European Consensus Statement on Acute HF Management

Editor's Note:
Recorded for Medscape France at the European Society of Cardiology meeting in London, United Kingdom, the following is a translation of a commentary by Dr Alexandre Mebazaa, lead author of a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society for Emergency Medicine, and the Society for Academic Emergency Medicine on the management of acute heart failure.

My name is Alexandre Mebazaa. I work at the Hôpital Lariboisière [Lariboisière Hospital] in Paris. I’m interested in acute heart failure, and with Professor Alain Cohen-Solal (chief of cardiology at the Hôpital Lariboisière), we have an acute heart failure research team and a biomarker unit at INSERM [Institut national de la santé et de la recherche médicale—French Institute of Health and Medical Research].

From our databases, which are now global in scope, we were able to see that acute heart failure is a disease with one of the highest mortality rates in the fields of cardiology and resuscitation. And quite unique in medicine, it’s a disease where the rehospitalization rate among patients who survive to leave the hospital is very high. Indeed, 20%-30% of them are rehospitalized within a month or two after their first admission for acute heart failure.

What Do the New Recommendations Say?

In terms of management, the drugs we use in acute heart failure have been essentially the same for the past 20-30 years. I'm the lead author of the new recommendations published in the European Journal of Heart Failure^[1] and the European Heart Journal^[2] that were developed by experts in cardiology and resuscitation and also emergency physicians. We recommend more optimal use of the drugs that are currently available—that is, diuretics, vasodilators, and inotropic agents.

Diuretics. Once the patient arrives, determine whether he or she is congested and adjust the diuretic dose accordingly. In the rare cases where there is insufficient urinary output even upon increasing the dose, the diuretic should be combined with one from another class.

Vasodilators and nitrates. Vasodilators are underutilized worldwide. Twenty percent to 25% of patients admitted for acute heart failure on an emergency basis receive vasodilators or nitrates. This percentage can be increased. The main indication is in patients with acute heart failure and a blood pressure greater than 110 mm Hg. All of these patients should be given nitrates.

Inotropic agents. Over the past several years, the harmful effects of catecholamines—mainly adrenaline, dobutamine, and norepinephrine—have been reported in the literature. These drugs are indicated only in cases where there are obvious clinical or electrocardiographic signs of decreased cardiac output. If there are no clear clinical or electrocardiographic signs of decreased cardiac output, these drugs are not indicated and may increase mortality.

So, in these recommendations and in the session I moderated at the 2015 European Society of Cardiology Congress, I clearly stressed the fact that much better use should be made of the drugs that we have today.

Future Therapies

In 2016, we will probably see a major turning point in the treatment of acute heart failure with the publication of two very large studies: RELAX-AHF-EU and TRUE-AHF, the former testing the effect of serelaxin, the latter testing ularitide. The preliminary studies are quite positive and these two drugs are now being tested in phase 3 international studies. The results should be published toward the end of 2016. If either or both studies show positive results, this will be a real turning point for the management of acute heart failure.

Treat as Soon as Possible

Nevertheless, what we are learning from these studies, and what we place a great deal of emphasis on in the recommendations, is that the treatment of acute heart failure should be initiated as soon as possible. We have developed the theory that time is muscle in acute heart failure, exactly like in coronary artery disease.

One of the articles clearly shows that if the same treatment is administered on admission, it can save patients with acute heart failure. Therefore, in the recommendations, we clearly state that one should ideally start treating the patient with nitrate derivatives if his or her blood pressure is greater than 110 mm Hg within 30 minutes to 1 hour of admission, while at the same time performing a clinical evaluation and ordering lab tests (especially, of course, natriuretic peptides [BNP or NT-proBNP]). When the patient arrives, you should also check whether there is any organ dysfunction or organ congestion.

Again, the new elements in 2015 and 2016 are as follows: (1) Make better use of the drugs that are currently available; (2) treat as quickly as possible; and (3) hope for positive results from the two large clinical studies in 2016.

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