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What's New In Heart Failure (HF) ?

The 2016 ESC Acute & Chronic Heart Failure Guidelines have been published. There are some changes from the 2012 Guidelines which need to be noted, as they directly interfere with a General Cardiologist's clinical daily practice.



  1. A new group of patients with HF and a left ventricular ejection fraction (LVEF) that ranges from 40 to 49%, is identified as  “HF with midrange EF (HFmrEF)”.
    This group takes place between  “HF with reducedEF (HFrEF)”with LVEF <40%,  and “HF with preserved EF (HFpEF)” with LVEF >49%.The aim of the classification of these 3 groups of HF patients is to “stimulate research into the underlying characteristics, pathophysiology and treatment of each population.
  2. The Algorithm for the diagnosis of heart failure in the non-acute setting starts with the assessment of HF probability based on clinical history, physical examination and EKG.
    If at least one element of the algorithm is abnormal, plasma Nariuretic Peptides (NP) should be measured (IIa recommendation) to identify those who need Trans Thoracic  Echocardiography (ETT)
    ETT remains the cornerstone of the diagnosis, indicated if NP level > exclusion threshold or if BNP levels cannot be assessed. It allows the stratification in one of the three HF groups, identifies patient suitable for pharmacological and device treatment, assesses eventual valvular disease and pulmonary arterial pressure, or myocardial structure and function.
    Cardiac magnetic resonance (CMR) is recommended for the assessment of myocardial structure and function (including right heart) in subjects with poor acoustic window and patients with complex congenital heart.
  3. The development of overt heart failure or death may be delayed through interventions aimed at modifying risk factors for HF or treating asymptomatic LV systolic dysfunction before the onset of symptoms.
    Treatment of hypertension is recommended to prevent or delay the onset of HF and prolong life; ACE-I in patients with asymptomatic LV systolic dysfunction, Beta-blockers in patients with asymptomatic LV systolic dysfunction and a history of myocardial infarction, Statins in patients with or at high-risk of CAD, counselling and treatment for smoking cessation and alcohol intake reduction are recommended in order to prevent or delay the onset of HF.
  4. Pharmacological treatment of symptomatic HF with reduced FE.
    An ACE-I in addition to a beta-blocker, is recommended to reduce the risk of HF hospitalisation and death and diuretics to reduce the symptoms of congestion. Patients who remain symptomatic despite this treatment should receive Mineralocorticoid/aldosterone receptor antagonists (MRAs) block receptors.
    Patients with HFrEF who remain symptomatic despite this optimal treatment should receive the new Angiotensin receptor neprilysin inhibitor (Sacubitril/valsartan) as a replacement for the ACE-I.
  5. Cardiac resynchronization therapy (CRT)
    Implantation of CRT is not recommended if QRS duration is <130ms.
    CRT is recommended for symptomatic patients in sinus rhythm with LVEF ≤35% despite OMT, with a QRS duration ≥130 msec and LBBB QRS morphology, in order to improve symptoms and reduce morbidity and mortality. (Class I)
    In case of non LBBB QRS morphology, CRT is still recommended if QRS duration ≥150 msec (with a class IIa recommendation) or if QRS duration is 130-149msec (with a class IIb recommendation)
    In patients scheduled to receive an ICD in sinus rhythm, CRT-D should be considered if QRS is between 130 and 149 ms and is recommended if QRS is≥150 ms.
  6. Multidisciplinary team management
    Multidisciplinary management programmes designed to improve outcomes through structured follow-up with patient education, optimization of medical treatment and psychosocial support are of fundamental value, in order to reduce HF hospitalization and mortality in patients discharged from the hospital.  Characteristics and components of such programmes can be found in these new guidelines.
  7. And we must not forget: some  treatments are not recommended  in patients with heart failure:
    Adaptive servo-ventilation is not recommended in patients with HFrEF and a predominant central sleep apnoea because of an increased all-cause and cardiovascular mortality. Glitazones, NSAIDs or COX-2 inhibitors, diltiazem or verapamil are not recommended in patients with HF, as they increase the risk of HF worsening and HF hospitalization.
    The addition of an ARB (or a renin inhibitor) to the combination of an ACE-I and an MRA is not recommended in patients with HF, because of the increased risk of renal dysfunction and hyperkalaemia.

The above is intended as a brief summary of the most important changes of these new ESC Guidelines.
Note that we do not comment about “Acute Heart Failure” which represents a huge part of the text. 
Read the full Guidelines.