role of General practitioners In some countries, primary care clinicians (general practitioners) play an important role may are FMC. Education and training of GPs in emergency, pre-hospital care is essential for the delivery of optimal pre-hospital care in this setting. The responsibilities include diagnosis, activation of the EMS, risk stratification, and initiation of pre-hospital treatment. However, in most settings, consultation with a general practitioner instead of a direct call to the EMS will increase the pre-hospital delay. Therefore, the public should be educated to call the EMS directly rather than a primary care physician for symptoms suggestive of ACS.

28. Acute pharmacotherapy Aspirin :LD of 150–300 mg orally or 75–250 mg i.v . if oral ingestion is not possible, followed by oral MD of 75–100 mg o.d .; no specific dose adjustment in CKD patients. P2Y12 receptor inhibitors (oral or i.v .) Clopidogrel LD of 300–600 mg orally , followed by an MD of 75 mg o.d .; no specific dose adjustment in CKD patients. Fibrinolysis : at the time of fibrinolysis an initial dose of 300 mg (75 mg for patients older than 75 years of age). Alternatives: Prasugrel / Ticagrelor / Cangrelor

29. Oxygen supplementation in patients who are not hypoxic (oxygen saturations >90%) is not associated with clinical benefits and is therefore not recommended. 148 , 149 (C1/LC) In patients with an ECG compatible with ongoing STEMI and symptom relief after nitroglycerine administration, it is recom - mended to obtain another 12-lead ECG . Complete normalization of ST-segment elevation, along with relief of symptoms, after nitroglycerine administration is suggestive of coronary spasm, with or without associated MI. Nitrates should not be given to patients with hypotension, marked bradycardia or tachycardia, RV infarction, known severe aortic stenosis , or phosphodiesterase 5 inhibitor use within the previous 24–48 h.

30. Intravenous opioid + mild tranquilizer should be considered in very anxious patients. ( CIla /L C) Intravenous opioids (e.g. morphine 5–10 mg) should be considered for the relief of severe chest pain. Other forms of pain relief (e.g. nitrous oxide/oxygen plus i.v . acetaminophen/ paracetamol ) have been re- ported to be inferior to morphine. Intravenous beta-blockers (preferably metoprolol ) should be considered at the time of presentation in patients undergoing PPCI with no signs of acute heart failure, an SBP >120 mmHg, and no other contraindications. 163 – 167 , 169 ( CIIa /EA)

31. Beta- blockers Beta-blockers are recommended in ACS patients with LVEF ≤ 40% regardless of HF symptoms. 801 , 870 – 872 I A Routine beta-blockers for all ACS patients regardless of LVEF should be considered. 798 , 873 – 878 IIa B RAAS system inhibitors Angiotensin -converting enzyme (ACE) inhibitors d are recommended in ACS patients with HF symptoms , LVEF ≤ 40%, diabetes, hypertension, and/ or CKD. 195 , 813 – 817 , 879 I A Mineralocorticoid receptor antagonists are recommended in ACS patients with an LVEF ≤ 40% and HF or diabetes. 826 , 880 I A Routine ACE inhibitors for all ACS patients regardless of LVEF should be considered. 816 , 817 IIa A

32. It is recommended to aim to achieve an LDL-C level of <1.4 mmol /L (<55 mg/ dL ) and to reduce LDL-C by ≥50% from baseline. 868 , 869 (CI/EA) If the LDL-C goal is not achieved despite maximally tolerated statin therapy after 4–6 weeks, the addition of ezetimibe is recommended. 788 If the LDL-C goal is not achieved despite maximally tolerated statin therapy and ezetimibe after 4–6 weeks, the addition of a PCSK9 inhibitor is recommended. 785 , 786 , 795 , 796

33. Proton pump inhibitors Proton pump inhibitors (PPIs) reduce the risk of upper gastroduodenal bleeding in patients treated with antiplatelet agents. 287 , 836 , 837 Therapy with a PPI is indicated for patients receiving any antithrombotic regimen who are at high risk of gastrointestinal bleeding Vaccination An annual influenza vaccination in patients with stable ASCVD appears to be associated with reduced incidence of MI, an improved prognosis in patients with HF, and decreased CV risk in adults aged 65 years and older.

