Emerging Topics Update of the Brazilian Heart Failure Guideline – 2021

Fabiana G. Marcondes-Braga Lídia Ana Zytynski Moura Victor Sarli Issa Jefferson Luis Vieira Luis Eduardo Rohde Marcus Vinícius Simões Miguel Morita Fernandes-Silva Salvador Rassi Silvia Marinho Martins Alves Denilson Campos de Albuquerque Dirceu Rodrigues de Almeida Edimar Alcides Bocchi Felix José Alvarez Ramires Fernando Bacal João Manoel Rossi Neto Luiz Claudio Danzmann Marcelo Westerlund Montera Mucio Tavares de Oliveira Junior Nadine Clausell Odilson Marcos Silvestre Reinaldo Bulgarelli Bestetti Sabrina Bernadez-Pereira Aguinaldo F. Freitas Jr Andréia Biolo Antonio Carlos Pereira Barretto Antônio José Lagoeiro Jorge Bruno Biselli Carlos Eduardo Lucena Montenegro Edval Gomes dos Santos Júnior Estêvão Lanna Figueiredo Fábio Fernandes Fabio Serra Silveira Fernando Antibas Atik Flávio de Souza Brito Germano Emílio Conceição Souza Gustavo Calado de Aguiar Ribeiro Humberto Villacorta João David de Souza Neto Livia Adams Goldraich Luís Beck-da-Silva Manoel Fernandes Canesin Marcelo Imbroinise Bittencourt Marcely Gimenes Bonatto Maria da Consolação Vieira Moreira Mônica Samuel Avila Otavio Rizzi Coelho Filho Pedro Vellosa Schwartzmann Ricardo Mourilhe-Rocha Sandrigo Mangini Silvia Moreira Ayub Ferreira José Albuquerque de Figueiredo Neto Evandro Tinoco Mesquita About the authors

Introduction

The latest Heart Failure Guidelines by the Department of Heart Failure of the Brazilian Society of Cardiology (DEIC/SBC) were finalized on March 2018. Since then, a significant number of therapeutic interventions and diagnostic approaches has arisen or consolidated their position in international clinical practice and in clinical research. In addition, the COVID-19 pandemic has taught us much about the pathophysiological model of myocardial damage and raised many questions about the continuity and safety of medication use in patients with chronic HF suffering from an acute manifestation of this new and complex clinical entity.

In the last few months, we have been working quickly and collaboratively, and for the first time in 20 years, DEIC used digital platforms to discuss, deliberate, and draft this important document, opting for a focused update instead of a full-text guideline.

We were inspired by the 2020 Canadian Heart Failure Guidelines,11. O’Meara E, McDonald M, Chan M, Ducharme A, Ezekowitz JA, Giannetti N, et al. CCS/CHFS Heart Failure Guidelines: Clinical Trial Update on Functional Mitral Regurgitation, SGLT2 Inhibitors, ARNI in HFpEF, and Tafamidis in Amyloidosis. Can J Cardiol. 2020;36(2):159-69. but had the benefit of observing the impact on clinical practice and the consolidation of this new knowledge, in addition to new results from clinical trials published over the last 12 months. In order to report on these developments, we hosted a pioneering scientific conference on September 19, 2020, the I Heart Failure Summit Brazil 2020 (digital), with approximately 900 participants, many of them DEIC associates.

The leadership of the Science Board was key in organizing the various working groups and developing a secure and practical method for discussions and votes. With social distancing and the use of digital technology, the conference enabled wide-ranging debates from various perspectives, based on the best available scientific evidence.

In this document, DEIC/SBC provides reviews and detailed updates to its Chronic Heart Failure Guidelines. The work started in July 2020, with the choice of the Editorial Board, which established priorities, divided the 52 participants into working groups, and developed a schedule of activities. These working groups, each consisting of five to seven participants, began intense online discussions that led to the elaboration of preliminary tables, widely circulated before their subsequent review by the 11-member Review Board. The final discussions took place during a virtual plenary session on December 4, 2020, with all collaborators, who had the opportunity to vote on the main recommendations. Decisions regarding classes of recommendation required a three-quarters supermajority vote.

