Download Decision Tree for International

VAD Therapy Changing the Treatment for Heart Failure.
Decision Tree For Heart Failure Treatments1
(Consistent with ESC Guidelines)
Diuretics to relieve symptoms/signs of congestion
+
ACE inhibitor (or ARB if not tolerated)
ADD a beta blocker
Still NYHA class II-IV?
Yes
No
Add a MR antagonist
Still NYHA class II-IV?
Yes
No
LVEF ≤ 35%?
Yes
No
Sinus rhythm and
HR ≥ 70 beats/min?
No
Yes
Add ivabradine
Still NYHA class II-IV?
and LVEF ≤ 35%?
No
Yes
QRS duration ≥ 120 ms?
No
Yes
Consider CRT-P/CRT-D
Consider ICD
Still NYHA class II-IV?
Yes
No
Consider digoxin and/or H-ISDN
if end stage, consider LVAD and/or
transplantation
No further specific treatment
Continue in disease-management
programme
ESC Criteria for VAD-Eligible Patients1
Patients with >2 months of severe symptoms despite optimal medical and device therapy and
more than one of the following:
• LVEF<25% and, if measured, peak VO2 <12mL/kg/min
• ≥3 HF hospitalizations in previous 12 months without an obvious precipitating cause.
• Dependence on IV inotropic therapy
• Progressive end-organ dysfunction (worsening renal and/or hepatic function) due to reduced
perfusion and not to inadequate ventricular filling pressure (PCWP ≥20 mmHg and SBP ≤ 80-90mmHg
or CI ≤ 2 L/min/m2).
• Deteriorating right ventricular function
LVEF = Left ventricular ejection fraction
VO2 = Maximal oxygen consumption
PCWP = Pulmonary capillary wedge pressure
CI = Cardiac index
IV = Intravenous
ESC HF Guideline 2012 Recommendation – LVADs in Patients with
Systolic Heart Failure1
• Recommended in selected patients with end-stage heart failure despite optimal pharmacological
and device treatment and who are otherwise suitable for heart transplantation.
• Class: I Level: B
• Should be considered in highly selected patients who have end-stage heart failure despite optimal
pharmacological and device therapy and who are not suitable for heart transplantation, but are
expected to survive >1 year with good functional status..
• Class: IIa Level: B
Improve symptoms
Risk of heart failure hospitalization
Risk of premature death
ESC HF Guidelines 2012 Definitions1
Classes of Recommendations
Definitions
Suggested Wording to Use
Class I
Evidence and / or
general agreement
that a given treatment
or procedure is beneficial, useful, effective
“Is recommended /
is indicated”
Class IIa
Weight of evidence /
opinion is in favor of
usefulness / efficacy
“Should be considered”
Levels of Evidence
Definition
B
Data derived from a single randomized clinical trial or
large non-randomized studies.
1. McMurray, J, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 European Heart Journal.
2012;33:1787-847.
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