Key issues of European Society of Cardiology guidelines on acute heart failure
Division of Cardiology, Helsinki University Central Hospital, PL 00029 HUS Helsinki, Finland
Corresponding author: E-mail address: markku.nieminen{at}hus.fi
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Abstract |
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 Top Abstract Definitions and classification...Goals of treatment of...Algorithms on diagnosis and...TreatmentNew medications and commentsReferences |
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The European Society of Cardiology guidelines on acute heart failure focused on stratifying the definition of acute heart failure and classification of severity. These guidelines also note that the patients are hospitalized because of acute de novo or chronic heart failure. Pulmonary odema or cardiogenic shock was present in 32% of acute de novo patients and in 11% of chronic decompensated heart failure patients. The haemodynamic responses may be more aggressive in the acute de novo patients.
The chapter on goals of therapy is to characterize measures for optimal care with the aim to optimize the length of stay in intensive care or on ward. The use of continuous positive airway pressure breathing is emphasized in patients with respiratory distress. The strength of evidence and level of recommendation on each medication used in treatment of acute heart failure are thoroughly discussed and introduced in table form in this compendium.
Key Words: Acute heart failure • Guidelines • Therapy • Definitions
European guidelines on acute heart failure (AHF) were recently published.1 They were written by the task force chaired by the author and the members from the ESC Working Group on Heart Failure (presently, Heart Failure Association of the ESC), consisting also the members of the Working Group of Acute Cardiac Care and members of the European Society of Intensive Care Medicine (ESICM). Several national societies of the ESC have endorsed the guidelines and the ESICIM.
The emphasis on the AHF guidelines is a consensus on definition of AHF and AHF severity classification.
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Definitions and classification of AHF |
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TopAbstractDefinitions and classification...Goals of treatment of...Algorithms on diagnosis and...TreatmentNew medications and commentsReferences |
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The task force definition of AHF is 'rapid onset of symptoms and signs secondary to abnormal cardiac function, with descriptive subdefinition stating that it is often life threatening and requires urgent treatment. It may occur with or without previous cardiac disease. The cardiac dysfunction can be related to systolic or diastolic dysfunction, to abnormalities of cardiac rhythm, or to preload and afterload mismatch'.
AHF presents with several distinct clinical conditions, with clear differences in severity (Table 1). The clinical pathophysiological classification is based on some early validated clinical grouping based on haemodynamic characteristics and clinical signs,2–4 which in general describe the patient groups in a clinically relevant way. They were also well related to in-hospital prognosis.2,3
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It is important to note that the patients with AHF can be patients with new onset heart failure or decompensated chronic heart failure. In American reviews, the AHF is described as AHF syndrome (AHFS) comprising mainly decompensated heart failure patients, without differentiating these two groups,5 and the outline of patient populations are classified in a different way compared with the European guidelines on AHF.
The difference between the de novo and decompensated chronic heart failure subtypes is clinically important. In chronic decompensated heart failure, the circulatory system is adopted, especially the pulmonary circulation. The neurohumoral system is well expressed and these patients usually have sodium and water retention in addition to vasoconstriction. Their responses to therapy are more subtle and predictive. Thus, they are easier to monitor clinically, as described by another grouping based on hospitalized advanced heart failure patients.6
In de novo AHF, haemodynamic regulation is strained and responses to therapy are more abrupt. There is often less adoptation and the sympathetic tone is well expressed.
In the ongoing EuroHeart survey on AHF (EHS HFII), it can (Table 2) clearly be seen that chronic decompensated heart failure patients rather present with decompensation and volume overload and that the acute de novo more often presents with pulmonary oedema or even cardiogenic shock, as presented at the ESC congress 2005 on the basis of the preliminary analysis of 2500 patients.
