XIII Reunión anual de la sección de Insuficiencia Cardiaca de la SEC OVIEDO, 16-18 JUNIO 2016 HOSPITAL UNIVERSITARIO CENTRAL DE ASTURIAS (HUCA) http://secardiologia.es/insuficiencia/cientifico/ic-oviedo-2016 Conferencia invitada: Presentacion de la Guía de Insuficiencia Cardiaca 2016 de la SEC VIERNES, 17 DE JUNIO 18:00-18:30 SALÓN DE ACTOS Presenta: José Luis Lambert Rodríguez (Presidente de la Sección de Insuficiencia Cardiaca) José Ramón González Juanatey, Santiago de Compostela

1. José R González Juanatey
Servicio de Cardiología y UCC
Hospital Clínico Universitario
Santiago de Compostela.
Algunos elementos para el debate y
tambien la discrepancia

2. Disclosures:
Research Grants: AZ, Boehringer Ingelheim,
Pfizer, Novartis, Daichii-Sankyo, Sanofi-Aventis,
Bayer, MSD, Servier, Ferrer
Consultant/Honorarium. AZ, Boehringer-
Ingelheim, Bayer, Pfizer, BMS, MSD, Daichii-
Sankyo, Servier, Menarini, Ferrer, Amgem

4. “ Heart Failure is a clinical syndrome characterized by
typical symptoms (e.g. breathlessness, ankle swelling
and fatigue) that may be accompanied by signs (e.g.
elevated jugular venous pressure, pulmonary crackles
and peripheral oedema) caused by a structural
and/or functional cardiac abnormality, resulting in
a reduced cardiac output and/ or elevated intracardiac
pressures at rest or during stress “
HEART FAILURE. “NEW DEFINITION”

5. Heart Failure
diagnosis.
Non-acute
onset

6. PATIENT WITH SUSPECTED HF (a)
(non-acute onset)
ASSESSMENT OF HF PROBABILITY
1. Clinical history:
• history of CAD (MI, revascularization)
• history of arterial hypertension
• exposition to cardiotoxic drug/radiation
• use of diuretics
• orthopnoea / paroxysmal nocturnal dyspnoea
2. Physical examination:
• basal rales (or more)
• bilateral ankle oedema
• heart murmur
• jugular venous dilatation
• laterally displaced/broadened apical beat
all absent
≥1 present
NATRIURETIC PEPTIDES
•NT-proBNP ≥125 pg/mL
•BNP ≥35 pg/mL *
HF unlikely:
consider other
diagnosis
no
Assessment of natriuretic
peptides not routinely done
in clinical practice

7. yes
If HF confirmed:
determine aetiology and start appropriate treatment
ECHOCARDIOGRAPHY
normal (b)
b - consider other
causes of elevated
natriuretic peptides
≥1 present
NATRIURETIC PEPTIDES
•NT-proBNP ≥125 pg/mL
•BNP ≥35 pg/mL *
HF unlikely:
consider other
diagnosis
no
Assessment of natriuretic
peptides not routinely done
in clinical practice
* not suitable for patients taking angiotensyn receptor neprilysin inhibitors

8. “ At the mentioned exclusionary cut-points, the negative predictive
values are very similar and high (0.94–0.98) in both the non-acute and
acute setting, but the positive predictive values are lower both in the
non-acute setting (0.44–0.57) and in the acute setting (0.66 – 0.67).
Therefore, the use of NPs is recommended for ruling-out HF, but not
to establish the diagnosis.
Heart Failure diagnosis.
Natriuretic Peptides

9. Definition of HF with Reduced (HFrEF), Mid-range (HFmrEF)
and Preserved Ejection Fraction (HFpEF)
LVEF<40% LVEF40-49% LVEF>50%
- LVEF 40 – 49% different phenotype compared with EF>50%.?
-Identifying HFmrEF as a separate group will stimulate research into
the underlying characteristics, pathophysiology and treatment of this
group of patients.
-Patients with an LVEF in the range of 40 – 49% represent a ‘grey area’.
-Potentially differential treatment effects.

