ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
2012; Elsevier BV; Volume: 14; Issue: 8 Linguagem: Inglês
10.1093/eurjhf/hfs105
ISSN1879-0844
AutoresJohn J.V. McMurray, Stamatis Adamopoulos, Stefan D. Anker, Angelo Auricchio, Michael Böhm, Kenneth Dickstein, Volkmar Falk, Gerasimos Filippatos, Cândida Fonseca, Miguel Ángel Gómez‐Sánchez, Tiny Jaarsma, Lars Køber, Gregory Y.H. Lip, Aldo P. Maggioni, Alexander Parkhomenko, Burkert Pieske, Bogdan A. Popescu, Per K. Rønnevik, Frans H. Rutten, Juerg Schwitter, Petar Seferović, Janina Stępińska, Pedro T. Trindade, Adriaan A. Voors, Faı̈ez Zannad, Andreas M. Zeiher, Jeroen J. Bax, Helmut Baumgartner, Claudio Ceconi, Verónica Dean, Christi Deaton, Robert Fagard, Christian Funck‐Brentano, David Hasdai, Arno W. Hoes, Paulus Kirchhof, Juhani Knuuti, Philippe Kolh, Theresa A. McDonagh, Bruno Moulin, Bogdan A. Popescu, Željko Reiner, Udo Sechtem, Per Anton Sirnes, Michał Tendera, Adam Torbicki, Alec Vahanian, Stephan Windecker, Theresa A. McDonagh, Udo Sechtem, Luis Almenar Bonet, Panayiotis Avraamides, Hisham A. Ben Lamin, Michele Brignole, António Coca, Peter J. Cowburn, Henry Dargie, Perry Elliott, Frank A. Flachskampf, G. Guida, Suzanna Hardman, Bernard Iung, Béla Merkely, Christian Mueller, John N. Nanas, Olav Wendelboe Nielsen, Stein Ørn, John Parissis, Piotr Ponikowski,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoEuropean Journal of Heart FailureVolume 14, Issue 8 p. 803-869 ESC GuidelineFree Access ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC Authors/Task Force Members, Authors/Task Force MembersSearch for more papers by this authorJohn J.V. McMurray, Corresponding Author John J.V. McMurray Chairperson UKCorresponding author. Chairperson: Professor John J.V. McMurray, University of Glasgow G12 8QQ, UK. Tel: +44 141 330 3479, Fax: +44 141 330 6955, Email: [email protected]Search for more papers by this authorStamatis Adamopoulos, Stamatis Adamopoulos GreeceSearch for more papers by this authorStefan D. Anker, Stefan D. Anker GermanySearch for more papers by this authorAngelo Auricchio, Angelo Auricchio SwitzerlandSearch for more papers by this authorMichael Böhm, Michael Böhm GermanySearch for more papers by this authorKenneth Dickstein, Kenneth Dickstein NorwaySearch for more papers by this authorVolkmar Falk, Volkmar Falk SwitzerlandSearch for more papers by this authorGerasimos Filippatos, Gerasimos Filippatos GreeceSearch for more papers by this authorCândida Fonseca, Cândida Fonseca PortugalSearch for more papers by this authorMiguel Angel Gomez-Sanchez, Miguel Angel Gomez-Sanchez SpainSearch for more papers by this authorTiny Jaarsma, Tiny Jaarsma SwedenSearch for more papers by this authorLars Køber, Lars Køber DenmarkSearch for more papers by this authorGregory Y.H. Lip, Gregory Y.H. Lip UKSearch for more papers by this authorAldo Pietro Maggioni, Aldo Pietro Maggioni ItalySearch for more papers by this authorAlexander Parkhomenko, Alexander Parkhomenko UkraineSearch for more papers by this authorBurkert M. Pieske, Burkert M. Pieske AustriaSearch for more papers by this authorBogdan A. Popescu, Bogdan A. Popescu RomaniaSearch for more papers by this authorPer K. Rønnevik, Per K. Rønnevik NorwaySearch for more papers by this authorFrans H. Rutten, Frans H. Rutten The NetherlandsSearch for more papers by this authorJuerg Schwitter, Juerg Schwitter SwitzerlandSearch for more papers by this authorPetar Seferovic, Petar Seferovic SerbiaSearch for more papers by this authorJanina Stepinska, Janina Stepinska PolandSearch for more papers by this authorPedro T. Trindade, Pedro T. Trindade SwitzerlandSearch for more papers by this authorAdriaan A. Voors, Adriaan A. Voors The NetherlandsSearch for more papers by this authorFaiez Zannad, Faiez Zannad FranceSearch for more papers by this authorAndreas Zeiher, Andreas Zeiher GermanySearch for more papers by this authorESC Committee for Practice Guidelines (CPG), ESC Committee for Practice Guidelines (CPG)Search for more papers by this authorJeroen J. Bax, Jeroen J. Bax CPG Chairperson The NetherlandsSearch for more papers by this authorHelmut Baumgartner, Helmut Baumgartner GermanySearch for more papers by this authorClaudio Ceconi, Claudio Ceconi ItalySearch for more papers by this authorVeronica Dean, Veronica Dean FranceSearch for more papers by this authorChristi Deaton, Christi Deaton UKSearch for more papers by this authorRobert Fagard, Robert Fagard BelgiumSearch for more papers by this authorChristian Funck-Brentano, Christian