Major developments in the 2016 European guidelines for heart failure

Carles Trullàs, J.; González-Franco, Á.

doi:10.1016/j.rceng.2017.01.002

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Abbreviations: HF, heart failure; IV, intravenous; NaP, plasma sodium concentration; HSS: hypertonic saline serum." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Pose, L. Almenar, L. Manzano, J.J. Gavira, A. López Granados, J. Delgado, O. Aramburu, J.C. Arévalo, M. Méndez, J. Comín, N. Manito" "autores" => array:11 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Pose" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Almenar" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Manzano" ] 3 => array:2 [ "nombre" => "J.J." "apellidos" => "Gavira" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "López Granados" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "Delgado" ] 6 => array:2 [ "nombre" => "O." "apellidos" => "Aramburu" ] 7 => array:2 [ "nombre" => "J.C." "apellidos" => "Arévalo" ] 8 => array:2 [ "nombre" => "M." "apellidos" => "Méndez" ] 9 => array:2 [ "nombre" => "J." "apellidos" => "Comín" ] 10 => array:2 [ "nombre" => "N." 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Carles Trullàs, Á. González-Franco" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Carles Trullàs" "email" => array:1 [ 0 => "jctv5153@comg.cat" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Á." 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The number of recommendations has also increased substantially (from 124 to 188), especially the sections on diagnosis, comorbidities and acute HF (AHF) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The proportion of recommendations in CPGs with a high level of scientific evidence (level A) is usually low.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> The 2012 CPGs had a low proportion of Type I-A recommendations (29 of 124, 23%), with a predominance of level of evidence C recommendations (45%) over level A recommendations (35%).<a class="elsevierStyleCrossRef" href="#bib0145">5</a> To assess whether the 2016 CPGs have improved the level of evidence, we analyzed and classified its 188 recommendations according to the levels of scientific evidence and degree of recommendation. In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, we can see that the increase in the number of recommendations is mainly at the expense of level B (30%) and C (49%) recommendations. The proportion of level A recommendations is still less than that of 2012 (only 21%).Main developmentsThe main developments of the 2016 CPGs, which are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, are as follows.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>New term: heart failure with “Mid-range left ventricular ejection fraction”The most widely used terminology for reporting and classifying HF is based on the left ventricular ejection fraction (LVEF). Two types have classically been considered: HF with normal LVEF (≥50%) or preserved (HFpEF) and HF with reduced LVEF (<40%; HFrEF). Patients with LVEF between 40% and 49% represented a “gray area” that, according to the new CPGs, constitute a new group: HF with mid-range LVEF (HFmrEF). The proposed diagnostic criteria are very similar to those of HFpEF: (1) presence of signs/symptoms of HF; (2) LVEF 40–49%; (3) high natriuretic peptide levels (BNP >35pg/mL or NT-proBNP >125pg/mL) and at least one echocardiographic criterion (ventricular hypertrophy, left atrial dilation or signs of diastolic dysfunction). The identification of HFmrEF as a separate group should stimulate research designed to determine the clinical characteristics, treatment and prognosis of this type of patient.New algorithm for diagnosing chronic heart failure: clinical probability of heart failureThe diagnostic algorithm for HF has been modified significantly compared with the 2012 version. In the current guidelines, the algorithm distinguishes between patients with acute or chronic HF. For chronic patients, the new guidelines introduce the assessment of the clinical probability of HF based on the medical history (coronary artery disease, arterial hypertension, use of diuretics), presentation symptoms (orthopnea and paroxysmal nocturnal dyspnea), physical examination (jugular vein engorgement, displacement of the apex beat, murmurs) and electrocardiogram findings. If all these elements are normal, the diagnosis of HF is highly unlikely, and alternative diagnoses need to be considered. Whether one of the elements is abnormal, the plasma concentration of natriuretic peptides needs to be measured, if possible, to identify patients who require echocardiography. The echocardiogram is indicated if the peptide levels are not available or if its values are above the diagnostic cutoff.New section: preventing or delaying the progression to heart failureThe new guidelines put greater emphasis on measures aimed at preventing HF or delaying its onset. Thus, the guidelines introduced a new section of specific recommendations focused on treating the risk factors, mainly arterial hypertension, diabetes and dyslipidemia. The guidelines also recommend treating the asymptomatic systolic left ventricular dysfunction (especially if there is a prior history of myocardial infarction) with angiotensin-converting enzyme inhibitors (ACEI) and beta-blockers, as well as placing implantable defibrillators to prevent sudden death.New treatment and drug group algorithm: angiotensin II receptor neprilysin inhibitorsThe new treatment algorithm for HFrEF continues to recommend ACEIs, beta-blockers and aldosterone antagonists as first-line treatments. If the patient continues to be symptomatic despite this optimal treatment, there are 3 possibilities: adding ivabradine, assessing the indication for cardiac resynchronization therapy (CRT) and substituting ACEI with a new drug: sacubitril-valsartan.The indications for the use of ivabradine have not changed compared with 2012: symptomatic patients with LVEF ≤35%, sinus rhythm and heart rate ≥70bpm despite treatment with beta-blockers (maximum tolerated dosage or evidence-based). This recommendation remains class IIa and level of evidence B.Angiotensin II-receptor neprilysin inhibitors are a new drug group that acts on renin–angiotensin and neutral endopeptidase systems. The first of this class is LCZ696, a molecule that combines an angiotensin II receptor inhibitor (valsartan) and a neprilysin inhibitor (sacubitril) into a single compound.