10. Pronóstico de Pacientes con HFmrEF. REDINSCOR II
REDINSCOR II. En Revisión.

11. Echocardiographic HFpEF/HFmrEF criteria for “structural
and/or functional cardiac abnormality”
The presence of symptoms
and/or signs of HF.
 A ‘preserved’ EF (defined as
LVEF ≥50% or 40–49% for
HFmrEF).
Elevated levels of NPs (BNP
≥35 pg/mL and/or NT-
proBNP≥125 pg/mL)
Objective evidence of other
cardiac functional and
structural alterations
underlying HF.
Stress test or invasively elevated
LV filling pressure may be needed
to confirm the diagnosis
Definition of HF with Reduced (HFrEF), Mid-range (HFmrEF)
and Preserved Ejection Fraction (HFpEF)

12. Definition of HF with Reduced (HFrEF), Mid-range (HFmrEF)
and Preserved Ejection Fraction (HFpEF)

13. Definition of HF with Reduced (HFrEF), Mid-range (HFmrEF)
and Preserved Ejection Fraction (HFpEF)

14. Recommendations for cardiac imaging in patients with suspected
or established HF
TTE
CMR
Poor acoustic window CMR
Myocarditis, amyloidosis,
Sarcoidosis, Chagas, Fabry,
Haemocromatosis
Coro-angio

15. Reassessment of myocardial structure and function
using non-invasive imaging
Worsening
HF symptoms,
other CV event
OMT patients
before ICD, CRTChemotherapy
(serial assessment)

16. Prevention or Delay development of HF or prevent
death before symptoms
Emplaglifocin in Type 2 Diabetics IIa B
ACE-i in Stable CAD IIa B

17. Heart Failure. An Extraordinary Journey
Innovation Year Impact
ACE Inhibitors 80´ Mortality
B-Blockers 00´ Mortality
Aldosterone Recept Block 00´ Mortality
Defibril/Cardiac RT 00´ Mortality
Nurses Process 00´ Mortality-morbi
Cardiac Transplant 80-00 Mortality
Ivabradin 10´ Morbi-mortality
VA Devices 10´ Morbi-mortality
LCZ-696 14´ Morbi-mortality
Acute HF code 00-15´ Mortality-Morbi?
Gene therapy 15´? Mortality?
40%
10%

18. Regular
aerobic
exercise and
cardiac
rehabilitation
Multidisciplinary care
Primary care long-
term follow-up…

19. Therapeutic
algorithm for
symptomatic
patient with
HFrEF

20. Add MR antagonistd
(up-titrate to maximum tolerated evidence-
based dose)
Therapy with ACEIc
and beta-blocker
(up-titrate to maximum tolerated evidence-based doses)
Still symptomatic
yes
no
Patient with symptomatic
a
HFrEF
b
No further action required
Consider reducing diuretic dose
Diureticstorelievesymptomsandsignsofcongestion
IfLVEF<35%despiteanadequatetrialof
pharmacologicaltherapyconsiderICD

21. If-channel inhibitor
…reduce the risk of HF
hospitalz and CV death…
…unable to tolerate or
have contra-indications for
a beta-blocker.
IIa c
2012 IIb

22. Angiotensin receptor neprilysin inhibitor
LCZ696 recommended as
a replacement for an ACE-I
…reduce risk HF
hospitalz and death
remain symptomatic with
optimal ACE-I+BB+MRA

23. 23
No de riesgo
LCZ696 4187 3922 3663 3018 2257 1544 896 249
Enalapril 4212 3883 3579 2922 2123 1488 853 236
MuerteporcausasCVoprimerahospitalizaciónporIC
McMurray JJ, et al. N Engl J Med. 2014;371:993-1004.
Hazard ratio = 0.80 (95% CI: 0.73–0.87)
p<0.001
Días desde la aleatorización
Probabilidadacumulada
1.0
0.6
0.4
0.2
0
0 180 360 540 720 900 1080 1260
Enalapril
LCZ696
RR 20%
PARADIGM-HF: Objetivo Primario
…symptomatic HFrEF, LVEF<40%
(changed to <35% during the study).
BNP>150 pg/mL or NT-proBNP>600
pg/mL; HF hopitalz previous 12
months, BNP>100 pg/mL or NT-
proBNP>400 pg/mL