34. In the Colchicine Cardiovascular Outcomes Trial (COLCOT), which enrolled 4745 patients with a recent ACS event, low-dose colchicine (0.5 mg daily) was associated with a significant reduction of the primary composite endpoint (CV death, resuscitated cardiac arrest, MI, stroke, or urgent revascularization) in comparison to placebo. The Low-dose Colchicine trial-2 (LoDoCo2) enrolled 5522 patients with CCS (84% of whom had prior ACS) who were randomized to colchicine (0.5 mg daily) or placebo. 851 The primary endpoint ( composite of CV death, MI, stroke, or ischaemia -driven coronary revascularization) rate was significantly lower in the colchicine group

35. Physical activity and exercise According to recommendations from the World Health Organization, adults with chronic conditions should limit their amount of sedentary time, replacing it with physical activity of any intensity (including light in- tensity ). 646 , 778 General physical activity recommendations include a combination of regular aerobic physical activity and resistance exercise throughout the week

36. KEY MESSAGES a recent change in clinical symptoms or signs, with or without changes on 12-lead ECG and with or without acute elevations in cardiac troponin concentrations. The incidence of STEMI is decreasing whereas the incidence of NSTEMI is increasing Chest pain/discomfort is the most common symptom initiating the ACS diagnostic and therapeutic pathway. High-sensitivity troponin measure- ments and rapid ‘rule-in’ and ‘rule-out’ algorithms should be used in patients with suspected NSTE-ACS.

37. Invasive strategies are time sensitive. For STEMI and very high-risk NSTE-ACS, an immediate invasive strategy is recommended . For patients with NSTE-ACS an inpatient invasive strategy is recommended, in NSTE-ACS patients with high-risk characteristics, an early invasive strategy (<24 h) should be considered . If timely ( within 120 min from time of diagnosis ) PPCI cannot be performed in patients with STEMI, fibrinolytic therapy is indicated within 12 h of symptom onset in patients without contraindications

38. Antithrombotic therapy is indicated in all ACS patients, regardless of the management strategy In addition to aspirin, a P2Y 12 receptor inhibitor is recommended, and should be maintained over 12months unless there are concerns regarding HBR Parenteral anticoagulation is recommended for all patients at the time of diagnosis For AF, TAT for up to 1 week, followed by DAT using a NOAC at the recommended dose for stroke prevention and a single oral antiplatelet agent (preferably clopidogrel ), is recommended as the default strategy A PPCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG with persistent ST elevation (or ST elevation equiva - lents )

39. coronary artery stenosis <50% in any major epicardial vessel. MINOCA a heterogenous group of underlying causes (both cardiac and extra-cardiac) and is found in 1–14% . CMR imaging is a key diagnostic tool. CKD is present in >30% of ACS patients. the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary ) An invasive strategy is recommended in cancer patients presenting with high-risk ACS with expected survival ≥6 months . Educating and informing the patient using the teach back method

40. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure Endorsed by the Heart Failure Society of America Published online ahead of print April 1, 2022