<a class="elsevierStyleCrossRef" href="#bib0150">6</a> The Prospective Comparison of Angiotensin II-receptor Neprilysin Inhibitors with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM) study researched the long-term effects of sacubitril-valsartan (compared with enalapril) on the morbidity and mortality of outpatients with symptomatic HFrEF (≤40%, although this was later changed to ≤35% during the study). Additionally, the patients needed to present increased plasma natriuretic peptide levels (BNP ≥150pg/mL or NT-proBNP ≥600pg/mL or, in the event of hospitalization for HF in the past 12 months, BNP ≥100pg/mL or NT-proBNP ≥400pg/mL) and an estimated glomerular filtration rate ≥30mL/min. Before the randomization, the patients needed to tolerate, for successive periods (run-in), the administration of enalapril (10mg/12h) and sacubitril-valsartan (97 and 103mg/12h). Sacubitril-valsartan was superior to enalapril, showing a 20% reduction in cardiovascular mortality, a 21% reduction in hospitalizations for HF and a 16% reduction in overall mortality.<a class="elsevierStyleCrossRef" href="#bib0155">7</a> Based on these results, the new CPGs considered the use of sacubitril-valsartan as indicated for patients with HFrEF who met the PARADIGM study criteria, with class I recommendation and level of evidence B.New recommendations on cardiac resynchronization therapyThe indications for CRT have changed significantly. The new guidelines require a QRS duration of at least 130ms, because it has been shown that CRT could be harmful with shorter QRS durations.<a class="elsevierStyleCrossRefs" href="#bib0160">8,9</a> CRT is mainly indicated for symptomatic patients with HF, sinus rhythm and LVEF ≤35% despite optimal medical treatment. This indication is type IA when the QRS is ≥150ms and has left bundle-branch block (LBBB) morphology. The level of evidence is lower when there is no associated LBBB or when the QRS is 130–149ms (regardless of LBBB).Developments in acute heart failureFor the initial assessment of patients with AHF, the guidelines introduced the clinical classification based on the presence/absence of symptoms or signs of congestion (“wet” vs. “dry”) or hypoperfusion (“cold” vs. “warm”). The combination of these options helps identify 4 groups of patients: warm/wet (well perfused and congestive) and the most common combination, cold/wet (hypoperfused and congestive), cold/dry (hypoperfused without congestion) and warm/dry (equivalent to being compensated, well perfused and without congestion). This classification provides prognostic information and is useful for guiding the initial treatment.The guidelines also introduced a treatment algorithm and early assessment that should help quickly analyze the patient's respiratory and hemodynamic situation to determine the need for circulatory assistance (drug or mechanical) and ventilatory support (including mechanical ventilation). In a second phase (first 60–120min), identification of the etiology/triggers will be attempted.Mention is also made of pocket-sized echocardiography and bedside thoracic ultrasonography (if available and there is sufficient experience) as a complement to the initial clinical examination to identify signs of interstitial edema and pleural effusion.There is no relevant drug news regarding AHF, but we should mention the introduction of the diuretic treatment recommendations following the results of the Diuretic Optimization Strategies Evaluation study.<a class="elsevierStyleCrossRef" href="#bib0170">10</a> Intravenous furosemide remains the diuretic of choice, and the initial intravenous dose should be at least equal to the take-home dose. There is no preference for intermittent bolus or continuous infusion administration. Ultrafiltration<a class="elsevierStyleCrossRefs" href="#bib0175">11,12</a> or the combination of a loop diuretic and a thiazide or spironolactone for patients with resistant edema may be considered, but these recommendations have less scientific evidence.<a class="elsevierStyleCrossRef" href="#bib0185">13</a>Finally, a new recommendation refers to maintaining the underlying oral treatment (ACEI and beta-blocker) during hospitalization for AHF, unless there is some absolute contraindication for its withdrawal (shock, symptomatic hypotension, bradycardia, hyperkalemia, etc.). A recent meta-analysis showed that the discontinuation of the beta-blocker in patients hospitalized for AHF is associated with an increase in hospital mortality, short-term mortality and the combined variable “short-term rehospitalization or mortality”.<a class="elsevierStyleCrossRef" href="#bib0190">14</a>Areas of greatest uncertaintyThe areas of greatest uncertainty are still the treatment of comorbidities, the management of HFpEF, the treatment for elderly patients and palliative treatment. In all of these sections, the evidence is scarce, and there are therefore few recommendations. Perhaps the most notable recommendation is the indication for treatment (IIa) with intravenous ferric carboxymaltose for symptomatic patients with HFrEF and iron deficiency (serum ferritin <100μg/L or 100–299μg/L with transferrin saturation <20%) to relieve symptoms and improve the quality of life and capacity for exercise.<a class="elsevierStyleCrossRefs" href="#bib0195">15,16</a>Applicability of the guidelines to daily clinical practiceFrequently, the representativeness of “real-life” patients in clinical trials is limited. As a result, there are often gaps in understanding between the CPG recommendations and their applicability to daily clinical practice. This situation can be more pronounced in HF, because it is a heterogeneous syndrome that mostly affects complex patients.<a class="elsevierStyleCrossRef" href="#bib0205">17</a>In addition to the limited knowledge, a number of barriers and limitations have been identified that contribute to the lack of applicability of the CPGs, which can be classified according to how they affect healthcare practitioners, patients, their caregivers and the healthcare system itself. Healthcare practitioners should improve their ability to acquire, integrate and, as much as possible, implement the recommendations and knowledge of the CPGs, with the objective of facilitating the decision-making process and reduce the clinical variability.