HF guidelines Flashcards
TAFAMIDIS
is recommended in patients with genetic testing proven hTTR-CA, wtTTR-CA who are NYHA I or II to reduce symptoms, CV hospitalization, motality
CLASS I
Right heart catheterization should be considered in patients where HF is thought to be due to constrictive pericarditis, restrictive cardiomyopathy, congenital heart disease, and high output states.
class IIa
Right heart catheterization may be considered in selected patients with HFpEF to confirm the diagnosis.
CLASS IIb
Dapagliflozin or empagliflozin are recommended for patients with HFrEF to reduce the risk of HF hospitalization and death.
CLASS I
Vericiguat
NYHA class II-IV who had worsening HF depsite treatment with 4 pillars
class IIb
HFmrEF
ACEI, ARB, BB, MRA, ENTRESTO
class IIb
Influenza and pneumococcal vaccinations should be considered in order to prevent HF hospitalizations.
class IIa
It is recommended that patients hospitalized for HF be carefully evaluated to exclude persistent signs of congestion before discharge and to optimize oral treatment.
class I
it is recommended that evidence-based oral medical treatment be administered before discharge.
class I
An early follow-up visit is recommended at 12 weeks after discharge to assess signs of congestion, drug tolerance, and start and/or uptitrate evidence-based therapy.
class I
Long-term treatment with an oral anticoagulant should be considered for stroke prevention in AF patients with a CHA2DS2-VASc score of 1 in men or 2 in women.
class IIa
revascularization in CCS and HF
CABG should be considered as the first-choice revascularization strategy, in patients suitable for surgery, especially if they have diabetes and for those with multivessel disease.
class IIa
In LVAD candidates needing coronary revascularization, CABG should be avoided, if possible.
class IIa
PCI may be considered as alternative to CABG, based on Heart Team evaluation, considering coronary anatomy, comorbidities, and surgical risk.
class IIb
Coronary revascularization may be considered to improve outcomes in patients with HFrEF, CCS, and coronary anatomy suitable for revascularization, after careful evaluation of the individual risk to benefit ratio, including coronary anatomy (i.e. proximal stenosis >90% of large vessels, stenosis of left main or proximal LAD), comorbidities, life expectancy, and patient’s perspectives
class IIb
Percutaneous edge-to-edge mitral valve repair should be considered in carefully selected patients with secondary mitral regurgitation, not eligible for surgery and not needing coronary revascularization, who are symptomatic despite OMT and who fulfil criteria to achieve a reduction in HF hospitalizations.
class IIa
Percutaneous edge-to-edge mitral valve repair may be considered to improve symptoms in carefully selected patients with secondary mitral regurgitation, not eligible for surgery and not needing coronary revascularization, who are highly symptomatic despite OMT and who do not fulfil criteria for reducing HF hospitalization.
class IIb
SGLT in HF and DM
recommended for pts with T2DM at risk of CV events
and for pts with HF and T2DM
class I
DPP4 saxagliptin
class III in HF
IV iron
if EF 50% and ferritin less than 100 or 100-299 with TSAT less than 20%
EPO in HF
Class III
cancer pts on antrhracycline
ACEI and BB (carvedilol) if developed LV systolic dysfunction (10% dec. in EF to a value lower than 50%)
diagnostic algorithm of HF 1
risk factors + sign and symptoms + ECG
diagnostic algorithm HF 2
NT pro BNP 125
BNP 35
in AF X3
NT pro BNP 365
BNP 105
diagnostic algorithm HF 3
ECHO
less than 40 = HFrEF
41-49 = HFmrEF
more than 50 = HFpEF
recommended diagnostic tests in all HF pts
BNP, pro BNP
ECG
ECHO
CXR
labs: CBC, urea, creat, electrolytes, thyroid, HBA1c, iron profile (ferritin, TSAT)
cardiac causes of elevated NPs
HF
ACS
PE
myocarditis
LVH
HCM, RCM
VHD
CHD
tachyarrythmias
heart contusion
cardioversion
ICD shock
surgery
PHTN
non cardiac causes of elevated NPs
advanced age
ischemic stroke
SAH
CKD
liver cirrhosis and ascitis
paraneoplastic syndrome
COPD
severe infection (pnuemonia, sepsis)
severe burns
anemia
severe metabloic and hormonal abnormalities (thyrotoxicosis, diabetic ketosis)
what decrease NPs ?
obesity
CMR
recommended for the assessment of myocardial structure and function in those with poor echocardiogram acoustic windows.
class I
CMR
recommended for the characterization of myocardial tissue in suspected infiltrative disease, Fabry disease, inflammatory disease (myocarditis), LV non-compaction, amyloid, sarcoidosis, iron overload/haemochromatosis.
class I
CMR with LGE
DCM to distinguish between ischaemic and non-ischaemic myocardial damage.