Funck-Brentano FranceSearch for more papers by this authorDavid Hasdai, David Hasdai IsraelSearch for more papers by this authorArno Hoes, Arno Hoes The NetherlandsSearch for more papers by this authorPaulus Kirchhof, Paulus Kirchhof Germany UKSearch for more papers by this authorJuhani Knuuti, Juhani Knuuti FinlandSearch for more papers by this authorPhilippe Kolh, Philippe Kolh BelgiumSearch for more papers by this authorTheresa McDonagh, Theresa McDonagh UKSearch for more papers by this authorCyril Moulin, Cyril Moulin FranceSearch for more papers by this authorBogdan A. Popescu, Bogdan A. Popescu RomaniaSearch for more papers by this authorŽeljko Reiner, Željko Reiner CroatiaSearch for more papers by this authorUdo Sechtem, Udo Sechtem GermanySearch for more papers by this authorPer Anton Sirnes, Per Anton Sirnes NorwaySearch for more papers by this authorMichal Tendera, Michal Tendera PolandSearch for more papers by this authorAdam Torbicki, Adam Torbicki PolandSearch for more papers by this authorAlec Vahanian, Alec Vahanian FranceSearch for more papers by this authorStephan Windecker, Stephan Windecker SwitzerlandSearch for more papers by this authorDocument Reviewers, Document ReviewersSearch for more papers by this authorTheresa McDonagh, Theresa McDonagh CPG Co-Review Coordinator UKSearch for more papers by this authorUdo Sechtem, Udo Sechtem CPG Co-Review Coordinator GermanySearch for more papers by this authorLuis Almenar Bonet, Luis Almenar Bonet SpainSearch for more papers by this authorPanayiotis Avraamides, Panayiotis Avraamides CyprusSearch for more papers by this authorHisham A. Ben Lamin, Hisham A. Ben Lamin LibyaSearch for more papers by this authorMichele Brignole, Michele Brignole ItalySearch for more papers by this authorAntonio Coca, Antonio Coca SpainSearch for more papers by this authorPeter Cowburn, Peter Cowburn UKSearch for more papers by this authorHenry Dargie, Henry Dargie UKSearch for more papers by this authorPerry Elliott, Perry Elliott UKSearch for more papers by this authorFrank Arnold Flachskampf, Frank Arnold Flachskampf SwedenSearch for more papers by this authorGuido Francesco Guida, Guido Francesco Guida ItalySearch for more papers by this authorSuzanna Hardman, Suzanna Hardman UKSearch for more papers by this authorBernard Iung, Bernard Iung FranceSearch for more papers by this authorBela Merkely, Bela Merkely HungarySearch for more papers by this authorChristian Mueller, Christian Mueller SwitzerlandSearch for more papers by this authorJohn N. Nanas, John N. Nanas GreeceSearch for more papers by this authorOlav Wendelboe Nielsen, Olav Wendelboe Nielsen DenmarkSearch for more papers by this authorStein Ørn, Stein Ørn NorwaySearch for more papers by this authorJohn T. Parissis, John T. Parissis GreeceSearch for more papers by this authorPiotr Ponikowski, Piotr Ponikowski PolandSearch for more papers by this author Authors/Task Force Members, Authors/Task Force MembersSearch for more papers by this authorJohn J.V. McMurray, Corresponding Author John J.V. McMurray Chairperson UKCorresponding author. Chairperson: Professor John J.V. McMurray, University of Glasgow G12 8QQ, UK. Tel: +44 141 330 3479, Fax: +44 141 330 6955, Email: [email protected]Search for more papers by this authorStamatis Adamopoulos, Stamatis Adamopoulos GreeceSearch for more papers by this authorStefan D. Anker, Stefan D. Anker GermanySearch for more papers by this authorAngelo Auricchio, Angelo Auricchio SwitzerlandSearch for more papers by this authorMichael Böhm, Michael Böhm GermanySearch for more papers by this authorKenneth Dickstein, Kenneth Dickstein NorwaySearch for more papers by this authorVolkmar Falk, Volkmar Falk SwitzerlandSearch for more papers by this authorGerasimos Filippatos, Gerasimos Filippatos GreeceSearch for more papers by this authorCândida Fonseca, Cândida Fonseca PortugalSearch for more papers by this authorMiguel Angel Gomez-Sanchez, Miguel Angel Gomez-Sanchez SpainSearch for more papers by this authorTiny Jaarsma, Tiny Jaarsma SwedenSearch for more papers by this authorLars Køber, Lars Køber DenmarkSearch for more papers by this authorGregory Y.H. Lip, Gregory Y.H. Lip UKSearch for more papers by this authorAldo Pietro Maggioni, Aldo Pietro Maggioni ItalySearch for more papers by this authorAlexander Parkhomenko, Alexander Parkhomenko UkraineSearch for more papers by this authorBurkert M. Pieske, Burkert M. Pieske AustriaSearch for more papers by this authorBogdan A. Popescu, Bogdan A. Popescu RomaniaSearch for more papers