Highlights of 2018 Thai Guidelines For Management of Heart ... of Thai Heart... · HFCT/HAT 2018 Heart Failure Guideline_ Official Slide Set Preliminary_ver2.3_13AUG2018 4 1. Taworn

Adisai Buakhamsri, MD Thammasat University Hospital

On-behalf of the writing committee of The 2018 Thai Guideline For Management of Heart Failure

Highlights of 2018 Thai Guidelines For Management of Heart Failure

HFCT/HAT 2018 Heart Failure Guideline_ Official Slide SetPreliminary_ver2.3_13AUG20184

1. Taworn Suithichaiyakul, MD President of The Heart Association of Thailand2. Prasart Laothavorn, MD Advisory 3. Kriengkrai Hengrussamee, MD Advisory 4. Rungroj Krittayaphong, MD Chairman 5. Teerapat Yingchoncharoen, MD Secretary and Council Committee6. Smonporn Boonyarattavej, MD Council Committee 7. Rapeephon Kunjara Na Ayudhya, MD Council Committee 8. Sarinya Puwanant, MD Council Committee9. Aekarach Ariyachaipanich, MD Council Committee10. Kasem Rattanasumawong, MD Council Committee11. Rungsrit Kanjanavanich, MD Council Committee12. Arintaya Phrominthikul, MD Council Committee13. Adisai Buakhamsri, MD Council Committee14. Sopon Sanguanwong, MD Council Committee15. Thoranis Chantrarat, MD Council Committee 16. Pornwalee Porapakkham, MD Council Committee17. Satit Janwanishstaporn, MD Council Committee 18. Srisakul Chirakarnjanakorn, MD Council Committee 19. Pranya Sakiyalak, MD Council Committee20. Pat Ongcharit, MD Council Committee21. Norasak Suvachittanont, MD Council Committee

Committee for Renew Guideline HFCT 2018Writing committee of the new guidelines


Table of Contents

Topics Slide Numbers

I: Guideline development 3

II: Introduction and guideline Implementation 7

III: Definition, diagnosis and evaluation of heart failure 16

IV: Pharmacological treatment of chronic heart failure 27

V: Acute heart failure 51

VI: Common comorbidities in heart failure 66

VII: Sudden cardiac death and device therapy in heart failure 82

VIII: End-stage heart failure 89

Sections of the new guidelines

Class of recommendation Representative phrases/words COR

Evidence and/or general agreement: given treatment/procedure is beneficial, useful, effective

Recommended or indicated I

Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure: weight of evidence/opinion is in favor of its usefulness/efficacy

Should be considered IIa

Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure: usefulness/efficacy is less well established by evidence/opinion

May be considered IIb

Evidence and/or general agreement: given treatment or procedure is not useful/effective, and in some cases may be harmful

Not recommended III

The 2018 Thai Guideline For Management of Heart Failure

Level of evidence LOE

Data derived from multiple randomized clinical trials or metanalysis A

Data derived from a single randomized clinical trial or a large non-randomized studies

B

Consensus of opinion of the expert and/or small studies. Retrospective studies, registries

C


Stages of HF and definition NYHA functional classification Symptom of HF

A At high risk for HF but without structural heart disease or symptoms of HF -

AbsentB Structural heart disease but without signs or symptoms of HF I No limitation of physical activity. Ordinary physical

activity does not cause symptoms of HF

CStructural heart disease

with prior or current symptoms of HF

I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF

IISlight limitation of physical activity.

Comfortable at rest, but ordinary physical activity results in symptoms of HF

PresentIII

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity

results in symptoms of HF

IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest

D Refractory HF requiring specialized interventions IV Unable to carry on any physical activity without

symptoms of HF,or symptoms of HF at restThe 2018 Thai Guideline For Management of Heart Failure


Guideline implementation: Central illustration








Recommendations COR LOE

ACE inhibitors are recommended in all patients with asymptomatic LV systolic dysfunction regardless of etiology, in order to prevent or delay the onset of symptomatic HF unless contraindicated.

