European and US heart failure guidelines updated simultaneously

By Laura Cowen

The European Society of Cardiology (ESC), with special contribution from the Heart Failure Association, has published a complete revision of its "Guidelines for the diagnosis and treatment of acute and chronic heart failure".

At the same time, a joint committee of the American College of Cardiologists (ACC), the American Heart Association (AHA) and the Heart Failure Society of America (HFSA) have released their "2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure".

Task Force chairperson Piotr Ponikowski (Wroclaw Medical University, Poland) and co-authors of the ESC Guidelines explain that "both working groups independently arrived at similar conclusions and constructed similar but not identical, recommendations.

"Given the concordance, the respective organizations simultaneously issued aligned recommendations on the use of these new treatments to minimize confusion and improve the care of patients with HF."

The treatments Ponikowski et al refer to are the angiotensin receptor-neprilysin inhibitor (ARNI), LCZ696, which combines the moieties of the angiotensin receptor blocker valsartan and the neprilysin inhibitor sacubitril; and a new sinoatrial node modulator, ivabradine.

Based on the findings of the PARADIGM-HF study, which showed LCZ696 to be superior to enalapril in reducing the risk of death and hospitalisation in HF, the guidelines recommend the use of LCZ696 in ambulatory HF with reduced ejection fraction (HFrEF) patients who remain symptomatic despite optimal therapy.

However, Ponikowski cautioned in a press release that the drug should only be used in patients who fit the PARADIGM-HF criteria. "The Task Force agreed that more data is needed before it can be recommended in a broader group of patients."

Ivabradine is recommended, where appropriate, for patients with HFrEF as it reduces heart rate and has been shown to improve outcomes such as HF hospitalisation and death.

In addition to the drug-related recommendations, the 2016 ESC guidelines also include several other key changes from the 2012 version.

One is the addition of a new category of heart failure with mid-range ejection fraction (HFmrEF) for patients with a left ventricular ejection fraction (LVEF) ranging from 40% to 49%. Ponikowski said: "There are no evidence based treatments for patients with LVEF 40% or above. Many patients fall into the mid-range category and this should stimulate research into novel therapies."

Clear recommendations on the diagnostic criteria for this new category as well HFrEF, and HF with preserved EF (HFpEF) are also provided in the 2016 ESC Guidelines.

As is a new algorithm for the diagnosis of HF in the non-acute setting based on the evaluation of HF probability, recommendations aimed at prevention or delay of the development of overt HF or the prevention of death before the onset of symptoms and modified indications for cardiac resynchronisation therapy.

Ponikowski concluded: "Heart failure is becoming a preventable and treatable disease. Implementing the guidelines published today will give patients the best chance of a positive outcome."

The full European guidelines are published in both the European Heart Journal and the European Journal of Heart Failure, while the American guidelines can be found in both Circulation and the Journal of the American College of Cardiology.

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