by this authorPer K. Rønnevik, Per K. Rønnevik NorwaySearch for more papers by this authorFrans H. Rutten, Frans H. Rutten The NetherlandsSearch for more papers by this authorJuerg Schwitter, Juerg Schwitter SwitzerlandSearch for more papers by this authorPetar Seferovic, Petar Seferovic SerbiaSearch for more papers by this authorJanina Stepinska, Janina Stepinska PolandSearch for more papers by this authorPedro T. Trindade, Pedro T. Trindade SwitzerlandSearch for more papers by this authorAdriaan A. Voors, Adriaan A. Voors The NetherlandsSearch for more papers by this authorFaiez Zannad, Faiez Zannad FranceSearch for more papers by this authorAndreas Zeiher, Andreas Zeiher GermanySearch for more papers by this authorESC Committee for Practice Guidelines (CPG), ESC Committee for Practice Guidelines (CPG)Search for more papers by this authorJeroen J. Bax, Jeroen J. Bax CPG Chairperson The NetherlandsSearch for more papers by this authorHelmut Baumgartner, Helmut Baumgartner GermanySearch for more papers by this authorClaudio Ceconi, Claudio Ceconi ItalySearch for more papers by this authorVeronica Dean, Veronica Dean FranceSearch for more papers by this authorChristi Deaton, Christi Deaton UKSearch for more papers by this authorRobert Fagard, Robert Fagard BelgiumSearch for more papers by this authorChristian Funck-Brentano, Christian Funck-Brentano FranceSearch for more papers by this authorDavid Hasdai, David Hasdai IsraelSearch for more papers by this authorArno Hoes, Arno Hoes The NetherlandsSearch for more papers by this authorPaulus Kirchhof, Paulus Kirchhof Germany UKSearch for more papers by this authorJuhani Knuuti, Juhani Knuuti FinlandSearch for more papers by this authorPhilippe Kolh, Philippe Kolh BelgiumSearch for more papers by this authorTheresa McDonagh, Theresa McDonagh UKSearch for more papers by this authorCyril Moulin, Cyril Moulin FranceSearch for more papers by this authorBogdan A. Popescu, Bogdan A. Popescu RomaniaSearch for more papers by this authorŽeljko Reiner, Željko Reiner CroatiaSearch for more papers by this authorUdo Sechtem, Udo Sechtem GermanySearch for more papers by this authorPer Anton Sirnes, Per Anton Sirnes NorwaySearch for more papers by this authorMichal Tendera, Michal Tendera PolandSearch for more papers by this authorAdam Torbicki, Adam Torbicki PolandSearch for more papers by this authorAlec Vahanian, Alec Vahanian FranceSearch for more papers by this authorStephan Windecker, Stephan Windecker SwitzerlandSearch for more papers by this authorDocument Reviewers, Document ReviewersSearch for more papers by this authorTheresa McDonagh, Theresa McDonagh CPG Co-Review Coordinator UKSearch for more papers by this authorUdo Sechtem, Udo Sechtem CPG Co-Review Coordinator GermanySearch for more papers by this authorLuis Almenar Bonet, Luis Almenar Bonet SpainSearch for more papers by this authorPanayiotis Avraamides, Panayiotis Avraamides CyprusSearch for more papers by this authorHisham A. Ben Lamin, Hisham A. Ben Lamin LibyaSearch for more papers by this authorMichele Brignole, Michele Brignole ItalySearch for more papers by this authorAntonio Coca, Antonio Coca SpainSearch for more papers by this authorPeter Cowburn, Peter Cowburn UKSearch for more papers by this authorHenry Dargie, Henry Dargie UKSearch for more papers by this authorPerry Elliott, Perry Elliott UKSearch for more papers by this authorFrank Arnold Flachskampf, Frank Arnold Flachskampf SwedenSearch for more papers by this authorGuido Francesco Guida, Guido Francesco Guida ItalySearch for more papers by this authorSuzanna Hardman, Suzanna Hardman UKSearch for more papers by this authorBernard Iung, Bernard Iung FranceSearch for more papers by this authorBela Merkely, Bela Merkely HungarySearch for more papers by this authorChristian Mueller, Christian Mueller SwitzerlandSearch for more papers by this authorJohn N. Nanas, John N. Nanas GreeceSearch for more papers by this authorOlav Wendelboe Nielsen, Olav Wendelboe Nielsen DenmarkSearch for more papers by this authorStein Ørn, Stein Ørn NorwaySearch for more papers by this authorJohn T. Parissis, John T. Parissis GreeceSearch for more papers by this authorPiotr Ponikowski, Piotr Ponikowski PolandSearch for more papers by this author First published: 18 February 2014 https://doi.org/10.1093/eurjhf/hfs105Citations: 1,653 Other ESC entities having participated in the development of this document: Associations: European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of Echocardiography (EAE), European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) Working Groups: Acute Cardiac Care, Cardiovascular Pharmacology and Drug Therapy, Cardiovascular Surgery, Grown-up Congenital Heart Disease, Hypertension and the Heart, Myocardial and Pericardial Diseases, Pulmonary Circulation and Right Ventricular Function, Thrombosis, Valvular Heart Disease Councils: Cardiovascular Imaging, Cardiovascular Nursing and Allied Professions, Cardiology Practice, Cardiovascular Primary Care The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary the patient's guardian or carer. It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription. The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Abbreviations and acronyms ACE angiotensin-converting enzyme ACHD adult congenital heart disease AF atrial fibrillation AF-CHF Atrial Fibrillation and Congestive Heart Failure AHF acute heart failure AIRE Acute Infarction Ramipril Efficacy ARB angiotensin receptor blocker ARR absolute risk reduction ATLAS Assessment of Treatment with Lisinopril And Survival AV atrioventricular AVP arginine vasopressin BEAUTIFUL MorBidity-mortality EvAlUaTion of the If inhibitor ivabradine in patients with coronary disease and left ventricULar dysfunction BEST Beta-Blocker Evaluation of Survival Trial BiVAD bi-ventricular assist device BNP B-type natriuretic peptide b.p.m. beats per minute BTC bridge to candidacy BTD bridge to decision BTR bridge to recovery BTT bridge to transplantation CABG coronary artery bypass graft CAD coronary artery disease CARE-HF Cardiac Resynchronization in Heart Failure Study CCB calcium-channel blocker CHA2DS2-VASc Cardiac failure, Hypertension, Age ≥75 (Doubled), Diabetes, Stroke (Doubled)-Vascular disease, Age 65–74 and Sex category (Female) CHARM Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity CIBIS II Cardiac Insufficiency Bisoprolol Study II CMR cardiac magnetic resonance COMET Carvedilol or Metoprolol European Trial COMPANION Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure CONSENSUS Cooperative North Scandinavian Enalapril Survival Study COPD chronic obstructive pulmonary disease COPERNICUS Carvedilol Prospective Randomized Cumulative Survival CORONA Controlled Rosuvastatin Multinational Trial in Heart Failure CPAP continuous positive airway pressure CRT cardiac resynchronization therapy CRT-D cardiac resynchronization therapy-defibrillator CRT-P cardiac resynchronization therapy-pacemaker CT computed tomography DEFINITE Defibrillators in Non-ischemic Cardiomyopathy Treatment Evaluation DIG Digitalis Investigation Group DT destination therapy ECG electrocardiogram ECMO extracorporeal membrane oxygenation EF ejection fraction eGFR estimated glomerular filtration rate ELITE II Second Evaluation of Losartan in the Elderly Trial EMPHASIS-HF Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure GFR glomerular filtration rate GISSI-HF Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico-heart failure H-ISDN hydralazine and isosorbide dinitrate HAS-BLED Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (>65), Drugs/alcohol concomitantly (1 point each) HEAAL Heart failure Endpoint evaluation of Angiotensin II Antagonist Losartan HF heart failure HF-ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training HF-PEF heart failure with 'preserved' ejection fraction HF-REF heart failure with reduced ejection fraction I-PRESERVE Irbesartan in heart failure with preserved systolic function i.v. intravenous IABP intra-aortic balloon pump ICD implantable cardioverter-defibrillator LA left atrial LBBB left bundle branch block LV left ventricular LVAD left ventricular assist device LVEF left ventricular ejection fraction MADIT-II Multicenter Automatic Defibrillator Implantation Trial II MCS mechanical circulatory support MDCT multi-detector computed tomography MERIT-HF Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure MRA mineralocorticoid receptor antagonist MR-proANP mid-regional atrial (or A-type) natriuretic peptide MUSTIC Multisite Stimulation in Cardiomyopathies NIPPV non-invasive positive pressure ventilation NNT number needed to treat NSAID non-steroidal anti-inflammatory drug NYHA New York Heart Association OPTIMAAL Optimal Therapy in Myocardial infarction with the Angiotensin II Antagonist Losartan PEP-CHF Perindopril for Elderly People with Chronic Heart failure PET positron emission tomography PUFA polyunsaturated fatty acid RAFT Resynchronization/Defibrillation for Ambulatory Heart Failure Trial RALES Randomised Aldactone Evaluation