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At this meeting organised by the Working Group on Heart Failure of the
European Society of Cardiology (ESC), a Task Force of the ESC introduced
updated and comprehensive, evidence-based guidelines for diagnosis and
treatment of patients with heart failure. The last set of European guidelines
for heart failure diagnosis was developed in 1995, and treatment guidelines
followed in 1997. Recent breakthroughs in these areas of care are reflected
in these guidelines. Excerpts from the 2001 guidelines are summarised
below
(Tables 1, 2).
These new guidelines underscore the importance of using a combination
of symptoms and objective evidence to diagnose heart failure. Tests to
identify or rule out heart failure are summarised in Table 1. Use of echocardiography
for objective diagnosis was strongly supported, and B-type natriuretic
peptide (BNP) assay was recognised as a highly consistent measure with
particularly good negative predictive value (i.e., if BNP is low, a diagnosis
other than heart failure is likely).
Table 1
Highlights of testing for heart failure: ESC Guidelines 2001
|
Test
|
Necessary test
|
Supports diagnosis
|
Opposes diagnosis
|
|
Electrocardiogram
|
++
|
|
If normal
|
|
Echocardiogram*
|
+++
|
|
If normal
|
|
Chest x-ray†
|
|
If congestion
|
If normal
|
|
Blood count‡
|
|
If normal
|
|
|
Blood chemistry§
|
|
If normal
|
|
|
BNP*
|
|
If elevated
|
If normal
|
|
Exercise
|
|
|
If normal
|
|
Cardiac catheterization
|
|
|
If normal
|
|
|
*Echocardiogram encouraged; use of BNP test upgraded
in 2001. †x-ray rules out pulmonary disease; ‡blood count
rules out anaemia; §blood chemistry rules out infection;
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Pharmacological therapy was a major focus of the revised guidelines;
highlights are summarised in Table 2. Changes from the 1995 and 1997 guidelines
include
- upgrade of beta-blocker use for all patients with mild, moderate,
or severe heart failure
- downgrade of vasodilator use, with angiotensin receptor blockade used
preferentially
- recognition of the calcium sensitiser levosimendan for treatment of
patients with acutely decompensated heart failure, as it appears to
be safer than dobutamine.
Table 2
Highlights of medical therapy: ESC Guidelines 2001
|
Treatment agent
|
Recommendations
|
|
Angiotensin converting enzyme (ACE)-inhibitors
|
- First-line therapy for patients with left ventricular ejection
fraction < 40-45%
- In absence of fluid retention, use alone; if fluid retention,
use with diuretics
- Slowly titrate upward
|
|
Beta-blockers*
|
- For all patients with mild, moderate, or severe heart
failure (ischaemic or non-ischaemic origin) who are on standard
therapy of ACE inhibitors and diuretics
- Also for patients with left ventricular dysfunction post-MI
|
|
Spironolactone
|
- For patients with advanced heart failure despite standard
therapy
|
|
Loop diuretics, thiazides, or potassium-sparing diuretics
|
- Essential therapy when fluid load is present
|
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Angiotensin receptor blockers (ARB)
|
- Consider in patients who cannot tolerate ACE inhibitors
- Not recommended in addition to ACE inhibitors because
of overlapping actions
|
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Digitalis glycosides
|
- For patients with atrial fibrillation and symptomatic
heart failure
|
|
Vasodilators†
|
- Adjunct therapy for relief of angina or acute dyspnoea
- ARBs preferable to vasodilators
|
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Positive inotropes,
e.g., dobutamine
|
- Short-term use in severe heart failure, mainly as a bridge
to heart transplantation
|
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Calcium sensitisers
( Levosimendan‡)
|
- Short-term use for decompensated heart failure
- Evidence suggests it is safer than dobutamine
|
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*Beta-blocker usage upgraded in 2001 Guidelines; †vasodilator
usage downgraded in 2001; ‡levosimendan newly recommended
in 2001.
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