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Hjertesvikt og nye europeiske
retningslinjer
Dagens medisin
7/9 -2016
Definisjon
(Nytt)
Algoritme for utredning (ny)
«Hjertesviktpakke»
21 dager
proBNP
>125pg/ml=15 pmol/l
BNP
>35 pg/ml=10 pmol/l
Forebygge utvikling av HF (nytt)
Progression of heart failure
ACC/AHA HF guidelines. Forekomst Olmstedt
Stage A
22% av folk >45 år
Progression of HF
At risk (HT,DM)
Stage B
Genetisk anlegg
No symp (LVH)
Miljø
Hormoner
34%
Stage C,
Symptoms
Immunsystem
ACC/AHA guidelines JACC 2001
Ammar Circulation 2007;115:1563:prevalense
12%
Stage D
Severe symptoms
0.2%
Behandling av HF (ny)
Medikamenter ved HFrEF
Klasse IA
Other pharmacological treatment in selected patients
Balance angiotensin-neprilisyn
Angiotensin II
PARADIGM-HF: Study design
Stabil HF
EF <40 (35%)
proBNP>71 pmol/L
eGFR>30
Randomization
n=8442
Double-blind
Treatment period
Single-blind active
run-in period
LCZ696 200 mg BID‡
Enalapril
10 mg BID*
LCZ696
100 mg BID†
LCZ696
200 mg BID‡
Enalapril 10 mg BID§
2 Weeks
1–2 Weeks
2–4 Weeks
Median of 27 months’ follow-up
On top of standard HFrEF therapy (excluding ACEIs and ARBs)
*Enalapril 5 mg BID (10 mg TDD) for 1–2 weeks followed by enalapril 10 mg BID (20 mg TDD) as an optional starting run-in dose for
those patients who are treated with ARBs or with a low dose of ACEI; †200 mg TDD; ‡400 mg TDD; §20 mg TDD.
McMurray et al. Eur J Heart Fail. 2013;15:1062–73; McMurray et al. Eur J Heart Fail. 2014;16:817–25;
McMurray, et al. N Engl J Med 2014; ePub ahead of print: DOI: 10.1056/NEJMoa1409077.
PARADIGM study
KM plots for Outcomes, According to Study Group
(primary outcome: CV death or first hosp for HF).
McMurray JJ et al. N Engl J Med 2014. DOI:
10.1056/NEJMoa1409077
2016 ACC/AHA/HFSA Focused Update on New
Pharmacological Therapy for Heart Failure: An Update
of the 2013 ACCF/AHA Guideline for the Management
of Heart Failure : A Report of the American College of
Cardiology/American Heart Association Task Force on
Clinical Practice Guidelines and the Heart Failure
Society of America
Recommendations for Renin-Angiotensin System Inhibition With ACE
Inhibitor or ARB or ARNI
In patients with chronic symptomatic HFrEF NYHA class II or III who
tolerate an ACE inhibitor or ARB, replacement by an ARNI is
recommended to further reduce morbidity and mortality (19).