Study RCT randomized controlled trial RRR relative risk reduction SAVE Survival and Ventricular Enlargement SCD-HeFT Sudden Cardiac Death in Heart Failure Trial SENIORS Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors With Heart Failure SHIFT Systolic Heart failure treatment with the If inhibitor ivabradine Trial SOLVD Studies of Left Ventricular Dysfunction SPECT single-photon emission computed tomography STICH Surgical Treatment for Ischemic Heart Failure TAPSE tricuspid annular plane systolic excursion TDI tissue Doppler imaging TOE transoesophageal echocardiography TRACE TRAndolapril Cardiac Evaluation Val-HeFT Valsartan Heart Failure Trial VALIANT Valsartan In Acute myocardial infarction VO2 maximal oxygen consumption 1. Preamble Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes, but are complements, for textbooks and cover the European Society of Cardiology (ESC) Core Curriculum topics. Guidelines and recommendations should help physicians to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible physician(s). A large number of Guidelines have been issued in recent years by the ESC as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC website (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated. Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology. Selected experts in the field undertook a comprehensive review of the published evidence for diagnosis, management, and/or prevention of a given condition according to ESC Committee for Practice Guidelines (CPG) policy. A critical evaluation of diagnostic and therapeutic procedures was performed including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of recommendation of particular treatment options were weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2. Table 1. Classes of recommendations Table 2. Levels of evidence The experts of the writing and reviewing panels filled in declarations of interest forms of all relationships which might be perceived as real or potential sources of conflicts of interest. These forms were compiled into one file and can be found on the ESC website (http://www.escardio.org/guidelines). Any changes in declarations of interest that arise during the writing period must be notified to the ESC and updated. The Task Force received its entire financial support from the ESC without any involvement from the healthcare industry. The ESC CPG supervises and coordinates the preparation of new Guidelines produced by Task Forces, expert groups, or consensus panels. The Committee is also responsible for the endorsement process of these Guidelines. The ESC Guidelines undergo extensive review by the CPG and external experts. After appropriate revisions, it is approved by all the experts involved in the Task Force. The finalized document is approved by the CPG for publication in the European Heart Journal. The task of developing ESC Guidelines covers not only the integration of the most recent research, but also the creation of educational tools and implementation programmes for the recommendations. To implement the guidelines, condensed pocket guidelines versions, summary slides, booklets with essential messages, and an electronic version for digital applications (smartphones, etc.) are produced. These versions are abridged and, thus, if needed, one should always refer to the full text version which is freely available on the ESC website. The National Societies of the ESC are encouraged to endorse, translate, and implement the ESC Guidelines. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations. Surveys and registries are needed to verify that real-life daily practice is in keeping with what is recommended in the guidelines, thus completing the loop between clinical research, writing of guidelines, and implementing them into clinical practice. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and, where appropriate and necessary, the patient's guardian or carer. It is also the health professional's responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription. 