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ESC GuidelinesExecutive summary of the guidelines on thediagnosis and treatment of acute heart failureThe Task Force on Acute Heart Failure of theEuropean Society of CardiologyEndorsed by the European Society of Intensive Care Medicine (ESICM)Authors/Task Force Members, Markku S. Nieminen, Chairperson* (Finland),Michael Bo hm (Germany), Martin R. Cowie (UK), Helmut Drexler (Germany),Gerasimos S. Filippatos (Greece), Guillaume Jondeau (France),Yonathan Hasin (Israel), Jose Lopez-Sendon (Spain),Alexandre Mebazaa{(France), Marco Metra (Italy),Andrew Rhodes{(UK), Karl Swedberg (Sweden)ESC Committee for Practice Guidelines (CPG), Silvia G. Priori (Chairperson) (Italy),Maria Angeles Alonso Garcia (Spain), Jean-Jacques Blanc (France), Andrzej Budaj (Poland),Martin R Cowie (UK), Veronica Dean (France), Jaap Deckers (The Netherlands),Enrique Fernandez Burgos (Spain), John Lekakis (Greece),Bertil Lindahl (Sweden),Gianfranco Mazzotta (Italy),Joa o Morais (Portugal), Ali Oto (Turkey), Otto A. Smiseth (Norway)Document Reviewers, Maria Angeles Alonso Garcia (Co-CPG Review Coordinator) (Spain),Kenneth Dickstein (Co-CPG Review Coordinator) (Norway), Anibal Albuquerque (Portugal), Pedro Conthe (Spain),Maria Crespo-Leiro (Spain), Roberto Ferrari (Italy), Ferenc Follath (Switzerland), Antonello Gavazzi (Italy),Uwe Janssens (Germany), Michel Komajda (France), Joa o Morais (Portugal), Rui Moreno (Portugal),Mervyn Singer (UK), Satish Singh (UK), Michal Tendera (Poland), Kristian Thygesen (Denmark)Online publish-ahead-of-print 28 January 2005Table of contentsPreamble......................... 3851. Introduction ................... 3852. Epidemiology, aetiology, andclinical context ................. 386I. Denitions, diagnostic steps, instrumentationand monitoring of the patient with AHF..... 3863. Denition and clinical classication of AHF . 3863.1. Denition.................. 3863.2. The clinical syndrome of AHF ...... 3884. Pathophysiology of AHF............. 3894.1. The vicious circle in the acute failingheart .................... 3894.2. Myocardial stunning............ 3894.3. Hibernation ................. 3895. Diagnosis of AHF................. 3905.1. Clinical evaluation ............. 3905.2. Electrocardiogram (ECG) ......... 3915.3. Chest X-ray and imaging techniques .. 3915.4. Laboratory tests .............. 3915.5. Echocardiography ............. 3915.6. Other investigations............ 3926. Goals of the treatment of AHF ........ 3926.1. Organization of the treatment of AHF . 3937. Instrumentation and monitoring of patients inAHF ........................ 3937.1. Non-invasive monitoring ......... 3937.2. Invasive monitoring ............ 393& The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oupjournals.org*Correspondingauthor.Chairperson:MarkkuS.Nieminen,DivisionofCardiology, Helsinki UniversityCentral Hospital, Haartmaninkatu4,00290 Helsinki, Finland. Tel.: 358 94717 22 00; fax: 358 9 4717 40 15.E-mail address: markku.nieminen@hus.{Members of the EuropeanSociety of Intensive Care MedicineEuropean Heart Journal (2005)26, 384416doi:10.1093/eurheartj/ehi044 by guest on December 3, 2010eurheartj.oxfordjournals.orgDownloaded from II. Treatment of AHF.................. 3948. General medical issues in thetreatment of AHF ................ 3949. Oxygen and ventilatory assistance ...... 3959.1. Rationale for using oxygen in AHF .... 3959.2. Ventilatory support withoutendotracheal intubation (non-invasiveventilation)................. 3959.3. Mechanical ventilation withendotracheal intubation in AHF ..... 39610. Medical treatment ............... 39610.1. Morphine and its analogues in AHF.. 39610.2. Anticoagulation ............. 39610.3. Vasodilators in the treatment of AHF 39610.4. Angiotensin converting enzyme(ACE)-inhibitors in AHF ......... 39710.5. Diuretics ................. 39810.6. b-blocking agents............ 39910.7. Inotropic agents ............. 40011. Underlying diseases and co-morbiditiesin AHF ...................... 40311.1. Coronary artery disease ........ 40311.2. Valvular disease............. 40511.3. Management of AHF due to prostheticvalve thrombosis (PVT) ......... 40511.4. Aortic dissection ............ 40511.5. AHF and hypertension ......... 40511.6. Renal failure ............... 40611.7. Pulmonary diseases andbronchoconstriction ........... 40611.8. Arrhythmias and AHF.......... 40611.9. Peri-operative AHF ........... 40812. Surgical treatment of AHF .......... 40812.1. AHF related to complications of AMI . 40813. Mechanical assist devices andheart transplantation ............. 40913.1. Indication ................ 40913.2. Heart transplantation ......... 41014. Summary comments .............. 411References ........................ 