Society Guidelines
The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: Anemia, Biomarkers, and Recent Therapeutic Trial Implications

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Abstract

The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides discussion on the management recommendations on 3 focused areas: (1) anemia; (2) biomarkers, especially natriuretic peptides; and (3) clinical trials that might change practice in the management of patients with heart failure. First, all patients with heart failure and anemia should be investigated for reversible causes of anemia. Second, patients with chronic stable heart failure should undergo natriuretic peptide testing. Third, considerations should be given to treat selected patients with heart failure and preserved systolic function with a mineralocorticoid receptor antagonist and to treat patients with heart failure and reduced ejection fraction with an angiotensin receptor/neprilysin inhibitor, when the drug is approved. As with updates in previous years, the topics were chosen in response to stakeholder feedback. The 2014 Update includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers to best manage patients with heart failure.

Résumé

La mise à jour 2014 des Lignes directrices de la Societe canadienne de cardiologie sur la prise en charge de l’insuffisance cardiaque aborde les recommandations de prise en charge de 3 domaines spécialisés : 1) l’anémie; 2) les biomarqueurs, particulièrement les peptides natriurétiques; 3) les essais cliniques qui changeraient la pratique de la prise en charge des patients souffrant d’insuffisance cardiaque. Premièrement, tous les patients souffrant d’insuffisance cardiaque et d’anémie devraient être examinés en vue d’éliminer les causes réversibles de l’anémie. Deuxièmement, les patients souffrant d’insuffisance cardiaque chronique stable devraient subir une analyse du peptide natriurétique. Troisièmement, l’attention devrait être portée au traitement des patients sélectionnés souffrant d’insuffisance cardiaque et d’une fonction systolique préservée par un antagoniste du récepteur minéralocorticoïde, et au traitement des patients souffrant d’insuffisance cardiaque et d’une fraction d’éjection réduite par un inhibiteur des récepteurs de l’angiotensine/inhibiteur de la néprilysine lorsque le médicament est approuvé. Comme les mises à jour des années précédentes, les sujets ont été choisis en réponse à la rétroaction des parties prenantes. La mise à jour de 2014 comprend les recommandations, les valeurs et les préférences, ainsi que les conseils pratiques pour aider les cliniciens et les professionnels de la santé à mieux prendre en charge les patients souffrant d’insuffisance cardiaque.

Section snippets

Anemia in HF

HF is a complex syndrome with effects beyond the myocardium and vasculature. Although treatments that improve survival, exercise capacity, and reduce hospitalizations have been established, the increased complexity of patients with their comorbidities often confounds treatment. These comorbidities become risk factors for future deterioration and might contribute to clinical deterioration, complicate management, or are associated with poorer prognosis. Anemia has been linked to a decrease in

Optimal Use of Biomarkers in HF

Establishing diagnosis and selecting optimal therapy for any patient are current challenges, because the costs associated with HF diagnostic and therapeutic strategies continue to increase. Biomarkers might help stratify risk and individualize therapy.32 In this update, the role of circulating biomarkers for the management of patients with HF are reviewed, with a focus on their role in monitoring for disease progression.

NPs

Recommendations

  • 1.

    We recommend that B-type NP (BNP)/amino-terminal fragment of propeptide BNP (NT-proBNP) levels be measured to help confirm or rule out a diagnosis of HF in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt (Strong Recommendation; High-Quality Evidence).

  • 2.

    We recommend that measurement of BNP/NT-proBNP levels be considered in patients with an established diagnosis of HF for prognostic stratification (Strong Recommendation; High-Quality

Other Biomarkers

As highlighted in previous guidelines,6 renal function has important prognostic implications in HF, as shown in a systematic review and meta-analysis.69 Although the more recently studied renal function-related markers such as neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C could provide earlier (NGAL) or more sensitive (cystatin C) detection of changes in renal function, and these biomarkers have, however, been shown to improve risk stratification in multiple studies,

Mineralocorticoid receptor antagonists in HFpEF

Recommendations

  • 1.

