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Evolution not revolution in the management of acute heart failure

Heart Failure 2016 Congress News

Veli-Pekka Harjola, Helsinki University Central Hospital, Finland

The new ESC Guidelines: Focus on acute heart failure; 21 May, 16:00–17:30; London



 

The details of the management acute heart failure have been refined and brought into sharper focus in the new European Society of Cardiology (ESC) guidelines, delegates were told yesterday afternoon.

In a session dedicated to the acute heart failure section of the guidelines, Veli-Pekka Harjola (Helsinki University Hospital, Finland) presented the latest evidence on key aspects such as the diagnostic workup and updates to the management algorithms.

Speaking to Heart Failure Congress News ahead of the session, Prof. Harjola emphasised that, while the “main message” of the acute heart failure section has not changed dramatically since the previous heart failure guidelines, published in 2012, the recommendations have become “more detailed”.

He said: “Many clinicians wanted to get more detailed advice about the indications of different management strategies, diagnostic tools and therapies, and more detailed advice on, for example, the dosing of certain drugs or ventilatory support in acute heart failure.”

In many cases, Prof. Harjola and colleagues based their recommendations around the 2015 consensus statement on the prehospital and early hospital management of acute heart failure.(1) Although in many areas, Level 1 evidence may not always be available, Prof. Harjola said: “We try to give the best clinical advice and recommendations as possible…so that the clinician can draw his or her own conclusions.”

One important area is the factors triggering acute heart failure, with a focus on the diagnostic workup to determine whether symptoms such as dyspnea are due to the disease. “This workup needs to be started in the prehospital setting and continued in the emergency department,” said Prof. Harjola.

The main tools available are echocardiography, ECG, chest X-ray, natriuretic peptides and routine laboratory tests, with early echocardiography recommended for shock patients and for de novo acute heart failure patients, preferably within 48 hours.

Prof. Harjola stressed that clinicians should be aware that, although natriuretic peptides such as brain natriuretic peptide are unspecific and there may be a number of reasons for elevated levels, they are definitely useful for excluding acute heart failure as a cause of dyspnoea.

The acute heart failure section also stress the role of SBP levels in decision making for management strategies. The cut-offs have been re-evaluated to be more in line with common definitions of hypertension and hypotension. Hypertensive acute heart failure is hence defined as acute heart failure with an SBP greater than 140 mmHg, while the hypotensive form is characterised by an SBP less than 90 mmHg. The latter also includes cardiogenic shock when in the presence of hypoperfusion.

The management algorithms have also been simplified and separated in two. One identifies the most important causes of decompensation that need urgent management, while the other focuses on the management options in acute heart failure, based on the patient’s clinical profile. The aim, Prof. Harjola noted, was to make the algorithms “clear enough that they could be easily followed and used in practical decision-making”.

Finally, a key area in the acute heart failure section is the criteria for ward versus intensive or coronary care unit hospitalisation. Prof. Harjola emphasised that it is important that care units are not filled with less severe patients, and vice versa for ward admission.

He said that, even though Level 1 evidence was not available to underpin these criteria, he and his colleagues want to ensure that the guidelines “give clinicians practical advice based on the best evidence or consensus opinions”.

To read a preview of this morning’s session on the impact and management of comorbidities in heart failure, turn to page 4.

References

  1. Mebazaa A, Yilmaz MB, Levy P et al. Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine. Eur J Heart Fail. 2015; 17: 544-558.

View the session programme and access the resources on SP&P