Class of Recommendation and Level of Evidence follow the same definitions used in the last guideline, as established by SBC/CONDir. See below.

The therapeutic recommendations proposed in this document are based on the latest available scientific evidence, considering not only the aspects of clinical efficacy from large clinical trials. We have sought to summarize the primary recommendations in flowcharts and algorithms that are easy to understand and to apply in clinical practice, proposing approaches for the diagnosis and treatment of heart failure.

Our commitment to the scientific community, linked to research and assistance to heart failure patients, public and private managers, and policy-makers, will certainly have the benefit of a document that sought to present scientific interventions in an accessible format, facilitating its implementation in the various spheres where heart failure patients receive care.

Dr. Evandro Tinoco Mesquita

1. Innovations in Heart Failure with Preserved (HFpEF), Mildly Reduced (HFmrEF) and Improved (HFimpEF) Ejection Fraction

1.1. Diagnosis of Heart Failure with Preserved Ejection Fraction (HFpEF)

In patients with unexplained fatigue or dyspnea, assessing the pretest probability of heart failure (HF) should be based on clinical, electrocardiography, echocardiography, and laboratory data. Next, two scoring systems have been developed to check that diagnosis; both the H2FPEF (Table 1.1) and the HFA-PEFF (Table 1.2) scores may be used. In these models, high- and low-probability patients can be classified as having or not heart failure with preserved ejection fraction (HFpEF), respectively. In patients with intermediary probability for HFpEF, assessing diastolic function during stress, which can be based on a diastolic stress echocardiogram or invasive hemodynamic monitoring, can help the diagnosis. In patients with low probability of HFpEF, investigating other causes of dyspnea and fatigue is recommended22. Borlaug BA. Evaluation and management of heart failure with preserved ejection fraction. Nat Rev Cardiol. 2020;17(9):559-73. (Figure 1.1 and Table 1.3).

Figure 1.1
Diagnostic flowchart for heart failure with preserved ejection fraction (HFpEF)
Tabela 1.1
H2FPEF score for HFpEF diagnosis
Table 1.2
HFA PEFF score HFpEF diagnosis
Table 1.3
HFpEF diagnosis recommendations

1.2. Treatment for Heart Failure with Preserved Ejection Fraction (HFpEF)

To date, there is no specific intervention to reduce cardiovascular events in patients with HFpEF. Clinical trials assessing the use of angiotensin-converting enzyme II inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), angiotensin II receptor-neprilysin inhibitors (ARNIs), and spironolactone were neutral in terms of risk reduction compared to placebo for patients with HFpEF.1111. Lund LH, Claggett B, Liu J, Lam CS, Jhund PS, Rosano GM, et al. Heart failure with mid-range ejection fraction in CHARM: characteristics, outcomes and effect of candesartan across the entire ejection fraction spectrum. Eur J Heart Fail. 2018;20(8):1230-9.1414. Solomon SD, Vaduganathan M, L Claggett B, Packer M, Zile M, Swedberg K, et al. Sacubitril/Valsartan Across the Spectrum of Ejection Fraction in Heart Failure. Circulation. 2020;141(5):352-61. Post-hoc analysis according to LV ejection fraction (LVEF) has consistently shown lack of benefit among subgroups with higher LVEF (above 50%). A meta-analysis of randomized controlled trials of beta-blockers provides similar findings.1313. Cleland JGF, Bunting KV, Flather MD, Altman DG, Holmes J, Coats AJS, et al. Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials. Eur Heart J. 2018;39(1):26-35. Therefore, the 2018 guideline recommendations for pharmacological treatment of HFpEF stand, including the use of diuretics for congestion and the treatment of comorbidities such as myocardial ischemia, atrial fibrillation, and hypertension, to reduce symptoms and potentially reduce the progression of HFpEF.1515. Diretriz Brasileira da Insuficiência Cardíaca Crônica e Aguda. Arq Bras Cardiol. 2018;Arquivos Brasileiros de Cardiologia. 2018;111(3):436-539. Hence, it is essential to investigate potentially reversible conditions associated with ‘secondary’ HFpEF, such as infiltrative and restrictive cardiomyopathies, in addition to considering alternative causes of exercise intolerance.