<a class="elsevierStyleCrossRef" href="#bib0210">18</a> The patient and caregiver should be involved in the management of the disease, improving their understanding, promoting self-care and increasing treatment adherence.<a class="elsevierStyleCrossRefs" href="#bib0215">19,20</a> Finally, the healthcare system should improve its organizational aspects, using patient-centered programs or multidisciplinary care models that ensure continuity of care and coordination among all healthcare levels involved (Barcelona Litoral Mar Model, Comprehensive Management Units for Patients with Heart Failure [UMIPIC] program, HF units, etc.).<a class="elsevierStyleCrossRefs" href="#bib0225">21–24</a>Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres907020" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec887303" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres907019" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec887302" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Main developments" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "New term: heart failure with “Mid-range left ventricular ejection fraction”" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "New algorithm for diagnosing chronic heart failure: clinical probability of heart failure" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "New section: preventing or delaying the progression to heart failure" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "New treatment and drug group algorithm: angiotensin II receptor neprilysin inhibitors" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "New recommendations on cardiac resynchronization therapy" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Developments in acute heart failure" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Areas of greatest uncertainty" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Applicability of the guidelines to daily clinical practice" ] ] ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-16" "fechaAceptado" => "2017-01-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec887303" "palabras" => array:3 [ 0 => "Heart failure" 1 => "Clinical guidelines" 2 => "Evidence-based medicine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec887302" "palabras" => array:3 [ 0 => "Insuficiencia cardiaca" 1 => "Guías clínicas" 2 => "Medicina basada en la evidencia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The European Society of Cardiology has recently published new guidelines on the diagnosis and treatment of acute and chronic heart failure (HF). This article aims to review these recommendations and their level of scientific evidence and to present the most innovative aspects. The most significant deviations from the 2012 edition are: (1) the introduction of the concept of HF with midrange LVEF (40–49%); (2) a new diagnostic algorithm for chronic HF, initially considering the clinical probability; (3) recommendations on preventing or delaying the apparition of HF; (4) indications for the use of the new sacubitril-valsartan compound, the first angiotensin receptor blocker and neprilysin inhibitor; (5) modification of indications for cardiac resynchronization therapy; and (6) a new algorithm for a combined diagnostic and treatment strategy for acute HF based on the presence or absence of congestion and hypoperfusion." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Recientemente se han publicado las nuevas guías sobre diagnóstico y tratamiento de la insuficiencia cardiaca (IC) aguda y crónica de la Sociedad Europea de Cardiología. El objetivo de este artículo es revisar estas recomendaciones, su nivel de evidencia científico y los aspectos más novedosos. Los cambios más importantes con respecto a la edición de 2012 se refieren a: 1) introducción del concepto de IC con fracción de eyección en rango medio (40–49%); 2) nuevo algoritmo diagnóstico de la IC crónica considerando inicialmente la probabilidad clínica; 3) recomendaciones para prevenir o retrasar la aparición de IC; 4) indicaciones para el uso del nuevo compuesto sacubitrilo-valsartán, el primer inhibidor del receptor de la angiotensina y neprilisina; 5) modificación de las indicaciones para la terapia de resincronización cardiaca; y 6) nuevo algoritmo para una estrategia combinada de diagnóstico y tratamiento de la IC aguda según la presencia o ausencia de congestión e hipoperfusión." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Carles Trullàs J, González-Franco Á. Principales novedades de las guías europeas de insuficiencia cardiaca del 2016. Rev Clin Esp. 2017;217:405–409." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Levels of evidence: Level A: multiple clinical trials or meta-analyses; Level B: a single clinical trial or nonrandomized studies; Level C: expert consensus/opinion, retrospective studies and case series. Grade of recommendation: class I: benefit>risk (the treatment/procedure should be performed)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2012 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Extent</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of pages \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">References \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">270 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">659 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of authors/reviewers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26/21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21/42 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total number of recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">124 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">188 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Number of recommendations by section</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnostic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Holistic or multidisciplinary management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prevention or slowing of the progression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Level of evidence of the recommendations</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class I and level A (I-A) recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (23%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (13%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Level A recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (35%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 (21%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Level B recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (20%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 (30%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Level C recommendations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 (45%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92 (49%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525539.