ESC Congress 2016 - 15B

Figure 1. Treatment Algorithm for Symptomatic HFrEF ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor neprilysin inhibitor; CRT, cardiac resynchronization therapy; HFrEF, heart failure with reduced ejection fraction; H-ISDN, hydralazine and isosorbide dinitrate; HR, heart rate; ICD, implantable cardioverter-defibrillator; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MR, mineralocorticoid receptor; OMT, optimal medical therapy; VF, ventricular fibrillation; VT, ventricular tachycardia. Reprinted from Ponikowski P et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail. 2016; 37:2129-2200. doi:10.1093/eurheartj/ ehw128. By permission of John Wiley & Sons on behalf of the European Society of Cardiology. Importantly, the majority of hospitalizations in patients with AHF are for non-HF, non-CV reasons. 9 Therefore, the guidelines call for better management of comorbidities (including through multidisciplinary teams) to reduce hospitalizations, improve outcomes, and reduce mortality. In patients with stable angina, ivabradine is recommended in addition to a ß-blocker or when a ß-blocker is contraindicated (Class IIa) in patients with a HR ≥ 70 bpm, and the drug should be considered an anti-anginal agent with a proven benefit to symptoms. The bidirectionality of HF and comorbidities was highlighted by Prof Böhm. HF begets comorbidities and comorbidities beget HF, and the treatment of each favorably influences the other. Data from the SOLVD trial10 and SHIFT trial11 show that the treatment effects achieved with ACEI and ivabradine, respectively, are not affected by the presence of comorbidities. Chronic obstructive pulmonary disease (COPD) may worsen HF, but COPD hospitalization is reduced with optimized treatment for HF and CV disease, while HFH is reduced with optimized treatment for COPD.12 Renal dysfunction is highly associated with adverse outcomes in patients with HF, stated Prof Böhm, and about one-half of patients with NYHA class II HF have renal dysfunction. Mortality is increased with a glomerular filtration rate (GFR) < 60 ml/min/m 2 , and the CHARM study13 showed a stepwise increase in mortality as GFR worsens; mortality was 50% lower in patients with normal renal function versus those with GFR < 45 ml/min/m 2 . Iron deficiency is another prominent comorbidity that when treated can improve outcomes in HF. Hospitalization was significantly reduced with longterm intravenous ferric carboxymaltose,14 and in the FAIR-HF study renal function was improved with the treatment of anemia.15 Setting the Course Before Discharge Discharge from hospital is only the start of the complex patient journey and the course for the road to follow must be established before discharge. In the vulnerable phase, HF death is 15-fold higher in the first 30 days after hospital discharge. In addition to assessing the criteria for discharge, as outlined by the ESC guidelines, the prognostic variables identified as associated with a higher level of risk during the vulnerable phase must be assessed, especially signs of congestion and HR. The algorithm for the treatment of symptomatic HFrEF should be followed to ensure optimization of all guideline-directed therapies. Discharge planning must start early during hospitalization, and should include: * Defining the goals of treatment * Defining the patient clinical profile * Strategizing post discharge follow-up and care * Monitoring effects of treatment

Table of Contents for the Digital Edition of ESC Congress 2016