Management of Heart Failure.
• Guideline Directed Medical Therapy is the Cornerstone of Management.
• In recent years, many new modalities have revolutionised the management.
• Challenge lies in giving proper order and priority to available resources
Issues in Choosing appropriate Guidelines for Indian population:
• No specific guidelines for Indian Population.
• Significant Epidemiological and Ethnic differences of Indian Heart Failure Population
compared to Western Societies.
• Different Healthcare delivery systems.
Data on Indian Heart Failure Management Recommendations:
• Mostly consensus documents of adapting Western Guidelines for Indian Population
• Old Literature, not taking into consideration latest developments
• Pressing need for Specific Guidelines suited to Indian Population.
In absence of above, currently reliance on Western Guidelines with
Global Appeal.
Most Updated, Globally Accepted and Practical Recommendations:
1. AHA/ACC Guidelines , Latest Updated in 2022
2. ESC Guidelines, Last update in 2021
Which Guidelines to choose?
• Different Guidelines are COMPLEMENTARY, and not exclusive.
• Consensus on Management across broad categories, but subtle
differences.
• Important to understand the differences, and reasons thereof, for
harmonious use of all available guidelines.
AHA vs ESC Guidelines
A. Definition and Categorisation of Heart Failure:
• ESC Guidelines (2021) updated earlier and do not take into consideration the Latest Universal Definition of
Heart Failure.
• AHA Guidelines (2022) take into consideration latest Universal Definition of HF
Common Categories in 2 Guidelines Additional Category in AHA
1. HFrEF
2. HFpEF HFimpEF
3. HFmrEF
Heart Failure with Improved EF
• Additional Category in AHA
HFimpEF. (Heart Failure with Improved EF)
• This category is prognostically important and takes into account updated
Universal HF definition.
For categorisation of HF, AHA more relevant than ESC.
AHA vs ESC Guidelines
B. Stage A of Heart Failure and Prevention:
• AHA = Detailed explanation and management of Stage A Heart Failure
and management of Risk Factors.
• Very Important from Indian Perspective.
• ESC only gives passing reference to Stage A and risk factors for HF.
For Stage A and Prevention of HF : AHA more informative
than ESC.
AHA vs ESC Guidelines
C. Heart Failure with Preserved Ejection Fraction
• ESC gives no specific management guidlines except
treatment of Etiological Risk factors.
• AHA incorporates latest evidence based drug therapy
For HFpEF = AHA more informative than ESC.
AHA vs ESC Guidelines
D. Newer Pharmacotherapy in Heart Failure:
• Both Guidelines emphasise Quadruple therapy for HF.
• Some differences pertinent to ARNi and New Modalities
like Omecativ.
• Differences Primarily due to timing of Issuance of
Guidelines
ESC issued earlier than AHA, the later incorporating more
1. ARNi in ESC guidelines.
• ESC guidelines, updated in 2021
• Take only PARADIGM study into consideration
• Advocate ARNi only as replacement for ACE
inhibitors.
2. ARNi in AHA guidelines.
• More updated data than ESC.
• Broad usage of ARNI
o De Novo Heart Failure
o Acute Heart Failure
Use of ARNi = AHA more detailed than ESC.
• New Medications like Omecamtiv
mecarbil
only in ESC guidelines as not
available in US
AHA vs ESC Guidelines
E. Cardio-Oncology:
• Incidence of HF in Cancer patients on the rise.
• Importance of early detection, prevention and management.
• ESC Guidelines have specific recommendations in this susbset.
Cardio-Oncology = ESC more informative than AHA.
SUMMARY:
• Pressing Need for Specific Guidelines for Heart Failure in Indian Population
• In absence of Specific Guidelines, Globally recognised Recommendations to be tailored in Indian
Setting.
• AHA / ESC guidelines incorporate most recent recommendations, relevant for current practice.
• AHA and ESC should be viewed as complimentary
• Subtle differences between the two are mostly due to timing of the issuance of guidelines
• AHA incorporates most recent trial data, and more emphasis on Early Stages and at Risk
population, that makes it more relevant to Indian Setting.
