Heart Failure Clinical Practice Guidelines (2020) by CCS/CHFS

The Canadian Cardiovascular Society (CCS) and Canadian Heart Failure Society (CHFS) have released their recommendations on selected topics of high clinical relevance in the management of heart failure (HF). These guidelines have been published in the Canadian Journal of Cardiology and incorporate new evidence from randomized clinical trials published after 2017.

Percutaneous Mitral Valve Repair for HF and Reduced Ejection Fraction and Severe Functional Mitral Regurgitation

1. We recommend that maximally tolerated GDMT, including cardiac resynchronization therapy and revascularization where appropriate, be implemented before consideration of PMVR for patients with HFrEF and severe FMR (Strong Recommendation, High-Quality Evidence).
2. We suggest that patients with symptomatic HF (HFrEF) despite maximal GDMT and severe mitral regurgitation be evaluated for PMVR (Weak Recommendation, Moderate-Quality Evidence).
3. We recommend that a multidisciplinary dedicated heart team (including interventionalists, cardiac surgeons, imaging specialists, and HF specialists) perform the evaluation and care of potential candidates for PMVR (Strong Recommendation, Low-Quality Evidence).

Practical tips

Use caution when treating FMR in patients with HFrEF.

Patients with HFrEF and FMR who have severe left ventricular (LV) dilatation (typically LV end-diastolic dimension >70 mm) and less than severe mitral regurgitation may be poor candidates for PMVR with MitraClip.

Patients with FMR should first receive maximally tolerated GDMT, including pharmacologic and nonpharmacologic HF therapies (eg, cardiac resynchronization therapy where applicable) for a reasonable minimum period (eg, 3 months) before PMVR is considered.

Refer patients considered for PMVR to centres experienced in evaluating patients with advanced HF, have high volumes of patients with valve disease managed medically and surgically, and have a high likelihood of achieving the volume of PMVR (eg, 2-4 per month) required for developing and maintaining competence in well-selected patients.

Treatment of Cardiac Amyloidosis

When cardiac amyloidosis (CA) is suspected, rule out light-chain amyloidosis (AL amyloidosis) using serum-free light chains (kappa and lambda), and serum and urine protein electrophoresis with immunofixation. Accurate identification of the amyloid subtype is essential to initiate specific treatment and avoid inappropriate application of therapy.

Practical tips

In the setting of undifferentiated CA, the presence of light chains does not confirm the diagnosis of light-chain cardiac amyloidosis (AL-CA) because monoclonal gammopathy of unknown significance and transthyretin cardiac amyloidosis (ATTR-CA) can coexist. In such settings, a tissue biopsy is often necessary to exclude AL-CA.

New Evidence for Angiotensin Receptor Neprilysin Inhibitors in Patients With HFpEF

HFpEF is rising in prevalence and is associated with significant morbidity and mortality.A comparison of sacubitril/valsartan with valsartan in HFpEF patients, PARAGON-HF showed a modest but nonsignificant 13% reduction in the primary outcome, which was driven by a reduction in first and recurrent HF hospitalizations. In secondary endpoint analysis, improvement in the quality of life and renal function suggested potential benefits with sacubitril/valsartan compared with valsartan. The data further suggest heterogeneity in the treatment response with greater benefit in women and in individuals with a lower LVEF

The CCS/CHFS indicate that the statistically negative results of the primary endpoint analysis preclude any recommendation for the general use of sacubitril/valsartan in patients with HFpEF.

New Evidence for SGLT2 Inhibitors and HF

SGLT2 inhibitors lead to a reduction in plasma glucose by inhibiting renal tubular glucose reabsorption, with resultant glucosuria.The SGLT2 inhibitor empagliflozin was the first glucose-lowering drug to show an improvement in cardiovascular outcomes in a large randomized controlled clinical trial.

• The CCS/CHFS recommend the use of SGLT2 inhibitors (eg, empagliflozin, canagliflozin, dapagliflozin) for treatment of patients with type 2 diabetes and atherosclerotic cardiovascular disease to reduce the risk of HF hospitalization and death (strong recommendation).
• We recommend SGLT2 inhibitors, such as dapagliflozin be used in patients with type 2 diabetes aged > 50 years with additional risk factors for atherosclerotic cardiovascular disease to reduce the risk of HHF (Strong Recommendation, High-Quality Evidence).
• New. We recommend SGLT2 inhibitors, such as canagliflozin, be used in patients aged > 30 years with type 2 diabetes, and macroalbumineric renal disease, to reduce the risk of HF hospitalization and progression of renal disease (Strong Recommendation, High-Quality Evidence).
• .New. We recommend SGLT2 inhibitors, such as dapagliflozin be used in patients with mild to moderate HF due to reduced LVEF (≤ 40%) and concomitant type 2 diabetes, to improve symptoms and quality of life and to reduce the risk of hospitalization and cardiovascular mortality (Strong Recommendation, High-Quality Evidence)
• We recommend SGLT2 inhibitors, such as dapagliflozin be used in patients with mild to moderate HF due to reduced LVEF (≤ 40%) and without concomitant diabetes, to improve symptoms and quality of life and to reduce the risk of hospitalization and cardiovascular mortality (Conditional Recommendation, High-Quality Evidence).

For further reference log on to :

O'Meara E, McDonald M, Chan M, et al. CCS/CHFS heart failure guidelines: clinical trial update on functional mitral regurgitation, SGLT2 inhibitors, ARNI in HFpEF, and tafamidis in amyloidosis. Can J Cardiol. 2020 Feb;36(2):159-69. https://www.onlinecjc.ca/article/S0828-282X(19)31514-4/fulltext