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main Changes in the 2016 Clinical Practice Guidelines for Heart Failure compared with 2012." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: ACEI, angiotensin-converting enzyme inhibitors; CRT, cardiac resynchronization therapy; HF, heart failure; LBBB, left bundle-branch block; LVEF, left ventricular ejection fraction. Levels of evidence: Level A: multiple clinical trials or meta-analyses; Level B: single clinical trial or nonrandomized studies. Grade of recommendation: class I: benefit>risk (the treatment/procedure should be performed)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. New classification of HF related to LVEF, introducing a third group called HF with mid-range LVEF for patients with an LVEF of 40–49%. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. New algorithm for diagnosing HF in nonacute patients, according to the clinical probability of HF based on the medical history, physical examination and electrocardiogram. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. New section on preventing (or delaying the progression of) HF by treating the cardiovascular risk factors and using ACEIs and beta-blockers in patients with asymptomatic left ventricular dysfunction and a history of myocardial infarction. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. New drug. Inclusion of a dual inhibitor of neprilysin and of the angiotensin receptor (sacubitril-valsartan). Recommended as a substitute for ACEI to further reduce the risk of hospitalization for HF and death in outpatients with HF and reduced LVEF who remain symptomatic despite treatment with an ACEI, a beta-blocker and an aldosterone antagonist (class I, level of evidence B). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. New recommendations on CRT. CRT is not recommended when the QRS amplitude is <130ms. Its indication is reinforced when the QRS duration is ≥150ms with LBBB morphology (class I, level of evidence A). The level of evidence is lower when the QRS is ≥150ms and there is no associated LBBB or when the QRS is 130–149ms (regardless of associated LBBB). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Developments in acute HF. Introduction of the concept of starting appropriate treatment early for acute HF, assessing in particular the patient's respiratory and hemodynamic condition. New algorithm that combines the diagnosis and treatment of acute HF depending on the presence or absence of signs and symptoms of congestion or of hypoperfusion. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1525538.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main developments in the 2016 clinical practice guidelines for heart failure." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Ponikowski" 1 => "A.A. Voors" 2 => "S.D. Anker" 3 => "H. Bueno" 4 => "J.G. Cleland" 5 => "A.J. Coats" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehw128" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2016" "volumen" => "37" "paginaInicial" => "2129" "paginaFinal" => "2200" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27206819" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0130" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016 ESC and ACC/AHA/HFSA heart failure guideline update – what is new and why is it important?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Jessup" 1 => "T.H. Marwick" 2 => "P. Ponikowski" 3 => "A.A. Voors" 4 => "C.W. Yancy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/nrcardio.2016.134" "Revista" => array:6 [ "tituloSerie" => "Nat Rev Cardiol" "fecha" => "2016" "volumen" => "13" "paginaInicial" => "623" "paginaFinal" => "628" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27625120" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0135" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. McMurray" 1 => "S. Adamopoulos" 2 => "S.D. Anker" 3 => "A. Auricchio" 4 => "M. Böhm" 5 => "K. 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Halperin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2014.06.001" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2014" "volumen" => "64" "paginaInicial" => "1373" "paginaFinal" => "1384" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25103073" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0145" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "What do experts think about heart failure guidelines?" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "en representación del Grupo de Trabajo de Insuficiencia Cardiaca y Fibrilación auricular de la Sociedad Española de Medicina Interna" "etal" => false "autores" => array:4 [ 0 => "J.C. Trullàs" 1 => "F. Formiga" 2 => "J.I. Pérez-Calvo" 3 => "L. Manzano" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2016.04.007" "Revista" => array:2 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2016" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0150" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combined angiotensin receptor antagonism and neprilysin inhibition" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.A. Hubers" 1 => "N.J. 