    We suggest that in individuals with HFpEF, an increased NP level, serum potassium < 5.0 mmol/L, and an estimated glomerular filtration rate (eGFR) ≥ 30 mL/min, a mineralocorticoid receptor antagonist like spironolactone should be considered, with close surveillance of serum potassium and creatinine (Weak Recommendation; Low-Quality Evidence).

Values and Preferences. This recommendation is based on a prespecified subgroup analysis of the Treatment Of Preserved CArdiac Function

Conclusions

The 2014 HF guideline update provides the following recommendations. All patients with HF and anemia should be investigated for reversible causes of anemia. Patients with chronic stable HF should undergo NP testing to monitor progress and hospitalized patients should have testing before discharge. Finally, considerations should be given to treat selected patients with HF and preserved systolic function with a mineralocorticoid receptor antagonist, and to treat patients with HF and reduced

References (92)

  • H.F. Groenveld et al.

    Anemia and mortality in heart failure patients a systematic review and meta-analysis

    J Am Coll Cardiol

    (2008)
  • W.H. Tang et al.

    Evaluation and long-term prognosis of new-onset, transient, and persistent anemia in ambulatory patients with chronic heart failure

    J Am Coll Cardiol

    (2008)
  • S. Ather et al.

    Impact of noncardiac comorbidities on morbidity and mortality in a predominantly male population with heart failure and preserved versus reduced ejection fraction

    J Am Coll Cardiol

    (2012)
  • N.P. Arora et al.

    Anemia and iron deficiency in heart failure

    Heart Fail Clin

    (2014)
  • A.S. Maisel et al.

    Bedside B-type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study

    J Am Coll Cardiol

    (2003)
  • B. Lindahl et al.

    Serial analyses of N-terminal pro-B-type natriuretic peptide in patients with non-ST-segment elevation acute coronary syndromes: a Fragmin and fast Revascularisation during In Stability in Coronary artery disease (FRISC)-II substudy

    J Am Coll Cardiol

    (2005)
  • A. Morello et al.

    Association of atrial fibrillation and amino-terminal pro-brain natriuretic peptide concentrations in dyspneic subjects with and without acute heart failure: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) study

    Am Heart J

    (2007)
  • J.G. Cleland et al.

    Plasma concentration of amino-terminal pro-brain natriuretic peptide in chronic heart failure: prediction of cardiovascular events and interaction with the effects of rosuvastatin: a report from CORONA (Controlled Rosuvastatin Multinational Trial in Heart Failure)

    J Am Coll Cardiol

    (2009)
  • J.A. Ezekowitz et al.

    Providing Rapid Out of Hospital Acute Cardiovascular Treatment 3 (PROACT-3)

    Can J Cardiol

    (2014)
  • R. Berger et al.

    N-terminal pro-B-type natriuretic peptide-guided, intensive patient management in addition to multidisciplinary care in chronic heart failure a 3-arm, prospective, randomized pilot study

    J Am Coll Cardiol

    (2010)
  • L.W. Eurlings et al.

    Management of chronic heart failure guided by individual N-terminal pro-B-type natriuretic peptide targets: results of the PRIMA (Can PRo-brain-natriuretic peptide guided therapy of chronic heart failure IMprove heart fAilure morbidity and mortality?) study

    J Am Coll Cardiol

    (2010)
  • J.L. Januzzi et al.

    Use of amino-terminal pro-B-type natriuretic peptide to guide outpatient therapy of patients with chronic left ventricular systolic dysfunction

    J Am Coll Cardiol

    (2011)
  • P. Jourdain et al.

    Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP Multicenter Study

    J Am Coll Cardiol

    (2007)
  • J.G. Lainchbury et al.

