ESC Guidelines for the diagnosis and

treatment of acute and chronic heart failure 2012

Authors/Task Force Members: John J V McMurray (Chairperson) et al.

Update on diagnosis of heart failure

Frans H. Rutten, MD, PhD, general practitioner

Conflict of Interest

2006 Lecture fee form Roche Diagnostics

2007 Lecture fee Chiesa Inc

Research support from the Netherlands Heart Foundation

Research support from the Netherlands Organisation for Health Research and Development

‘The very essence of cardiovascular practice

is recognition of early heart failure’

Sir Thomas Lewis – 1933

Definition of heart failure

abnormality of cardiac structure or function

leading to

failure of the heart to deliver oxygen at a rate commensurate with the requirements of the

metabolizing tissues (or only at the expense of increased filling pressures)

Fluid overload compensation reduced oxygen delivery (‘backward failure’) adaptation (‘forward failure’)

Definition of heart failure

Problems in patients treated with diuretics because:

The more specific signs are related to fluid overload

Few signs are related to reduced oxygen delivery

or compensation/adaptation

Apical impulse

Background information to flowchart (1) • In the acute setting:

- MR-proANP may also be used (exclusionary cut-off point 120 pmol/L)

- Oxygen saturation measurement

- D-dimer (pulmonary embolism?)

- Troponins

• Other causes of elevated natriuretic peptide levels in the acute setting are:

- an acute coronary syndrome

- atrial or ventricular arrhythmias

- pulmonary embolism

- severe COPD with elevated right heart pressures

- renal failure

- sepsis

• Other causes of an elevated natriuretic level in the non-acute setting are:

- old age (>75 years)

- atrial arrhythmias/atrial fibrillation

- left ventricular hypertrophy

- COPD

- chronic kidney disease

Background information to flowchart (2)

• Exclusion cut-off points to minimize false-negative rate while reducing

unnecessary referrals for echocardiography

• Treatment may reduce natriuretic peptide concentration

• Natriuretic peptide concentrations may not be markedly elevated in patients with

HF-PEF

• In patients suspected of non-acute HF and prior MI:

echocardiography ‘straightaway’

•When ECG is normal, likelihood of acute new HF <2%

• When ECG is normal, likelihood of non-acute new HF <10-14%

• When NTproBNP <300 pg/ml, likelihood of acute new HF <2%

• When BNP<100 pg/ml, likelihood of acute new HF <2%

• When NTproBNP <125 pg/ml, likelihood of non-acute new HF <10%

• When BNP <35 pg/ml, likelihood of non-acute new HF <10%

(NTpro)BNP tests: Why difference in exclusionary cut points in acute vs non acute

setting?

Differences in prior change (prevalence)

Difference in severity of disease

different patient profile

Other

Positive predictive values

Negative predictive values

Sensitivity

Specificity

BNP in 1872 patients suspected of non-acute HF

NT-proBNP in 1297 patients suspected of non-acute HF

On behalve of all Task Force members

Thank you for your attention