The New ESC Guidelines:

HFrEF:

Devices & Interventions.

John GF ClelandImperial College

London

8:30am: 9.15-9.30

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ESC Guidelines on Heart Failure

• Professional (Expert) Guidelines– No patient involvement (yet)

• Evolved from 2012 Guideline– Discouraged from re-interpreting old evidence– Encouraged to respond to new evidence (trials or meta-/re-analyses)

• Interpret & Apply Results (Not a Textbook!)– Rather than long summaries

• Coordinated with Other ESC Guidelines

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New (Published) Landmark Trials Since 2012

BIOPACE not yet published

Echo-CRT

BLOCK-HFMortality

Inappropriate Activation

2013

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New Published Meta-Analyses Since 2012

Only QRS duration predicts CRT prognostic benefit

Independent predictors of Benefit of CRT• Younger patients• Women• QRS Duration

• Not LVEF• Not Aetiology• Not QRS Morphology

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20122016

The ‘Rise’ of Rhythm in Heart Failure

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Recommendations for implantable cardioverter-defibrillator in patients with heart failure

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2012

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‘New’ Issues: >30% of ICD Implants are for Generator Exchange EHRA: units pa ~4,000 (32%) Italy, ~2,000 (27%) UK; ~20,000 (39%) Germany (includes CRT-D)

Of patients who required exchange 68% had received no ATP/shock of whom 11% received ATP/shock (FU ~30m) 24% of whom died anyway

ATP/Shock

Shock

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2012

2016

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Recommendations for cardiac resynchronization therapy implantation in patients with heart failure

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QRS Duration / Morphology Debate

• Longer QRS Duration• Consistently associated with

benefit• Threshold 130-140ms• Planned trial inclusion criterion• Prospective subgroup analyses

• LBBB QRS Morphology• Most of the data is LBBB

But• Not used for inclusion• Mainly retrospective subgroup analyses• Most reports conflate RBBB/IVCD

• IVCD have shorter QRS

• RBBB more IHD; often sicker• LBBB is a surrogate for longer QRS,

DCM and less sick patients

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Is LBBB is just a surrogate for QRS duration?

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Conclusions: CRT13

QRS >150ms (+/- LBBB)(+/- AF)

NYHA III

LVEF <35%

QRS 120(130 if NYHA II)-150ms• Only LBBB• Only AF if NYHA III

NYHA II

LVEF <30%

2016• QRS >130ms• LVEF <35%• If SR - NYHA II-IV• If AF - NYHA III-IV

• Longer QRS Greater Benefit• Does QRS Morphology Matter?

2012

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Coronary Revascularization

• Two RCTs:- HEART-UK & STICH – both neutral

• If revascularization does not improve outcome – why do a coronary angiogram?

• Revascularization improved neither cardiac function nor HF symptoms• Neither the presence of viability, ischaemia nor angina identify those

who had a greater benefit from CABG on mortality.• CABG does improve angina

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Other Interventions

• Other Implantable Devices• Vagal Stimulation• Baroreceptor Stimulation• Cardiac Contractility Modulation• Circulatory Support

• Other Interventions• Valves• Ablation (AV / PV / Renal)• Transplantation• Ultrafiltration• Algisyl LVR• Other