AHF: ESC 2016 Guidelines - unispital-basel.ch · AHF: ESC 2016 Guidelines Professor Christian Müller ESC-ACCA AHF Study group, chair HFA AHF Study group, member GREAT-Network, Vice

AHF: ESC 2016 Guidelines

Professor Christian Müller

ESC-ACCA AHF Study group, chair HFA AHF Study group, member GREAT-Network, Vice president

Disclosures

• Swiss National Science Foundation

• .

• .

..

• Research support / travel support / consulting fees

from several diagnostic and pharmaceutical

companies

AKUTE HERZINSUFFIZIENZ

1. Fall (häufige Fehler)

2. Interdisziplinäre Behandlung

3. Diagnose

4. THERAPIE

• 76y, male, acute dyspnea, since 24h

+ coughing, sputum

Previously: Exertional dyspnea, never at rest

• PH: CAD, CABG, persistent Afib, VVIR-PM, COPD, Chronic lymph edema (regular drainage)

Vitals:

RR 26, Temp 38,5°, Puls 60, BP 120/80, Oxy 94%

• Physical:

- Tachypnea, no rales, Exspirium, Wheezing

- Neck veins +/-, mild ankle edema (preexisting)

- barely hearable HS, no 3. HS

HF: yes/no

HF: yes/no

Lab:

BNP 2‘100 pg/ml (n<50)

Lehren:

1) Infekt ist ein häufiger Trigger der AHF (nicht nur der COPD)

2) BNP/NT-proBNP obligat bei allen Patienten mit Atemnot

- weil klinische Zeichen + RöTh NICHT sensitiv genug

What is the key symptom in AHF?

What are the key diagnostic tools? Symptoms & signs ECG, Chest x-ray, BNP Echo

Dyspnea

Pathophysiology?

Intracardiac filling pressures

AKUTE HERZINSUFFIZIENZ

1. Fall (häufige Fehler)

2. Interdisziplinäre Behandlung

3. Diagnose

4. THERAPIE

Herzinsuffizienz

„Stauung“ „Dekompensation“ „AHF“

„Stabile Phase“ „kompensiert“ „chronische HF“

„kardiogener Schock“ „plötzlicher Herztod“

5 Jahre

AHF: Interdisciplinary Care

Congestion Decompensation AHF

5-10 days

Ambulance

GP

FU

Mueller C, et al. EHJ-ACC 2017

AKUTE HERZINSUFFIZIENZ

1. Fall (häufige Fehler)

2. Interdisziplinäre Behandlung

3. Diagnose

4. THERAPIE

14

Echo

EKG: STEMI cTn

EKG: VT rapid Afib

Sepsis CRP, PCT

Pathophysiology

Common errors

Pulmonary disease is the most common cause of

acute dyspnea

I am done once AHF is diagnosed AHF can nearly always be reliably diagnosed clinically by a HF expert

1. Is it AHF?

2. Cardiac disease?

3. Trigger?

AHF: Diagnosis

History, physical, ECG

Chest x-ray, BNP✓

ECG, Temp, BP cTn, D-Dimers, CRP/PCT, Hb, TSH Ferritin, Transferrin saturation

Mueller C, et al. Eur Heart J Acute Cardiovasc Care 2017. Mebazaa A, et al. Eur Heart J 2015

BNP: Quantitativer HF-Marker

ANP

BNP =

CNP Volumen

Druck LV Syst. Dysfunktion

+

LV Diast. Dysfunktion

+

Valvul. Dysfunktion

+

RV Dysfunktion

1) Diagnose

2) HF Schweregrad

Maisel A, et al. NEJM 2002. Mueller C, et al. NEJM 2004

<300pg/ml* <50y: >450pg/ml

50-75: >900pg/ml

>75y: >1800pg/ml

300-450pg/ml

300-900pg/ml

300-1800pg/ml No AHF

2) Immer zusammen mit Klinik

No AHF AHF

Diuretika

Nitrate

ACE-Inhibitor

*Cave: a)Obesity

Interpretation von NT-proBNP bei Atemnot

1) Quantitative Variable

Maisel A, Mueller C, et al. Eur J Heart Fail 2008;10:824-39

AHF

Obesity: BNP/NT-proBNP

Courtesy of Alan Maisel, M.D.

1) Diagnose HF: Clinical + ECG + BNP

2) Echo

LVEF Valves isolated RV LA

HFrEF VHD RV-HF HFpEF HFmEF

(LVEF 40-50%)

Price S, et al. Nature Rev Cardiol 2017

AKUTE HERZINSUFFIZIENZ

1. Fall (häufige Fehler)

2. Interdisziplinäre Behandlung

3. Diagnose

4. THERAPIE

M

m

Breidthardt T, et al. J Intern Med 2010;267:322-30.

Mmmmmmmmmmm

Mmmmmmmmmmm

mmmmmmmmmmmmmmmmm Mmmmm

BNP/PCWP

We underestimate the severity of disease: Objective Assessment of the Efficacy of current Therapy

Non-ICU Setting

AHF: Mortalität

Owan T et al. N Engl J Med 2006;355:251-259

Kein

kardiogener

Schock!!

US

Heart Failure

Congestion Decompensation AHF

Stable phase Compensated Chronic HF

Cardiogenic shock Sudden death

5 years

5-10 days

Therapien belegt durch positive RCT

Chronische HF:

Akute HF:

Heart Failure

Congestion Decompensation AHF

Stable phase Compensated Chronic HF

Cardiogenic shock Sudden death

5 years

5-10 days

Therapien belegt durch positive RCT

Chronische HF: 8

Akute HF:

Heart Failure

Congestion Decompensation AHF

Stable phase Compensated Chronic HF

Cardiogenic shock Sudden death

5 years

5-10 days

Therapien belegt durch positive RCT

Chronische HF: 8

Akute HF: 0 (Nitrate bei Lungenödem)

Mmmmmmmmmmmmmm

M

mmmm

AHF Therapy: 1980

Mmmmmmmmmmmmmm

M

mmmm

AHF Therapy: 2017

Levosimendan: +/- Neseritide: +/- Ularitide: +/-

Diuretics: Furosemide

How to use? Low dose vs high dose?

Omecamtiv Myosin-Aktivator GALACTIC-HF Tel: 87540

Vasodilators Or sublingual!!

Benefit from nitrates may depend on the AHF phenotype Dyspnea ++++ + Edema + ++++

Nitrates ++++ +

M

m

Breidthardt T, et al. J Intern Med 2010;267:322-30.

s.l. & transdermal

GALACTIC:

Strategy vs Single drug

Maximal Preload/Afterload with Vasodilators

Target BPsys: 90-110 mmHg

BNP

PCWP, …

time 24h 48h 72h 96h 120h

Standard

Early Goal-Directed Treatment

GALACTIC:

Strategy vs single drug

1. ACE-Inhibitors (Entresto) 2. Beta-Blocker 3. Aldo-Antag. 4. ICD/CRT 5. HTX (LVAD)

- Start low dose, steadily increase dose - Mortality

Diuretics (Torem) + Nitrates „Symptomatic Therapy“

Patient education Patient empowerment Regular follow-up

AHF:

1) kurze Phase der HF

2) Syndrom, ≠ einheitliche Krankheit

3) D: BNP/NT-proBNP

4) Th: Lasix + Metolazon + Aldactone

5) Engmaschiges FU (Gewicht, Crea)

AHF: Diagnosis & Therapie