Sunday , January 29 2023

European guides on CI: “They are outdated and confusing”


Jose Mª Fernandez Rodriguez, 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 diagnosis and treatment of acute and chronic heart failure. The long-awaited measure of the sector, which, however, was diluted with criticism a few months later. The latest specialty to attack this guide was Internal Medicine, which considers them “Outdated” and poorly written, which leads to “confusion”.

“Feeling that the guidelines are outdated should make them look at them,” said Jose Maria Fernandez Rodriguez of Carmen and Severo Ochoa Hospital’s Internal Medicine Service, who, along with Jorge Rubio Gracio, an internist at Lausanne Blessa Clinical University Hospital; and Pau Llacer Iborra, an intern at Ramon and Cajal University Hospital, condemned the update of guidelines at the 23rd meeting of the Heart Failure and Atrial Fibrillation Group Spanish Society of Internal Medicine (SEMI) which is held in Marbella.

Changes in IC-FEr

For Fernandez Rodriguez, 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.

“Treatment of IC-FEr, it is now transposed with the use of a magnificent four as soon as possible (RNAI + BB + iSGLT2 + ARM). A little of everything is better than a lot of one, ”explains the internist from Carmen and Severo Ochoa Hospital.

According to scientific evidence, RNAI can start even in the congestive phase and when it is depleted of BB. While the use of empaglifocin and dapaglifocin has been shown to reduce cardiovascular mortality and admission of heart failure in an outpatient setting, “more evidence is needed” for a hospitalized patient waiting for an EMPULSE.

As for the low SEC recommendations for these treatments, it is due to abnormal behavior: “A patient with HF-FErm behaves like HF-FEr and therefore recommendation IIB is given for certain treatments (IECAs / ARNI / ARAII, BB, ARM) ”, explains Fernandez Rodriguez.

Some “outdated” guides

For Interna these guides They are now “outdated” in the management of heart failure with a preserved ejection fraction since they do not include evidence in EMPEROM-PRESERVED OPERATION with empagliflocin that reduces CV mortality and admission for heart failure by 21%.

Another of the most controversial aspects of the guide is diuretic use: “In acute heart failure, we must adequately use doses of diuretics, with early assessment of responses to them, advising intensification and / or early combination, otherwise we get the answer for nephron blockade at different levels,” estimates Fernandez Rodriguez.

Other aspects that should be pointed out, according to internists, when updating the guidelines are those that indicate when to use devices (ICD and CRT) and which patients benefit from them. In addition, they have set guidelines for the treatment of various forms of exacerbation or diagnosis and treatment 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 raise several new questions. The first one is high grade of the drug iSGLT-2. “We agree on this, they are safe and effective drugs to improve the prognosis for all patients,” explains Pau Llacer Iborra, who believes that there are probably drugs with a more balanced diuretic effect between the intravascular and extravascular beds.

As for use donorguat (class IIB in the guidelines), it is recommended for 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 ongoing readmissions.

Finally, Omecamtiv-Mecabil, a drug not approved by the European Medicines Agency (EMA) because 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 andReduced heart failure (GALATIC less than 35 percent), ischemic origin and with devices.

Although they may contain statements, data or notes from healthcare institutions or experts, the information contained in the Medical Record is edited and prepared by journalists. We recommend that the reader consult with a healthcare professional about any health issues.

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