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www.hfcc.ca Recommendations on Heart Failure: Update 2007 Prevention Management during intercurrent illness Treatment of acute decompensation Use of biomarkers Arnold JMO, Howlett JG, Dorian P et al. Can J Cardiol 2007;23(1):21-45. Leadership. Knowledge. Community. 2 CCS HF Guidelines • First CCS recommendations were published in 1994 with updates in 2001, 2003 and 2006 • New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel whose recommendations and practical tips were reviewed by a secondary panel • Practical advice for specialists, family physicians, nurses, pharmacists and others involved in HF care • Goal is to translate best evidence-based therapies into clinical practice with a measurable impact on the health of HF patients in Canada Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45. Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 3 Proposed Timeline Through Five Development Cycles Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Heart Failure Heart Failure Heart Failure Heart Failure Heart Failure 12 Months 12 Months 12 Months 12 Months 12 Months Jan ‘05 Start Jan ‘06 CJC Paper Jan ‘07 Jan ‘08 Jan ‘09 Jan ‘10 CJC CJC Paper ? Paper Acute Coronary Syndrome Arnold JMO, Liu P, Demers C et al. Can J Cardiol 2006;22(1):23-45. ? Arrhythmia Arnold JMO, Howlett JG, Dorian P et al. Can J Cardiol 2007:23(1);21-45 © 2004 Canadian Cardiovascular Society 4 Process and Purpose of 2007 HF Recommendations Update • Priority challenges identified through the national HF workshop program in 2006 • New evidence-based recommendations for – Prevention of HF – Management of HF during intercurrent illness – Treatment of acute decompensated HF – Use of biomarkers (eg BNP/NT-BNP) in HF care Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 5 Consensus Conference Panelists 2007 Primary panelists: J Malcolm O Arnold, Jonathan G Howlett, Anique Ducharme, Justin Ezekowitz, Martin J Gardner, Nadia Giannetti, Haissam Haddad, George A Heckman, Andrew Ignaszewski, Debra Isaac, Philip Jong, Peter Liu, Elizabeth Mann, Robert S McKelvie, Gordon W Moe, Kelly O’Halloran, John D Parker, Heather J Ross, Errol J Sequeira, Anna M Svendsen, Ross T Tsuyuki, Michel White Secondary panelists: Tom Ashton, Victor Huckell, Marie-Helene Leblanc, Gary E Newton, Joel Niznick, Sherryn N Roth, Denis Roy, Stuart Smith, Bruce A Sussex, Salim Yusuf Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 6 Class of Recommendation and Grade of Evidence Evidence or general agreement that a given procedure or treatment is beneficial, useful and effective. Conflicting evidence or a divergence of opinion about the usefulness or efficacy of a procedure or treatment. Weight of evidence in favour of usefulness or efficacy. Usefulness or efficacy is less well established by evidence or opinion. Evidence or general agreement that the procedure or treatment is not useful or effective and in some cases may be harmful. Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 7 Class of Recommendation and Grade of Evidence Data derived from multiple randomized trials or meta-analyses Data derived from a single randomized clinical trial or nonrandomized studies Consensus of opinion of experts and/or small studies Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 8 Key Emphases in 2006 • Management of HF requires • an accurate diagnosis • aggressive treatment of known risk factors (e.g. hypertension, diabetes) • rational combination drug therapy • Care should be individualized for each patient based on: • symptoms • clinical presentation • disease severity • underlying cause Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 9 Key Emphases in 2006 • Patient and caregiver education should be tailored and repeated • Mechanical interventions (e.g. revascularization and devices) should be available • Collaboration is required among healthcare professionals • Access to primary, emergency and specialist care must be timely Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 10 Key Clinical Questions Addressed in 2007 • Which patients should be identified as being at high risk of developing heart failure and which interventions should be used? • What complications can occur in heart failure patients during an intercurrent illness, how should these patients be monitored and which medications may require a dose adjustment or discontinuation? • What are the best therapies, both drug and nondrug strategies, for patients with acute heart failure? • How can new biomarkers help in the treatment of heart failure and when and how should BNP/NT-proBNP be measured in heart failure patients? Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 11 Heart Failure Management Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 12 Prevention of Heart Failure 13 Goals of HF Prevention Primary Prevention • Prevent the development of asymptomatic or symptomatic LV dysfunction in patients with risk factors but no history of symptomatic HF Secondary Prevention • Reduce HF-related morbidity and mortality in patients who already have symptomatic disease Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 14 Risk Factors for HF Development • Hypertension* • Ischemic heart disease* • Diabetes*/metabolic syndrome • Hyperlipidemia* • Smoking* • Obesity • Older age • Male gender • Ethnicity • Physical inactivity • Heavy alcohol consumption * Most important targets for prevention • • • • • • • • • • • Excessive salt intake Cardiotoxic agents Family history/genetics Low ejection fraction* Impaired diastolic function Left ventricular hypertrophy Elevated neurohormonal biomarkers Abnormal ECG Increased cardiothoracic ratio Microalbuminuria Elevated resting heart rate Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 15 Patients at Risk of Developing HF • Clinical assessment is recommended in all patients to identify known or potential risk factors for HF (eg hypertension, IHD, diabetes, hyperlipidemia, smoking) (Class I, Level C) • All modifiable risk factors for HF, including those for CAD, such as hypertension, diabetes mellitus and hyperlipidemia, should be treated according to current national guidelines Practical Tips (Class I, Level A) • Poor adherence to preventive measures is common. Reassess regularly to ensure targets achieved/maintained • Patients at high risk for HF should receive influenza vaccine (yearly) and pneumococcal vaccine (if not in last 6 yrs) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 16 Hypertension, LV Hypertrophy and HF Risk • Presence of hypertension increases risk of HF eg Framingham Study • Presence of LVH increases risk of HF and risk is independent of association with hypertension • Treatment of hypertension clearly reduces risk of HF eg BP Lowering Treatment Trialists’ Collaboration Practical Tips • BP goal <140/90mmHg in most individuals • <130/80mmHg in diabetes and/or kidney disease and perhaps in patients with multiple risk factors Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 17 Ischemic Heart Disease and HF Risk • 52% of HF diagnoses in general population attributed to CAD • 40% of patients who have experienced an MI will develop HF over time • 8-fold increase in risk of subsequent death when a new MI occurs in patients with established HF • 1/3 of all deaths in HF are preceded by an ischemic event • Target dyslipidemia, hypertension, diabetes, smoking. Treat aggressively Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 18 Diabetes Mellitus and HF Risk • DM increases risk 2 to 4 fold compared to patients without DM • DM is well established risk factor for CAD/IHD • DM may produce HF independently of CAD (diabetic CM) • While increased HbA1C is associated with increased HF, no study to date has shown improved glycemic control reduces HF • Canadian Diabetes Association recommends HbA1C ≤7.0% in most patients with DM Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 19 Microalbuminuria and HF Risk • Microalbuminuria is an independent risk factor for HF • In diabetes, microalbuminuria increases HF risk 2-4 fold • Clinical trial data are insufficient at present to support the treatment of microalbuminuria as a strategy to prevent HF Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 20 Hyperlipidemia and HF Risk • Elevated TG and elevated TC/HDL are associated with increase in HF risk • Statin therapy may reduce HF risk Practical Tips • Hyperlipidemia should be treated aggressively • In patients at high risk for HF, target LDL may be <2.0mmol/L • Statins may be the preferred drug Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 21 Smoking and HF Risk • Smoking may account for 17% of new HF cases • Smoking has a direct and independent relationship with the development of asymptomatic ventricular dysfunction • Smoking cessation can reduce morbidity and mortality by 30% within 2 years in patients with HF Practical Tip • Smoking cessation is an important strategy to prevent HF Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 22 Obesity and HF Risk • Overweight (BMI > 25 kg/m2) and obesity (BMI > 30 kg/m2) are independent risk factors for HF • Overweight and obesity may lead to changes in LV structure and function regardless of BP, age, sex and LV mass • Improvement in LV function and HF can occur after bariatric surgery in morbidly obese HF patients Practical Tip • Weight reduction in overweight or obese individuals may is an important strategy to prevent HF Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 23 Patients with Asymptomatic LV Dysfunction • ACE inhibitors should be used in all asymptomatic patients with LV dysfunction and LVEF <40% (Class 1, Level A, LVEF <35%; Class I, Level B, LVEF 35-40%) • Beta-blockers should be considered in all asymptomatic patients with LV dysfunction and LVEF < 40% (Class I, Level B, prior MI; Class IIa, Level C, no prior MI) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 24 Screening for LV Dysfunction • Community epidemiological studies document a prevalence of 1-6% for impaired systolic function and 11-21% for isolated impaired diastolic function • No consensus on optimal screening method to detect asymptomatic