24. 24
No de riesgo
LCZ696 4187 3922 3663 3018 2257 1544 896 249
Enalapril 4212 3883 3579 2922 2123 1488 853 236
MuerteporcausasCVoprimerahospitalizaciónporIC
McMurray JJ, et al. N Engl J Med. 2014;371:993-1004.
Hazard ratio = 0.80 (95% CI: 0.73–0.87)
p<0.001
Días desde la aleatorización
Probabilidadacumulada
1.0
0.6
0.4
0.2
0
0 180 360 540 720 900 1080 1260
Enalapril
LCZ696
RR 20%
PARADIGM-HF: Objetivo Primario
…estimated GFR>30 mL/min/1.73
m2 able to tolerate separate
treatment periods with enalapril (10
mg b.i.d.) and LCZ696 (97/103 mg
b.i.d.) during a run-in period

25. Angiotensin receptor neprilysin inhibitor
…combined treatment
with an ACEI (or ARB)
and LCZ696 is
contraindicated.
… the ACEI should be
withheld for at least 36 h.
before initiating LCZ696

26. QRS ≥140 msec f
Still symptomatic
yes
Sinus rhythm
LVEF ≤ 35%
Elevated BNP/NT-proBNP e
Tolerant to ACEI and ARB
(in doses equivalent to enalapril
10mg bid and valsartan 160 mg bid)
HR ≥70 bpm
Ivabradine *
* These treatments may be combined if indicated
ARNI *
to replace ACEI
CRT *
Consider
digoxin or H-ISDN or
LVAD, heart transplantation
Resistant symptoms
no
yes
No further action
required
Consider reducing
diuretic dose
IfLVEF<35%despiteanadequatetrialof
pharmacologicaltherapyconsiderICD

27. ICD implantation in patients with HF
. IHD (unless AMI prior 40 days).
. DCM
Generator replacement:
¿FEVI recovered w/out
shocks; end-of-life?

28. CRT implantation in patients with HF
…symptomatic HF, SR, QRS>150
ms and LBBB QRS, LVEF<35%
with OMT: improve symptoms and
reduce morbi/mortality
…symptomatic HF, SR, QRS 130-149
ms and LBBB QRS, LVEF<35% with
OMT: improve symptoms and reduce
morbi/mortality

29. …symptomatic HF, SR, QRS 130-149
ms and LBBB QRS, LVEF<35% with
OMT: improve symptoms and reduce
morbidity/mortality
CRT Implantation in HF Patients. 2016
Recommendation based on two meta-analysis:
1. Cleland JG, et al. Eur Heart J 2013; 34: 3547-3556.
2. Woods B, et al. Heart 2015; 101: 1800-1810

30. CRT implantation in patients with HF
CRT rather than RV
pacing…HFrEF…indication for V.
Pacing and AV block…reduce
morbidity. Includes patients with AF
…symptomatic HF, SR, QRS>150
ms and non-LBBB QRS, LVEF<35%
with OMT: improve symptoms and
reduce morbi/mortality

31. CRT Implantation in HF Patients. 2016
QRS duration
Mortality end-point

32. LVAD a New Heart Failure Pardigm

33. Indications for
Mechanical
Circulatory
Support
Short-term
Long-term
Inotropics I.V.
Organ Damage
(kidney/Liver)
No severe
RVD + TR
“Frequent Flyers”
> 3/yr
LVEF < 25%, VO2 < 12

34. INTERMACS stages for classifying patients with AHF
LAICA.
Spanish Multicenter Study

35. VAD vs Cardiac Transplant 2016
LVD Recommendations
Heart Transplant
Bridge to transplant
Mehra M, et al J Heart Lung Transplant 2016
No limite de edad como
contraindicación absoluta
No intervalo de tiempo definido
tras historia de cáncer
BMI < 35 kg/m2
IC terminal sin otras opciones
Motivación, Información
Adherencia al tratamiento
Soporte social
LVAD* si HTP irreversible
*LVAD si otras co-morbilidades potencialmente
reversibles: cáncer, obesidad, tabaquismo o IR y
reevaluación posterior

36. Treatment
of patients
with HFpEF
and HFmrEF
HFmrEF
treatment? Should
be recommended
the HFrEF
therapy?

37. • CAD / ischemia &
Hypertension
• Diabetes mellitus & Metabolic
syndrome
• Sleep apnoea
• Depression & Stroke
• Anemia and iron deficiency
• COPD
• Renal dysfunction & injury
• Liver & bowel dysfunction
• Cachexia & muscle wasting
Empagliflozin
EMPA-REG-OUTCOME
SERVE-HF
CONFIRM-HF
HYPERKALEMIA
- Patiromer: OPAL-HK trial
-Sodiumzirconium
cyclosilicate (ZS-9)
Importance of Co-morbidities in Patients with HF

38. Recommendations for the treatment of iron
deficiency in patients with HF

39. Treatment of Valvular Disease in HF Patients
Mitral regurgitation a “big issue”

40. Treatment of Valvular Disease in HF Patients.
Mitral Regurgitation
Ischemic MR

41. Importance of
Angina in
Patients with
Coronary
Disease, Heart
Failure, and
Left
Ventricular
Systolic
Dysfunction.
Insights from
STICH
Jolicoeur EM, et al. JACC
2015; 66: 2092-2100.