class IIA
Invasive coronary angiography
recommended in patients with angina despite pharmacological therapy or symptomatic ventricular arrhythmias.
class I
Invasive coronary angiography in HFrEF
with an intermediate to high pre-test probability of CAD and the presence of ischaemia in non-invasive stress tests.
class IIb
CTCA
is considered in low to intermediate pre test probability of CAD or those with equivocal non invasive stree tests to rule out CAD
class IIa
Non-invasive stress imaging (CMR, stress echocardiography, SPECT, PET)
may be considered for the assessment of myocardial ischaemia and viability in patients with CAD who are considered suitable for coronary revascularization
class IIb
Exercise testing
may be considered to detect reversible myocardial ischaemia and investigate the cause of dyspnoea
class IIb
Cardiopulmonary exercise testing
is recommended as a part of the evaluation for heart transplantation and/or MCS
class I
Cardiopulmonary exercise testing
should be considered to optimize prescription of exercise training.
class IIa
Cardiopulmonary exercise testing
should be considered to identify the cause of unexplained dyspnoea and/or exercise intolerance
class IIa
Right heart catheterization
recommended in patients with severe HF being evaluated for heart transplantation or MCS.
class I
Right heart catheterization
should be considered in patients where HF is thought to be due to constrictive pericarditis, restrictive cardiomyopathy, congenital heart disease, and high output states.
class IIa
Right heart catheterization
should be considered in patients with probable pulmonary hypertension, assessed by echo in order to confirm the diagnosis and assess its reversibility before the correction of valve/structural heart disease.
class IIa
right side heart cath to confirm diagnosis of HFpEF
class IIb
endomyocardial biopsy
considered in patients with rapidly progressive HF despite standard therapy when there is a probability of a specific diagnosis, which can be confirmed only in myocardial samples
class IIa
EF less than 35 with QRS less than 130
ICD non ishcemic class IIA
ischemic class I
LVEF less than 35 and QRS more than 130
CRT D/P
QRS 130-150 class IIa
QRS more than 150 class I
MRA
coution in impaired renal function and K conc more than 5
Ivabradine
syptomatic pt with LVEF less than 35 and HR more than 70 despite treatment with BB, ACEI, MRA
class IIa
Ivabradine
symptomatic patients with LVEF <_35%, in SR and a resting heart rate >_70 b.p.m. who are unable to tolerate or have contraindications for a beta-blocker to reduce the risk of HF hospitalization and CV death. Patients should also receive an ACE-I (or ARNI) and an MRA.
class IIa
Verciguat
class IIb in NYHA II-IV who had worsening HF despite treatment with 4 pillars
hydralazine and ISD
in black patients with LVEF less than 35 or with LVEF less than 45 + dilated LV in NYHA III-IV despite 4 pillars
class IIA
hydralazine and ISD
in pt with symptomatic HFrEF who cant tolerate any of ACEI, ARB, ARNI
Digoxin
considered in patients with SR and HFrEF symptomatic on 4 pillars
ACEI doses
captopril
ramipril
enalapril
lisdinopril
capto 25 1X3 to 50 1X3
enalapril ramipril (2.5 1X2) to rami 5 1X2 enala 10-20 1X2
lisino 2.5 to 5 once to 20-35 once
entresto does
50 1X2 start dose
100 1X2 target dose
BB doses
biso (concor) 1.25 to 10 mg once
carvid 6.125 to 25 twice
metoprolol (selekonzoc) 12.5-25 to 200 once
nevilob 1.25 to 10 mg once
MRA doses
spironolactone and eplerenone 25mg to 50 mg once
SGLT2
Dapa and Empa 10 mg once a start and a target
DOSES
candesartan
losartan
valsartan
cande 4 to 32 mg once
losa 50 to 150 mg once
valsartan 40 to 160 mg twice
DOSES
vericiguat
digoxin
hydralazine/ISM
verci 2.5 to 10 mg once
digoxin 62.5 to 250 mg once
H/ISM 37/20 to 75/40 3 times daily
ARNI, MRA,SGLT2
has diuretic effect
H/ISD
after ACEI, ARNI, ARB in pts who canot tolerate and still sympotomatic
SR with LBBB more than 150
CRT P/D
SR with LBBB 130 to 149 or non LBBB more than 150
CRT P/D
CAD + HF
CABG
iron defeciency
ferric carboxymaltose
HR more than 70
ivabradine
Verciguit
victoria trail found that as an add on therapy it decrease risk of CV mortality and HF hospitalization
Omecamtiv
not liscenced to use
ICD as 2ry prevention
recommended to reduce the risk of sudden death and all-cause mortality in patients who have recovered from a ventricular arrhythmia causing haemodynamic instability, and who are expected to survive for >1 year with good functional status, in the absence of reversible causes or unless the ventricular arrhythmia has occurred <48 h after a MI
CLASS IA
ICD as primary prevention