I A

ACE inhibitors are recommended in all patients with HFrEF and current or prior HF symptoms to reduce HF hospitalization and mortality.

I A

ACE inhibitors



ACE inhibitors should be initiated in clinically stable patients at a low dose and gradually uptitrated to the maximum tolerated dose.

I A

ACE inhibitors



ARBs are recommended in all patients with HFrEF with current or prior HF symptoms who are intolerant to ACE inhibitors, unless contraindicated, to reduce morbidity and mortality. Patients should also receive a beta-blocker and an MRA

I A

ARBs should be initiated in clinically stable patients at a low dose and gradually uptitrated to the maximum tolerated dose

I A

ARBs



ARBs are reasonable to reduce morbidity and mortality as alternative to ACE Inhibitors as first-line therapy for patients with HFrEF, especially for patients already taking ARBs for other indications,unless contraindicated

IIa A

Routine combined use of ACEI, ARB and MRA is harmful for patients with HFrEF.

III C

ARBs



Beta-blockers are recommended in all patients with asymptomatic LV systolic dysfunction and a history of myocardial infarction in order to prevent or delay the onset of symptomatic HF and reduce mortality.

I B

Beta-blockers are recommended in all patients with asymptomatic LV systolic dysfunction, even they do not have a history of myocardial infarction, in order to prevent or delay the onset of symptomatic HF.

I C

Beta-blockers



A beta-blocker (bisoprolol, carvedilol, sustained-release metoprolol succinate and nebivolol ) is recommended, in addition to an ACEI, for all stable patients with current or prior symptoms of HFrEF to reduce the risk of HF hospitalization and death.

I A

Beta-blockers should be initiated in clinically stable patients at a low dose and gradually uptitrated to the maximum tolerated dose.

I A

Beta-blockers



Low-dose MRA ( spironolactone ) is recommended in symptomatic chronic HFrEF patients, unless contraindicated, preferably after treatment with ACE-I/ARB and BB, to further reduce HF hospitalization and mortality

I A

Routine combined use of ACEI, ARB and MRA is harmful for patient with HFREF

I A

MRA


Drugs Drugs Initial dose (mg)

Target dose (mg)

Mean dose achieved in clinical trials

ACE inhibitors

Captopril 6.35 mg 3 times 50 mg 3 times 122.7 mg/d

Enalapril 2.5 mg twice 10-20 mg twice 16.6 mg/d

Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35 mg/d

Perindopril 2 mg once 8 to16 mg once n/a

Quinapril 5 mg twice 20 mg twice n/a

Ramipril 1.25 to 2.5 mg once 10 mg once n/a

ARBs

Candesartan 4 to 8 mg once 32 mg once 24 mg/d

Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d

Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d

Beta-blockers

Bisoprolol 1.25 mg once 10 mg once 8.6 mg/d

Carvedilol 3.125 mg twice 25 mg twice 37 mg/d

Metorpolol succinate extended release

12.5 to 25 mg once 200 mg once 159 mg/d

Nebivolol 1.5 mg once 10 mg once 7.7 mg/dThe 2018 Thai Guideline For Management of Heart Failure

Drugs Drugs Initial dose (mg)

Target dose (mg)

Mean dose achieved in clinical trials

ACE inhibitors

Captopril 6.35 mg 3 times 50 mg 3 times 122.7 mg/d

Enalapril 2.5 mg twice 10-20 mg twice 16.6 mg/d

Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35 mg/d

Perindopril 2 mg once 8 to16 mg once n/a

Quinapril 5 mg twice 20 mg twice n/a

Ramipril 1.25 to 2.5 mg once 10 mg once n/a

ARBs

Candesartan 4 to 8 mg once 32 mg once 24 mg/d

Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d

Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d

Beta-blockers

Bisoprolol 1.25 mg once 10 mg once 8.6 mg/d

Carvedilol 3.125 mg twice 25 mg twice 37 mg/d

Metorpolol succinate extended release

12.5 to 25 mg once 200 mg once 159 mg/d

Nebivolol 1.5 mg once 10 mg once 7.7 mg/dThe 2018 Thai Guideline For Management of Heart Failure





Replacement of ACEI (or ARB) with ARNI (Sacubitril/valsartan) is recommended to further reduce the risk of HF hospitalization and mortality in patients with HFrEF who remain symptomatic despite optimal medical treatment with an ACEI (or ARB), a beta-blocker and an MRA.

