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Heart Failure: Drug Thaerapies &
462 Revascularization Strategies

gradually up-titrated to the maximum tolerated dose. and concomitant HF, most of whom had HFrEF.
In patients admitted due to acute HF (AHF) beta-
blockers should be cautiously initiated in hospital, Coronary angiography
once the patient is stabilized. An individual patient Coronary angiography is recommended in patients
data meta-analysis of all the major betablocker trials with HF who suffer from angina pectoris recalcitrant

in HFrEF has shown no benefit on hospital admissions to medical therapy, provided the patient is otherwise
and mortality in the subgroup of patients with HFrEF suitable for coronary revascularization. Coronary
who are in AF. However, since this is a retrospective angiography is also recommended in patients with
subgroup analysis, and because beta-blockers a history of symptomatic ventricular arrhythmia or
did not increase the risk, the guideline committee aborted cardiac arrest. Coronary angiography should
decided not to make a separate recommendation be considered in patients with HF and intermediate
according to heart rhythm. Beta-blockers should be to high pre-test probability of CAD and the presence
considered for rate control in patients with HFrEF of ischaemia in non-invasive stress tests in order to
and AF, especially in those with high heart rate. establish the ischaemic aetiology and CAD severity.
Beta-blockers are recommended in patients with a
history of myocardial infarction and asymptomatic
LV systolic dysfunction to reduce the risk of death. Myocardial revascularization
Percutaneous and surgical revascularization are
Combination of hydralazine and isosorbide complementary approaches for symptomatic relief
of angina in HFpEF, but whether these interventions
dinitrate
improve outcomes is not entirely clear. Recent
There is no clear evidence to suggest the use of ESC guidelines on myocardial revascularization
this fixed-dose combination therapy in all patients recommended coronary artery bypass grafting (CABG)
with HFrEF. Evidence on the clinical utility of this for patients with significant left main stenosis and
combination is scanty and comes from one relatively left main equivalent (proximal stenosis of both the
small RCT conducted exclusively in men and before left anterior descending and left circumflex arteries)
ACEIs or beta-blockers were used to treat HF. A to improve prognosis. However, one needs to be
combination of hydralazine and isosorbide dinitrate aware of a lack of studies including patients who
may be considered in symptomatic patients with have well-defined HF, therefore this recommendation
HFrEF who can tolerate neither ACEI nor ARB (or they is solely based on expert opinion. On the basis of the
are contraindicated) to reduce mortality. However, results of the STICH trial [which excluded patients
this recommendation is based on the results of the with left main disease and Canadian Cardiovascular
Veterans Administration Cooperative Study, which Society (CCS) angina classes III–IV], CABG is also
recruited symptomatic HFrEF patients who received recommended in patients with HFrEF, significant
only digoxin and diuretics. CAD (left anterior descending artery or multivessel

In patients with NYHA class II and III HF and iron disease) and LVEF ≤35% to reduce death and
deficiency (ferritin <100 ng/mL or 100 to 300 ng/ hospitalization for cardiovascular causes. Patients
Ml if transferrin saturation is <20%), intravenous with >10% dysfunctional but viable LV myocardium
iron replacement might be reasonable to improve may be more likely to benefit from myocardial
functional status and QoL(ACC/AHA 2017 class II b). revascularization (and those with ≤10% are less likely
to benefit), although this approach to patient selection
Digoxin and other digitalis glycosides for revascularization is unproven. In the STICH trial,
neither the presence of viability nor the severity of
Digoxin may be considered in patients in sinus LV remodelling identified those who benefited from
rhythm with symptomatic HFrEF to reduce the CABG in terms of a reduction in mortality. Post hoc
risk of hospitalization (both all-cause and HF analyses from the STICH trial revealed that the
hospitalizations), although its effect on top of presence of inducible myocardial ischaemia (either
betablockers has never been tested. The effects on radionuclide stress test or dobutamine stress
of digoxin in patients with HFrEF and AF have echocardiogram) or angina does not identify those
not been studied in RCTs, and recent studies have with worse prognosis and greater benefit from CABG
suggested potentially higher risk of events n patients over OMT.However, CABG does improve angina to a
with AF receiving digoxin. However, this remains greater extent than medical therapy alone. The choice
controversial, as another recent meta-analysis between CABG and PCI should be made by the Heart
concluded on the basis of non-RCTs that digoxin has Team after careful evaluation of the patient’s clinical
no deleterious effect on mortality in patients with AF

GCDC 2017