LV dysfunction Practical Tips • Routine screening for asymptomatic LV dysfunction is not recommended • Selective screening may be considered for patients at higher risk: IHD, hypertension, DM, certain ethnic groups, elderly Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 25 Heart Failure and Intercurrent Illness 26 Heart Failure and Cognitive Impairment Recommendation • Elderly or frail patients with HF who present with acute illness should be assessed for evidence of delirium and, before discharge, cognitive impairment (Class IIa, Level C) Practical Tip • In a hospitalized elderly or frail patient with HF, screening for chronic cognitive impairment is best performed pre-discharge once the patient has been stabilized Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 27 CSHA* Clinical Frailty Scale * Canadian Study of Health and Aging 28 Heart Failure and Comorbidities Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 29 Heart Failure and Diabetes Recommendation • Treat elevated blood glucose to achieve: - HbA1C ≤ 7.0% - fasting/preprandial blood glucose 4.4 mmol/L to 7.0 mmol/L (Class I, Level A) Practical Tips • Oral antidiabetic therapy should be individualized; no compelling evidence exists to recommend one agent over another • Metformin may be considered a first-line agent if the eGFR is > 30 mL/min but should be discontinued temporarily if renal function worsens significantly Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 30 Renal Dysfunction: Impact on HF CV events eGFR < 60 mL/min Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 31 Heart Failure and Renal Dysfunction Recommendations • Patients with stable renal function, and serum creatinine < 200 µmol/L, should receive standard therapy (ACE-I, ARB or spironolactone). However, monitor potassium and creatinine more frequently, especially with combination therapy or acute dehydrating illness (Class I, Level B) • Patients with HF who continue to experience volume overload or increasing serum creatinine should be assessed for reversible causes (eg. NSAIDs, hypovolemia, hypotension, urinary tract obstruction or infection) (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 32 Heart Failure and Renal Dysfunction Recommendations • In stable patients who are not oliguric but have increasing serum creatinine levels (> 30% from previously stable baseline), the dose of diuretics, ACE-I, ARBs and spironolactone may be reduced until renal function stabilizes (Class I, Level C) • In patients with oliguria who are hemodynamically stable, diuretics, ACE-I, ARBs, spironolactone and non-HF drugs that impair renal function should be reviewed daily (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 33 Heart Failure and Renal Dysfunction Recommendation • Routine use of ACE-I, ARBs or spironolactone in the setting of severe renal dysfunction (serum creatinine > 250 µmol/L or an increase of > 50% from baseline) is not recommended due to a lack of evidence for efficacy in HF patients (Class IIa, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 34 Heart Failure and Renal Dysfunction Recommendations • Indications for the use of digoxin should be re-evaluated in patients with severe renal dysfunction • Adjust dose to maintain trough level of < 1 nmol/L • If patients have rapid deterioration in renal function, withhold digoxin and re-evaluate once renal function has stabilized (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 35 Heart Failure and Renal Dysfunction Recommendation • In patients not responding adequately to > 240 mg intravenous furosemide daily, treatment options include: ○ More frequent or higher doses of intravenous boluses of diuretic (Class IIb, Level C) ○ Combination with thiazide diuretic, eg, hydrochlorothiazide or metolazone (Class IIA, Level B) ○ Continuous intravenous furosemide infusion (Class IIa, Level B) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 36 Heart Failure with Renal Dysfunction Practical Tips • Serum creatinine increased by > 30% of baseline value over several days OR oliguria and rising serum creatinine Repeat careful daily assessments of volume status and clinical perfusion including – body weight – urine output – BP – serum electrolytes – serum creatinine Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 37 Heart Failure with Renal Dysfunction Practical Tips • In the setting of worsening renal function, follow patients closely • Volume-overloaded patients who do not respond to bolus IV furosemide may respond better to continuous infusion • In highly selected cases, under experienced supervision, hypertonic saline with high-dose loop diuretic or intermittent slow continuous venovenous ultrafiltration may be considered • When diuretics are reduced (especially in the setting of a combination ACE inhibitor, ARB or spironolactone) serum electrolytes should be rechecked within 2 to 4 weeks to assess serum potassium Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 38 Heart Failure and Anemia Recommendation • In patients with anemia (plasma hemoglobin < 110 g/L or hematocrit < 