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Goals of treatment of AHF |
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The third key issue in the ESC guidelines for AHF1 is the definition of the goals on AHF therapy. There are two main targets for clinical care. First of all, it is the improvement on clinical condition by optimizing the haemodynamic situation and improvement of the symptoms. Secondly, it is the aim to limit and avoid any myocardial damage and prevent negative remodelling, rather than aiming for positive remodelling of the involved cardiac pathophysiology, left sided or right sided or both.
During the development process of the ESC guidelines on AHF, the European Medical Agengy's (EMEA) aim was that the objectives of care were well defined, owing to evident need for defining the clinical endpoints for documentation of medical care, especially for new pharmaceutical agents developed for the treatment of AHF.
In general, the task force defined these goals for favourable effects on long-term prognosis. The efficacy can be documented as objective measures of improvement in haemodynamic measurements by pulmonary artery catheter, or non-invasively, by echocardiography.
The second issue is improvement in symptoms, and as such, dyspnoea together with improvement in oxygenation, improvement in clinical signs, and improvement or no adverse observation in essential laboratory measures (serum creatinine, transaminases, and BNP) are essential objectives.1,7
Thirdly, an important goal is effective care with optimal duration in intensive care, with a short duration of intravenous therapy and good guidance for less rehospitalizations and decreased mortality. Some of these measures can be used in quality control of care or benchmarking.
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Algorithms on diagnosis and treatment of AHF |
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The diagnosis of AHF is usually easy but may require diagnostic procedures to differentiate AHF from other catastrophes, such as serious bleeding, or from respiratory diseases, such as asthma or exacerbation of COPD or even pneumonia. The algorithm on diagnoses of AHF was published in the EHJ.1 After the publication, some comments have been received. One of the comments has been that in patients who present with dyspnoea and congestion, many of them present with acute coronary syndrome, and these patients should, after initial rescue therapies or stabilization, go directly to catheter laboratory (Figure 1). In fact, it is true by various reports that 60% of heart failure patients have coronary heart disease,8,9 and also according to preliminary analysis from the EuroHeart survey on AHF, 33% have acute coronary syndrome, most frequently AHF related to myocardial infarction (Figure 1).
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The guidelines note (Table 3) that many of the AHF patients are elderly and they frequently have several concomitant clinical problems, and often complicated by infections, most frequently pneumonia, anaemia, renal dysfunction, and chronic obstructive lung disease.
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The main objectives of therapy are improvement in clinical situation and improvement in oxygenation to improve tissue perfusion and symptoms, such as dyspnoea in AHF patients. They also frequently present with life-threatening arrhythmias. They have anxiety and are dyspnoeic. Resuscitation and basic life support are not needed frequently. The most important issues are optimization of haemodynamics and oxygenation. Oxygenation is usually best improved by oxygen mask or by continuous positive airway pressure (CPAP) breathing.10,11 Intubation should be avoided. For oxygenation, the stabilization and optimization of haemodynamics are important (Figure 2).
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Many of the patients have fast heart rate due to high preload and sympathetic tone. Some present with life-threatening arrhythmia. Others have rapid atrial fibrillation (AF) or supraventricular tachycardia. These should be treated without compromising the circulatory conditions, especially contractility or blood pressure.12,13 New AF or flutter can be converted, and if imperative for acute care, even after eosophageal echocardiography.13 When blood pressure is adequate, digitalization and or beta-blocking agents can be used (Figure 2).
In addition to general care (Table 3) of the heart failure, the cause or the underlying cardiovascular disease must be treated (Figure 2).
Several new medications are available, which have great efficacy and potentially may abruptly decrease preload resulting in hypotension. The patient, due to active prescription of vasodilators and diuretics, may be relatively ‘hypovolemic’. A test volume of 200–500 mL of isotonic volume can be given to observe whether test load may improve the objective measures of haemodynamic condition (Figure 2).
Hypotension may more frequently occur in patients with acute de novo serious heart failure, also severe cases if treated too vigorously. Some concern has been thrown over the use of pulmonary artery catheter. In seriously ill patients, with severely compromised haemodynamics, if the patient is not responding to therapy properly, a pulmonary artery catheter is indicated to monitor the central haemodynamics and responses to therapy. These measurements are also imperative when circulatory assist devices, i.e. intra-aortic balloon pumping or temporary pumps are considered (Figure 2).
