Re-elaborate the staging of heart failure, recommend a new quadruple!Updated GUIDELINES for HEART failure in the United States


On April 1, the American College of Cardiology (ACC), the American Heart Association (AHA), and the American Society of Heart Failure (HFSA) jointly released the 2022 guidelines for managing heart failure, which are updated in several ways.The new guidelines classify heart failure into four categories, based on left ventricular ejection fraction (LVEF) :(1) heart failure with reduced ejection fraction (HFrEF, LVEF≤40%) (2) heart failure with slightly reduced ejection fraction (HFmrEF, LVEF 41% to 49%) (3) heart failure with preserved ejection fraction (HFpEF),LVEF≥50% with increased left ventricular filling pressure (4) Increased heart failure with improved ejection fraction (HFimpEF), defined as a previous diagnosis of HFrEF and current LVEF>40%.That is, LVEF≤40% before was increased to > 40% later, suggesting that HFmrEF comes from the progression of HFpEF, while HFimpEF is effective for HFrEF patients.Stage A was proposed as at-risk for HF, and stage B was proposed as pre-HF.Emphasize the importance of primary prevention of heart failure for both periods.Stage C and D are called symptomatic and advanced heart failure, respectively.Such naming is clear and reasonable, which is also conducive to the understanding of various stages of heart failure.Staging of heart failure 3. Primary prevention: lifestyle interventions, screening, and medication are recommended to maintain healthy lifestyle habits, such as regular physical activity, maintaining a normal weight, and eating a healthy diet;Patients with hypertension should manage their blood pressure according to existing clinical practice guidelines;Guidelines suggest that 2-3 g/d sodium intake may improve cardiac function and leg edema.Sodium intake here is not “sodium chloride”. In addition to salt, it also includes meat, pasta, vegetables and fruits.Sodium-glucose cotransporter 2 inhibitor (SGLT2i) is recommended for type 2 diabetes in patients with cardiovascular disease or at high cardiovascular risk.Screening for biomarkers such as natriuretic peptide, followed by standardized management, can help prevent heart failure.ACEI, ARB, evidence-based beta blockers, statins, and implantable cardioverter defibrillators are recommended for patients with LVEF≤40% and preheart failure.4. “Golden Triangle” +SGLT2i= “New quadruple” According to the 2022 guide, for HFrEF, it is recommended to change the new SGLT2i into “new quadruple” on the basis of “Golden Triangle”.Engliazin and dagliazin are first-line drugs.The other three drugs in the new quadruple are RAS inhibitors (ARNI/ACEI/ARB), β blockers and aldosterone receptor antagonists (MRA).The new guidelines abandon the “FIRST ACEI/ARB and beta blocker, then MRA” step and emphasize the “new quadruple” as soon as possible.The guideline proposes ARNI as the agent of choice for RAS inhibitors, giving A Class 1 recommendation, grade A evidence, representing ARNI as A first-line agent.The order of selection is ARNI first, then ACEI, and finally ARB.For MRA, the 2013 AHA guidelines limit of LVEF < 35% was removed.HFrEF with eGFR > 30 mL /min/1.73 m2 and serum potassium < 5 mmol/L can be routinely used.Loop diuretic should be the main diuretic.The combination of thiazide diuretics increases sodium excretion but is associated with electrolyte disturbances and mortality.HFmrEF: SGLT2i is the first choice. For HFmrEF, SGLT2i is newly recommended in the guidelines and is class 2A, while ARNI, ACEI, ARB, MRA and β blockers are recommended at a lower level of class 2B.HFpEF: Three new types of drugs are recommended in the guidelines for HFpEF, of which SGLT2i is class 2A and MRA and ARNi are class 2B.The new guidelines also update several previous recommendations, including that patients with hypertension should have their blood pressure under control, that managing atrial fibrillation improves symptoms, that arBs should be considered, and that routine use of nitrates or phosphodiesterase 5 inhibitors should be avoided.In addition to the four categories mentioned above, HFpEF patients can also use diuretics when needed (Category 1 recommended).HFimpEF: Continue HFrEF treatment as recommended by the new guidelines, HFimpEF patients should continue to receive HFrEF treatment.Statement of value of high quality evidence-based interventions the new guidelines suggest interventions with effective price ratios based on published high quality cost-effective studies, including :(1) ACEI or ARB when ARNI is not available for past or current symptomatic patients with chronic HFrEF;(2) For symptomatic chronic HFrEF patients, use ARNI instead of ACEI;(3) Patients with current or previous symptoms of HFrEF should be treated with β blockers;(4) PATIENTS with NYHA heart function grade ⅱ ~ ⅳ and symptomatic HFrEF were treated with MRA;(5) African-American patients with NYHA cardiac function grade ⅲ to ⅳ were treated with phenylhydrazine and isosorbide nitrate in addition to ACEI or ARB, β blockers and MRA;(6) Implantation of implantable cardioverter defibrillators in primary prevention of sudden cardiac death, especially when the risk of death from ventricular arrhythmia is considered high but not low according to the burden of complications and functional status of the patient;(7) Patients with LVEF≤35%, sinus rhythm, left fascicular branch block with QRS ≥150 ms, and drug therapy guided by guidelines but NYHA cardiac function grade ⅱ ~ ⅲ or mild activity grade ⅳ received cardiac resynchronization therapy.Intervention recommendations of moderate economic value include :(1) SGLT2i for symptomatic patients with chronic HFrEF;(2) Patients with stage D (advanced) heart failure receiving a heart transplant under the guidance of drug therapy.Diagnosis of heart failure when LVEF>40% : Evidence of increased filling pressure The new guidelines emphasize the importance of supporting evidence of increased filling pressure when LVEF>40% for the diagnosis of heart failure.When the LVEF is 41% to 49% (slightly reduced ejection fraction) or ≥50% (preserved ejection fraction), evidence of spontaneous or induced increased left ventricular filling pressure is required to confirm heart failure.Filling pressure can be assessed either by noninvasive (e.g., natriuretic peptide, radiographic assessment of diastolic function) or invasive (e.g., hemodynamic) tests.Advanced heart failure: Referral to a professional heart failure team Patients with advanced heart failure who wish to prolong their survival should be referred to a professional heart failure team.Evaluate the suitability of treatments for end-stage hf (left ventricular assist devices, heart transplantation, etc.) and use palliative care consistent with the patient’s treatment goals, including palliative use of positive inotropic agents.Other new guidelines update treatment recommendations for cardiac amyloidosis, as well as recommendations for the management of heart failure patients with iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary heart disease, and malignant tumors.Source:2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, Apr 01, 2022. Chinese circulation miscellaneous many complicated cases, a doctor can only see once in his life please contact: 18656052587(wechat) or zgxhzz@vip.163.com

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