    N-terminal pro-B-type natriuretic peptide-guided treatment for chronic heart failure: results from the BATTLESCARRED (NT-proBNP-Assisted Treatment To Lessen Serial Cardiac Readmissions and Death) trial

    J Am Coll Cardiol

    (2009)
  • M.R. Shah et al.

    The STARBRITE trial: a randomized, pilot study of B-type natriuretic peptide-guided therapy in patients with advanced heart failure

    J Card Fail

    (2011)
  • R.W. Troughton et al.

    Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations

    Lancet

    (2000)
  • E. Braunwald

    Heart failure

    JACC Heart Fail

    (2013)
  • G.M. Felker et al.

    Biomarker-guided therapy in chronic heart failure: a meta-analysis of randomized controlled trials

    Am Heart J

    (2009)
  • D. Logeart et al.

    Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure

    J Am Coll Cardiol

    (2004)
  • M. Huelsmann et al.

    PONTIAC (NT-proBNP selected prevention of cardiac events in a population of diabetic patients without a history of cardiac disease): a prospective randomized controlled trial

    J Am Coll Cardiol

    (2013)
  • G.L. Smith et al.

    Renal impairment and outcomes in heart failure: systematic review and meta-analysis

    J Am Coll Cardiol

    (2006)
  • J. Bartunek et al.

    Nonmyocardial production of ST2 protein in human hypertrophy and failure is related to diastolic load

    J Am Coll Cardiol

    (2008)
  • J.L. Januzzi et al.

    Measurement of the interleukin family member ST2 in patients with acute dyspnea: results from the PRIDE (Pro-Brain Natriuretic Peptide Investigation of Dyspnea in the Emergency Department) study

    J Am Coll Cardiol

    (2007)
  • A.H. Wu et al.

    Biological variation of galectin-3 and soluble ST2 for chronic heart failure: implication on interpretation of test results

    Am Heart J

    (2013)
  • A. Bayes-Genis et al.

    Soluble ST2 serum concentration and renal function in heart failure

    J Card Fail

    (2013)
  • A. Bayes-Genis et al.

    Head-to-head comparison of 2 myocardial fibrosis biomarkers for long-term heart failure risk stratification: ST2 versus galectin-3

    J Am Coll Cardiol

    (2014)
  • J.B. Kostis et al.

    Omapatrilat and enalapril in patients with hypertension: the Omapatrilat Cardiovascular Treatment vs. Enalapril (OCTAVE) trial

    Am J Hypertens

    (2004)
  • J. Malcom et al.

    Canadian Cardiovascular Society Consensus Conference guidelines on heart failure–2008 update: best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies

    Can J Cardiol

    (2008)
  • J.P. McCormack et al.

    Adding “value” to clinical practice guidelines

    Can Fam Physician

    (2007)
  • World Health Organization

    Vitamin and Mineral Nutrition Information System (VMNIS). Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity

    (2011)
  • Y.D. Tang et al.

    Anemia in chronic heart failure: prevalence, etiology, clinical correlates, and treatment options

    Circulation

    (2006)
  • A.S. Androne et al.

    Hemodilution is common in patients with advanced heart failure

    Circulation

    (2003)
  • T.E. Owan et al.

    Trends in prevalence and outcome of heart failure with preserved ejection fraction

    N Engl J Med

    (2006)
  • C. Opasich et al.

    Blunted erythropoietin production and defective iron supply for erythropoiesis as major causes of anaemia in patients with chronic heart failure

    Eur Heart J

    (2005)
  • L. Guo et al.

    Serum erythropoietin level predicts the prognosis of chronic heart failure with or without anemia

    Exp Ther Med

    (2013)
  • E. O’Meara et al.

    Heart failure with anemia: novel findings on the roles of renal disease, interleukins, and specific left ventricular remodeling processes

    Circ Heart Fail

    (2014)
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    The disclosure information of the authors and reviewers is available from the CCS website: www.ccs.ca.

    This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.

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