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European Heart Journal dvance ccess published May 20, 2016 European Heart Journal doi: /eurheartj/ehw128 ES GUDELNES 2016 ES Guidelines for the diagnosis and treatment of acute and chronic heart
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European Heart Journal dvance ccess published May 20, 2016 European Heart Journal doi: /eurheartj/ehw128 ES GUDELNES 2016 ES Guidelines for the diagnosis and treatment of acute and chronic heart failure The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of ardiology (ES) Developed with the special contribution of the Heart Failure ssociation (HF) of the ES Document Reviewers: Gerasimos Filippatos (PG Review oordinator) (Greece), John J. V. McMurray (PG Review oordinator) (UK), Victor boyans (France), Stephan chenbach (Germany), Stefan gewall (Norway), Nawwar l-ttar (UK), John James therton (ustralia), Johann auersachs (Germany),. John amm (UK), Scipione arerj (taly), laudio econi (taly), ntonio oca (Spain), Perry Elliott (UK), Çetin Erol (Turkey), Justin Ezekowitz (anada), ovadonga Ferna ndez-golfı n (Spain), Donna Fitzsimons (UK), Marco Guazzi (taly), * orresponding authors: Piotr Ponikowski, Department of Heart Diseases, Wroclaw Medical University, entre for Heart Diseases, Military Hospital, ul. Weigla 5, Wroclaw, Poland, Tel: , Tel/Fax: , driaan Voors, ardiology, University of Groningen, University Medical enter Groningen, Hanzeplein 1, PO ox , 9700 R Groningen, The Netherlands, Tel: , Fax: , ES ommittee for Practice Guidelines (PG) and National ardiac Societies document reviewers: listed in the ppendix. ES entities having participated in the development of this document: ssociations: cute ardiovascular are ssociation (), European ssociation for ardiovascular Prevention and Rehabilitation (EPR), European ssociation of ardiovascular maging (EV), European Heart Rhythm ssociation (EHR), Heart Failure ssociation (HF). ouncils: ouncil on ardiovascular Nursing and llied Professions, ouncil for ardiology Practice, ouncil on ardiovascular Primary are, ouncil on Hypertension. Working Groups: ardiovascular Pharmacotherapy, ardiovascular Surgery, Myocardial and Pericardial Diseases, Myocardial Function, Pulmonary irculation and Right Ventricular Function, Valvular Heart Disease. The content of these European Society of ardiology (ES) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ES Guidelines may be translated or reproduced in any form without written permission from the ES. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ES Disclaimer. The ES Guidelines represent the views of the ES and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ES is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ES Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ES Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ES Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient s caregiver. Nor do the ES Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. t is also the health professional s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. The article has been co-published with permission in European Heart Journal and European Journal of Heart Failure. ll rights reserved in respect of European Heart Journal. & European Society of ardiology ll rights reserved. For permissions please uthors/task Force Members: Piotr Ponikowski* (hairperson) (Poland), driaan. Voors* (o-hairperson) (The Netherlands), Stefan D. nker (Germany), He ctor ueno (Spain), John G. F. leland (UK), ndrew J. S. oats (UK), Volkmar Falk (Germany), Jose Ramo n Gonza lez-juanatey (Spain), Veli-Pekka Harjola (Finland), Ewa. Jankowska (Poland), Mariell Jessup (US), ecilia Linde (Sweden), Petros Nihoyannopoulos (UK), John T. Parissis (Greece), urkert Pieske (Germany), Jillian P. Riley (UK), Giuseppe M.. Rosano (UK/taly), Luis M. Ruilope (Spain), Frank Ruschitzka (Switzerland), Frans H. Rutten (The Netherlands), Peter van der Meer (The Netherlands) Page 2 of 85 ES Guidelines Maxime Guenoun (France), Gerd Hasenfuss (Germany), Gerhard Hindricks (Germany), rno W. Hoes (The Netherlands), ernard ung (France), Tiny Jaarsma (Sweden), Paulus Kirchhof (UK/Germany), Juhani Knuuti (Finland), Philippe Kolh (elgium), Stavros Konstantinides (Germany/Greece), Mitja Lainscak (Slovenia), Patrizio Lancellotti (elgium), Gregory Y. H. Lip (UK), Francesco Maisano (Switzerland), hristian Mueller (Switzerland), Mark. Petrie (UK), Massimo F. Piepoli (taly), Silvia G. Priori (taly), dam Torbicki (Poland), Hiroyuki Tsutsui (Japan), Dirk J. van Veldhuisen (The Netherlands), Stephan Windecker (Switzerland), lyde Yancy (US), Jose Luis Zamorano (Spain) The disclosure forms of all experts involved in the development of these guidelines