I B

ARNI



Initiation of ARNI (sacubitril/valsartan) may be considered in ACEI/ARB-naive patients who have no vulnerable characteristics (e.g. systolic blood pressure< 100 mmHg, age≥ 75 years). Low-dose ARNI should be carefully initiated and slowly uptitrated to target dose.

IIb C

ARNI


• Avoid using ARNI in patients who has — hypotension (SBP < 90 mmHg)— eGFR <30 mL/min/1.73m2 — serum K+ > 5.2 mmol/L — history of angioedema — pregnancy

• ARNI must not be used concomitantly with an ACEI

• When switching from ACE-I to ARNI, stop ACE-I for at least 36 hours before starting ARNI, while no wash-out period is required when switching from ARB to ARNI

ARNI Precautions


Patient with Initial doseUptitration and target

dose

Enalapril ≥ 10 mg/d Lisinopril ≥ 10 mg/d Perindopril ≥ 4 mg/d Ramipril ≥ 5 mg/d

Candesartan ≥ 16 mg/d Irbesartan ≥ 150 mg/d Losartan ≥ 50 mg/d Olmesartan ≥ 10 mg/d Telmisartan ≥ 40 mg/d Valsartan ≥ 160mg/d

100 mg twice daily

Increase over 3-4 weeks to target dose of

200 mg twice daily

Low-dose ACEI/ARB50 mg

twice daily

Increase over 6 weeks to target dose of

200 mg twice daily ACEI/ARB-naive

High risk of hypotension

OR

Sacubitril/Valsartan


ConditionsQRS duration and morphology

< 130 ms 130-150 ms >150 ms

Any LBBBNon-LBBB

LBBBNon-LBBB

Primary prevention LVEF ≤ 35% after 3 months of OMT, are expected to survive at least 1 year with good functional status

ICD CRT-D CRT-D CRT-D CRT-D

Secondary prevention History of SCA, sustained VT/VF, recurrent syncope with inducible sustained VT at the EPs

ICD CRT-D CRT-D CRT-D CRT-D

Device therapy - ICD/CRT






Initiation of ivabradine should be considered to reduce the risk of HF hospitalization or cardiovascular death in symptomatic patients with LVEF ≤ 35%, in sinus rhythm and a resting heart rate ≥70 bpm despite optimal medical treatment, including maximum tolerated dose of beta-blocker, ACE Inhibitor (or ARB), and an MRA

IIa B

Ivabradine

Ivabradine should not be routinely used in patients with atrial fibrillation



Hydralazine and isosorbide dinitrate may be considered in symptomatic patients with HFrEF who are unable to tolerate or have contraindication for either an ACE-I or an ARB to reduce HF symptoms

IIb B

Hydralazine-Nitrate







Recommendations COR LOEOptimal treatment of patients with hypertension with HFpEF is recommended in accordance with published clinical practice guidelines with a target systolic BP < 130 mmHg

I B

Diuretics are recommended in HFpEF patients who have evidence of volume overload to improve symptoms and reduce hospitalization. Care must be taken (in diuretics use) to avoid over-diuresis

I C

Cardiovascular and noncardiovascular comorbidities should be actively screened and optimally treated in all patients with HFpEF

I C

Concomitant coronary artery disease should be screened as a possible cause of exertional dyspnea and/or acute decompensation in HFpEF patients

IIa C


Sleep disorder

Hypertension

AFDiabetes

Other; Depression

CKD PH etc.

