Novedades en el tratamiento no farmacológico

Lo mejor del Congreso Europeo de Insuficiencia Cardiaca Florencia 2016

Novedades en el tratamiento no farmacológico

Marisa Crespo Leiro

Complejo Hospitalario Universitario A Coruña

HF 2016


Declaración de Intereses

• Ninguna


Tratamiento no farmacológico

• Desfibrilador Implantable (ICD)

• Resincronización (CRT)

• Trasplante cardiaco (TC)

• Asistencia mecánica circulatoria (MCS)

• Otras novedades


ESC GUIDELINES

2016 ESC Guidelines for the diagnosis and

treatment of acute and chronic heart failure

The Task Force for the diagnosis and t reatment of acute and chronic

heart failure of the European Society of Cardiology (ESC)

Developed with the special cont r ibut ion of the Heart Failure

Associat ion (HFA) of the ESC

Authors/Task Force Members: Piot r Ponikowski* (Chairperson) (Poland),

Adr iaan A. Voors* (Co-Chairperson) (The Nether lands), Stefan D. Anker (Germany),

Hector Bueno (Spain), John G. F. Cleland (UK), Andrew J. S. Coats (UK),

Volkmar Falk (Germany), Jose Ramon Gonzalez-Juanatey (Spain), Veli-Pekka Har jola

(Finland), Ewa A. Jankowska (Poland), Mar iell Jessup (USA), Cecilia Linde (Sweden),

Pet ros Nihoyannopoulos (UK), John T. Par issis (Greece), Burker t Pieske (Germany),

Jillian P. Riley (UK), Giuseppe M. C. Rosano (UK/Italy), Luis M. Ruilope (Spain),

Frank Ruschitzka (Switzer land), Frans H. Rut ten (The Nether lands),

Peter van der Meer (The Nether lands)

Document Reviewers: Gerasimos Filippatos (CPG Review Coordinator) (Greece), John J. V. McMurray (CPG Review

Coordinator) (UK), Vict or Aboyans (France), Stephan Achenbach (Germany), Stefan Agewall (Norway),

Nawwar Al-A t tar (UK), John James Athert on (Aust ralia), Johann Bauersachs (Germany), A. John Camm (UK),

Scipione Carer j (Italy), Claudio Ceconi (Italy), Antonio Coca (Spain), Perry Elliot t (UK), Çet in Erol (Turkey),

Just in Ezekowit z (Canada), Covadonga Fernandez-Gol fın (Spain), Donna Fitzsimons (UK), Marco Guazzi (Italy),

* Correspondingauthors: Piotr Ponikowski, Department of Heart Diseases, Wroclaw Medical University, Centre for Heart Diseases, Military Hospital, ul. Weigla5, 50-981 Wroclaw,

Poland, Tel: + 48 261 660 279, Tel/Fax: + 48 261 660 237, E-mail: [email protected] .

Adriaan Voors, Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1,PO Box 30.001, 9700 RBGroningen, TheNetherlands, Tel: + 31503612355,

Fax: + 31 50 3614391, E-mail: [email protected] .

ESC Commit tee for Pract ice Guidelines (CPG) and Nat ional Cardiac Societ ies document reviewers: listed in the Appendix.

ESC ent it ies having part icipated in the development of this document:

Associat ions: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention and Rehabilitation (EACPR), European Association of

Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA).

Councils: Council on Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Council on Hypertension.

W orking Groups: Cardiovascular Pharmacotherapy,Cardiovascular Surgery, Myocardial and Pericardial Diseases, Myocardial Function, Pulmonary Circulation and Right Ventricular

Function, Valvular Heart Disease.

Thecontent of these European Society of Cardiology (ESC) Guidelines hasbeen published for personal and educational use only.No commercial use isauthorized.No part of theESC

Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford

University Press, the publisher of the European Heart Journal and the party authorized to handle such permissionson behalf of the ESC ([email protected]).

Disclaimer . The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at

the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-

mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-

aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or

therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and

accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor

do theESC Guidelinesexempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by thecompetent

public health authorities, in order to manage each patient’s case in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the

health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

The article hasbeen co-published with permission in European Heart Journal and European Journal of Heart Failure. All rights reserved in respect of European Heart Journal.

& European Society of Cardiology 2016. All rights reserved. For permissions please email: [email protected].

European Heart Journal

doi:10.1093/eurheartj/ehw128

European Heart Journal Advance Access published May 20, 2016 b

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Guidelines!!