412PreambleGuidelines and Expert Consensus documents aimto presentall therelevant evidenceonaparticular issueinordertohelpphysicians toweighthebenets andrisks of aparticular diagnostic or therapeutic procedure. Theyshould be helpful in everyday clinical decision-making.Agreat number of Guidelines andExpert ConsensusDocuments have been issued in recent years by theEuropeanSocietyof Cardiology(ESC) andbydifferentorganizationsandotherrelatedsocieties.This profusioncan put at stake the authority and validity of guidelines,whichcanonlybeguaranteediftheyhavebeendevel-oped by an unquestionable decision-making process.ThisisoneofthereasonswhytheESCandothershaveissued recommendations for formulating and issuingGuidelines and Expert Consensus Documents.Inspiteof thefact that standards for issuing goodqualityGuidelinesandExpertConsensusDocumentsarewell dened, recent surveys of Guidelines andExpertConsensus Documents publishedinpeer-reviewedjour-nalsbetween1985and1998haveshownthatmethodo-logical standards were not complied with in the vastmajority of cases. It is thereforeof great importancethat guidelines and recommendations are presentedin formats that are easily interpreted. Subsequently,their implementation programmes must also be wellconducted. Attempts have been made to determinewhetherguidelinesimprovethequalityofclinicalprac-tice and the utilization of health resources.The ESC Committee for Practice Guidelines (CPG)supervises and coordinates the preparation of new Guide-lines and Expert Consensus Documents produced by TaskForces, expertgroupsorconsensuspanels. Thechosenexperts in these writing panels are asked to provide dis-closurestatements of all relationships they may havewhichmightbeperceivedasreal orpotential conictsof interest. Thesedisclosureforms arekept onleatthe European Heart House, headquarters of the ESC.TheCommitteeisalsoresponsiblefortheendorsementoftheseGuidelinesandExpertConsensusDocumentsorstatements.The Task Force has classied and ranked the usefulnessor efcacy of the recommended procedure and/or treat-ments and the Level of Evidence as indicated in thetables below:1. IntroductionTheaimoftheseguidelinesistodescribetherationalebehind the diagnosis and treatment of acute heartfailure (AHF) in the adult population.Classes of RecommendationsClass I Evidence and/or general agreement that a givendiagnostic procedure/treatment is benecial,useful and effective;Class II Conicting evidence and/or a divergence ofopinion about the usefulness/efcacy of thetreatment;Class IIa Weight of evidence/opinion is in favour of use-fulness/efcacy;Class IIb Usefulness/efcacy is less well established byevidence/opinion;Class IIIEvidence or general agreement that the treat-ment is not useful/effective and in some casesmay be harmful.Use of Class III is discouragedby the ESC.Levels of EvidenceLevel of Evidence A Data derived from multiple random-ized clinical trials or meta-analysesLevel of Evidence B Data derived from a single random-ized clinical trial or large non-randomized studiesLevel of Evidence C Consensus of opinion of the expertsand/or small studies; retrospectivestudies and registriesESC Guidelines 385 by guest on December 3, 2010eurheartj.oxfordjournals.orgDownloaded from TheCommitteefor PracticeGuidelines (CPG) of theEuropean Society of Cardiology nominated the TaskForcefortheAHFGuidelines. TheTaskForceincludedrepresentatives fromthe Heart Failure Association ofthe ESC and members of the European Society ofIntensiveCareMedicine(ESICM).TheTaskForcerecom-mendationswerecirculatedamongareviewboardandapproved by the CPGof the ESC and by the ESICM.Together with the Guidelines for the diagnosis and treat-ment of chronic heart failure1these Guidelines form therecommendations ondiagnosis andtreatment of heartfailure.The recommendations are also published as an un-abridged version of the document,2as a pocket guideline,and as an ESC educational product CD.2. Epidemiology, aetiology, andclinical contextThecombinationoftheagingofthepopulationinmanycountries,andimprovedsurvivalafteracutemyocardialinfarction (AMI)3has created a rapid growth in thenumber of patients currentlylivingwithchronicheartfailure (CHF),4with a concomitant increase in thenumber of hospitalizations for decompensated heartfailure. Coronaryheartdiseaseistheaetiologyof AHFin 6070% of patients,57particularly in the elderly popu-lation.Inyoungersubjects,AHFisfrequentlycausedbydilatedcadiomyopathy,arrhythmia,congenitalorvalvu-lar heart disease, or myocarditis. The causes and compli-cations of AHF are described in Table 1.Themanagement of heart failureconsumes 12%ofhealthcareexpenditureinEuropeancountries,8,9witharound75%relatingtoinpatient care. Advancedheartfailureandrelatedacutedecompensationhavebecomethe single most costly medical syndrome incardiology.10,11Patients with AHF have a very poor prognosis. Mortalityis particularly high in patients with acute myocardialinfarction (AMI) accompanied by severe heart failure,with a 30% 12 month mortality.12Likewise, in acutepulmonary oedema a 12% in-hospital and 40% 1 yearmortality have been reported.13About 45%of patients hospitalizedwithAHFwill berehospitalized at least once (and 15%at least twice)within twelve months.