What’s the new evidence base for heart failure diagnosis & management?Mar. 31, 2017 - news
Professor Arno Hoes – University of Utrecht, Julius Center of Health Sciences and Primary Care, Utrecht, The Netherlands
What’s the new evidence base for heart failure diagnosis & management?
Professor Hoes highlighted recent developments in recommendations on the diagnosis of HF. Early diagnosis is crucial to improve prognosis, and the role of primary care is pivotal. Evidence is accumulating that a more pro-active approach to case-finding pays off. Breathlessness is often considered as an inevitable aspect of ageing, but this does not need to be the case. Also, when patients do not complain about breathlessness, it is worth asking about it, among other symptoms.
The ESC guideline recommends at least performing echocardiography. It was clear that the accessibility of echocardiography varies a lot per country. The same is true for the existence of HF nurses or dedicated HF clinics. Depending on the facilities, suspected or newly diagnosed HF patients should be referred to a cardiologist or HF clinic, and may later be referred back to the GP for follow-up management. The same variability is seen for accessibility of BNP measurements.
A Dutch study revealed that in primary care, 20% of patients considered to have COPD, actually had COPD and HF, or HF alone. Half of these cases were HFrEF, and the other half HFpEF. Primary care is well-equipped for case-finding in high-risk groups. Also, a study in patients with type 2 diabetes aged at least 60 years, found that 28% had unknown HF, of which the majority had HFpEF (82%). Survival of patients with diabetes and HFpEF was better than of those with diabetes and HFrEF.
The latest ESC HF Guidelines have added a HF category, namely for those with ejection fraction between 40 and 49%, baptised HFmrEF for mid-range EF. The reason for adding this category is that this patient group should receive more attention in studies, as little is known as to whether the patients are more similar to HFpEF or to HFrEF.
Treatment options now include the novel angiotensin receptor/neprilysin inhibitor (ARNI) sacubitril/valsartan. One pivotal RCT (PARADIGM-HF) showed a benefit of treatment with this agent in patients with HFrEF, as compared with the ACE-inhibitor enalapril. The trial was stopped prematurely due to the positive findings. Based on these results, it is recommended that those who can tolerate ACE-inhibition and who still have symptoms, are switched to treatment with sacubitril/valsartan.
With regard to the many HFpEF patients seen in primary care, currently no evidence exists of a beneficial treatment. In case of symptoms of congestion, diuretics can be given to alleviate symptoms, and it is important to focus on co-morbidities to improve quality of life. On ongoing study evaluates a potential benefit of treatment with sacubitril/valsartan in HFpEF.
The Guidelines also recommend enrolment of HF patients in multidisciplinary care management programmes to reduce the risk of HF hospitalisation and mortality. Again, such programmes will vary according to the facilities and organisation of healthcare in a given country. The potential role of telemonitoring needs more evaluation, and may also depend on the healthcare setting and country.