2016 ESC Guidelines for the

Diagnosis and treatment of

on Acute & Chronic
Heart Failure

Acute heart failure:

Management of the early phase

John Parissis, MD
Heart Failure Unit
Attikon University Hospital
Athens, Greece
2
Disclosures

• Research grants and honoraria for lectures from Pfizer,

Servier, Novartis International, Orion Pharma

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 Goals of treatment in acute
heart failure

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 Goals of treatment in acute
heart failure

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Criteria for hospitalization in ICU/CCU

• High risk patients (persistent significant dyspnea, hemodynamic

instability, severe arrhythmias, AHF due to ACS)
• Need for intubation (or already intubated)
• Signs/symptoms of hypoperfusion
• SpO2 <90% despite supplemental oxygen
• Use of accessory muscles for breathing, RR >25/min
• Heart rate <40 or >130 bpm, SBP <90 mmHg

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 Initial
management
of a patient
with acute HF

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 Oxygen therapy and ventilatory support

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Pharmacologic treatment of AHF

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 Pathophysiology of congestion in AHF

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Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015
 Pathophysiology of congestion in AHF

www.escardio.org/guidelines Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015

 Diuretics in AHF
DOSE Trial

• 308 pts with AHF

• Bolus every 12h vs continuous infusion
• Low dose (=oral) vs high dose (2.5 x oral)

No significant differences:
• in symptoms at 72h
• in creatinine change at 72h
• in death, rehospitalization or RF visits at 60 d

Felker et al, N Engl J Med 2011

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Pharmacotherapy
Diuretics

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 Pathophysiology of congestion in AHF

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Farmakis, Parissis, Filippatos. ESC IACC Textbook 2015
Pharmacotherapy
Vasodilators

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Pharmacotherapy
Vasodilators

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Pharmacotherapy
Inotropes and vasopressors

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Inotropes and outcome in AHF

O’Connor CM, et al. Am Heart J 1999 Cuffe MS, et al. JAMA 2002

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 Inotropes and outcome in AHF

ALARM-HF

Mebazaa A, et al. Intens Care Med 2011

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Pharmacotherapy
Inotropes and vasopressors

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Pharmacotherapy
TE prophylaxis and other drugs

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Management of cardiogenic shock

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 Management of
patients with acute
heart failure based on
clinical profile during
an early phase

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Management of patients with AHF based on clinical profile during
early phase

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Clinical profiles of patients with AHF based on the presence/absence of
congestion and/or hypoperfusion

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What’s new

• New treatment algorithm based mainly on clinical evaluation rather

than SBP levels only
• Definition of criteria for ICU/CCU admission
• Specific guidance for diuretic use
• Change in cut-off levels of SBP for vasodilator use
• Change of recommendation class for inotropes
• Change of recommendation class for opiates

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What’s missing

• Prospective evaluation of the ‘time-to-treatment’ concept

• Role of inadequate phenotyping in treatments failure
• Better definition and treatment of diuretic resistance
• Role of new drugs
• Treatments improving mortality and morbidity

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