Guidelines >
> ACC & Nice
ACC and NICE published their new guidelines last year and this year respectively.
Minor dissimiarlities do occur, of course.
Guidelines >
> NT proBNP
NICE said... NT proBNP has a greater
sensitivity over a range of thresholds compared to BNP.
Also, NT proBNP has a longer stability in blood samples and is not interfered by Sacubitril Valsartan
compared to BNP. NICE, therefore, recommended NT proBNP over BNP as a diagnostic and prognostic marker
of heart failure. ACC, on the other hand, recommended either one.
Guidelines >
> Fundamental of HF Rx
- INFORMATION & SUPPORT
- SALT & FLUID CONSUMPTION
- ALCOHOL & SMOKING CESSATION
- TRAVELLING & DRIVING
- CONTRACEPTION
- VACCINATIONS
Guidelines >
> HFrEF
ACEI/ARB and Beta Blockers remain the first line treatment of HFrEF to reduce morbidity
and mortality.
Diuretic is recommended to relieve the symptoms of congestion and fluid retention.
Guidelines >
> HFrEF -- ARNI
In patients with HFrEF NYHA class II or III
who tolerate an ACEI or ARB, replacement by an ARNI is
recommended to further reduce morbidity and mortality.
In ARNI, an ARB is combined with an inhibitor of neprilysin, an enzyme that degrades
natriuretic peptides, bradykinin, adrenomedullin, and other vasoactive peptides.
Inhibition of neprilysin increases the levels of these substances, countering the neurohormonal overactivation that contributes to vasoconstriction, sodium retention, and maladaptive remodeling.
Inhibition of neprilysin increases the levels of these substances, countering the neurohormonal overactivation that contributes to vasoconstriction, sodium retention, and maladaptive remodeling.
Guidelines >
> HFrEF -- second-line
Recommendation for MRA and hydralazine/nitrates remained unchanged.
Guidelines >
> HFrEF -- Ivabradine
Recommended for the 1st time, as class IIa, in ACC.
Ivabradine can be beneficial to reduce HF hospitalization for patients
with stable chronic HFrEF who are receiving GDEM, including a beta blocker at maximum
tolerated dose, and who are in sinus rhythm with a heart rate of 70 bpm
or greater at rest.
NICE recommended Ivabradine since 2012.
NICE recommended Ivabradine since 2012.
Guidelines >
> HFrEF -- CIEDs
Nothing new. Just added the end-of-life care planning.
Before implantation,
explain the function of the device and the circumstances in which
deactivation might be offered, and
discuss the consequence of deactivation.
Provide the person and, if they wish, their family or carers with written information covering the information discussed.
Provide the person and, if they wish, their family or carers with written information covering the information discussed.
Guidelines >
> HFpEF -- TOPCAT
In addition to antihypertensives and diuretic, ACC recommended spironolactone
as a class IIb for patients with HFpEF.
"A positive re-look from a negative trial"
In TOPCAT trial, treatment with spironolactone in HFpEF did not significantly reduce primary outcome. A post-hoc analysis, however, showed significant regional variation and a greater benefits in patients from Americas than those from Russia and Georgia.
In TOPCAT trial, treatment with spironolactone in HFpEF did not significantly reduce primary outcome. A post-hoc analysis, however, showed significant regional variation and a greater benefits in patients from Americas than those from Russia and Georgia.
Guidelines >
> Summary
A "NICE" summary on management of chronic heart failure
Trials >
> CAMERA-MRI
- CAMERA-MRI
- RCT, MULTICENTER
- PERSISTENT AF
- IDIOPATHIC CM
- CATHETER ABLATION vs. MEDICAL RATE CONTROL
- N=301, Age=61, LVEF=33%.
- Catheter ablation = PVI + Box lesion.
- Agerage resting HR on medical rate control arm = 77bpm.
- Primary Endpoint = change in LVEF on repeat cardiac MRI at 6 months.
-
RESULTS
- Catheter ablation (CA) significantly improved LVEF (18.3% increased) at 6 months compared to medical rate control (MRC) group (4.4% increased).
- At 6 months, 58% of patients undergoing CA had normalized systolic function (LVEF ≥50%) compared with 9% in the MRC group (p = 0.0002).
- LVESV, LA volume, and BNP level were significantly improved in the CA group.
Sub-Group Analysis
- In those undergoing CA (n = 36), the LGE-negative group (n = 22) had a significantly greater improvement in absolute LVEF at 6 months compared with LGE-positive patients (n = 14) (11.6% vs. 22.3%; p = 0.0069).
- On multivariable analysis, only the absence of LGE predicted LVEF normalization (p = 0.0342)
CONCLUSIONS: CAMERA-MRI
AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control.
The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR.
AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control.