Iron deficiency

& Anemia

Comorbidity


Iron deficiency

& Anemia


Assessment of anemia and iron deficiency should be performed in heart failure patients who remain symptomatic after optimizing guideline-directed medical therapy

IIa B

Intravenous iron should be considered to improve functional status and quality of life in symptomatic heart failure patients with NYHA functional class II and III and iron deficiency (serum ferritin <100 ng/mL, or serum ferritin 100-299 ng/mL and transferrin saturation <20%)

IIa B

Routine use of erythropoietin-stimulating agents to improve functional status and quality of life in heart failure patients with anemia is not recommended

III A


Diabetes


Metformin should be used as a first-line therapy in heart failure patients with diabetes, unless contraindicated

IIa C

SGLT-2 inhibitors should be considered in CVD patients with diabetes type 2 to reduce heart failure hospitalization

IIa B

Thiazolidinediones are not recommended in patients with heart failure because of an increased risk of worsening of heart failure and hospitalization

III A


AF • CHA2DS2-VASc score to initially identify patients at truly low risk of stroke who do not need any antithrombotic treatment

• No direct evidence in favor of rhythm control strategy over rate control in patients with AF and HF

• Rate control using beta-blockers and digitalis in some selected patients are appropriated with the amiodarone as the next step with considering the acceptable long term side effects

• Catheter ablation of AF or ablation of the AV node (with subsequent pacemaker implantation) may be indicated in symptomatic or refractory symptoms from AF



79

Comorbidities- Atrial fibrillation: Management

Patient with HF and AFPatient with HF and AF

Acute AFand acute HF

Acute AFand acute HF

Electrical cardioversionElectrical cardioversion

Significant heart failureUnstable v/s

Ongoing ischemia

anticoagulationanticoagulation

HR control < 110 bpmHR control < 110 bpm

Fluid balanceFluid balance

Mild HF

Pharmacologic cardioversion

Pharmacologic cardioversion

anticoagulationanticoagulation

Chronic AFand chronic HF

Chronic AFand chronic HF

EF ≥ 40digoxindigoxin

Diltiazem, verapamilDiltiazem, verapamil

diltiazemdiltiazem

betablockersbetablockers

digoxindigoxin

amiodaroneamiodarone

Atrioventricular node ablationAtrioventricular node ablation

amiodaroneamiodarone

Catheter ablationCatheter ablation

Rate control Rhythm control

EF < 40

unsuccess

Stroke prevention*Stroke prevention*

* See table



Patient with HF and AF with: NOAC warfarin Aspirin alone

Men: CHA2DS2-VASc = 0Woman: CHA2DS2-VASc = 0 or 1 III III III

Men: CHA2DS2-VASc = 1Woman: CHA2DS2-VASc = 2 IIa IIa III

Men: CHA2DS2-VASc ≥ 2Woman: CHA2DS2-VASc ≥ 3 I* I* III

Moderate-to-severe mitral stenosis or mechanical heart valves III I III

Comorbidities- Atrial fibrillation: Stroke Prevention in AF with HF

When oral anticoagulation is initiated, if the patient are eligible for a NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban), a NOAC is preferred. If the patients are treated with a vitamin K antagonist, time in therapeutic range (TTR) should be kept as high as possible and closely monitored.

*If the patient are eligible for a NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban), a NOAC is preferred


Risk score to guide selection of antithhrombotic




ARBs may be considered to decrease hospitalizations in HFpEF patients

IIb B

Low-dose MRA may be considered to decrease hospitalizations in HFpEF patients with elevated natriuretic peptides or history of recent HF hospitalization

IIb B



Annual influenza vaccine are recommended in all patients with HF I B

Combined pneumococcal vaccine and influenza vaccine are recommended in all patients with HF IIa B

Vaccination



Routine use of coenzyme Q10 is not recommended in patients with HFrEF due to insufficient data III B

Routine use of nitrates to improve functional capacity in HFpEF patients is not recommended

III B

Routine use of phosphodiesterase-5 inhibitors to improve symptoms in HFpEF is not recommended

III B

Other medications





\




Management of patients with cardiogenic shock or respiratory failure in intensive care unit is recommended

I C

Identification of etiology and management of precipitating factors in AHF patients are recommended

I C

Intubation is recommended in patients with respiratory failure who cannot be managed non-invasively

I C

Non-invasive positive pressure ventilation (e.g. CPAP, BiPAP) should be considered in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 < 90%) who have SBP > 85 mmHg and normal consciousness

