The diagnosis of heart failure was discussed by Philip Poole-Wilson (London, UK).
Guidelines not primarily for cardiologists, but for other professionals caring for patients with heart failure (HF). The new guidelines have combined acute and chronic aspects.
As regards evidence level, diagnostic tools cannot stand up for evidence grading and therefore, an evidence level is not given for diagnostic approaches.
See P. Poole-Wilson presentation online
The importance of heart structure and function has now been recognised, and these aspects have been added to the definition of heart failure, which now reads: “Heart failure is a clinical syndrome in which patients have the following features:
• Symptoms typical of heart failure (breathlessness at rest or on exercise, fatigue, tiredness, ankle swelling)
and
• Signs typical of heart failure (tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure, peripheral oedema, hepatomegaly, ascites, cachexia)
and
• Objective evidence of a structural or functional abnormality of the heart at rest (cardiomegaly, third heart sound, cardiac murmurs, abnormality on the echocardiogram, raised natriuretic peptide).
Importantly, it was emphasised that the diagnosis is not dependent on a certain ejection fraction (EF), although it has implications for prognosis.
In this session, ACC/AHA and ESC definitions were compared.
Furthermore, time is important for various types of heart failure, such as new onset, transient and chronic.
Possible causes of HF include CHD, hypertension and heart muscle disease, valvular diseases.
As regards diagnostic tools, the importance of BNP/NT-proBNP was stressed, and it is now recommended not only for excluding heart failure, but also for confirmation of the diagnosis.
Echocardiography is mandatory for the diagnosis! Michael Böhm spoke about drug treatment. For ACE-inhibitors, ARBs, beta-blockers, aldosterone antagonists and diuretics there are no important changes.
See M. Bohm presentation online
There is still uncertainty about use of angiotensin receptor blockers (ARB) or aldosterone antagonists in patients who remain symptomatic under ACE inhibitors and beta blockers. Which agent to start with is still an open question.
Statins are recommended with grade IIb for prevention of cardiovascular hospitalisations.
Use of devices was discussed by Silvia Priori. ICDs and EFs were reviewed. Cut-offs of EF <30, <35 or <40% have been used. Cut-offs vary in trials but <35% is a reasonable compromise. The recommendations were changed from <30-35% in 2005, to<35%, while the Class of Recommendation and strength of evidence remain unchanged. See S.Priori presentation online
The use of ICDs in asymptomatic patients was not discussed, and recommendations for ICD use in heart failure can be found in other guidelines focusing more particularly on devices.
As regards CRT, there exist no data to support the superiority on survival of CRT above CRT-D or vice versa. Both alternatives received a recommendation grade IA.
The various barriers to implementation were stressed by Kenneth Dickstein. The involvement of the patient is crucial to success. In particular, physicians and patients are encouraged to use the patient oriented web site: http://www.hearfailurematters.org/
See K.Dickstein presentation online
Access the ESC Practice Guidelines on Acute and Chronic Heart Failure (Diagnosis and Treatment)
Notes to editor
This congress report accompanies a presentation given at the ESC Congress 2008. Written by the author himself/herself, this report does not necessarily reflect the opinion of the European Society of Cardiology.