are available on the ES website Keywords Guidelines Heart failure Natriuretic peptides Ejection fraction Diagnosis Pharmacotherapy Neuro-hormonal antagonists ardiac resynchronization therapy Mechanical circulatory support Transplantation rrhythmias o-morbidities Hospitalization Multidisciplinary management bbreviations and acronyms Preamble ntroduction Definition, epidemiology and prognosis Definition of heart failure Terminology Heart failure with preserved, mid-range and reduced ejection fraction Terminology related to the time course of heart failure Terminology related to the symptomatic severity of heart failure Epidemiology, aetiology and natural history of heart failure 3.4 Prognosis Diagnosis Symptoms and signs Essential initial investigations: natriuretic peptides, electrocardiogram, and echocardiography lgorithm for the diagnosis of heart failure lgorithm for the diagnosis of heart failure in the non-acute setting Diagnosis of heart failure with preserved ejection fraction ardiac imaging and other diagnostic tests hest X-ray Transthoracic echocardiography ssessment of left ventricular systolic function ssessment of left ventricular diastolic function ssessment of right ventricular function and pulmonary arterial pressure Transoesophageal echocardiography Stress echocardiography ardiac magnetic resonance Single-photon emission computed tomography and radionuclide ventriculography Positron emission tomography oronary angiography ardiac computed tomography Other diagnostic tests Genetic testing in heart failure Delaying or preventing the development of overt heart failure or preventing death before the onset of symptoms Pharmacological treatment of heart failure with reduced ejection fraction Objectives in the management of heart failure Treatments recommended in all symptomatic patients with heart failure with reduced ejection fraction ngiotensin-converting enzyme inhibitors eta-blockers Mineralocorticoid/aldosterone receptor antagonists. 7.3 Other treatments recommended in selected symptomatic patients with heart failure with reduced ejection fraction Diuretics ngiotensin receptor neprilysin inhibitor f - channel inhibitor ngiotensin type receptor blockers ombination of hydralazine and isosorbide dinitrate Other treatments with less certain benefits in symptomatic patients with heart failure with reduced ejection fraction Digoxin and other digitalis glycosides n-3 polyunsaturated fatty acids Treatments not recommended (unproven benefit) in symptomatic patients with heart failure with reduced ejection fraction Hydroxy-3-methylglutaryl-coenzyme reductase inhibitors ( statins ) Oral anticoagulants and antiplatelet therapy Renin inhibitors Treatments not recommended (believed to cause harm) in symptomatic patients with heart failure with reduced ejection fraction alcium-channel blockers Table of ontents Page 3 of 85 ES Guidelines cute heart failure Definition and classification Diagnosis and initial prognostic evaluation Management dentification of precipitants/causes leading to decompensation that needs urgent management riteria for hospitalization in ward vs intensive care/coronary care unit Management of the early phase Management of patients with cardiogenic shock Management of evidence-based oral therapies Monitoring of clinical status of patients hospitalized due to acute heart failure riteria for discharge from hospital and follow-up in high-risk period Goals of treatment during the different stages of management of acute heart failure Mechanical circulatory support and heart transplantation Mechanical circulatory support Mechanical circulatory support in acute heart failure Mechanical circulatory support in end-stage chronic heart failure Heart transplantation Multidisciplinary team management Organization of care Discharge planning Lifestyle advice Exercise training Follow-up and monitoring The older adult, frailty and cognitive impairment Palliative and end-of-life care Gaps in evidence To do and not to messages from the Guidelines Web ddenda ppendix References bbreviations and acronyms /H F/H E E S F HF H DS K ldo-dhf L LT merican ollege of ardiology/merican Heart ssociation merican ollege of ardiology Foundation/ merican Heart ssociation angiotensin-converting enzyme angiotensin-converting enzyme inhibitor acute coronary syndrome atrial fibrillation acute heart failure apnoea/hypopnoea index acquired immunodeficiency syndrome acute kidney injury aldosterone receptor blockade in diastolic heart failure amyloid light chain alanine aminotransferase 8. Non-surgical device treatment of heart failure with reduced ejection fraction mplantable cardioverter-defibrillator Secondary prevention of sudden cardiac death Primary prevention of