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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">New clinical practice guidelines &#40;CPG&#41; for heart failure &#40;HF&#41; have recently been published by the European Society of Cardiology&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> The objective of this article is to review these recommendations&#44; their level of evidence and their main developments&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a> Compared to the 2012 guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> the 2016 guidelines have increased their size &#40;from 61 to 85 pages&#41; and changed the structure&#44; title and organization of a number of chapters&#46; The number of recommendations has also increased substantially &#40;from 124 to 188&#41;&#44; especially the sections on diagnosis&#44; comorbidities and acute HF &#40;AHF&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The proportion of recommendations in CPGs with a high level of scientific evidence &#40;level A&#41; is usually low&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> The 2012 CPGs had a low proportion of Type I-A recommendations &#40;29 of 124&#44; 23&#37;&#41;&#44; with a predominance of level of evidence C recommendations &#40;45&#37;&#41; over level A recommendations &#40;35&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> To assess whether the 2016 CPGs have improved the level of evidence&#44; we analyzed and classified its 188 recommendations according to the levels of scientific evidence and degree of recommendation&#46; In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; we can see that the increase in the number of recommendations is mainly at the expense of level B &#40;30&#37;&#41; and C &#40;49&#37;&#41; recommendations&#46; The proportion of level A recommendations is still less than that of 2012 &#40;only 21&#37;&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Main developments</span><p id="par0015" class="elsevierStylePara elsevierViewall">The main developments of the 2016 CPGs&#44; which are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; are as follows&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">New term&#58; heart failure with &#8220;Mid-range left ventricular ejection fraction&#8221;</span><p id="par0020" class="elsevierStylePara elsevierViewall">The most widely used terminology for reporting and classifying HF is based on the left ventricular ejection fraction &#40;LVEF&#41;&#46; Two types have classically been considered&#58; HF with normal LVEF &#40;&#8805;50&#37;&#41; or preserved &#40;HFpEF&#41; and HF with reduced LVEF &#40;&#60;40&#37;&#59; HFrEF&#41;&#46; Patients with LVEF between 40&#37; and 49&#37; represented a &#8220;gray area&#8221; that&#44; according to the new CPGs&#44; constitute a new group&#58; HF with mid-range LVEF &#40;HFmrEF&#41;&#46; The proposed diagnostic criteria are very similar to those of HFpEF&#58; &#40;1&#41; presence of signs&#47;symptoms of HF&#59; &#40;2&#41; LVEF 40&#8211;49&#37;&#59; &#40;3&#41; high natriuretic peptide levels &#40;BNP &#62;35<span class="elsevierStyleHsp" style=""></span>pg&#47;mL or NT-proBNP &#62;125<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41; and at least one echocardiographic criterion &#40;ventricular hypertrophy&#44; left atrial dilation or signs of diastolic dysfunction&#41;&#46; The identification of HFmrEF as a separate group should stimulate research designed to determine the clinical characteristics&#44; treatment and prognosis of this type of patient&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">New algorithm for diagnosing chronic heart failure&#58; clinical probability of heart failure</span><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnostic algorithm for HF has been modified significantly compared with the 2012 version&#46; In the current guidelines&#44; the algorithm distinguishes between patients with acute or chronic HF&#46; For chronic patients&#44; the new guidelines introduce the assessment of the clinical probability of HF based on the medical history &#40;coronary artery disease&#44; arterial hypertension&#44; use of diuretics&#41;&#44; presentation symptoms &#40;orthopnea and paroxysmal nocturnal dyspnea&#41;&#44; physical examination &#40;jugular vein engorgement&#44; displacement of the apex beat&#44; murmurs&#41; and electrocardiogram findings&#46; If all these elements are normal&#44; the diagnosis of HF is highly unlikely&#44; and alternative diagnoses need to be considered&#46; Whether one of the elements is abnormal&#44; the plasma concentration of natriuretic peptides needs to be measured&#44; if possible&#44; to identify patients who require echocardiography&#46; The echocardiogram is indicated if the peptide levels are not available or if its values are above the diagnostic cutoff&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">New section&#58; preventing or delaying the progression to heart failure</span><p id="par0030" class="elsevierStylePara elsevierViewall">The new guidelines put greater emphasis on measures aimed at preventing HF or delaying its onset&#46; Thus&#44; the guidelines introduced a new section of specific recommendations focused on treating the risk factors&#44; mainly arterial hypertension&#44; diabetes and dyslipidemia&#46; The guidelines also recommend treating the asymptomatic systolic left ventricular dysfunction &#40;especially if there is a prior history of myocardial infarction&#41; with angiotensin-converting enzyme inhibitors &#40;ACEI&#41; and beta-blockers&#44; as well as placing implantable defibrillators to prevent sudden death&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">New treatment and drug group algorithm&#58; angiotensin II receptor neprilysin inhibitors</span><p id="par0035" class="elsevierStylePara elsevierViewall">The new treatment algorithm for HFrEF continues to recommend ACEIs&#44; beta-blockers and aldosterone antagonists as first-line treatments&#46; If the patient continues to be symptomatic despite this optimal treatment&#44; there are 3 possibilities&#58; adding ivabradine&#44; assessing the indication for cardiac resynchronization therapy &#40;CRT&#41; and substituting ACEI with a new drug&#58; sacubitril-valsartan&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The indications for the use of ivabradine have not changed compared with 2012&#58; symptomatic patients with LVEF &#8804;35&#37;&#44; sinus rhythm and heart rate &#8805;70<span class="elsevierStyleHsp" style=""></span>bpm despite treatment with beta-blockers &#40;maximum tolerated dosage or