41. CLASS (STRENGTH) OF RECOMMENDATION CLASS 1 (STRONG) Benefit >>> Risk Suggested phrases for writing recommendations: Is recommended Is indicated/useful/effective/beneficial Should be performed/administered/other Comparative-Effectiveness Phrases†: Treatment/strategy A is recommended/indicated in preference to treatment B Treatment A should be chosen over treatment B CLASS 2a (MODERATE) Benefit >> Risk Suggested phrases for writing recommendations: Is reasonable Can be useful/effective/beneficial Comparative-Effectiveness Phrases†: Treatment/strategy A is probably recommended/indicated in preference to treatment B It is reasonable to choose treatment A over treatment B CLASS 2b (Weak) Benefit ≥ Risk Suggested phrases for writing recommendations: May/might be reasonable May/might be considered Usefulness/effectiveness is unknown/unclear/uncertain or not well- established CLASS 3: No Benefit (MODERATE) Benefit = Risk Suggested phrases for writing recommendations: Is not recommended Is not indicated/useful/effective/beneficial Should not be performed/administered/other CLASS 3: Harm (STRONG) Risk > Benefit Suggested phrases for writing recommendations: Potentially harmful Causes harm Associated with excess morbidity/mortality Should not be performed/administered/other LEVEL (QUALITY) OF EVIDENCE‡ LEVEL A High-quality evidence‡ from more than 1 RCT Meta-analyses of high-quality RCTs One or more RCTs corroborated by high-quality registry studies LEVEL B- R (Randomized) Moderate-quality evidence‡ from 1 or more RCTs Meta-analyses of moderate-quality RCTs LEVEL B- NR (Nonrandomized) Moderate-quality evidence‡ from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies Meta-analyses of such studies LEVEL C- LD (Limited Data) Randomized or nonrandomized observational or registry studies with limitations of design or execution Meta-analyses of such studies Physiological or mechanistic studies in human subjects LEVEL C- EO (Expert Opinion) Consensus of expert opinion based on clinical experience.

42. TOP 10 TAKE-HOME MESSAGES 1. Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction ( HFrEF ) now includes 4 medication classes that include sodium-glucose cotransporter-2 inhibitors (SGLT2i). 2. SGLT2i have a Class of Recommendation 2a in HF with mildly reduced ejection fraction ( HFmrEF ). 3. New recommendations for HFpEF are made for SGLT2i (Class of Recommendation 2a), MRAs (Class of Recommendation 2b), and ARNi (Class of Recommendation 2b ) 4. Improved LVEF is used to refer to those patients with previous HFrEF who now have an LVEF >40%. These patients should continue their HFrEF treatment.

43. 5. Value statements were created for select recommendations where high-quality, cost-effectiveness studies of the intervention have been published 6. Amyloid heart disease- new recommendations, screening for serum and urine monoclonal light chains, bone scintigraphy , genetic sequencing, tetramer stabilizer therapy, and anticoagulation. 7. Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is >40%.

44. 8. Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. A HF specialty team reviews HF management, assesses suitability for advanced HF therapies, and uses palliative care including palliative inotropes where consistent with the patient’s goals of care. 9. Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Heart Failure Guideline HF were revised to emphasize the new terminologies of “at risk” for HF for stage A and pre-HF for stage B. 10. Recommendations are provided for iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary artery disease, and malignancy

45. Table 4. Classification of HF by LVEF Type of HF According to LVEF Criteria HFrEF (HF with reduced EF) LVEF ≤40% HFimpEF (HF with improved EF) Previous LVEF ≤40% and a follow-up measurement of LVEF >40% HFmrEF (HF with mildly reduced EF) LVEF 41%–49% Evidence of spontaneous or provokable increased LV filling pressures (e.g., elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement) HFpEF (HF with preserved EF) LVEF ≥50% Evidence of spontaneous or provokable increased LV filling pressures (e.g., elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement)

46. 2 major or 1 major + 2 minor

47. BOSTON CRITERIA Definite HF: 8-12 Possible HF: 5-7 No HF: < 4 points

48. H2FPEF Score for Diagnosis Circulation. 2018;138:861–870 H2PEF score HFpEF probability 0 – 1 < 25% 2 – 5 40-80% ≥6 90%

49. STEPWISE @ED, AFTER CAREFUL ASSESSMENT OF INITIAL ABCDE 1. O2- >95% +/- S/L, NG -2 SPRAYS OR TAB 0.4MG/ 5MIN 2. SEV DYSPNOEA-(ABG) NIV TO INTUBATION ACCORDINGLY 3. IF BP >150MMHG 1.IV NITROGLYCERINE &/OR 2. IV NITROPRUSSIDE 0.3mcg/kg/min titrate / 5 min (STOP IF SBP100MMHG) 4. VOL OVERLOAD – IV LOOP DIURETICS ( NITRATES BEFORE DIURETICS) 5. ASSESSMENT OF SEVERITY OF ILLNESS- LOOK FOR ACS DESPITE NIV (LOOK FOR CARDIOGENIC SHOCK 3%) CONSIDER ADMIT ICU- RISK OF DECOMPENSATION DISCHARGE OR ED OBSERVATION UNIT IF RESPONSE TO THERPAY