42. 1. Cardiac arrest ?
3. Respiratory failure ?
2. Cardiogenic shock ?
Urgent phase
after first medical
contact
no
no
Patient with
suspected AHF
yes
yes
yes
CPR
Ventilatory suport
•oxygen
•non-invasive positive
presure ventilation
(CPAP, BiPAP)
•mechanical ventilation
Immediate stabilization
and transfer to ICU/CCU
no
Circulatory suport
• pharmacological
• mechanical

43. Diagnostic work-up
to confirm AHF and clinical evaluation
to select optimal management
If any present, immediately
initiate specific treatment *
C Coronary syndrome
H Hypertension emergency
A Arrhythmia
M Mechanical defect
P Pulmonary embolism
Identification of acute
co-morbidities
Immediate phase
(initial 60-120 minutes) Immediate stabilization
and transfer to ICU/CCU

44. CV/Kidneydamage
Congestion/
Hypoperfusion
Time
No Early
CV/Kidney
stabilization
CV/Kidney stabilization
CV and Kidney damage during an
episode of Acute HF

45. ADEQUATE PERIPHERAL
PERFUSION
PATIENT WITH ACUTE HEART FAILURE
signs/symptoms:
•orthopnoea, PND, breathlessness, bi-basal rales, an abnormal blood pressure
response to the Valsalva maneuver (left-sided);
•symptoms of gut congestion, elevated jugular venous distention, hepatojugular
reflux, hepatomegaly, ascites, and peripheral oedema (right-sided);
PRESENCE OF CONGESTION
YES (95% of all
AHF patients)
NO (5% of all
AHF patients)
’Dry’ patient
Bedside assessment to identify
haemodynamic profiles
’Wet’ patient

46. CONGESTION (+)
HYPOPERFUSION (+)
WARM-DRY WARM-WET
COLD-DRY COLD-WET
CONGESTION (-)
HYPOPERFUSION (-)
cold sweated extremities
oliguria
mental confusion
dizziness
narrow pulse pressure
Hypoperfusion is not synonymous with hypotension,
but often hypoperfusion is accompanied by hypotension.
pulmonary congestion
orthopnoea/PND
peripheral (bilateral) oedema
jugular venous dilatation congested
hepatomegaly
gut congestion, ascites
hepatojugular reflux

47. ADEQUATE PERIPHERAL
PERFUSION
YES
’Wet and Warm’ patient
(typically elevated or normal
systolic blood pressure)
NO
’Wet and Cold’ patient
(typically low SBP)
•inotropes: dobutamine,
levosimendan, milrinone
•vasodilators (if peripheral
vasoconstriction):
nitroprusside, nitrates
•diuretics
Vascular type
(fluid redistribution):
•vasodilators
•diuretics (small dose)
Cardiac type
(fluid accumulation):
• diuretics
• ultrafiltration (if
diuretic resistance)
’Wet’ patient

48. ’Dry’ patient
ADEQUATE PERIPHERAL
PERFUSION
YES NO
’Dry and Warm’
Adequately perfused
+ Compensated
Adjust oral therapy
’Dry and Cold’
Hypoperfused,
Hypovolemic
Consider fluid
Consider inotropics if
still hypoperfused

49. Recommendations in Patients with Cardiogenic Shock
Immediate ECG and Echo
Transfer to a tertiary center
24/7
ACS coroangio 2h/revasc

50. PATIENT WITH ACUTE HEART FAILURE
“Gaps in Evidence”
. Prospective evaluation of the “time-to-treatment” concept in AHF
. Evaluation whether inadequate phenotiping is responsible for the
failure of treatments to improve outcome in AHF
. Better definition and treatment of diuretic resistance
. Role of Nitrates in the management of AHF
. Treatment improving morbidity and mortality
. Strategies and therapies to prevent early rehospitalization after
discharge for a hospital admissionfor AHF