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Treatment |
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TopAbstractDefinitions and classification...Goals of treatment of...Algorithms on diagnosis and...TreatmentNew medications and commentsReferences |
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The therapy of patients can be outlined to general care, including instrumentation and oxygenation, to medical management, based on proven therapies, to surgical management when indicated, and to tertiary care with devices especially and rarely, when patients are severely compromised and dependent on inotropic therapy, for soon cardiac transplantation usually with assist devices as bridge to transplantation (Table 4).
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The general care consists of instrumentation of the patients with IV lines, and when haemodynamically compromised, instrumented also with intra-arterial line for continuous blood pressure monitoring. The AHF patients are connected to central monitoring for the heart rate and rhythm and/or ischaemia, together with blood pressure for basic haemodynamic monitoring.
Oxygenation, if not adequate by mask, is enhanced by continuous airway pressure breathing to improve oxygenation. Intubation should be commenced only if the patients are weary for spontaneous respiration.
Medical management can be referred in the AHF guidelines, which deal with medication, its indications and concerns. Table 3 presents the current consent on level on recommendation and evidence for each medical therapy group. The problem with most of the medical therapies is lack of evidence-based controlled trial with hard endpoints. Thus, many of the recommendations are IIa or IIb and class of evidence B or C.
Surgical management of valvular heart disease is managed as in valvular heart disease or endocarditis guidelines,14,15 and revascularization as in ACS guidelines published by ESC.16,17
The devices are a new extension to our means of care of haemodynamics. When the guidelines were written, left ventricular (LV) assist devices were used for endstage heart failure or as a bridge to heart transplantation.18 During last years, new information has emerged. There are several so-called minipumps in development, which in small trials have been shown to significantly improve haemodynamics.19 Similarly, temporary haemodialysis or haemofiltration has been shown beneficial in diuretic-resistant advanced heart failure.20
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New medications and comments |
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TopAbstractDefinitions and classification...Goals of treatment of...Algorithms on diagnosis and...TreatmentNew medications and commentsReferences |
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Likewise, new agents are emerging especially for diuretic-resistant heart failure. Vasopressin levels are increased and vasopressin antagonists increase diuresis and sodium excretion.21,22 Similarly, adenosine receptor 1 antagonists increase sodium excretion and thus diuresis.23
The use of inotropic agents and also levosimendan needs further studies, as the long-term treatment by low enoximone did not improve prognosis (ESSENTIAL study); in the SURVIVE study, the long-term prognosis by levosimendan was slightly better but non-significant when compared with low-dose dobutamine.
In general, the guidelines have been well accepted and very few comments have been received. Control on serum potassium levels and potassium supplementation is of course essential. This may also concern magnesium supplementation in patients with ventricular arrhythmias.
The anaesthesiologists have commented that in the recommendations mentioned, noradrenaline infusion rates are generally high, and that noradrenaline infusion is usually started as 0.02–0.1 µg/kg/min in clinical practice.
It may be highlighted that in the care of patients, the evaluation of preload is important, especially in acute de novo patients and especially in the elderly, as they may easily be hypovolemic because of complicating factors, such as infection, and/or due to aggressive use of diuretics or vasodilators, and thus volume supplementation is important.
In conclusion, AHF guidelines have outlined the definition and classification of AHF patients and are generally well accepted. The goals of therapy have been written out as consensus of the task force. Current evidence and practices of care have been described. Minor comments have been received and will be upgraded in future update. Some new modalities of medical and device therapies are emerging, which potentially may improve the care of AHF patients. Some current practices and also new could benefit of controlled trials.
Conflict of interest. none declared.
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Footnotes |
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This article is based on a presentation in Madrid on 3 February 2006 and on ESC guidelines on acute heart failure written by the task force as nominated by the ESC.
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References |
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