IIa B

Oxygen therapy is recommended in AHF patients with SpO2 < 90% or PaO2 < 60 mmHg to correct hypoxemia I C

Oxygen therapy is not routinely recommended III C

\




Pulmonary artery pressure monitoring may be considered

See texts

See texts

Mechanical circulatory support should be considered in patients with cardiogenic shock despite adequate medical therapy

IIa C




Warm - Dry Warm - Wet

Cold - Dry Cold - Wet

Cardiac type Vascular type

Dry Wet

Warm

Cold

Congestion

Perfusion



Loop diuretics are recommended to relieve signs and/or symptoms of congestion in heart failure patients

I B

Diuretics should be considered to reduce the risk of HF hospitalization in patients with signs and/or symptoms of congestion

IIa B

V2-selective vasopressin antagonist (tolvaptan) may be considered for adjunctive treatment in hospitalized heart failure patients with volume overload and inadequate response to diuretics with short-term use

IIb B

A V2-selective vasopressin antagonist (tolvaptan) may be considered for short-term use in hospitalized patients with symptomatic hyponatremia associated with hypervolumic state secondary to heart failure

IIb B

Decongestion



For warm and wet ( vascular type ), for congestive symptoms relief in patients with normal or elevated blood pressure (SBP>90 mmHg)

IIa B

Patients with signs/symptoms of hypoperfusion and congestion (cold and wet) with SBP > 90 mmHg, intravenous vasodilators should be considered with caution

IIa C

Cardiogenic shock I C

Signs/symptoms of hypoperfusion and/or end organ damage with hypotension (MAP < 65 mmHg) despite adequate filling status

I C

Intravenous infusion of milrinone or levosimendan may be considered to reverse the effects of beta blocker if beta blocker is considered as the cause of hypoperfusion

IIb C

Vasopressors (e.g. norepinephrine) may be considered in patients with cardiogenic shock, despite treatment with inotropic agents IIb B

IV Vasodilator

IV inotrope

IV vasopressor





90

ACC/AHA 2009(stage D HF)

“Patients with truly refractory HF who might be eligible for specialized, advanced treatment strategies, such as mechanical circulatory support (MCS), procedures to facilitate fluid removal, continuous inotropic infusions, or cardiac transplantation or other innovative or experimental surgical procedures, or for end-of-life care, such as hospice.”

ACC/AHA 2013(stage D HF)

“A subset of patients with chronic HF will continue to progress and develop persistently severe symptoms despite maximum guideline-directed medical treatment (GDMT). Patients with marked HF symptoms at rest or recurrent hospitalizations despite GDMT.”

ESC 2007

1. Severe symptoms of HF with dyspnea and/or fatigue at rest or with minimal exertion (NYHA class III or IV).

2. Episodes of fluid retention (pulmonary and/or systemic congestion, peripheral edema) and/or reduced cardiac output at rest (peripheral hypoperfusion).

3. Objective evidence of severe cardiac dysfunction shown by at least 1 of the following:a. LVEF <30%b. Pseudonormal or restrictive mitral inflow patternc. Mean PCWP >16 mmHg and/or RAP >12 mmHg by PA catheterizationd. High BNP or NT-proBNP plasma levels in the absence of noncardiac causes

4. Severe impairment of functional capacity shown by 1 of the following:a. Inability to exerciseb. 6-Minute walk distance ≤300 md. Peak VO2 <12 to 14 mL/kg/min

5. History of ≥1 HF hospitalization in past 6 months.6. Presence of all the previous features despite “attempts to optimize” therapy, including diuretics

and GDMT, unless these are poorly tolerated or contraindicated, and CRT when indicated.