1.3. Treatment for Heart Failure with mildly reduced Ejection Fraction (HFmrEF) (Table 1.4)

Table 1.4
HFmrEF treatment recommendations

1.4 Treatment for Heart Failure with Improved Ejection Fraction (HFimpEF) (Table 1.5)

Table 1.5
HFimpEF treatment recommendations

2. Innovations in Cardiac Amyloidosis

We have recently seen great advances in cardiac amyloidosis, with a profound transformation of its clinical and epidemiological significance and the development of specific treatments. Evidence suggests that cardiac amyloidosis is not a rare disease, but rather a largely underdiagnosed condition, now considered a relatively common and treatable cause of HFpEF, particularly transthyretin amyloidosis (ATTR) in its wild type (ATTR-wt), of which diagnosis has increased expressively.1919. Lane T, Fontana M, Martinez-Naharro A, Quarta CC, Whelan CJ, Petrie A, et al. Natural History, Quality of Life, and Outcome in Cardiac Transthyretin Amyloidosis. Circulation. 2019;140(1):16-26.2222. Tanskanen M, Peuralinna T, Polvikoski T, Notkola IL, Sulkava R, Hardy J, et al. Senile systemic amyloidosis affects 25% of the very aged and associates with genetic variation in alpha2-macroglobulin and tau: a population-based autopsy study. Ann Med. 2008;40(3):232-9.

It is a multisystemic disease caused by the tissue deposition of insoluble fibrillary proteins that lose their conformation, leading to organ dysfunction, including the heart. Over 30 types of amyloidogenic proteins have been described,2323. Benson MD, Buxbaum JN, Eisenberg DS, Merlini G, Saraiva MJM, Sekijima Y, et al. Amyloid nomenclature 2018: recommendations by the International Society of Amyloidosis (ISA) nomenclature committee. Amyloid. 2018;25(4):215-9. with two of them responsible for 95% of all cases of cardiac involvement: light-chain amyloidosis (AL), related to monoclonal production of immunoglobulins due to plasma cell dyscrasias; and transthyretin amyloidosis (ATTR), caused by misfolded transthyretin, a plasma protein that transports thyroxine and retinol and is secreted mainly by the liver. ATTR can be secondary to an abnormal (mutant or variant) protein (ATTRm) or to the wild-type form (ATTRwt), caused by post-transcriptional modification or by chaperone-related mechanisms, both associated with aging.

AL incidence ranges from 6 to 10 million people/year and, until recently, was considered the primary cause of cardiac amyloidosis.2424. Kyle RA, Linos A, Beard CM, Linke RP, Gertz MA, O’Fallon WM, et al. Incidence and natural history of primary systemic amyloidosis in Olmsted County, Minnesota, 1950 through 1989. Blood. 1992;79(7):1817-22. However, with the development of noninvasive diagnosis techniques and effective treatment, the diagnosis of ATTR, especially of ATTRwt, has increased significantly.1919. Lane T, Fontana M, Martinez-Naharro A, Quarta CC, Whelan CJ, Petrie A, et al. Natural History, Quality of Life, and Outcome in Cardiac Transthyretin Amyloidosis. Circulation. 2019;140(1):16-26. Studies demonstrate ATTR in up to 13% of patients with HFpEF and left ventricular wall thickening greater than 12 mm,2020. González-López E, Gallego-Delgado M, Guzzo-Merello G, de Haro-Del Moral FJ, Cobo-Marcos M, Robles C, et al. Wild-type transthyretin amyloidosis as a cause of heart failure with preserved ejection fraction. Eur Heart J. 2015;36(38):2585-94. with up to 25% of necropsies of very elderly people showing TTR in the heart.2222. Tanskanen M, Peuralinna T, Polvikoski T, Notkola IL, Sulkava R, Hardy J, et al. Senile systemic amyloidosis affects 25% of the very aged and associates with genetic variation in alpha2-macroglobulin and tau: a population-based autopsy study. Ann Med. 2008;40(3):232-9. ATTRm is an autosomal dominant condition, with more than 130 mutations described and several phenotypes of neurological and cardiac impairment.