35%) – Evaluate for underlying causes such as chronic blood loss or other inflammatory illness – Treat iron, vitamin B12 or folate deficiencies (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 39 Heart Failure and Anemia Practical Tips • There is insufficient evidence to support the routine use of bone marrow-stimulating drugs to increase hemoglobin levels in HF • If plasma hemoglobin < 90 g/L is associated with increased symptoms of HF, blood transfusion or a bone marrowstimulating agent may be considered if advanced symptoms are present and after substrate deficiencies have been corrected • If anemia is severe, patient should be assessed by a physician experienced in its diagnosis and management. Underlying causes should be treated, using intravenous means if necessary Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 40 Heart Failure and Acute Intercurrent Medical Illness Recommendations • Continue beta-blockers and ACE-I at their usual dose during acute intercurrent illness (eg, pneumonia, exacerbation of COPD, other systemic infection, etc), unless they are not tolerated (eg, if significant reactive airways disease is present) (Class IIa, Level C) • In a life-threatening complication, beta-blockers and ACE-I or ARBs may be discontinued abruptly, but – Generally, the dose should be decreased by one-half, and the patient should be reassessed – Dose should be uptitrated to the previous well-tolerated dose as soon as safely possible (Class IIa, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 41 Heart Failure and Acute Intercurrent Medical Illness Recommendations • Initiate beta blockers as soon as possible after diagnosis of HF, including during the index hospitalization, provided that the patient is clinically stable Clinicians should not wait until hospital discharge to start a beta blocker in stablized patients (Class I, Level B) • Continue beta blockers in patients hospitalized with acute HF unless they develop cardiogenic shock, refractory volume overload or symptomatic bradycardia (Class IIa, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 42 Heart Failure and Acute Dehydrating Illness Recommendations • Patients with an acute dehydrating illness should undergo prompt evaluation including measurement of: ○ serum electrolytes ○ blood urea nitrogen ○ creatinine even if not clinically volume-overloaded or volume-depleted. Follow patients carefully until they return to their previous state of health (Class IIa, Level C) • In an acute dehydrating illness with risk of worsening renal function, spironolactone may be temporarily withheld because hyperkalemia is more common in this setting (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 43 Heart Failure and Acute Intercurrent Medical Illness Recommendations • Consider colchicine (or oral or intra-articular steroid) for treatment of acute gout (Class IIa, Level C) • In noncardiac surgery requiring general anesthesia, patients with HF should be evaluated preoperatively by a physician experienced in HF management (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 44 Acute Heart Failure 45 Presentation of Acute Heart Failure (AHF) Rapid onset of appropriate signs and symptoms: • Reduced cardiac output • Decreased tissue perfusion • Increased pulmonary/peripheral congestion • Dyspnea with minimal exertion • Orthopnea/PND • Cough • Increasing abdominal girth • Peripheral edema • Fatigue associated with systolic or diastolic dysfunction, valve dysfunction, or cardiac rhythm abnormalities Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 46 Clinical Presentation of AHF • De novo • Decompensation of known HF • Hypertension • Pulmonary edema • Cardiogenic shock • High output failure (anemia, thyrotoxicosis, arrhythmia, Paget’s disease) • Predominant right-heart failure (elevated JVP, peripheral edema, ascites) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 47 Clinical Presentation of AHF Data from ADHERE database (Acute Decompensated Heart Failure National Registry in the US) • Dyspnea in 89% of patients at presentation • Rales in 68% • Peripheral edema in 66% • SBP <90mmHg in <2% Adams KF Jr, Fonarow GC, Emerman CL, et al; ADHERE Scientific Advisory Committee and Investigators. Am Heart J 2005;149:209-16. 48 Clinical Evaluation of Acute HF Recommendation • Perform thorough clinical evaluation including assessment of perfusion and volume status (cold or warm, wet or dry) (Class IIa, Level C) Nohria A et al. J Am Coll Cardiol 2003;41:1797-804. Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 49 Clinical Evaluation of Acute HF Recommendations • Initial investigations should include ○ Renal function, lytes, CBC, troponin ○ ECG ○ CXR ○ Echocardiogram (if recent results unavailable) ○ BNP if diagnosis remains uncertain • A precipitating cause should be sought in all patients (Class I, Level C) • Serum albumin, D-dimer, liver and thyroid function, arterial blood gas may be useful in selected patients Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 50 Initial Management of AHF Recommendations • Measure vital signs frequently until patient is stable (BP, HR, O2 sat) (Class IIa, Level C) • Monitor fluid balance including urine output (may require bladder catheterization) (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 51 Initial Management of AHF Recommendations • Patients in shock or with significant renal dysfunction require lab investigations (especially serum electrolytes, renal function) regularly in first 24 h (Class I, Level C) • Patients in cardiogenic shock or who require pressors may require invasive monitoring with arterial or CVP lines (Class IIb, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 52 Medical Treatment of AHF Recommendations • Identify and promptly correct underlying/ precipitating cause when possible (Class I, Level B) • Give oxygen initially to all patients with acute HF and hypoxia (Class I, Level C) • If hypoxemia persists despite increasing incremental fraction of oxygen, consider CPAP, BIPAP or endotracheal intubation (Class IIa, Level B) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 53 Medical Treatment of AHF Recommendations • Intravenous diuretics should be given as first-line therapy for patients with acute HF and congestion (Class I, Level B) • Consider vasodilators for patients with dyspnea at rest (Class I, Level C) • Reserve positive inotropes for patients in cardiogenic shock and/or volume overload with diuretic resistance and use short-term to stablize patient. In hypotensive patients (SBP 90 mmHg), dobutamine is preferred over milrinone (Class I, Level C Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 54 Medical Treatment of AHF Recommendations • ACE-I are not recommended routinely in the first few hours of AHF. They should be introduced when the patient is stabilized (Class I, Level B) • CCBs are not recommended in AHF; specifically, diltiazem and verapamil are to be avoided in AHF with systolic dysfunction (Class III, Level B) • Diltiazem may be used in AHF with preserved systolic dysfunction in the setting of AF with rapid ventricular response (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 55 Treatment of AHF Recommendations • In patients with refractory HF despite medical therapy, an intra-aortic balloon pump may be considered (Class IIb, Level B) • Patients who remain in cardiogenic shock and have a low comorbid burden should be transferred early to a tertiary care centre in which circulatory mechanical support and transplantation are available (Class I, Level C) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 56 Management of AHF Practical Tips • Vasodilators, including nitroglycerin (sl or iv), oral nitrates, intravenous nitroprusside and neseritide may be useful in patients with AHF + SBP > 100 mmHg • Patients in cardiogenic shock but who are expected to recover with support or are candidates for heart transplant should be considered for ECMO and VAD support Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 57 Treatment Algorithm for Acute HF Erratum. Can J Cardiol 2006;22(3):271. 58 Biomarkers in Heart Failure 59 Biomarker: Definition and Expectation “A characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” - NIH working group 2001 A cardiac biomarker can enhance clinicians’ abilities to optimally manage patients with a cardiac disorder. Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 60 Elevated BNP Predictive of HF BNP is secreted by ventricular myocytes in response to excessive stretch BNP Trial – ROC curves for BNP predicting diagnosis of CHF in patients with or without CHF history Strunk A et al. Am J Med 2006;119:69:e1-11. 61 NT-proBNP Complements Clinical Judgment Moe GW et al. Circulation 2007;115(24):3103-10. 62 BNP/NT-proBNP in Heart Failure Recommendations • BNP or NT-proBNP should be measured to help confirm or rule out a diagnosis of HF in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt (Class I, Level A) • Measurement may also be considered in patients with known HF for prognostic stratification (Class IIa, Level A) • Sequential measurement of BNP/NT-proBNP levels may be considered to guide therapy in HF patients (Class IIb, Level B) Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 63 BNP/NT-proBNP in Heart Failure Practical Tips • Biomarkers such as BNP and NT-proBNP are complementary to, but do not replace, good clinical evaluation • No compelling factors favor the use of BNP versus NTproBNP • The choice of assay is dictated by – availability – clinician’s familiarity and ability to interpret the results Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 64 BNP and NT-proBNP In HF Cut Points for HF Diagnosis Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45. 65 Looking Forward • HF knowledge has grown exponentially in the last two decades • Many additional clinical trials, planned or in progress, will add to current knowledge and guide therapy: further updates to recommendations are planned (next is Jan 2008) • A national health care strategy for HF would assist in ensuring implementation of recommendations • For Updates visit www.hfcc.ca Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.