Definition of Advanced HF in Various Guidelines.Definition of advanced/end-staged heart failure


• Relatively invasive and life-changing for all involved

• Allow patients to gain functional capacity and to improve so-called “quality of death” in inotrope-dependent patients

• Heart transplant as a gold standard treatment with new mechanical circulatory support systems (MCS)

• Palliative care — patient and family-centered QOL

Treatment in end-staged heart failure


Clinical findings suggested of patients with advanced HF


Clinical findings suggested of patients with advanced HF

Persistent severe symptoms - NYHA class III, IV- Dyspnea with taking shower, eating, talking or at rest- Homebound≥ 2 HF Hospitalization within 6 months *Cannot tolerate the same doses of ACE/ARB, ARNI or BB that used to be able to tolerate Need high dose of diuretics (daily furosemide equivalent dose > 240 mg) and/or supplement with second diureticsEnd-organ failure- Cachexia (BMI <19)- CKD stage > 3, progressive worsening in BUN and/or Cr , hyponatremia- Cardiac cirrhosis, hypoalbuminemia- Pulmonary hypertension due to left heart diseaseMultiple ICD shocksUnresponsive to CRT treatmentDependence on intravenous inotropic medications * After a careful consideration of any reversible causes and optimization of treatment including HF self-care such as fluid and salt limitation, medication adherence, and medical and CRT/ICD therapy.



Recommendation COR LOEDiagnosisAn evaluation of prognosis is recommended in patients with persistent symptomatic HF. I C

It is recommended to investigate etiology of heart failure, patient compliance to treatment and alternative explanation for symptoms in patient with advanced HF. I C

ManagementSelection of treatments for advanced HF depends upon patient’s goal of care, prognosis and transplant candidacy. I C

Patient who is considered for heart transplant or MCS should be managed in conjunction with a referral center. I C

MedicationDigoxin may be considered in patient with advanced HF to improve symptoms and reduce HF hospitalization. IIb B

Continuous long-term use of intravenous inotropes such as dobutamine, milrinone, levosimendan or dopamine may be considered in patients with advanced HF with reduced EF to maintain end-organ performance and evaluating for appropriate treatment such as heart transplant, MCS , palliative care or other treatments

IIb B

Continuous long-term use of intravenous inotropes are not recommended in patients with life threatening arrhythmia, patients who have no hemodynamically response to these medications or patients with HFpEF.

III B

End-Staged Heart Failure- RecommendationRecommendations for end-staged heart failure


Recommendations for end-staged heart failure


Recommendation COR LOEHeart transplantIn carefully selected patients who are transplant candidates, heart transplants are recommended to improve survival, symptoms and quality of life. I C

Mechanical circulatory support (MCS) include LVADIn carefully selected patients, a short-term MCS should be considered in patients with severe cardiogenic shock to improve hemodynamic in between evaluation (“bridge to decision”).

IIa B

In carefully selected patients, a short-term or long-term MCS should be considered in patients with advanced HF who are transplant candidates to improve survival, symptoms and quality of life while awaiting suitable donors (“bridge to transplant”)

IIa B

In carefully selected patients, a long-term MCS should be considered in patients with advanced HF who are not transplant candidates to improve survival, symptoms and quality of life. (“destination therapy”)

IIa B

Palliative careIntegration of palliative care as an adjunctive treatment in combination with other curative treatments is recommended for patients with advanced HF to improve quality of life.

I B

In patients whose prognosis are weeks to months, an end-of-life or specialized hospice care service should be considered. IIa B

End-Staged Heart Failure- Recommendation


Summary— 2018 Thai guidelines on heart failure

• Comprehensive review of evidences

• The recommendations span across spectrum of HF — more details on management of acute heart failure

• New recommendations have been added or updated on — ARNI in HFrEF— Iron deficiency and anemia — Diabetes (SGLT2-i)— MRA in HFpEF— AF, Device therapy, MCS/VADs— End-staged HF including cardiac transplant , palliative care

• Role of multidisciplinary approach

Adisai Buakhamsri, MD Thammasat University Hospital

On-behalf of the writing committee of The 2018 HAT Guideline For The Management of Heart Failure

Highlights of 2018 Thai Guidelines For The Management of Heart Failure

Documents

Highlights of 2018 Thai Guidelines For Management of Heart ... of Thai Heart... · HFCT/HAT 2018 Heart Failure Guideline_ Official Slide Set Preliminary_ver2.3_13AUG2018 4 1. Taworn