to reduce the risk of sudden death and all-cause mortality in patients with symptomatic HF (NYHA class II-III) of an ischaemic aetiology (unless they have had a MI in the prior 40 days—see below), and an LVEF <_35% despite >_3 months of OMT, provided they are expected to survive substantially longer than 1 year with good functional status
CLASS IA
ICD in 1ry prevention
to reduce the risk of sudden death and all-cause mortality in patients with symptomatic HF (NYHA class IIIII) of a non-ischaemic aetiology, and an LVEF <_35% despite >_3 months of OMT, provided they are expected to survive substantially longer than 1 year with good functional status
CLASS IIA
wearable ICD
may be considered for pts at risk of SCD for limited period or as a bridge to implanted device
CLASS IIb
ICD 40 days after MI
CLASS III not recommended
CRT in NYHA class IV
not recommended in pts with severe symptoms refractory to OMT unless they are candidates for CRT, VAD, transplant
ICD in EF more than 35
servival benfit is uncertian
Amoidarone
has no mortality benfit
class I anti arrythmics in HF (disopyramide, flecanide)
increase mortlaity
DANISH trial
showed that ICD in NICM didnt improve the overall mortality risk
so its downgraded to class IIA
ICD 40 days after MI
increase non arrythmic death
so its contraindicated
severe HF pts NYHA class IV where symptoms are refractory to OMT
no benefit from ICD
CRT
recommended for symptomatic patients with HF in SR with a QRS duration >_150 ms and LBBB QRS morphology and with LVEF <_35% despite OMT in order to improve symptoms and reduce morbidity and mortality.
CLASS I
CRT rather than RV pacing
recommended for patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high degree AV block in order to reduce morbidity. This includes patients with AF.
CLASS I
CRT in QRS greater than 150 and no LBBB
CLASS IIA
CRT if QRS from 130-149 and LBBB
CLASS IIA
pts with LVEF less than 35 who recived pacemaker or ICD and developed worsening symptoms
upgrade to CRT
CRT in QRS 130-149 and non LBBB
CLASS IIB
if QRS less than 130
CRT is class III
HFmrEF
EF 41-49 with symptoms of HF and elevated NPs
treatment of HFmrEF
diuretics for HFmrEF and congestion class I
ACEI,ARB, BB, MRA, ENTRESTO CLASS IIB
CANDESARTAN in HFmrEF
reduce HF hospitalization
nebivolol in HFmrEF
reduced the composite primary endpoint of all cause mortality and cv hospital admission in SENIORS
spironolactone
TOPCAT trial in pts with EF from 45-55%
reduced hospitalization
digoxin in HFmrEF
fewer hospitalization
HFpEF measurements
LA volume index > 32
In the absence of AF or valve disease, LA enlargement reflects chronically elevated LV filling pressure (in the presence of AF, the threshold is >40 mL/m2)
mitral E velocity > 90
septal e velocity <9
E/e ratio > 9
PASP > 35
TR velocity at rest > 2.8
diagnostic approach of HFpEF
symptoms and signs of HF + LVEF > or = 50%
+ objective evidence of cardiac structural or functional abnormalities consistent with the presence of lv diastolic dysfunction and raised LV filling pressure including raised NPs
pt with EF 40% that improved and present with EF 50%
cosidered to have recovered HFrEF or HF with improved EF
in AF, meassurement to diagnose HFpEF
LA volume index > 40
E/e` ratio >= 15
TR preak velocity > 3.4
LV global longitudinal strain < 16%
PCWP in HFpEF
EDP
> = 15 at rest or >= 25 exercise
= 16 at rest
HFpEF
LV mass index
relative wall thickness
> = 95 in female, >= 115 in male
0.42
Although the presence of concentric LV remodelling or hypertrophy is supportive, the absence of LV hypertrophy does not exclude the diagnosis of HFpEF
HFpEF
NT proBNP
BNP
SR >125
>35
AF >365
>105
Treatment of hypertension is recommended to prevent or delay the onset of HF, and to prevent HF hospitalizations.
CLASS I
Treatment with statins is recommended in patients at high risk of CV disease or with CV disease in order to prevent or delay the onset of HF, and to prevent HF hospitalizations.
CLASS I
SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, sotagliflozin) are recommended in patients with diabetes at high risk of CV disease or with CV disease in order to prevent HF hospitalizations
CLASS I
Influenza and pneumococcal vaccinations should be considered in order to prevent HF hospitalizations
CLASS IIA
To avoid large volumes of fluid intake. A fluid restriction of 1.52 L/day may be considered in patients with severe HF/hyponatraemia to relieve symptoms and congestion.
alcohol in HF
(2 units per day in men or 1 unit per day in women
In the case of increasing dyspnoea or oedema or a sudden unexpected weight gain of >2 kg in 3 days, patients may increase their diuretic dose and/or alert their healthcare team.
