New ESC heart failure guidelines with South African expert comment.

The new ESC heart failure guidelines, an update of the 2008 version, was released at the ESC Heart Failure Congress in Belgrade this weekend. This is the first time the guidelines have been presented at the Heart Failure Congress as opposed to at the annual European Society of Cardiology (ESC) Congress. Major updates are in the provision of new algorithms for the diagnosis of patients with suspected heart failure, treatment for systolic heart failure patients with reduced ejection fraction (HF-REF), and the management of acute heart failure. The diagnostic algorithm recognises the increasing importance of cardiac MRI and includes mid-regional proBNP as a ‘rule-out’ blood test in patients with acute heart failure. The pharmacological therapy section of the guideline has been updated to specifically relate the treatment to clinical outcome effects and provides the level of evidence supporting a use of the particular agent (Table 1). The cornerstone use of ACE inhibitors has been acknowledged with a class I, level A recommendation as has the use of the ARBs (also class I, level A). ‘ARBs, as they become generically available, can also be regarded as a cornerstone therapy, particularly as drug adherence is such an important issue’, Dr Erik Klug (cardiologist, Johannesburg) noted at the recent Physicians Congress held in Cape Town. In these 2012 guidelines, there is a new indication for the mineralocorticoid/ aldosterone receptor antagonists (MRA), eplerenone in patients with systolic heart failure (HF-REF) and mild symptoms. This broadens the indication for a MRA to essentially all HF-REF remaining symptomatic, despite adequate treatment with a beta-blocker and ACE inhibitor or ARB. A further innovation is the recommendation that ivabradine be added to an ACE inhibitor, beta-blocker (at maximum tolerated doses) and MRA to HF-REF patients in sinus rhythm with a persistently high heart beat above 70 beats/min (Table 2). The new guidelines devote substantial space to co-morbidities, given their importance in relation to symptoms and progress, and therapeutic decision making. In this way, the guidelines recognise that heart failure and left ventricular systolic dysfunction (LVSD) may alter therapies for co-morbidities and that co-morbidities may also influence the use of heart failure therapies. Co-morbidities such as chronic obstructive pulmonary disease (COPD), diabetes, hypertension, kidney dysfunction and cardiorenal syndrome are discussed and guidelines presented. Recent evidence has also pointed to the value of physicians managing patients with chronic heart failure and co-morbidities.