2.1. When to Suspect Amyloidosis

Considering that ATTR, particularly ATTRwt, is more prevalent than previously expected, it is important to suspect it in the presence of clinical clues for further diagnostic investigation (Table 2.1). ATTR commonly manifests as infiltrative restrictive cardiomyopathy, with ventricular wall thickening, diastolic dysfunction, and conduction disorders. In certain clinical contexts, a differential diagnosis with hypertrophic cardiomyopathy, HFpEF2525. Mesquita ET, Jorge AJL, Souza CV, Andrade TR. Cardiac Amyloidosis and its New Clinical Phenotype: Heart Failure with Preserved Ejection Fraction. Arq Bras Cardiol. 2017;109(1):71-80., advanced atrioventricular blocks and atrial arrhythmias with no apparent cause are necessary. The simultaneous finding of ATTRwt and calcific aortic stenosis may cause severe ventricular hypertrophy and can present as low-flow, low-gradient aortic stenosis. In addition, some multisystemic manifestations may raise suspicion of ATTR: bilateral carpal tunnel syndrome, biceps tendon rupture, orthostatic hypotension, spinal canal stenosis, digestive problems, and intolerance to antihypertensive medications.2626. Maurer MS, Elliott P, Comenzo R, Semigran M, Rapezzi C. Addressing Common Questions Encountered in the Diagnosis and Management of Cardiac Amyloidosis. Circulation. 2017;135(14):1357-77. Family history is very important in the hereditary forms of amyloidosis, carrying a worse prognosis than the wild-type form.

Table 2.1
Clinical clues for amyloidosis diagnosis

2.2. Cardiac Amyloidosis Diagnosis (Table 2.1)

When suspected, the first step in investigating cardiac amyloidosis is the search for the presence of immunoglobulin light chains for the diagnosis of AL, which requires specific treatment with chemotherapeutic agents and has a worse prognosis with delayed treatment initiation. Confirmation of AL depends on the detection of amyloid protein in the tissues involved (biopsy), but the ATTR form can be confirmed noninvasively, using cardiac scintigraphy with bone-avid radiotracers. In Brazil, Tc-99m pyrophosphate is used in the examination.

2.3. Diagnostic Methods

2.3.1. Electrocardiogram

A low-amplitude QRS complex is a frequent finding in AL, but less prevalent in ATTR (around 30% of cases), that more commonly presents discrepancy between the magnitude of the hypertrophy on the echocardiogram and the amplitude of QRS complexes is more frequent. Atrial fibrillation and a “pseudo-infarction” pattern may also be found.

2.3.2. Echocardiogram

Echocardiogram is the most important exam to raise the suspicion of CA. Suggestive findings include left ventricular wall thickening greater than 12 mm, especially in the absence of hypertension, bi-atrial enlargement disproportionate to ventricle size, atrioventricular valve and interatrial septum thickening, and increased myocardial echogenicity with a granular aspect. Myocardial longitudinal systolic strain rates may show the preservation of left ventricular apical contractility as compared to the remaining segments (apical sparing or “cherry on top” pattern) as compared to the reduced contractility in the remaining segments.2727. Dorbala S, Cuddy S, Falk RH. How to Image Cardiac Amyloidosis: A Practical Approach. JACC Cardiovasc Imaging. 2020;13(6):1368-83.