evidence-based&#41;&#46; This recommendation remains class IIa and level of evidence B&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Angiotensin II-receptor neprilysin inhibitors are a new drug group that acts on renin&#8211;angiotensin and neutral endopeptidase systems&#46; The first of this class is LCZ696&#44; a molecule that combines an angiotensin II receptor inhibitor &#40;valsartan&#41; and a neprilysin inhibitor &#40;sacubitril&#41; into a single compound&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> The Prospective Comparison of Angiotensin II-receptor Neprilysin Inhibitors with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure &#40;PARADIGM&#41; study researched the long-term effects of sacubitril-valsartan &#40;compared with enalapril&#41; on the morbidity and mortality of outpatients with symptomatic HFrEF &#40;&#8804;40&#37;&#44; although this was later changed to &#8804;35&#37; during the study&#41;&#46; Additionally&#44; the patients needed to present increased plasma natriuretic peptide levels &#40;BNP &#8805;150<span class="elsevierStyleHsp" style=""></span>pg&#47;mL or NT-proBNP &#8805;600<span class="elsevierStyleHsp" style=""></span>pg&#47;mL or&#44; in the event of hospitalization for HF in the past 12 months&#44; BNP &#8805;100<span class="elsevierStyleHsp" style=""></span>pg&#47;mL or NT-proBNP &#8805;400<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41; and an estimated glomerular filtration rate &#8805;30<span class="elsevierStyleHsp" style=""></span>mL&#47;min&#46; Before the randomization&#44; the patients needed to tolerate&#44; for successive periods &#40;run-in&#41;&#44; the administration of enalapril &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and sacubitril-valsartan &#40;97 and 103<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; Sacubitril-valsartan was superior to enalapril&#44; showing a 20&#37; reduction in cardiovascular mortality&#44; a 21&#37; reduction in hospitalizations for HF and a 16&#37; reduction in overall mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> Based on these results&#44; the new CPGs considered the use of sacubitril-valsartan as indicated for patients with HFrEF who met the PARADIGM study criteria&#44; with class I recommendation and level of evidence B&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">New recommendations on cardiac resynchronization therapy</span><p id="par0050" class="elsevierStylePara elsevierViewall">The indications for CRT have changed significantly&#46; The new guidelines require a QRS duration of at least 130<span class="elsevierStyleHsp" style=""></span>ms&#44; because it has been shown that CRT could be harmful with shorter QRS durations&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">8&#44;9</span></a> CRT is mainly indicated for symptomatic patients with HF&#44; sinus rhythm and LVEF &#8804;35&#37; despite optimal medical treatment&#46; This indication is type IA when the QRS is &#8805;150<span class="elsevierStyleHsp" style=""></span>ms and has left bundle-branch block &#40;LBBB&#41; morphology&#46; The level of evidence is lower when there is no associated LBBB or when the QRS is 130&#8211;149<span class="elsevierStyleHsp" style=""></span>ms &#40;regardless of LBBB&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Developments in acute heart failure</span><p id="par0055" class="elsevierStylePara elsevierViewall">For the initial assessment of patients with AHF&#44; the guidelines introduced the clinical classification based on the presence&#47;absence of symptoms or signs of congestion &#40;&#8220;wet&#8221; vs&#46; &#8220;dry&#8221;&#41; or hypoperfusion &#40;&#8220;cold&#8221; vs&#46; &#8220;warm&#8221;&#41;&#46; The combination of these options helps identify 4 groups of patients&#58; warm&#47;wet &#40;well perfused and congestive&#41; and the most common combination&#44; cold&#47;wet &#40;hypoperfused and congestive&#41;&#44; cold&#47;dry &#40;hypoperfused without congestion&#41; and warm&#47;dry &#40;equivalent to being compensated&#44; well perfused and without congestion&#41;&#46; This classification provides prognostic information and is useful for guiding the initial treatment&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The guidelines also introduced a treatment algorithm and early assessment that should help quickly analyze the patient&#39;s respiratory and hemodynamic situation to determine the need for circulatory assistance &#40;drug or mechanical&#41; and ventilatory support &#40;including mechanical ventilation&#41;&#46; In a second phase &#40;first 60&#8211;120<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; identification of the etiology&#47;triggers will be attempted&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Mention is also made of pocket-sized echocardiography and bedside thoracic ultrasonography &#40;if available and there is sufficient experience&#41; as a complement to the initial clinical examination to identify signs of interstitial edema and pleural effusion&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There is no relevant drug news regarding AHF&#44; but we should mention the introduction of the diuretic treatment recommendations following the results of the Diuretic Optimization Strategies Evaluation study&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> Intravenous furosemide remains the diuretic of choice&#44; and the initial intravenous dose should be at least equal to the take-home dose&#46; There is no preference for intermittent bolus or continuous infusion administration&#46; Ultrafiltration<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">11&#44;12</span></a> or the combination of a loop diuretic and a thiazide or spironolactone for patients with resistant edema may be considered&#44; but these recommendations have less scientific evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally&#44; a new recommendation refers to maintaining the underlying oral treatment &#40;ACEI and beta-blocker&#41; during hospitalization for AHF&#44; unless there is some absolute contraindication for its withdrawal &#40;shock&#44; symptomatic hypotension&#44; bradycardia&#44; hyperkalemia&#44; etc&#46;&#41;&#46; A recent meta-analysis showed that the discontinuation of the beta-blocker