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The 2012 ESC Guidelines on Heart Failure.

The ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 were developed by the European Society of Cardiology (ESC) in collaboration with the Heart Failure Association (HFA) of the ESC. They were presented for the first time in May 2012 at the Heart Failure Congress in Belgrade, Serbia, and are published in full, in this EHJ issue and in European Journal of Heart Failure. There are a number of new features since the last ESC Guidelines on this topic were published in 2008. In the area of diagnostics, there is a new biomarker called midregional pro-A-type natriuretic peptide. In pharmacological treatments, two new drugs are discussed: ivabradine and the mineralocorticoid receptor antagonist eplerenone. New evidence with the latter drug has extended the indication for mineralocorticoid receptor antagonists, meaning that for many patients, standard therapy should include three neurohumoral antagonists—an angiotensin-converting enzyme (ACE) inhibitor [or angiotensin receptor blocker (ARB)], a beta-blocker and, if symptoms persist, now a mineralocorticoid receptor antagonist as well. In devices, there is a new indication for cardiac resynchronization therapy (CRT) in patients with mild symptoms. There is also more clarity about the effects of CRT—it is clear that patients with left bundle branch block QRS morphology and those who are in sinus rhythm have the greatest benefit from CRT; conversely, those who have a non-left bundle branch block QRS morphology, and patients in atrial fibrillation have less certain benefit. ‘This is because more evidence from new trials and further analysis of existing trials has emerged since the last Guidelines were published’, says Prof. John McMurray (Glasgow, UK), chairperson of the Guidelines Task Force. Also in the device arena, new transcatheter valve interventions are discussed, offering the possibility of treatment for aortic stenosis in patients unsuitable for surgery. In surgery, there is new information about the role of coronary artery bypass based on the long-awaited results of the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Also, Left Ventricular Assist Device (LVAD) technology has improved; the devices are more reliable and lead to fewer complications. ‘Increasingly there is probably a place for these devices as a treatment in their own right, not just as a temporary support while awaiting transplantation’, says McMurray. ‘It is controversial and we had a lot of discussion about it’. The Task Force took a new approach to lifestyle interventions, such as restricting salt intake, which sound good in principle, but do not have robust support from clinical trials. These interventions remained in the Guidelines but, unlike in 2008, did not receive a class of recommendation or level of evidence. Another new approach was to link the class of recommendation or level of evidence more clearly to the effect of the intervention. The change came about because it seemed unfair to give two interventions the same grading when one lowers, say, pulmonary capillary wedge pressure whereas the other reduces all-cause mortality. This increased focus on whether treatments improve important clinical outcomes led to some treatments receiving a lower recommendation than in the previous Guidelines. For example, the use of nitrates in the management of patients with acute heart failure was downgraded from a class I, level A, to a class IIa, level B, recommendation. The original higher recommendation was based on the acute haemodynamic effects of nitrates. The lower recommendation in the 2012 Guidelines reflects the higher emphasis placed on symptoms, hospitalization and mortality in the grading process. The Task Force readily agreed on 95% of the issues, while the remainder merited more discussion and received a lot of comment from the guideline reviewers. The relative value and place of different imaging modalities in the diagnosis of heart failure received the most comment. Transthoracic echocardiography is still recommended as the first-line imaging investigation in patients with suspected heart failure because of its wide availability, safety and because it is relatively inexpensive. However, the high-quality images generated by CMR and the value of this technique in the assessment of congenital heart disease and infiltrative myocardial diseases, as well as its growing role in the assessment of ischaemia and viability, were recognized. The role of other imaging modalities, including nuclear techniques and CT angiography, is also discussed in the Guidelines. In pharmacological treatment, the two big discussion points were ivabradine and intravenous iron therapy. The concern about ivabradine was that it should not be added before beta-blocker dosing is optimized. ‘Beta blockers are longer established, more effective, certainly a lot less expensive, and really should be given first’, says McMurray. When attempting to reduce the heart rate, they felt it was important to maximize the dose of beta-blocker before giving ivabradine. However, patients with a persistently high heart rate, despite an evidence-based dose of beta-blocker, should then be considered for ivabradine. Another discussion point was the use of intravenous iron therapy in iron-deficient patients. The Task Force was uncertain about whether to make a recommendation based on a single trial with relatively small numbers of patients, short-term follow-up and ‘soft’ endpoints (symptoms, quality of life, exercise