2.3.3. Cardiac Scintigraphy with Bone-Avid Radiotracers

Cardiac scintigraphy with bone-avid radiotracers, such as Tc-99m pyrophosphate as used in Brazil, can be used for the differential diagnosis between amyloidosis AL and ATTR, with the latter showing anomalous myocardial uptake, higher than or equivalent to bone uptake. However, cardiac uptake may occur, albeit with milder intensity, in up to 30% of AL cases. The combination of intense cardiac uptake (grades 2 or 3) and the absence of light chains in biochemical exams presents 100% specificity for ATTR, and can obviate a cardiac biopsy for the diagnosis of the disease.1919. Lane T, Fontana M, Martinez-Naharro A, Quarta CC, Whelan CJ, Petrie A, et al. Natural History, Quality of Life, and Outcome in Cardiac Transthyretin Amyloidosis. Circulation. 2019;140(1):16-26.

2.3.4. Cardiac Magnetic Resonance Imaging

Cardiac magnetic resonance imaging has high sensitivity and specificity for the diagnosis and discrimination between cardiac amyloidosis and other cardiomyopathies. Amyloid deposits in the myocardium cause an increase in the distribution volume of paramagnetic contrast agent in myocardial regions where cardiomyocytes are replaced or displaced by inflammation or fibrosis, originating a diffuse subendocardial and circumferential late enhancement pattern of the left ventricle; a diffuse transmural pattern can also be found.2727. Dorbala S, Cuddy S, Falk RH. How to Image Cardiac Amyloidosis: A Practical Approach. JACC Cardiovasc Imaging. 2020;13(6):1368-83.

2.4. Treatment of Cardiac Transthyretin Amyloidosis (ATTR-CA) (Table 2.2)

Table 2.2
Recommendations for specific treatment for cardiac transthyretin amyloidosis (ATTR-CA)

Given its clinical and epidemiological importance, in addition to new emerging therapies for the condition, a Position Paper on Diagnosis and Treatment of Cardiac Amyloidosis will be published shortly, and should review the different aspects of the disease more broadly.

3. Innovations in Telemonitoring for Heart Failure (Table 3.1)

Table 3.1
Recommendations for telemonitoring, wearables, artificial intelligence, and machine learning in heart failure

4. Innovations in Cardiac Interventions

4.1. Percutaneous Intervention in Secondary Mitral Insufficiency (Table 4.1)

Table 4.1
Recommendations for percutaneous interventions in severe secondary mitral insufficiency

4.2. Atrial Fibrillation Ablation (Table 4.2)

Table 4.2
Recommendations for atrial fibrillation ablation in HFrEF

5. COVID-19 and Heart Failure (Table 5.1)

Table 5.1
Recommendations for COVID-19 management in heart failure patients

6. Innovations in Advanced Heart Failure

6.1. Definition of Advanced Heart Failure

The natural history of HF is characterized by a progressive deterioration of cardiac function and HF symptoms. Despite advances in pharmacological treatment and the prognostic impact of implantable devices such as cardiac resynchronization therapy, HF patients may progress to a clinical condition known as advanced HF, where traditional treatment is not effective and advanced therapies are required, such as heart transplantation, mechanical circulatory support device (MCSD) or palliative care are required.