in patients hospitalized for AHF is associated with an increase in hospital mortality&#44; short-term mortality and the combined variable &#8220;short-term rehospitalization or mortality&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Areas of greatest uncertainty</span><p id="par0080" class="elsevierStylePara elsevierViewall">The areas of greatest uncertainty are still the treatment of comorbidities&#44; the management of HFpEF&#44; the treatment for elderly patients and palliative treatment&#46; In all of these sections&#44; the evidence is scarce&#44; and there are therefore few recommendations&#46; Perhaps the most notable recommendation is the indication for treatment &#40;IIa&#41; with intravenous ferric carboxymaltose for symptomatic patients with HFrEF and iron deficiency &#40;serum ferritin &#60;100<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;L or 100&#8211;299<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;L with transferrin saturation &#60;20&#37;&#41; to relieve symptoms and improve the quality of life and capacity for exercise&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Applicability of the guidelines to daily clinical practice</span><p id="par0085" class="elsevierStylePara elsevierViewall">Frequently&#44; the representativeness of &#8220;real-life&#8221; patients in clinical trials is limited&#46; As a result&#44; there are often gaps in understanding between the CPG recommendations and their applicability to daily clinical practice&#46; This situation can be more pronounced in HF&#44; because it is a heterogeneous syndrome that mostly affects complex patients&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In addition to the limited knowledge&#44; a number of barriers and limitations have been identified that contribute to the lack of applicability of the CPGs&#44; which can be classified according to how they affect healthcare practitioners&#44; patients&#44; their caregivers and the healthcare system itself&#46; Healthcare practitioners should improve their ability to acquire&#44; integrate and&#44; as much as possible&#44; implement the recommendations and knowledge of the CPGs&#44; with the objective of facilitating the decision-making process and reduce the clinical variability&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> The patient and caregiver should be involved in the management of the disease&#44; improving their understanding&#44; promoting self-care and increasing treatment adherence&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">19&#44;20</span></a> Finally&#44; the healthcare system should improve its organizational aspects&#44; using patient-centered programs or multidisciplinary care models that ensure continuity of care and coordination among all healthcare levels involved &#40;Barcelona Litoral Mar Model&#44; Comprehensive Management Units for Patients with Heart Failure &#91;UMIPIC&#93; program&#44; HF units&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">21&#8211;24</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "New term&#58; heart failure with &#8220;Mid-range left ventricular ejection fraction&#8221;"
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              "identificador" => "sec0020"
              "titulo" => "New algorithm for diagnosing chronic heart failure&#58; clinical probability of heart failure"
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              "identificador" => "sec0025"
              "titulo" => "New section&#58; preventing or delaying the progression to heart failure"
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              "titulo" => "New treatment and drug group algorithm&#58; angiotensin II receptor neprilysin inhibitors"
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              "identificador" => "sec0035"
              "titulo" => "New recommendations on cardiac resynchronization therapy"
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              "identificador" => "sec0040"
              "titulo" => "Developments in acute heart failure"
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              "titulo" => "Areas of greatest uncertainty"
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    "fechaRecibido" => "2016-12-16"
    "fechaAceptado" => "2017-01-29"
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            1 => "Clinical guidelines"
            2 => "Evidence-based medicine"
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          "palabras" => array:3 [
            0 => "Insuficiencia cardiaca"
            1 => "Gu&#237;as cl&#237;nicas"
            2 => "Medicina basada en la evidencia"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The European Society of Cardiology has recently published new guidelines on the diagnosis and treatment of acute and chronic heart failure &#40;HF&#41;&#46; This article aims to review these recommendations and their level of scientific evidence and to present the most innovative aspects&#46; The most significant deviations from the 2012 edition are&#58; &#40;1&#41; the introduction of the concept of HF with midrange LVEF &#40;40&#8211;49&#37;&#41;&#59; &#40;2&#41; a new diagnostic algorithm for chronic HF&#44; initially considering the clinical probability&#59; &#40;3&#41; recommendations on preventing or delaying the apparition of HF&#59; &#40;4&#41; indications for the use of the new sacubitril-valsartan compound&#44; the first angiotensin receptor blocker and neprilysin inhibitor&#59; &#40;5&#41; modification of indications for cardiac resynchronization therapy&#59; and &#40;6&#41; a new algorithm for a combined diagnostic and treatment strategy for acute HF based on the presence or absence of congestion and hypoperfusion&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Recientemente se han publicado las nuevas gu&#237;as sobre diagn&#243;stico y tratamiento de la insuficiencia cardiaca &#40;IC&#41; aguda y cr&#243;nica de la Sociedad Europea de Cardiolog&#237;a&#46; El objetivo de este art&#237;culo es revisar estas recomendaciones&#44; su nivel de evidencia cient&#237;fico y los aspectos m&#225;s novedosos&#46; Los cambios m&#225;s importantes con respecto a la edici&#243;n de 2012 se refieren a&#58; 1&#41; introducci&#243;n del concepto de IC