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The new Guidelines: Focus on Chronic Heart Failure
New Classification and Diagnosis
Petros NihoyannopoulosMD, FRCP, FESCProfessor of CardiologyImperial College London
andNational & Kapodistrian University of Athens
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New Classification and DiagnosisThe principal changes from the 2012 guidelines relate to:
(i) a new term for patients with HF and a LVEF that ranges from 40 to 49% — ‘HF with midrange EF (HFmrEF)’; this may stimulate research into the underlying Characteristics, pathophysiology and treatment of this population
(ii) clear recommendations on the diagnostic criteria for HF with reducedEF (HFrEF), HFmrEF and HF with preserved EF (HFpEF)
(iii) a new algorithm for the diagnosis of HF in the non-acute settingbased on the evaluation of HF probability
(iv) a new algorithm for a combined diagnosis and treatment of acute HF based on the presence/absence of congestion/hypoperfusion
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New Classification and DiagnosisThe principal changes from the 2012 guidelines (continue):
(v) recommendations aimed at prevention or delay of the developmentof overt HF or the prevention of death before the onset of symptoms;
(vi) indications for the use of the new compound sacubitril/valsartan, the first in the class of angiotensin receptor neprilysin inhibitors (ARNIs);
(vii) modified indications for cardiac resynchronization therapy (CRT);
(viii) the concept of an early initiation of appropriate therapy going along with relevant investigations in acute HF that follows the ‘time to therapy’ approach already well established in acute coronary syndrome (ACS);
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New Classification and DiagnosisDefinition of heart failure
HF is a clinical syndrome characterized by typical symptoms(e.g. SOB, ankle swelling and fatigue) that may be accompaniedby signs (e.g. elevated JVP, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in:
•a reduced cardiac output and/or •elevated intracardiac pressures at rest or during stress
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New Classification and DiagnosisNew Classification!
•Heart failure with preserved, mid-range and reduced EF
HF comprises a wide range of patients:
• those with normal LVEF [typically considered as ≥50% or HF with preserved EF (HFpEF) to those with
• Reduced LVEF - typically considered as ≤40% (HFrEF)]
• Patients with an LVEF in the range of 40–49% represent a ‘grey area’,
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New Classification and DiagnosisNew Classification!
•Heart failure with preserved, mid-range and reduced EF
it is only in patients with HFrEF that therapies have been shown to reduce both morbidity and mortality
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New Classification and Diagnosis
v The diagnosis of HFpEF is more challenging than that of HFrEF
v Patients with HFpEF do not have a dilated LV, but often have:
• increase in LV wall thickness and/or
• increased LA size (sign of increased filling pressures)
• most have additional ‘evidence’ of impaired LV filling or suction capacity, also classified as diastolic dysfunction
New Classification!
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New Classification and Diagnosis
v Identifying HFmrEF as a separate group will stimulate research into the underlying characteristics and treatment of this group
Patients with HFmrEF most probably have primarily mild systolicdysfunction, but with features of:
• diastolic dysfunction
• relevant structural heart disease (LVH, LA enlargement)
• elevated BNP
New Classification!
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New Classification and DiagnosisDiagnosis
•Demonstration of an underlying cardiac cause is central to the diagnosis of HF.
•This is usually a myocardial abnormality causing systolic and/or diastolic ventricular dysfunction
•Abnormalities of the valves, pericardium, endocardium, heart rhythm and conduction can also cause HF
•Identification of the underlying cardiac problem is crucial fortherapeutic reasons
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New Classification and DiagnosisDiagnosis – Symptoms & Signs
•Non-specific, difficult to identify•Detailed clinical history
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New Classification and DiagnosisDiagnosis – initial investigations
BNP – ECG - Echo
•Patients with normal plasma NP concentrations are unlikely tohave HF
•AF, age and renal failure are the most important factors impeding the interpretation of NP measurements
•An abnormal electrocardiogram (ECG) increases the likelihoodof the diagnosis of HF – but low specificity (rule out)
•Echocardiography is the most useful, widely available test in patientswith suspected HF to establish the diagnosis
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•If no history, -ve examination & N ECG•Normal BNP•Normal echo
v Heart Failure unlikely:
The probability of HF should first be evaluated(History, HT, diuretic use, symptoms, examination, ECG)
v An Echo is indicated if NP level above the exclusion level
Algorithm for the diagnosis of HF
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v The diagnosis of HFpEF requires the following:
• The presence of symptoms and/or signs of HF
• A ‘preserved’ EF (defined as LVEF ≥50% or 40–49% for HFmrEF)
• Elevated levels of NPs (BNP >35 pg/mL and/or NT-proBNP >125 pg/mL)
• An abnormal ECG increases the likelihood of HF
• Objective evidence of other cardiac functional and structural alterationsunderlying HF – The pivotal role of Echo
• In case of uncertainty, a stress test or invasively measured elevatedLV filling pressure may be needed
New Classification and DiagnosisDiagnosis of HFpEF
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New Classification and DiagnosisDiagnosis of HFpEF
• Clinical signs & symptoms the same as HFrEF, HFpEF, HFmrEF
• ECG may be abnormal (LVH, AF, repol abnormalities)
• Objective evidence of structural/functional cardiac alterations
• LAVI >34 mL/m2, LVMI ≥115 g/m2 (M) / ≥95g/m2 (F)
• E/e’ ≥13, mean e’ septal & lateral wall <9cm/s GLS, TR velocities
• Diastolic stress test with echo (semi-supine bicycle ergometer) LV E/e’, PAP, GLS, SV, CO
• Diagnosis difficult when AF
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New Classification and DiagnosisCardiac Imaging
• Central role in the diagnosis of HF and in guiding treatment• Echocardiography is the method of choice in patients with
suspected HF (accuracy, availability, portability, safety and cost)
• Other modalities can be complimentary, chosen according to their ability to answer specific clinical questions and taking account of contraindications to and risks of specific tests
• Imaging tests should only be performed when they have a meaningful clinical consequence
• Reliability depends on the operator, centre experience and imaging quality
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New Classification and DiagnosisChest X-ray
• Of limited use
• Pulmonary venous congestion
• Most useful in identifying alternative, pulmonary explanation of symptoms
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New Classification and DiagnosisTransthoracic Echocardiography
• The Teichholz and Quinones methods of calculating LVEF from M-mode, as well as a measurement of FS, are not recommended!
