To know more visit HeartFailure.com © 2015 Novartis Pharma AG, May 2015, GLCM/HTF/0028 HEART FAILURE DISEASE MANAGEMENT STANDARDS

To know more visit HeartFailure.com

© 2015 Novartis Pharma AG, May 2015, GLCM/HTF/0028

HEART FAILUREDISEASE MANAGEMENTSTANDARDS

Current standards in disease management What is heart failure and what are the treatment guidelines?

How is heart failure defined?According to European Society of Cardiology (ESC) guidelines, “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

DEFINITIONS OF HFrEF AND HFpEF1

Classification EF (%)

Heart failure with reduced ejection fraction (HFrEF) 35%

Heart failure with preserved ejection fraction (HFpEF) 50%

HFpEF, borderline 35% to 50%

NEW YORK HEART ASSOCIATION (NYHA) CLASSES1

NYHA class I NYHA class II NYHA class III NYHA class IV

• No limitation on physical activity

• No overt symptoms

• Slight limitation on physical activities

• Comfortable at rest, but ordinary physical activity causes symptoms of heart failure

• Marked limitation on physical activities

• Comfortable at rest, but less than ordinary activity causes symptoms of heart failure

• Inability to carry on any activity without symptoms

• Presence of symptoms even at rest

EF: Ejection fraction

HFrEF = Heart failure with reduced ejection fraction / HFpEF = Heart failure with preserved ejection fraction

1. McMurray JJV, Adamopoulos S, Anker SD, et al. 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. Eur Heart J. 2012;33(14):1787-1847. 2. Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008. 3. Ponikowski P, Anker SD, AlHabib KF, et al. Heart failure: preventing disease and death worldwide. ESC Heart Failure. 2014;1(1):4-25.

NYHA classification is important for evaluating patient symptomsThe New York Heart Association (NYHA) functional classification is widely used and accepted based on exercise capacity and symptoms of the disease.1


Recommended guidelines for care1

The overall goals for chronic heart failure management, including patients with established HFrEF, “are to relieve symptoms and signs (eg, oedema), prevent hospitalisations, and improve survival.”

• Recent studies have shown that including a focus on reducing hospitalisations can be highly important to patients and health care systems

Treatment effectiveness at slowing or preventing progressive worsening of disease can be determined by reductions in the rates of both hospital admissions and mortality.


ACE = angiotensin-converting enzyme; ARB = angiotenstin blocker; CRT-D = cardiac resynchronisation therapy defibrillator; CRT-P = cardiac resynchronisation therapy pacemaker; H-ISDN = hydralazine and isosorbide dinitrate; HR = heart rate; ICD = implantable cardioverter-defibrillator; LVAD = left ventricular assist device; LVEF = left ventricular ejection fraction; MR antagonist = mineralocorticoid receptor antagonist; NYHA = New York Heart Association.a. Diuretics may be used as needed to relieve the signs and symptoms of congestion but they have not been shown to reduce hospitalisation or death.b. Should be titrated to evidence-based dose or maximum tolerated dose below the evidence-based dose.c. Asymptomatic patients with an LVEF ≤35% and a history of myocardial infarction should be considered for an ICD.d. If mineralcorticoid recptor antagonist not tolerated, an ARB may be added to an ACE inhibitor as an alternative.e. European Medicines Agency has approved ivabradine for use patients with a heart rate ≥75 bpm. May also be considered in patients with a contraindication to a beta-blocker or beta-blocker intolerance.f. Indication differs according to heart rhythm, NYHA class, QRS duration, QRS morphology and LVEF.g. Not indicated in NYHA class IV.h. Digoxin may be used earlier to control the ventricular rate in patients with atrial fibrillation-usually in conjunction with a beta-blocker.i. The combination of hydralazine and isosorbide dinitrate may also be considered earlier in patients unable to tolerate an ACE inhibitor or an ARB.

© European Society of Cardiology 2015 - All Rights Reserved*


Recommended treatment guidelines per NYHA class

ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker;

EF = ejection fraction; HF = heart failure;

MRA = mineralocorticoid receptor

a. Class of recommendation.

b. Level of evidence

Adapted from McMurray. European Heat Journal. 2012

*Level of evidence A represents data derived from multiple randomised clinical trials or meta-analyses. Level of evidence B however, includes data derived from a single randomised clinical trial or large non-randomised studies. Consensus of opinion of the experts and/or small studies, retrospective studies, and registries, are classified under level of evidence C.


PHARMACOLOGICAL TREATMENTS INDICATED IN POTENTIALLY ALL PATIENTS WITH SYMPTOMATIC(NYHA FUNCTIONAL CLASS II-IV) SYSTOLIC HEART FAILURE*

Recommendations Classa Levelb

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


Benefits of a multidisciplinary approach to care

During the management of heart failure, it is imperative to provide a system of care that ensures optimal management of every patient. Thus, a multifaceted approach to care – focused on holistic management, including exercise training and multidisciplinary management programmes, patient monitoring, and palliative care – can play an important role in the lives of heart failure patients.1

Despite these treatment strategies, the survival rate for heart failure patients across the globe is poor. Continuing research and new pharmacological treatments are essential to addressing unmet needs in caring for patients with heart failure.2,3

For further information regarding the quality of care measures recommended by ESC, please click here.


http://www.escardio.org/Guidelines-&-Education/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure

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To know more visit HeartFailure.com © 2015 Novartis Pharma AG, May 2015, GLCM/HTF/0028 HEART FAILURE DISEASE MANAGEMENT STANDARDS