Heart Failure: state of the art


2016 ESC Guidelines HF www.escardio.org

ICD




CRT



Desfibrilador Implantable (ICD) Prevención secundaria



No cambios I-A


Desfibrilador Implantable (ICD) Prevención primaria



Síntomas (NYHA II-III) ≥ 3 meses tratamiento médico óptimo FEVI ≤ 35% Supervivencia esperada “sustancialmente” > 1 año Buen estado funcional


Comorbidities

Steinberg, JACC HF 2014; 2: 623-29

• Smoking • Pulmonary disease • Diabetes • Peripheral vascular disease • Atrial fibrillation • Ischemic heart disease • Chronic kidney disease

MADIT I, MADIT II, DEFINITE, SCD-HeFT


No recomendado si: - IAM 40 días antes - NYHA IV (salvo candidatos a CRT, TC o VADs)


Recambios de generador

• Cuando el generador se agota…., no debe de ser “automaticamente” reemplazado • Es controvertido si pacientes con mejoría clara de la FEVI que no han necesitado

terapias ICD... se benefician de un nuevo implante... • Desactivacion en fase terminal



Wearable ICD


Riesgo de MS durante un periodo de tiempo limitado - FEVI reducida post-IAM - Lista de espera TC

http://lifevest.zoll.com/medical-professionals


Limitaciones: No ATP ni CRT No ensayos clínicos


Resincronizacion cardiaca (CRT)

• Duración QRS ≥ 150 ms • Ritmo sinusal vs FA • BRI • Necesidad Estimulación



CRT. Ensayos clínicos relevantes desde 2012

NEJM 2013; 368:1585-93

Biventricular pacing superior to conventional RV pacing in HFrEF, NYHA I-III.

NEJM 2013; 369: 1395-1405

BLOCK-HF

Echo-CRT


CRT. Meta-análisis

.....................................................................................................................................................................................

.....................................................................................................................................................................................

.....................................................................................................................................................................................

CLIN ICAL RESEARCH

An individual pat ient meta-analysisof five

randomized tr ialsassessing the effectsof cardiac

resynchronizat ion therapy on morbidity and

mortality in pat ientswith symptomat ic heart

failure

John G. Cleland1*, W illiam T. Abraham 2, Cecilia Linde3, Michael R. Gold4,

James B. Young5, J. Claude Dauber t 6, Lou Sher fesee7, George A. W ells8,

and Anthony S.L. Tang9

1National Heart and LungInstitute, Imperial College London (Royal Brompton &Harefield Hospitals) and Department of Cardiology, Castle Hill Hospital,University of Hull, Kingston-

upon-Hull, UK; 2Division of Cardiovascular Medicine and the DavisHeart and LungResearch Institute, The Ohio State University, Columbus, OH, USA; 3Department of Cardiology,

Karolinska University Hospital, Stockholm, Sweden; 4Medical University of South Carolina, Charleston, SC, USA; 5Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA;6Departement de Cardiologie, CHU, Rennes, France; 7Medtronic, Inc., Minneapolis, MN, USA; 8The University of OttawaHeart Institute, Ottawa, Canada; and 9The Island Medical

Program, University of British Columbia, Vancouver, Canada

Received 15 May2013; revised 24 June 2013; accepted 4 July2013;online publish-ahead-of-print 29 July2013

A im s Cardiac resynchronization therapy (CRT) with or without adefibrillator reduces morbidity and mortality in selected

patients with heart failure (HF) but response can be variable. We sought to identify pre-implantation variables that

predict the response to CRT in ameta-analysisusing individual patient-data.

Met hods

and r esult s

An individual patient meta-analysisof five randomized trials, funded byMedtronic, comparingCRT either with no active

device or with a defibrillator was conducted, including the following baseline variables: age, sex, New York Heart

Association class, aetiology, QRS morphology, QRS duration, left ventricular ejection fraction (LVEF), and systolic

blood pressure. Outcomes were all-cause mortality and first hospitalization for HFor death. Of 3782 patients in sinus

rhythm, median (inter-quartile range) age was 66 (58–73) years, QRSduration was 160 (146–176) ms, LVEFwas 24

(20–28)%, and 78%had left bundle branch block. A multivariable model suggested that only QRSduration predicted

the magnitude of the effect of CRT on outcomes. Further analysis produced estimated hazard ratios for the effect of

CRT on all-cause mortality and on the composite of first hospitalization for HF or death that suggested increasing

benefitwithincreasingQRSduration,the95%confidenceboundsexcluding1.0at 140 msfor eachendpoint,suggesting

ahigh probability of substantial benefit from CRT when QRSduration exceedsthisvalue.

Conclusion QRSduration isapowerful predictor of theeffectsof CRT on morbidity and mortality in patientswith symptomatic HF

and left ventricular systolicdysfunction who areinsinusrhythm.QRSmorphologydidnot provideadditional information

about clinical response.