Although the expression advanced HF has been used since 2007, recent updates were described to include clinical situation that may also require advanced therapies such as HFpEF patients with severe restrictive condition, rather than limiting it to patients with HF with severely reduced ejection fraction.11. O’Meara E, McDonald M, Chan M, Ducharme A, Ezekowitz JA, Giannetti N, et al. CCS/CHFS Heart Failure Guidelines: Clinical Trial Update on Functional Mitral Regurgitation, SGLT2 Inhibitors, ARNI in HFpEF, and Tafamidis in Amyloidosis. Can J Cardiol. 2020;36(2):159-69.33. Maisel AS, McCord J, Nowak RM, Hollander JE, Wu AH, Duc P, et al. Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol. 2003;41(11):2010-7.,44. Lam CS, Rienstra M, Tay WT, Liu LC, Hummel YM, van der Meer P, et al. Atrial Fibrillation in Heart Failure With Preserved Ejection Fraction: Association With Exercise Capacity, Left Ventricular Filling Pressures, Natriuretic Peptides, and Left Atrial Volume. JACC Heart Fail. 2017;5(2):92-8. In this scenario, isolated severe right ventricular dysfunction and severe inoperable valvular disease as well as congenital abnormalities may also be considered causes of severe cardiac dysfunction (Table 6.1).5353. Givertz MM, Stevenson LW, Costanzo MR, Bourge RC, Bauman JG, Ginn G, et al. Pulmonary Artery Pressure-Guided Management of Patients With Heart Failure and Reduced Ejection Fraction. J Am Coll Cardiol. 2017;70(15):1875-86.6868. Truby LK, Rogers JG,. Advanced heart failure:epidemiology, diagnosis and therapeutic approaches. JACC Heart Fail. 2020;8(7):523-36.

Table 6.1
Criteria for the definition of advanced heart failure

Different societies of cardiology adopt different criteria for the condition, but all of them include the presence of persistent severe symptoms, exercise intolerance, and recurrent episodes of systemic or pulmonary congestion requiring hospitalization, as described in Table 6.2.

Table 6.2
Criteria proposed by various cardiology societies to identify advanced HF patients

Early recognition is decisive for the prognosis of patients with advanced HF, since it allows timely referral to a specialized center able to provide the necessary advanced therapies to manage such cases.

A particularly useful mnemonic that may help identify patients requiring referral to a HF specialist is I-NEED-HELP, which combines clinical history, hospitalizations and intolerance to medications, as well as symptoms and end-organ dysfunction. (Table 6.3)

Table 6.3
Warning signs in advanced HF patients

6.2. The Role of the Specialist in Advanced Heart Failure

As the specific profile of patients fitting the current definition of advanced HF becomes increasingly clear, there is also a need to define the importance of the specialist in advanced HF in specialized centers. These professionals must be familiar (and trained) in the care of potential heart transplant candidates and their subsequent follow-up, as well as in patients with CS. They should coordinate the work of the shock team and therefore must be familiar with the diverse and growing options for circulatory support. Finally, the advanced HF specialist should be able to understand the timing and implications of discussing palliative care and advanced directives for patients who are not eligible for heart transplantation, as well as the use of long-term devices.

6.3. Approach to the Advanced Heart Failure Patient (Figure 6.1)

Figure 6.1
Treatment algorithm for patients with advanced heart failure

6.4. Innovations in Managing Congestion in Patients with Advanced Heart Failure (Table 6.4)

Table 6.4
Ambulatory monitoring of congestion in heart failure

6.5. Current Classification of Cardiogenic Shock

In 2019, the Society for Cardiovascular Angiography and Interventions (SCAI) proposed a new classification for cardiogenic shock (CS) in order to make it easier to identify the various stages of clinical deterioration as well as the need for more intensive treatment.5858. Baran DA, Grines CL, Bailey S, Burkhoff D, Hall SA, Henry TD, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv. 2019;94(1):29-37.,5959. Jentzer JC, van Diepen S, Barsness GW, Henry TD, Menon V, Rihal CS, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. J Am Coll Cardiol. 2019;74(17):2117-28. The 5-stage classification incorporates signs of tissue hypoperfusion and organic dysfunction, offering a simple hemodynamic definition and granularity to the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) classification (Figure 6.2, Table 6.5).