The restoration of sinus rhythm with CA results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on CMR.
Trials >
> CASTLE-AF
CATHETER ABLATION versus standard conventional treatment in patients with
LEFT VENTRICULAR DYSFUNCTION and AF.
- RCT, MULTICENTER, OPEN-LABELLED.
- Symptomatic AF, LVEF≤35%, NYHAII+, AAD: failed/side effects/unwilling, ICD/CRT-D with A lead.
- Catheter Ablation for AF vs. Medical Therapy for AF (rate and/or rhythm).
- Primary endpoint of death or worsening HF; mean F/U 37.8mo.
Primary composite endpoint occured in significantly fewer
patients in the ablation group than in the medical therapy group.
(51 patients [28.5%] vs. 82 patients [44.6%]; hazard ratio, 0.62;
95% confidence interval [CI], 0.43 to 0.87; P=0.007.)
Fewer deaths and lower AF burden in catheter ablation group.
LVEF improvement also occurred more in ablation group.
The median absolute increase in LVEF from baseline to the 60-month follow-up visit was 8.0% (interquartile range, 2.2 to 19.1) in the ablation group and was 0.2% (−3.0 to 16.1) in the medical-therapy group (P=0.005).
The median absolute increase in LVEF from baseline to the 60-month follow-up visit was 8.0% (interquartile range, 2.2 to 19.1) in the ablation group and was 0.2% (−3.0 to 16.1) in the medical-therapy group (P=0.005).
Benefits were seen more in those with LVEF ≥25%.
Conclusions
Catheter ablation for AF in patients with heart failure
was associated with a significantly
lower rate of a composite end point of
death from any cause or hospitalization
for worsening heart failure than was medical therapy.
Trials >
> COMMANDER HF
- RCT, DOUBLE-BLINDED.
- 5022 patients with HFrEF, CAD, without AF.
- Rivaroxaban 2.5 mg BID vs. placebo.
- Primary efficacy outcome: death, MI, or stroke.
- Primary safety outcome: fatal bleeding or bleeding into critical space.
No significant difference in primary efficacy endpoint was noted between
the rivaroxaban group and the placebo group.
The primary efficacy outcome occurred in 626 patients (25.0%) assigned to rivaroxaban
and 658 patients (26.2%) assigned to placebo (HR, 0.94; 95% CI, 0.84 to 1.05; P=0.27).
A total of 1284 events occurred which is enough to provide more than 80% power to detect a 20% lower HR, with a 2-sided type I error of 0.05.
A total of 1284 events occurred which is enough to provide more than 80% power to detect a 20% lower HR, with a 2-sided type I error of 0.05.
...the results of COMMANDER HF support the position that oral anticoagulation is not indicated for patients with heart failure and reduced ejection fraction in the absence of atrial fibrillation.
Trials >
> APAF-CRT
- Multicenter, open-labelled, RCT, N=102, mean age 72, f/u 16 months.
- Severely symptomatic permanent AF, QRS ≤110ms, and at least 1 hospitalization for AF or HF in the previous year.
- AF: Permanent AF for > 6months; unsuitable for or failed catheter ablation.
- AV junction ablation + CRT vs. pharmacologic rate control (target resting HR <110 bpm).
- Primary composite outcome: death due to HF, or hospitalization due to HF, or worsening HF.
In comparison with control arm, AV junction ablation + CRT reduced
the risks of primary endpoint by 62%.
Ablation+CRT patients also showed a 36% decrease in the specific
symptoms and physical limitations of AF at 1 year follow-up (P = 0.004).
...AV junction ablation and CRT is both safe and superior to conventional medical strategy in relieving symptoms of HF and reducing hospitalization for HF in elderly patients affected by permanent AF and narrow QRS.
...Such interventional therapy should be offered to patients with symptomatic HF refractory to pharmacological therapy who cannot undergo catheter ablation of AF for the maintenance of sinus rhythm, or in whom ablation has failed.
CONCLUSIONS
NT proBNP
NT proBNP is preferred over BNP for a wider range of sensitivity and utility.
Non-MEDICAL Rx
Non-medical therapy, including lifestyle modification and rehabilitation, should be emphasized to improved quality of life and reduce heart failure hospitalization.
CATHETER ABLATION
Catheter ablation for rhythm control of atrial fibrillation should be considered in patients with AF and cardiomyopathy to improve cardiovascular outcomes.
NT proBNP is preferred over BNP for a wider range of sensitivity and utility.
Non-MEDICAL Rx
Non-medical therapy, including lifestyle modification and rehabilitation, should be emphasized to improved quality of life and reduce heart failure hospitalization.
CATHETER ABLATION
Catheter ablation for rhythm control of atrial fibrillation should be considered in patients with AF and cardiomyopathy to improve cardiovascular outcomes.
