ESC - Diagnosis of Heart Failure
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Transcript of ESC - Diagnosis of Heart Failure
ESC Guidelines for the diagnosis and
treatment of acute and chronic heart failure 2012
Authors/Task Force Members: John J V McMurray (Chairperson) et al.
Update on diagnosis of heart failure
Frans H. Rutten, MD, PhD, general practitioner
Conflict of Interest
2006 Lecture fee form Roche Diagnostics
2007 Lecture fee Chiesa Inc
Research support from the Netherlands Heart Foundation
Research support from the Netherlands Organisation for Health Research and Development
‘The very essence of cardiovascular practice
is recognition of early heart failure’
Sir Thomas Lewis – 1933
Definition of heart failure
abnormality of cardiac structure or function
leading to
failure of the heart to deliver oxygen at a rate commensurate with the requirements of the
metabolizing tissues (or only at the expense of increased filling pressures)
Fluid overload compensation reduced oxygen delivery (‘backward failure’) adaptation (‘forward failure’)
Definition of heart failure
Problems in patients treated with diuretics because:
The more specific signs are related to fluid overload
Few signs are related to reduced oxygen delivery
or compensation/adaptation
Apical impulse
Background information to flowchart (1) • In the acute setting:
- MR-proANP may also be used (exclusionary cut-off point 120 pmol/L)
- Oxygen saturation measurement
- D-dimer (pulmonary embolism?)
- Troponins
• Other causes of elevated natriuretic peptide levels in the acute setting are:
- an acute coronary syndrome
- atrial or ventricular arrhythmias
- pulmonary embolism
- severe COPD with elevated right heart pressures
- renal failure
- sepsis
• Other causes of an elevated natriuretic level in the non-acute setting are:
- old age (>75 years)
- atrial arrhythmias/atrial fibrillation
- left ventricular hypertrophy
- COPD
- chronic kidney disease
Background information to flowchart (2)
• Exclusion cut-off points to minimize false-negative rate while reducing
unnecessary referrals for echocardiography
• Treatment may reduce natriuretic peptide concentration
• Natriuretic peptide concentrations may not be markedly elevated in patients with
HF-PEF
• In patients suspected of non-acute HF and prior MI:
echocardiography ‘straightaway’
•When ECG is normal, likelihood of acute new HF <2%
• When ECG is normal, likelihood of non-acute new HF <10-14%
• When NTproBNP <300 pg/ml, likelihood of acute new HF <2%
• When BNP<100 pg/ml, likelihood of acute new HF <2%
• When NTproBNP <125 pg/ml, likelihood of non-acute new HF <10%
• When BNP <35 pg/ml, likelihood of non-acute new HF <10%
(NTpro)BNP tests: Why difference in exclusionary cut points in acute vs non acute
setting?
Differences in prior change (prevalence)
Difference in severity of disease
different patient profile
Other
Positive predictive values
Negative predictive values
Sensitivity
Specificity
BNP in 1872 patients suspected of non-acute HF
NT-proBNP in 1297 patients suspected of non-acute HF
On behalve of all Task Force members
Thank you for your attention