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17 ‘What to do’ and ‘what not to do’ messages from the guidelines

Recommendations Classa Levelb

Recommendations for the diagnosis of chronic HF BNP/NT-proBNP.c I B 12-lead ECG. I C Transthoracic echocardiography. I C Chest radiography (X-ray). I C Routine blood tests for comorbidities (including full blood count, urea and electrolytes, thyroid function, fasting glucose and HbA1c, lipids. Iron studies (TSAT and ferritin). I C CMR is recommended for the assessment of myocardial structure and function in those with poor echocardiogram acoustic windows. I C CMR is recommended for the characterization of myocardial tissue in suspected infiltrative disease, Fabry disease, inflammatory disease (myocarditis), LV non-compaction, amyloid, sarcoidosis, iron overload/haemochromatosis. I C Invasive coronary angiography is recommended in patients with angina despite pharmacological therapy or symptomatic ventricular arrhythmias. I B Cardiopulmonary exercise testing is recommended as a part of the evaluation for heart transplantation and/or MCS. I C Right heart catheterization is recommended in patients with severe HF being evaluated for heart transplantation or MCS. I C Recommendations for the treatment of HFrEF ACE-I is recommended for patients with HFrEF to reduce the risk of HF hospitalization and death. I A Beta-blocker is recommended for patients with stable HFrEF to reduce the risk of HF hospitalization and death. I A MRA is recommended for patients with HFrEF to reduce the risk of HF hospitalization and death. I A Dapagliflozin or empagliflozin are recommended for patients with HFrEF to reduce the risk of HF hospitalization and death. I A Sacubitril/valsartan is recommended as a replacement for an ACE-I in patients with HFrEF to reduce the risk of HF hospitalization and death. I B Diuretics are recommended in patients with HFrEF with signs and/or symptoms of congestion to alleviate HF symptoms, improve exercise capacity and reduce HF hospitalizations. I C An ARBc is recommended to reduce the risk of HF hospitalization and CV death in symptomatic patients unable to tolerate an ACE-I or ARNI (patients should also receive a beta-blocker and an MRA). I B The addition of an ARB (or renin inhibitor) to the combination of an ACE-I and an MRA is not recommended in patients with HF, because of the increased risk of renal dysfunction and hyperkalaemia. III C An ICD is recommended to reduce the risk of sudden death and all-cause mortality in patients who have recovered from a ventricular arrhythmia causing haemodynamic instability, and who are expected to survive for >1 year with good functional status, in the absence of reversible causes or unless the ventricular arrhythmia has occurred <48 h after a MI. I A An ICD is recommended to reduce the risk of sudden death and all-cause mortality in patients with symptomatic HF (NYHA class IIIII) of an ischaemic aetiology (unless they have had an MI in the prior 40 days—see below), and an LVEF <_35% despite >_3 months of OMT, provided they are expected to survive substantially longer than 1 year with good functional status. I A ICD implantation is not recommended within 40 days of an MI as implantation at this time does not improve prognosis. III A ICD therapy is not recommended in patients in NYHA class IV with severe symptoms refractory to pharmacological therapy unless they are candidates for CRT, a VAD, or cardiac transplantation. III C CRT is recommended for symptomatic patients with HF in SR with a QRS duration >_150 ms and LBBB QRS morphology and with LVEF <_35% despite OMT in order to improve symptoms and reduce morbidity and mortality. I A CRT rather than RV pacing is recommended for patients with HFrEF regardless of NYHA class or QRS width who have an indication for ventricular pacing for high degree AV block in order to reduce morbidity. This includes patients with AF. I A CRT is not recommended in patients with a QRS duration <130 ms who do not have an indication for pacing due to highdegree AV block. III A Recommendations for the treatment of HFmrEF and HFpEF Diuretics are recommended in patients with congestion and HFmrEF in order to alleviate symptoms and signs. I C

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