• 3D echocardiography of adequate quality improves the quantification of LV volumes and LVEF and has the best accuracy compared with values obtained through CMR
• For LVEF, the modified biplane Simpson’s rule is recommended.Contrast should be used in case of poor imaging!
• Doppler for calculating haemodynamic variables (Svi and CO)• TDI (S wave) and deformation imaging (strain & strain rate) are reproducible and feasible for clinical use
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New Classification and DiagnosisTransthoracic Echocardiography
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New Classification and DiagnosisAssessment of LV diastolic function
v Diastolic dysfunction may be the underlying pathophysiological abnormality in patients with HFpEF and perhaps HFmrEF
v Echocardiography is at present the only imaging technique that can allow for the diagnosis of diastolic dysfunction
• Objective evidence of structural/functional cardiac alterations• LAVI >34 mL/m2, LVMI ≥115 g/m2 (M) / ≥95g/m2 (F)• E/e’ ≥13, mean e’ septal & lateral wall <9cm/s GLS, TR velocities• Diastolic stress test with echo (semi-supine bicycle ergometer) LV E/e’, PAP, GLS, SV, CO
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New Classification and DiagnosisAssessment of RV function & PA Pressures
An obligatory element of echocardiography examination!v RV structure & functionv RA sizev Estimate RV systolic function:
• TAPSE <17mm• S’ <9.5m/sec• PASP from TR velocity• 3D echo volumes is recommended• speckle tracking – specialised centres
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New Classification and DiagnosisTransoesophageal Echocardiography (TOE)
v Not needed in the routine diagnostic assessment of HF
But may be valuable in:
• valve disease and assessing severity• aortic dissection• suspected endocarditis• congenital heart disease• for ruling out thrombi in AF patients requiring cardioversion
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New Classification and DiagnosisStress Echocardiography
v Exercise or pharmacological stress echocardiography may be used for the assessment of inducible ischaemia and/or viability
v In valve disease, e.g. dynamic mitral regurgitation, low-flow–low-gradient aortic stenosis
v For the detection of diastolic dysfunction in patients with exertional dyspnoea, preserved LVEF and inconclusive diastolic parameters at rest
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New Classification and DiagnosisCardiac magnetic resonance
v CMR is the gold standard for the measurements of volumes, mass and EF of both the left and right ventricles
v The best alternative cardiac imaging modality for patients with non-diagnostic echocardiographic studies
v The method of choice in patients with complex congenital heart diseases
v CMR is the preferred imaging method to assess myocardial fibrosis using LGE along with T1 mapping and can be useful for establishing HF aetiology
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New Classification and DiagnosisCardiac magnetic resonance
v CMR may also be used for the assessment of myocardial ischaemia and viability in patients with HF and CAD
§ local expertise, lower availability and higher costs § uncertainty about safety in patients with metallic implants (devices)§ less reliable measurements in patients with tachyarrhythmias§ claustrophobia § contrast agents contraindicated in individuals with a GFR <30
mL/min/1.73m2 - nephrogenic systemic fibrosis (NSF)
v Clinical limitations:
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New Classification and DiagnosisSingle-photon emission computed tomography
and radionuclide ventriculography
v Single-photon emission CT (SPECT) may be useful in assessing ischaemia and myocardial viability
v Gated SPECT can also yield information on ventricular volumes and function, but exposes the patient to ionizing radiation
v PET useful in ishaemia and viability but limited availability, radiation exposure and cost are the main limitations
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New Classification and DiagnosisCardiac CT
v Cardiac CT may be considered in patients with HF and low to intermediate pre-test probability of CAD or those with equivocal non-invasive stress tests in order to rule out CAD (IIb C)
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New Classification and DiagnosisCoronary angiography
v In concordance with the recommendations of other relevant ESC guidelines
v Coronary angiography is recommended in patients with HF and angina pectoris recalcitrant to medical therapy, provided that are suitable for revascularisation (IC)
v Coronary angiography recommended in patients with a history of symptomatic ventricular arrhythmia or aborted cardiac arrest
v Should be considered in patients with HF and intermediate to high pre-test probability of CAD and presence of ischaemia in non-invasive stress tests in order to establish CAD severity (IIa C)