Figure 6.2
Society for Cardiovascular Angiography and Interventions (SCAI) classification of cardiogenic shock.
Table 6.5
Descriptors of shock stages: physical exam, biochemical markers, and hemodynamics

Stage A includes patients at risk of cardiogenic shock, while stages B through E describe progressive stages of conventional cardiogenic shock. The difference between stages B and C is the presence of hypoperfusion, present in stages C and above. Stage D indicates initial cardiogenic shock management measures were not enough to restore hemodynamic stability or tissue perfusion within at least 30 minutes of observation, while stage E characterizes extreme cases, where patients present as hemodynamically unstable and frequently in circulatory collapse. Patients in SCAI stages D and E have higher mortality rates and may benefit from early referral to specialized centers, where more advanced modes of circulatory support may be available.5959. Jentzer JC, van Diepen S, Barsness GW, Henry TD, Menon V, Rihal CS, et al. Cardiogenic Shock Classification to Predict Mortality in the Cardiac Intensive Care Unit. J Am Coll Cardiol. 2019;74(17):2117-28.

6.6. Applicability of Pulmonary Artery Catheters in Advanced Heart Failure (Table 6.6)

Table 6.6
Recommendations for pulmonary artery catheter use in patients with advanced HF

6.7. Innovations in Short-Term Circulatory Support Devices in Advanced Heart Failure (Table 6.7)

Table 6.7
Recommendation for left ventricular venting in patients receiving extracorporeal membrane oxygenation (ECMO)

6.8. Innovations in Palliative Care for Advanced Heart Failure (Table 6.8)

Table 6.8
Outpatient use of intravenous inotropes in patients with advanced HF who are not eligible for heart transplantation or mechanical circulatory support devices

7. Treatment of Heart Failure with Reduced Ejection Fraction (HFrEF)

7.1. Previously Consolidated Pharmacological Strategies for Treatment of Heart Failure with Reduced Ejection Fraction (HFrEF) (Table 7.1)

Table 7.1
Recommendations for pharmacological treatment of HFrEF previously consolidated in 2018

7.2. Sacubitril-Valsartan (Table 7.2)

Table 7.2
Recommendations for the use of sacubitril-valsartan in HFrEF patients

7.3. Sodium-glucose Cotransport 2 (SGLT2) Inhibitors (Table 7.3)

Table 7.3
Recommendations for use of SGLT2 inhibitors in the treatment of HFrEF patients

7.4. Treatment of Comorbidities in Heart Failure with Reduced Ejection Fraction

7.4.1. Type 2 Diabetes (Table 7.4)

Table 7.4
Recommendations for use of SGLT2 inhibitors in preventing hospitalizations for HF in type 2 diabetes patients

7.4.2. Renal Dysfunction (Table 7.5)

Table 7.5
Recommendations for use of SGLT2 inhibitors in preventing worsening of renal function in HFrEF patients

7.4.3. Iron Deficiency (Table 7.6)

Table 7.6
Recommendations for use of intravenous iron in HFrEF patients

7.5. Treatment Algorithm for Heart Failure with Reduced Ejection Fraction (Table 7.5)

Figure 7.5
Treatment algorithm for heart failure with reduced ejection fraction

8. Innovations in Other Areas Related to Heart Failure

8.1. Biomarkers in Heart Failure with Reduced Ejection Fraction (Table 8.1)

Table 8.1
Recommendations for the use of biomarkers in HFrEF patients

8.2. Immunizations in Heart Failure (Table 8.2)

Table 8.2
Recommendations for immunizations for HFrEF patients

8.3. Indications for Genetic Assessment in Cardiomyopathies and Heart Failure (Table 8.3)

Table 8.3
Recommendations for genetic assessments for patients with cardiomyopathies and HF