2. Introduction The aim of this document is to provide practical, evidence-based guidelines for the diagnosis and treatment of heart failure (HF). The principal changes from the 2008 guidelines1 relate to: an expansion of the indication for mineralocorticoid (aldosterone) receptor antagonists (MRAs); a new indication for the sinus node inhibitor ivabradine; an expanded indication for cardiac resynchronization therapy (CRT); new information on the role of coronary revascularization in HF; recognition of the growing use of ventricular assist devices; and the emergence of transcatheter valve interventions. There are also changes to the structure and format of the guidelines. Therapeutic recommendations now state the treatment effect supported by the class and level of recommendation in tabular format; in the case of chronic heart failure due to left ventricular (LV) systolic dysfunction, the recommendations focus on mortality and morbidity outcomes. Detailed summaries of the key evidence supporting generally recommended treatments have been provided. Practical guidance is provided for the use of the more important disease-modifying drugs and diuretics. When possible, other relevant guidelines, consensus statements, and position papers have been cited to avoid unduly lengthy text. All tables should be read in conjunction with their accompanying text and not read in isolation. 3. Definition and diagnosis Definition of heart failure Heart failure can be defined as an 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, despite normal filling pressures (or only at the expense of increased filling pressures).1 For the purposes of these guidelines, HF is defined, clinically, as a syndrome in which patients have typical symptoms (e.g. breathlessness, ankle swelling, and fatigue) and signs (e.g. elevated jugular venous pressure, pulmonary crackles, and displaced apex beat) resulting from an abnormality of cardiac structure or function. The diagnosis of HF can be difficult (see Section 3.6). Many of the symptoms of HF are non-discriminating and, therefore, of limited diagnostic value.2–6 Many of the signs of HF result from sodium and water retention and resolve quickly with diuretic therapy, i.e. may be absent in patients receiving such treatment. Demonstration of an underlying cardiac cause is therefore central to the diagnosis of HF (see Section 3.6). This is usually myocardial disease causing systolic ventricular dysfunction. However, abnormalities of ventricular diastolic function or of the valves, pericardium, endocardium, heart rhythm, and conduction can also cause HF (and more than one abnormality can be present) (see Section 3.5). Identification of the underlying cardiac problem is also crucial for therapeutic reasons, as the precise pathology determines the specific treatment used (e.g. valve surgery for valvular disease, specific pharmacological therapy for LV systolic dysfunction, etc.). Terminology related to left ventricular ejection fraction The main terminology used to describe HF is historical and is based on measurement of LV ejection fraction (EF). Mathematically, EF is the stroke volume (which is the end-diastolic volume minus the end-systolic volume) divided by the end-diastolic volume. In patients with reduced contraction and emptying of the left ventricle (i.e. systolic dysfunction), stroke volume is maintained by an increase in end-diastolic volume (because the left ventricle dilates), i.e. the heart ejects a smaller fraction of a larger volume. The more severe the systolic dysfunction, the more the EF is reduced from normal and, generally, the greater the end-diastolic and end-systolic volumes. The EF is considered important in HF, not only because of its prognostic importance (the lower the EF the poorer the survival) but also because most clinical trials selected patients based upon EF (usually measured using a radionuclide technique or echocardiography). The major trials in patients with HF and a reduced EF (HF-REF), or 'systolic HF', mainly enrolled patients with an EF ≤35%, and it is only in these patients that effective therapies have been demonstrated to date. Other, more recent, trials enrolled patients with HF and an EF >40–45% and no other causal cardiac abnormality (such as valvular or pericardial disease). Some of these patients did not have an entirely normal EF (generally considered to be >50%) but also did not have a major reduction in systolic function either. Because of this, the term HF with 'preserved' EF (HF-PEF) was created to describe these patients. Patients with an EF in the range 35–50% therefore represent a 'grey area' and most probably have primarily mild systolic dysfunction. The diagnosis of HF-PEF is more difficult than the diagnosis of HF-REF because it is largely one of exclusion, i.e. potential non-cardiac causes of the patient's symptoms (such as anaemia or chronic lung disease) must first be discounted (Table 3).7,8 Usually these patien
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