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13.14 Infection

Infective disorders may worsen HF symptoms and be a precipitant factor for AHF.872,873 Severe sepsis and pneumonia can cause myocardial injury and depress cardiac function leading to cardiac dysfunction and HF and this risk is greater in patients with a history of HF.873875 More recently, the coronavirus disease 2019 (COVID- 19) pandemic has emerged as a major cause of morbidity and mortality as well as of HF decompensation.873,876878 Specific guidance is available.879 General recommendations related to infections are given in Table 24. Influenza vaccination is associated with a reduced risk of all-cause death in patients with HF in observational studies and retrospective analyses.880882 Influenza and pneumococcal vaccination, as well as COVID-19 vaccination, when available, should be considered in patients with HF.879,883

14 Special conditions

14.1 Pregnancy

14.1.1 Pregnancy in pre-existing heart failure Women with pre-existing HF have a higher risk of pregnancy-related CV complications including HF decompensation. Moderate- and high-risk patients according to the modified World Health Organization (mWHO) class IIIIV should be referred to a specialist centre with a multidisciplinary Pregnancy Heart Team.884 An algorithm for the management of HF patients before and during pregnancy is reported in Figure 19.

Pre-pregnancy management includes the modification of existing HF medications to avoid foetal harm. ACE-Is, ARBs, ARNI, MRAs, ivabradine, and SGLT2 inhibitors are contraindicated and should be stopped prior to conception with close clinical and echocardiographic monitoring. Beta-blockers should be continued and switched to beta-1-selective blockers (bisoprolol, metoprolol succinate). Hydralazine, oral nitrates and methyldopa can be started if required. Therapeutic anticoagulation with low-molecular-weight heparin (LMWH), in the first and last trimesters, and VKAs, with the usual target international normalized ratios (INRs) or LMWH for the second trimester, is recommended for patients with HF and AF. DOACs should be avoided.884 Assessment of patients with HF in pre-pregnancy or at presentation with a new pregnancy should include a clinical assessment (symptoms, clinical examination, BP, SaO2), ECG and resting echocardiography. The modalities of delivery should be planned by cardiologists, obstetricians, and anaesthesiologists around 35 weeks in a multidisciplinary Pregnancy Heart Team. Bimonthly assessments for women in mWHO IIIII, and monthly assessments for women with pre-existing HF in mWHO III, must be performed. Women with advanced HF (LVEF <30%, NYHA class IIIIV) in mWHO IV who are pregnant can be referred to a specialist centre for counselling regarding any consideration of termination of pregnancy. The decision regarding modalities of delivery can be planned by cardiologists, obstetricians, and anaesthesiologists around 35 weeks in a multidisciplinary Pregnancy Heart Team and discussed with the patient.884

14.1.2 New heart failure presenting during pregnancy The increased demands on ventricular function due to the increased circulating volume and cardiac output of pregnancy can unmask pre-

Recommendations for the management of patients with cancer and heart failure

Recommendation Classa Levelb

It is recommended that cancer patients at increased risk for cardiotoxicity, defined by a history or risk factors of CV disease, previous cardiotoxicity or exposure to cardiotoxic agents, undergo CV evaluation before scheduled anticancer therapy, preferably by a cardiologist with experience/interest in Cardio- Oncology. I C Treatment with an ACE-I and a beta-blocker (preferably carvedilol) should be considered in cancer patients developing LV systolic dysfunction, defined as a 10% or more decrease in LVEF and to a value lower than 50%, during anthracycline chemotherapy.861,862 IIa B A baseline CV risk assessment should be considered in all cancer patients scheduled to receive a cancer treatment with the potential to cause heart failure.846,865 IIa C

ACE-I = angiotensin-converting enzyme inhibitor; CV = cardiovascular; LV = left ventricular; LVEF = left ventricular ejection fraction. aClass of recommendation. bLevel of evidence. Table 24 Infections in patients with heart failure

Patients with HF are at increased risk of infections and have poorer outcomes once infected. Telemonitoring avoids the risks of infections caused by close contact. It is useful during pandemic conditions. Telemonitoring may be implemented for patients’ follow-up in pandemic conditions. During pandemics, HF patients should be screened for infection at the time of hospitalization, in case of urgent admissions, or before elective hospitalizations. Careful assessment of fluid status, in addition to clinical signs of HF, is mandatory during hospitalization in patients with concomitant sepsis. Repeated measures of inferior vena cava diameter and collapsibility by echocardiography may be used to assess fluid status. OMT (including beta-blocker, ACE-I, ARB or ARNI, MRA and SGLT2 inhibitors), should be continued in chronic HF patients whenever BP and haemodynamic conditions permit and considering drug interaction with infection related therapies and side effect profile. ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; ARNI = angiotensin receptor-neprilysin inhibitor; BP = blood pressure; HF = heart failure; MRA = mineralocorticoid receptor antagonist; OMT = optimal medical therapy; SGLT2 = sodium-glucose co-transporter 2.

ESC 2021 ESC 2021

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