José Mª Fernández Rodríguez, Jorge Rubio Gracia, Jesus Casado Cerrada and Pau Llacer Iborra.
At the end of August this year, the European Society of Cardiology (SEC) updated its clinical guidelines for the diagnosis and treatment of acute and chronic heart failure. A long-awaited measure by the sector, which, however, months later has been diluted by criticism. The latest specialty to attack this guide has been Internal Medicine, who considers them “Outdated” and poorly written leading to “confusion.”
“Having the feeling that the guidelines are already obsolete is to make them look at it”, declares José María Fernández Rodríguez, from the Internal Medicine Service of the Carmen y Severo Ochoa Hospital, who together with Jorge Rubio Gracia, internist at the Lozano Blesa Clinical University Hospital; and Pau Llacer Iborra, internist at the Ramón y Cajal University Hospital, have shelled the update of the guidelines in the 23rd Meeting of the Heart Failure and Atrial Fibrillation Group from Spanish Society of Internal Medicine (SEMI) taking place in Marbella.
Changes in IC-FEr
For Fernández Rodríguez, the diagnostic criteria have not changed, except for the new classification of heart failure and moderately reduced ejection fraction (CI-FEr), in which structural or functional changes no longer need to be demonstrated.
“The treatment of IC-FEr, now it is transversal with the use of the magnificent four asap (RNAI + BB + iSGLT2 + ARM). A little of everything is better than a lot of one, ”explains the internist at Hospital Carmen y Severo Ochoa.
According to scientific evidence, RNAI can be started even in the congestive phase and when it is depleted with BB. While the use of Empaglifocin and dapaglifocin has been shown to reduce cardiovascular mortality and heart failure admissions in the outpatient, but “more evidence is still needed” for the hospitalized patient pending EMPULSE.
As for the low recommendations for these treatments by the SEC, it is due to an anomalous behavior: “The patient with HF-FErm behaves like a HF-FEr and therefore an IIB recommendation is given to certain treatments (IECAs / ARNI / ARAII, BB, ARM) ”, explains Fernández Rodríguez.
Some “obsolete” guides
For Interna these guides They are now “obsolete” in the management of Heart Failure with preserved ejection fraction since they do not include the evidence in the EMPEROR-PRESERVED OP with empagliflocin that reduces CV mortality and admissions for Heart Failure by 21%.
Another of the most controversial aspects of the guide is the use of diuretics: “In acute heart failure we must make an adequate use of diuretic doses, with early evaluations of the responses to them, advising intensification and / or early combination, otherwise we obtain a response for the nephron blockade at various levels”, estimates Fernández Rodriguez.
Other aspects to highlight, according to internists, in the update of the guidelines is that they indicate when to use devices (ICD and CRT) and which patients benefit from them. In addition, they set the treatment guidelines for the different forms of exacerbation or diagnosis and treatments for specific forms of heart failure.
New drugs for patients with reduced LVEF
Regarding patients with heart failure with reduced left ventricular ejection fraction (LVEF), the guidelines establish several novel issues. The first one is the high rating of the iSGLT-2 drug. “In this we agree, they are safe and effective drugs to improve the prognosis of all patients,” explains Pau Llacer Iborra, who believes that there are probably drugs with a more balanced diuretic effect between intra and extravascular bed
Regarding the use of donorguat (class IIB in the guidelines), they recommend it in patients with heart failure with reduced and slightly reduced LVEF (VICTORIA LVEF less than 45 percent) together with patients with advanced heart failure with optimized background treatment and persistent readmissions.
Finally, the Omecamtiv-Mecabil, a drug not approved by the European Medicines Agency (EMA) since it is not currently considered for patients with heart failure, internists believe that if there is scientific evidence to support its use in patients with iReduced heart failure (GALATIC less than 35 percent), of ischemic origin and with devices.
Although it may contain statements, data or notes from health institutions or professionals, the information contained in Medical Writing is edited and prepared by journalists. We recommend that the reader be consulted with any health-related question with a healthcare professional.