sudden cardiac death ardiac resynchronization therapy Other implantable electrical devices Treatment of heart failure with preserved ejection fraction Effect of treatment on symptoms in heart failure with preserved ejection fraction Effect of treatment on hospitalization for heart failure in heart failure with preserved ejection fraction Effect of treatment on mortality in heart failure with preserved ejection fraction Other considerations rrhythmias and conductance disturbances trial fibrillation Prevention of atrial fibrillation in patients with heart failure Management of new-onset, rapid atrial fibrillation in patients with heart failure Rate control Rhythm control Thromboembolism prophylaxis Ventricular arrhythmias Symptomatic bradycardia, pauses and atrio-ventricular block o-morbidities Heart failure and co-morbidities ngina and coronary artery disease Pharmacological management Myocardial revascularization achexia and sarcopenia (for frailty, please refer to Section 14) ancer entral nervous system (including depression, stroke and autonomic dysfunction) Diabetes Erectile dysfunction Gout and arthritis Hypokalaemia and hyperkalaemia Hyperlipidaemia Hypertension ron deficiency and anaemia Kidney dysfunction (including chronic kidney disease, acute kidney injury, cardio-renal syndrome, and prostatic obstruction) Lung disease (including asthma and chronic obstructive pulmonary disease) Obesity Sleep disturbance and sleep-disordered breathing Valvular heart disease ortic stenosis ortic regurgitation Mitral regurgitation Tricuspid regurgitation Page 4 of 85 M M HRM-Preserved -K S K KD K-M MP MR OMPNON ONFRM-HF ONSENSUS OPD OPERNUS OX-2 inhibitor PP PG RT RT-D RT-P S SR T YP34 DM DES DH DG-PEF DN DOSE DPD DPP4i DT e EG Echo-RT ELS EMO ED EF egfr EHR EM EM EMF andesartan ilexetil in Heart Failure ssessment of Reduction in Mortality and Morbidity cardiac index contrast-induced acute kidney injury ardiac nsufficiency isoprolol Study creatine kinase chronic kidney disease creatine kinase M cardiomyopathy cardiac magnetic resonance omparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure Ferric arboxymaltose evaluation on performance in patients with Ron deficiency in combination with chronic Heart Failure ooperative North Scandinavian Enalapril Survival Study chronic obstructive pulmonary disease arvedilol Prospective Randomized umulative Survival cyclooxygenase-2 inhibitor continuous positive airway pressure ommittee for Practice Guidelines cardiac resynchronization therapy defibrillator with cardiac resynchronization therapy pacemaker with cardiac resynchronization therapy central sleep apnoea heyne-stokes respiration computed tomography cytochrome P dilated cardiomyopathy desmin docosahexaenoic acid ancillary Digitalis nvestigation Group trial deoxyribonucleic acid Diuretic Optimization Strategies Evaluation 3,3-diphosphono-1,2-propanodicarboxylic acid dipeptidyl peptidase-4 inhibitor destination therapy early diastolic tissue velocity electrocardiogram Echocardiography Guided ardiac Resynchronization Therapy extracorporeal life support extracorporeal membrane oxygenation emergency department ejection fraction estimated glomerular filtration rate European Heart Rhythm ssociation European Medicines gency endomyocardial biopsy endomyocardial fibrosis acute myocardial infarction trial fibrillation Management n ongestive heart failure with blation NP -type natriuretic peptide NS autonomic nervous system R angiotensin receptor blocker RN angiotensin receptor neprilysin inhibitor RV arrhythmogenic right ventricular cardiomyopathy ST aspartate aminotransferase SV assisted servo-ventilation TLS ssessment of Treatment with Lisinopril nd Survival TTR transthyretin-mediated amyloidosis V atrio-ventricular VP arginine vasopressin b.i.d. bis in die (twice daily) iope iventricular Pacing for trio-ventricular lock to Prevent ardiac Desynchronization ipp bilevel positive airway pressure ivd biventricular assist device LOK-HF iventricular versus Right Ventricular Pacing in Heart Failure Patients with trio-ventricular lock M body mass index NP -type natriuretic peptide P blood pressure bpm beats per minute S body surface area T bridge to bridge T bridge to candidacy TD bridge to decision TR bridge to recovery TT bridge to transplantation UN blood urea nitrogen N atheter lation versus Ntiarrhythmic drug therapy for trial fibrillation G coronary artery bypass graft/grafting D coronary artery disease RE-HF rdiac REsynchronization in Heart Failure STLE-F atheter blation versus Standard conventional Treatment in patients with LEft ventricular dysfunction and trial Fibrillation calcium-channel blocker M cardiac contractility modulation S anadian ardiovascular Society U coronary