50. INDICATIONS OF SPIROLACTONE Recently (within 60 days) elevated natriuretic peptide (either [BNP] ≥100 pg per mL or [NT- proBNP ] ≥360 pg per mL ). To initiate MRA, the patient's serum potassium should be ≤4.7 mEq /L and eGFR must be ≥30 mL/min per 1.73 m 2 . To uptitrate the MRA dose, the patient's serum potassium should be ≤4.5 mEq /L. The initial dose is 12.5 mg once daily, which is titrated as tolerated every four weeks to the maximum tolerated dose. The goal dose is 25 to 50 mg.

51. Recommendation for Beta Blockers COR LOE Recommendation 1 A 1. In patients with HFrEF , with current or previous symptoms, use of 1 of the 3 beta blockers proven to reduce mortality ( e.g., bisoprolol , carvedilol , sustained-release metoprolol succinate ) is recommended to reduce mortality and hospitalizations. Value Statement: High Value (A) 2. In patients with HFrEF , with current or previous symptoms, beta-blocker therapy provides high economic value.

52. Sodium-Glucose Cotransporter 2 Inhibitors Recommendation for SGLT2i Referenced studies that support the recommendation are summarized in the Online Data Supplements. COR LOE Recommendation 1 A 1. In patients with symptomatic chronic HFrEF , SGLT2i are recommended to reduce hospitalization for HF and cardiovascular mortality, irrespective of the presence of type 2 diabetes. Value Statement: Intermediate Value (A) 2. In patients with symptomatic chronic HFrEF , SGLT2i therapy provides intermediate economic value.

53. HF and Pregnancy . COR LOE Recommendations 1 C- LD 1. In women with a history of HF or cardiomyopathy , including previous peripartum cardiomyopathy , patient-centered counseling regarding contraception and the risks of cardiovascular deterioration during pregnancy should be provided. 2b C- LD 2. In women with acute HF caused by peripartum cardiomyopathy and LVEF <30 %, anticoagulation may be reasonable at diagnosis, until 6 to 8 weeks postpartum, although the efficacy and safety are uncertain. 3: Harm C- LD 3. In women with HF or cardiomyopathy who are pregnant or currently planning for pregnancy, ACEi , ARB, ARNi , MRA, SGLT2i, ivabradine , and vericiguat should not be administered because of significant risks of fetal harm.

54. Pathophysiological targets in Chronic Hemodynamically stable HFrEF

55. Clinical trials in HFpEF most management is directed toward associated conditions ( eg , hypertension) and symptoms ( eg , edema). Goal directed medical therapy for associated comorbid conditions. General measures: Salt restriction < 2 gm /day Fluid restriction Moderation in alcohol consumption Pneumococcal & Influenza vaccination

56. SALT INTAKE IN NEPAL

57. Ongoing Researches for HFpEF Transcatheter Intracardiac Shunt Device REDUCE LAP – HF REDUCE LAP – HF 1 Implantation of an interatrial shunt device is feasible, seems to be safe, reduces left atrial pressure during exercise, and could be a new strategy for the management of HFPEF.

58. Palliative and Supportive Care Domains to Improve Processes of Care and Patient Outcomes High-quality communication Conveyance of prognosis Clarifying goals of care Shared decision-making Symptom management Caregiver support

59. Take home messages HF is a clinical diagnosis and underlying treatable cause need to be identified as early Timely referral recommended for Grade 4 NYHA class HFpEF is a heterogeneous syndrome which is continues to rise in prevalence. A normal level of BNP doesn’t rule out HFpEF . There is no evidence that any of the current pharmacological interventions can reduce mortality. The present treatment includes decongestion with diuretics and careful management of co-morbidities. Education regarding illness, outcome prognosis mortality and morbidity on HF must be provided to patient and parties as well

60. Thank you