ClinicalT r ials.

gov num ber s

NCT00170300, NCT00271154, NCT00251251.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Keywor ds Cardiac resynchronization therapy † Morbidity † Mortality † Heart failure

* Correspondingauthor. Tel: + 44 1482 46 1780; fax: + 44 1482 46 1779, Email: [email protected]

& The Author 2013. Published by Oxford University Presson behalf of the European Society of Cardiology. This isan Open Accessarticle distributed under the termsof the Creative

CommonsAttributionNon-Commercial License(http://creativecommons.org/licenses/by-nc/3.0/),whichpermitsnon-commercial re-use,distribution,andreproductioninanymedium,

provided the original work isproperly cited. For commercial re-use, please contact [email protected]

European Heart Journal (2013) 34, 3547–3556

doi:10.1093/eurheartj/eht290

by

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EHJ 2013; 34: 3547-3556

Solo duración QRS predice beneficio

pronostico


Resincronización cardiaca (CRT)




Síntomas, FEVI ≤ 35%, RS, QRS ≥ 150 y BRI

Síntomas, FEVI ≤ 35%, RS, QRS 130-149 y BRI

Necesidad de estimulación ventricular, FE reducida, Independiente de NYHA (reduce morbilidad)




Síntomas, FEVI ≤ 35%, RS, QRS ≥ 150 y no-BRI

Síntomas, FEVI ≤ 35%, RS, QRS ≥ 130-149 y no-BRI

Síntomas III-IV, FEVI ≤ 35%, FA, QRS ≥ 130 y no-BRI

Upgrading si Mp / ICD FEVI reducida y Empeoramiento IC a pesar de TMO



Muerte cualquier causa u hospitalización IC

Muerte cualquier causa

NEJM 2013; 369: 1395-1405

Contraindicado si QRS < 130 ms


EchoCRT


Trasplante Cardiaco

Mehra M, et al J Heart Lung Transplant 2016

Mehra M, et al J Heart Lung Transplant 2006


No limite de edad como contraindicación absoluta

No intervalo de tiempo definido tras historia de cáncer

BMI < 35 kg/m2

Trasplante Cardiaco

IC terminal sin otras opciones y mal px Motivación, Información

Adherencia al tratamiento

Soporte social

LVAD* si HTP irreversible

*LVAD si otras co-morbilidades potencialmente reversibles: cáncer, obesidad, tabaquismo o IR y reevaluación posterior



Trasplante Cardiaco

Limitaciones y Consecuencias de la

Inmunosupresión

Supervivencia a largo plazo

Adult and Pediatric Heart Transplants Median Donor Age by Location

20

25

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JHLT. 2014 Oct; 33(10): 996-1008

2015 JHLT. 2015 Oct; 34(10): 1244-1254

Donantes MCS como puente al TC

Lund J Heart Lung Transplant 2015


MCS. Terminología

BTD / BTB

BTC

BTT

BTR

DT


Protocolo Heartware CHUAC- Octubre 2014 | PRÓLOGO 1

DISPOSITI VO DE ASISTENCI A

VENTRI CULAR I ZQUIERDA

MANUAL DE USO

PROTOCOLO DE I MPLANTE Y MANEJO

SERVICIO DE UCI

Short-term

Long-term


Asistencia mecánica circulatoria (MCS)

Inotrópicos

Daño orgánico (riñón/hígado)

VD + IT

Hospitalizaciones

FEVI < 25%, VO2 < 12

Pacientes potencialmente elegibles para MCS izda ( LVAD)


Protocolo Heartware CHUAC- Octubre 2014 | PRÓLOGO 1

DISPOSITI VO DE ASISTENCI A

VENTRI CULAR I ZQUIERDA

MANUAL DE USO

PROTOCOLO DE I MPLANTE Y MANEJO

SERVICIO DE UCI


Perfiles INTERMACS Interagency Registry for Mechanically Asisted Circulatory Support

Kirklin J JHLT 2015; 34; 1498-1504 INTERMACS Registry: > 15.000 patients


Fracaso VD severo post LVAD

Kirklin J JHLT 2015; 34; 1498-1504


Recomendaciones MCS

BTT

DT



Dispositivos monitorización IC

Monitorización presión AP (CardioMems)

ICD


IC aguda. Ultrafiltración

Ultrafiltración

Terapia sustitución renal



Tratamiento no farmacológico IC ¿Qué hay de nuevo (vs 2012)?

• DAI

– prevención secundaria: No cambios

– prevención primaria: Pocos cambios • Comorbilidad / Recambios generador / Desactivación en fase

terminal

• CRT: Duración QRS

• TC: Actualización criterios selección

• MCS: El futuro que ya está aquí

• Monitorización hemodinámica “ a distancia”:

– prometedor


Nos vemos en Oviedo, 16-19 Junio

Muchas gracias!


4 days of scientific exchange

+100 scientific sessions

+6 100 healthcare professionals

+100 countries represented

+ 2010 abstracts and cases submitted

+ 300 expert faculty members

+ 2000m2 exhibition space

+ 40 industry sessions and workshops

Heart Failure 2017 29 April – 2 May 2017

Call for abstracts: November 3

www.escardio.org/heartfailure

Novedades en el tratamiento no farmacológico

Health & Medicine

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