care unit H2DS2-VSc ongestive heart failure or left ventricular dysfunction, Hypertension, ge 75 (doubled), Diabetes, Stroke (doubled)-vascular disease, ge 65 74, Sex category (female) HRM-lternative andesartan in heart failure assessment of reduction in mortality and morbidity HRM-dded andesartan ilexetil in Heart Failure ssessment of Reduction in Mortality and Morbidity ES Guidelines Page 5 of 85 ES Guidelines EMPHSS-HF EP EPHESUS ES EU EULR Ex-DHF FT-Pal FR-HF Hb1c HM HES HF HF HFmrEF HFpEF HFrEF H-SDN HV/DS HR Hs troponin P P-SHOK P-SHOK D U HD L NH NTERMS N-TME PD -PRESERVE i.v. V VRT KQ L LE LV L LGE LMN LMWH LV LVD LVEDP LVEDV LVEF LVESV LVD LVM LVSD MDT-RT MS MERT-HF MR MR MR-proNP MV MV -Wave MV E-Wave MYP3 MYH7 n-3 PUF NEP NO NP NPPV NSD NSTE-S NT-proNP NYH o.d. OMT OS PaO2 PH PaO2 PRDGM-HF PRMOUNT P isovolumetric relaxation time Kansas ity ardiomyopathy Questionnaire left atrial/atrium left atrial enlargement left atrial volume index left bundle branch block late gadolinium enhancement lamin / low-molecular-weight heparin left ventricular/left ventricle left ventricular assist device left ventricular end diastolic pressure left ventricular end diastolic volume left ventricular ejection fraction left ventricular end systolic volume left ventricular internal dimension left ventricular mass index left ventricular systolic dysfunction Multicenter utomatic Defibrillator mplantation Trial with ardiac Resynchronization Therapy mechanical circulatory support Metoprolol R/XL Randomised ntervention Trial in ongestive Heart Failure mineralocorticoid receptor/magnetic resonance mineralocorticoid receptor antagonist mid-regional pro -type natriuretic peptide mitral valve mitral valve late diastolic flow mitral valve early diastolic flow cardiac myosin binding protein cardiac b-myosin heavy chain n-3 polyunsaturated fatty acid neprilysin non-vitamin K antagonist oral anticoagulant natriuretic peptide non-invasive positive pressure ventilation non-steroidal anti-inflammatory drug non-st elevation acute coronary syndrome N-terminal pro- type natriuretic peptide New York Heart ssociation omne in die (once daily) optimal medical therapy obstructive sleep apnoea partial pressure of carbon dioxide in arterial blood pulmonary arterial hypertension partial pressure of oxygen in arterial blood Prospective omparison of RN with E to Determine mpact on Global Mortality and Morbidity in Heart Failure Trial LZ696 ompared to Valsartan in Patients With hronic Heart Failure and Preserved Left-ventricular Ejection Fraction percutaneous coronary intervention FM FiO2 GFR GGTP GH GLS GLP-1 HS-LED Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure eicosapentaenoic acid Eplerenone Post-cute Myocardial nfarction Heart Failure Efficacy and Survival Study European Society of ardiology European Union European League gainst Rheumatism Exercise training in Diastolic Heart Failure Functional ssessment of hronic llness Therapy - Palliative are Ferinject ssessment in Patients with ron Deficiency and hronic Heart Failure ferric carboxymaltose fraction of inspired oxygen glomerular filtration rate gamma-glutamyl transpeptidase growth hormone global longitudinal strain glucagon-like peptide 1 Hypertension, bnormal renal/liver function (1 point each), Stroke, leeding history or predisposition, Labile international normalized ratio, Elderly (.65 years), Drugs/alcohol concomitantly (1 point each) glycated haemoglobin hypertrophic cardiomyopathy hypereosinophilic syndrome heart failure Heart Failure ssociation heart failure with mid-range ejection fraction heart failure with preserved ejection fraction heart failure with reduced ejection fraction hydralazine and isosorbide dinitrate human immunodeficiency virus/acquired immune deficiency syndrome heart rate high sensitivity troponin intra-aortic balloon pump ntraortic alloon Pump in ardiogenic Shock ntraortic alloon Pump in ardiogenic Shock implantable cardioverter-defibrillator intensive care unit ischaemic heart disease interleukin nterdisciplinary Network for Heart Failure nteragency Registry for Mechanically ssisted irculatory Support mplant-based multiparameter telemonitoring of patients with heart failure individual patient data rbesartan in Heart Failure with Preserved Ejection Fraction Study intravenous inferior vena cava Page 6 of 85 PWP PDE5 Peak VO2 PEP-HF PET PLN PPV PRSM 7 PROTET PS-PEEP R RS RFT RLES RT RELX REVERSE RV RVD SDHRT SVE SP SD-HeFT SD SENORS SERVE-HF SHFT SGNFY SOLVD SPET pulmonary capillary wedge pressure phosphodiesterase 5 inhibitor peak oxygen uptake Perindopril in Elderly People with hronic Heart Failure positron emission tomography phospholamban positive
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