con fracci&#243;n de eyecci&#243;n en rango medio &#40;40&#8211;49&#37;&#41;&#59; 2&#41; nuevo algoritmo diagn&#243;stico de la IC cr&#243;nica considerando inicialmente la probabilidad cl&#237;nica&#59; 3&#41; recomendaciones para prevenir o retrasar la aparici&#243;n de IC&#59; 4&#41; indicaciones para el uso del nuevo compuesto sacubitrilo-valsart&#225;n&#44; el primer inhibidor del receptor de la angiotensina y neprilisina&#59; 5&#41; modificaci&#243;n de las indicaciones para la terapia de resincronizaci&#243;n cardiaca&#59; y 6&#41; nuevo algoritmo para una estrategia combinada de diagn&#243;stico y tratamiento de la IC aguda seg&#250;n la presencia o ausencia de congesti&#243;n e hipoperfusi&#243;n&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Carles Trull&#224;s J&#44; Gonz&#225;lez-Franco &#193;&#46; Principales novedades de las gu&#237;as europeas de insuficiencia cardiaca del 2016&#46; Rev Clin Esp&#46; 2017&#59;217&#58;405&#8211;409&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Levels of evidence&#58; Level A&#58; multiple clinical trials or meta-analyses&#59; Level B&#58; a single clinical trial or nonrandomized studies&#59; Level C&#58; expert consensus&#47;opinion&#44; retrospective studies and case series&#46; Grade of recommendation&#58; class I&#58; benefit<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>risk &#40;the treatment&#47;procedure should be performed&#41;&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Extent</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of pages&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>References&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">270&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">659&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Number of authors&#47;reviewers&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#47;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total number of recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">124&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">188&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Number of recommendations by section</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diagnostic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Comorbidities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Acute heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Holistic or multidisciplinary management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prevention or slowing of the progression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Level of evidence of the recommendations</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Class I and level A &#40;I-A&#41; recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;23&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;13&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Level A recommendations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57 &#40;30&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92 &#40;49&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ACEI&#44; angiotensin-converting enzyme inhibitors&#59; CRT&#44; cardiac resynchronization therapy&#59; HF&#44; heart failure&#59; LBBB&#44; left bundle-branch block&#59; LVEF&#44; left ventricular ejection fraction&#46; <span class="elsevierStyleItalic">Levels of evidence</span>&#58; Level A&#58; multiple clinical trials or meta-analyses&#59; Level B&#58; single clinical trial or nonrandomized studies&#46; <span class="elsevierStyleItalic">Grade of recommendation</span>&#58; class I&#58; benefit<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>risk &#40;the treatment&#47;procedure should be performed&#41;&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#46; <span class="elsevierStyleItalic">New classification</span> of HF related to LVEF&#44; introducing a third group called HF with mid-range LVEF for patients with an LVEF of 40&#8211;49&#37;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; <span class="elsevierStyleItalic">New algorithm</span> for diagnosing HF in nonacute patients&#44; according to the clinical probability of HF based on the medical history&#44; physical examination and electrocardiogram&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; <span class="elsevierStyleItalic">New section</span> on preventing &#40;or delaying the progression of&#41; HF by treating the cardiovascular risk factors and using ACEIs and beta-blockers in patients with asymptomatic left ventricular dysfunction and a history of myocardial infarction&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; <span class="elsevierStyleItalic">New drug&#46;</span> Inclusion of a dual inhibitor of neprilysin and of the angiotensin receptor &#40;sacubitril-valsartan&#41;&#46; Recommended as a substitute for ACEI to further reduce the risk of hospitalization for HF and death in outpatients with HF and reduced LVEF who remain symptomatic despite treatment with an ACEI&#44; a beta-blocker and an aldosterone antagonist &#40;class I&#44; level of evidence B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; <span class="elsevierStyleItalic">New recommendations on CRT&#46;</span> CRT is not recommended when the QRS amplitude is &#60;130<span class="elsevierStyleHsp" style=""></span>ms&#46; Its indication is reinforced when the QRS duration is &#8805;150<span class="elsevierStyleHsp" style=""></span>ms with LBBB morphology &#40;class I&#44; level of evidence A&#41;&#46; The level of evidence is lower when the QRS is &#8805;150<span class="elsevierStyleHsp" style=""></span>ms and there is no associated LBBB or when the QRS is 130&#8211;149<span class="elsevierStyleHsp" style=""></span>ms &#40;regardless of associated LBBB&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&#46; <span class="elsevierStyleItalic">Developments in acute HF</span>&#46; Introduction of the concept of starting appropriate treatment early for acute HF&#44; assessing in particular the patient&#39;s respiratory and hemodynamic condition&#46; New algorithm that combines the diagnosis and treatment of acute HF depending on the presence or absence of signs and symptoms of congestion or of hypoperfusion&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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