CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 5, June 2012
AFRICA
295
Drug Trends in Cardiology
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.
1,2
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 decisionmaking.
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, kidneydysfunction
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.
3
Comment from Dr Martin Mpe
Cardiologist in private practice, Pretoria
and a member of the CVJA editorial board
The update of the 2008 guidelines is
intended to advance the treatment of
heart failure in the light of the new
scientific evidence from recent clinical
trials. The purpose is to improve the
clinical outcomes from contemporary
interventions with improvement in both
morbidity and mortality. This comes at
a price since stringent application of the
recommendations has cost implications
on the already financially strained
healthcare systems all over the world.
Local adaptations of these guidelines
are mandatory and should be sensitive to
local circumstances. For the majority of
patients, the logical approach is to ensure
access to the ‘maximum’ recommended
pharmacological intervention as the
minimum standard of care.
Special investigations in the setting of
heart failure have been re-emphasised,
which leads to further increase in cost.
The escalation of therapy depends on
special investigations over and above the
symptom response.
The main changes, as presented by
the chairperson of the Task Force for the
review committee of the 2012 ESC heart
failure guidelines committee, John JV
McMurray, are the following:
An expanded indication for mineralo-
corticoid (aldosterone) receptor antag-
onists (MRAs)
The use of MRAs following the use
of ACEI/ARB and beta-blockers in
symptomatic patients implies a revisit
on the wider use of eplerenone.
Spironolactone has an unpleasant side
effect of gynaecomastia in a significant
number of users, which may be more
TABLE 1. PHARMACOLOGICAL TREATMENTS INDICATED IN POTENTIALLYALL PATIENTSWITH
SYMPTOMATIC (NYHA FUNCTIONAL CLASS II–IV) SYSTOLIC HEART FAILURE
Recommendations
Class
a
Level
b
An ACE inhibitor is recommended, in addition to a beta-blocker, for all patients with an EF
≤
40% to reduce the risk of heart
failure hospitalisation and the risk of premature death.
I
A
A beta-blocker is recommended, in addition to an ACE inhibitor (or ARB if ACE inhibitor not tolerated), for all patients with an
EF
≤
40% to reduce the risk of heart failure hospitalisation and the risk of premature death.
I
A
An MRA is recommended for all patients with persisting symptoms (NYHA class II–IV) and an EF
≤
35%, despite treatment
with an ACE inhibitor (or an ARB if an ACE inhibitor is not tolerated) and a beta-blocker, to reduce the risk of heart failure
hospitalisation and the risk of premature death.
I
A
ACE = angiotensin converting enzyme; ARB
=
angiotensin receptor blocker; EF
=
ejection fraction; MRA
=
mineralocorticoid receptor antago-
nist; NYHA
=
NewYork Heart Association.
a
Class of recommendation;
b
Level of evidence.