JACC august 2016
Hvilke pasienter kan man gi Entresto
Følgende vilkår for refusjon:
– NYHA II-IV
– EF<40%
– NYHA II-IV og EF<40% påvist under behandling
med ACE-I/ARB ved utilstrekkelig effekt
– Krav til tidligere behandling: ACE-I eller ARB
– Spesialistkrav: spesialist i Indremedisin eller lege
ved tilsvarende sykehusavdeling
The cumulative probability of a first hospitalization
for heart failure during the first 30 days after
randomization
1.5
Enalapril (N=4,212)
Kaplan-Meier estimate of
cumulative rate
LCZ696 (N=4,187)
HR 0.60 (95% CI: 0.38–0.94)
p=0.027
1.0
0.5
0
0
10
20
Days after randomization
Packer et al. Circulation. 2015 Jan 6;131(1):54-61
30
CRT ved HF
• HFrEF, EF<35%, QRS > 130 ms, venstre grenblokk
• Aller best effekt ved QRS > 150 ms
• Kontraindisert ved QRS<130 ms
ICD
• Overlevende etter hjertestans
• Primærprofylakse: HFrEF, EF<35%, >3mnd medikamentell beh
Ischemisk HF: minst 40 d etter infarkt
DANISH: flow chart
1116 pas med CMP
EF<35, NYHAII-IV
58% CRT
proBNP: ca 135
pmol/l
ACE/ARB: 97%
BB: 92%
Aldost ant:58%
Amiodaron 6%
Køber L et al. N Engl J Med 2016. DOI: 10.1056/NEJMoa1608029
DANISH: Primary outcome: death from any
cause
Køber L et al. N Engl J Med 2016. DOI: 10.1056/NEJMoa1608029
DANISH: CV death and sudden death
CV death: 13.8% (ICD) vs 17.0% (control)
Sudden death: 4.3% (ICD) vs
8.2% (control)
Køber L et al. N Engl J Med 2016. DOI: 10.1056/NEJMoa1608029
Effect according to age
Køber L et al. N Engl J Med 2016
Komorbiditet
Recommendations to prevent or delay the development of overt heart failure or prevent
death before the onset of symptoms
2016ESCGuidelinesfortheDiagnosisandtreatmentofonAcute&Chronic Heart Failure
®
EMPA-REG OUTCOME
• Randomised, double-blind, placebo-controlled CV outcomes
trial, to examine the long-term effects of empagliflozin versus
placebo, in addition to standard of care, on CV morbidity and
mortality in patients with type 2 diabetes and high risk of CV
events(Prior myocardial infarction, coronary artery disease,
stroke, unstable angina or occlusive peripheral arterial
disease)
Placebo
(n=2333)
Screening
(n=11531)
Randomised and
treated
(n=7020)
B Zinman et al New Engl J Med 2015;
Empagliflozin 10 mg
(n=2345)
Empagliflozin 25 mg
(n=2342)
23
Primary outcome:
3-point MACE
HR 0.86
(95.02% CI 0.74, 0.99)
p=0.0382*
Cumulative incidence function. MACE, Major Adverse Cardiovascular Event; HR, hazard ratio. 24
* Two-sided tests for superiority were conducted (statistical significance was indicated if p≤0.0498)
CV death
HR 0.62
(95% CI 0.49, 0.77)
p<0.0001
Cumulative incidence function. HR, hazard ratio
25
Hospitalisation for heart failure
HR 0.65
(95% CI 0.50, 0.85)
p=0.0017
Cumulative incidence function. HR, hazard ratio
26
HFmrPEF og HFpEF
NORSTENT: Flow chart
9013 pas med stabil eller
ustabil AP, ACS
Randomisert: DES eller
BMS
Prim outcome: composite:
død+ nonfatal MI
Sekundært:
Ny revaskularisering
Stenttrombose
QoL
K Bønaa New Engl J Med 2016
NORSTENT: Primary outcome
• Død eller MI: ingen
forskjell
• Død: ingen forskjell
• QoL: Ingen forskjell
• Ny revaskularisering
↓34% (NNT 30 pas)
• Stent trombose ↓
K Bønaa New Engl J Med 2016
NORSTENT: Main results
K Bønaa New Engl J Med 2016
Back up
Atrieflimmer: frekvenskontroll
• Snarlig elektrokonvertering
ved hemodynamisk ustabil
situasjon
• Betablokker som
grunnbehandling
• Digoxin som neste
medikament for å kontrollere
frekvens
• Ablasjon uavklart
• Dronedarone kontraindisert
Atrieflimmer: rytmekontroll
Atrieflimmer: antikoagulasjon
• Regn ut risiko etter CHA2DS2-VASc og
HAS-BLED
• Antikoagulasjon anbefalt ved CHA2DS2VASc >2
– NOAC (eller Marevan)
– Marevan ved kunstige klaffer
Behandling som er kontraindisert ved ulik
komorbiditet
Behandling av stabil angina ved HF
Randomization and Follow-up.
Velazquez EJ et al. N Engl J Med 2016;374:1511-1520.
Kaplan–Meier Estimates of the Rates of Death from Any
Cause, Death from Cardiovascular Causes, and Death
from Any Cause or Hospitalization for Cardiovascular
Causes.
Velazquez EJ et al. N Engl J Med 2016;374:1511-1520.
Behandling av klaffefeil