9. Perspectives in Heart Failure – New Molecules

9.1. Guanylate Cyclase Stimulators (Table 9.1)

Table 9.1
Guanylate cyclase stimulators for the treatment of HFrEF patients

9.2. Selective Cardiac Myosin Activator (Table 9.2)

Table 9.2
Omecamtiv mercabil in the treatment of HFrEF patients

  • Development: Department of Heart Failure (Departamento de Insuficiência Cardíaca – DEIC) of the Brazilian Society of Cardiology (Sociedade Brazileira de Cardiologia – SBC)
  • Norms and Guidelines Council (2020-2021): Antonio Carlos Sobral Sousa, Aurora Felice Castro Issa, Bruno Ramos Nascimento, Harry Corrêa Filho, Marcelo Luiz Campos Vieira
  • Norms and Guidelines Coordinator (2020-2021): Brivaldo Markman Filho
  • Guideline Editorial Board: Fabiana Marcondes-Braga, Lídia Ana Zytynski Moura, Victor Sarli Issa, José Albuquerque Figueiredo Neto, Evandro Tinoco Mesquita
  • Guideline Review Board: Fabiana Marcondes-Braga, Lídia Ana Zytynski Moura, Victor Sarli Issa, Jefferson Luis Vieira, Luis Eduardo Rohde, Marcus Vinícius Simões, Miguel Morita Fernandes-Silva, Salvador Rassi, Silvia Marinho Martins Alves, José Albuquerque de Figueiredo Neto, Evandro Tinoco Mesquita
  • Discussion Group Coordinators: Denilson Campos de Albuquerque, Dirceu Rodrigues de Almeida, Edimar Alcides Bocchi, Felix José Alvarez Ramires, Fernando Bacal, João Manoel Rossi Neto, Luiz Claudio Danzmann, Luis Eduardo Rohde, Marcelo Westerlund Montera, Marcus Vinicius Simões, Miguel Morita Fernandes-Silva, Mucio Tavares de Oliveira Junior, Nadine Clausell, Odilson Marcos Silvestre, Reinaldo Bulgarelli Bestetti, Sabrina Bernadez-Pereira, Salvador Rassi, Silvia Marinho Martins
  • Other Collaborators: Aguinaldo F. Freitas Jr, Andréia Biolo, Antonio Carlos Pereira Barretto, Antônio José Lagoeiro Jorge, Bruno Biselli, Carlos Eduardo Lucena Montenegro, Edval Gomes dos Santos Júnior, Estêvão Lanna Figueiredo, Fábio Fernandes, Fabio Serra Silveira, Fernando Antibas Atik, Flávio de Souza Brito, Germano Emílio Conceição Souza, Gustavo Calado de Aguiar Ribeiro, Humberto Villacorta, João David de Souza Neto, Livia Adams Goldraich, Luís Beck-da-Silva Neto, Manoel Fernandes Canesin, Marcelo Bittencourt, Marcely Bonatto, Maria da Consolação Vieira Moreira, Mônica Samuel Avila, Otavio Rizzi Coelho Filho, Pedro Vellosa Schwartzmann, Ricardo Mourilhe-Rocha, Sandrigo Mangini, Silvia Moreira Ayub Ferreira
  • Note: These updates are for information purposes and should not replace the clinical judgment of a physician, who must ultimately determine the appropriate treatment for each patient.

References

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    O’Meara E, McDonald M, Chan M, Ducharme A, Ezekowitz JA, Giannetti N, et al. CCS/CHFS Heart Failure Guidelines: Clinical Trial Update on Functional Mitral Regurgitation, SGLT2 Inhibitors, ARNI in HFpEF, and Tafamidis in Amyloidosis. Can J Cardiol. 2020;36(2):159-69.
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    Maisel AS, McCord J, Nowak RM, Hollander JE, Wu AH, Duc P, et al. Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol. 2003;41(11):2010-7.
  • 4
    Lam CS, Rienstra M, Tay WT, Liu LC, Hummel YM, van der Meer P, et al. Atrial Fibrillation in Heart Failure With Preserved Ejection Fraction: Association With Exercise Capacity, Left Ventricular Filling Pressures, Natriuretic Peptides, and Left Atrial Volume. JACC Heart Fail. 2017;5(2):92-8.
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Publication Dates

  • Publication in this collection
    14 June 2021
  • Date of issue
    June 2021
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