Abstract
Résumé
- Howlett J.G.
- McKelvie R.S.
- Costigan J.
- et al.
- Malcom J.
- Arnold O.
- Howlett J.G.
- et al.
Anemia in HF
Epidemiology and mechanisms

Treatment of anemia in HF
- 1.We suggest that for patients with documented iron deficiency, oral or intravenous iron supplement be initiated to improve functional capacity. (Weak Recommendation; Low-Quality Evidence).
- 2.We recommend erythropoiesis stimulating agents not be routinely used to treat anemia in HF. (Strong Recommendation; High-Quality Evidence).
Concomitant medications
Oral and intravenous iron supplementation
Ponikowski P, van Veldhuisen DJ, Comin-Colet J, et al. Beneficial effects of long-term intravenous iron therapy with ferric carboxymaltose in patients with symptomatic heart failure and iron deficiency. Eur Heart J 2014; doi:10.1093/eurheartj/ehu385.
ESAs
Optimal Use of Biomarkers in HF
NPs
- 1.We recommend that B-type NP (BNP)/amino-terminal fragment of propeptide BNP (NT-proBNP) levels be measured to help confirm or rule out a diagnosis of HF in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt (Strong Recommendation; High-Quality Evidence).
- 2.We recommend that measurement of BNP/NT-proBNP levels be considered in patients with an established diagnosis of HF for prognostic stratification (Strong Recommendation; High-Quality Evidence).
Age, Years | HF is unlikely | HF is possible but other diagnoses need to be considered | HF is very likely | |
---|---|---|---|---|
BNP | All | < 100 pg/mL | 100-500 pg/mL | > 500 pg/mL |
NT-proBNP | < 50 | < 300 pg/mL | 300-450 pg/mL | > 450 pg/mL |
50-75 | < 300 pg/mL | 450-900 pg/mL | > 900 pg/mL | |
> 75 | < 300 pg/mL | 900 - 1800 pg/mL | > 1800 pg/mL |
- Lindahl B.
- Lindback J.
- Jernberg T.
- et al.
- Morello A.
- Lloyd-Jones D.M.
- Chae C.U.
- et al.
- Cleland J.G.
- McMurray J.J.
- Kjekshus J.
- et al.
NP-guided management
- 1.We suggest, in ambulatory patients with HF due to systolic dysfunction, measurement of BNP or NT-proBNP to guide management should be considered to decrease HF-related hospitalizations and potentially reduce mortality. The benefit is uncertain in individuals older than 75 years of age (Weak Recommendation; Moderate-Quality Evidence).
- Eurlings L.W.
- van Pol P.E.
- Kok W.E.
- et al.
- Persson H.
- Erntell H.
- Eriksson B.
- et al.
- Eurlings L.W.
- van Pol P.E.
- Kok W.E.
- et al.
- Persson H.
- Erntell H.
- Eriksson B.
- et al.

Hospital predischarge NP measurements
- 1.We suggest that measurement of BNP or NT-proBNP in patients hospitalized for HF should be considered before discharge, because of the prognostic value of these biomarkers in predicting rehospitalization and mortality (Strong Recommendation; Moderate-Quality Evidence).

Prevention of HF
Other Biomarkers
Biomarkers | Pathophysiological pathways/comorbid conditions with prognostic implications | HF populations targeted | Advantages | Potential benefits | Challenges before implementation |
---|---|---|---|---|---|
NGAL | Renal function | Acute HF | Early detection of renal function deterioration | Adjusting therapy to improve prognosis by avoiding acute renal failure progression | Unclear if using NGAL in acute HF to modify therapies improves clinical outcomes |
Cystatin C | Renal function | Acute and chronic HF | More sensitive detection of changes in renal function | Same as above | Unclear if using cystatin C, over using eGFR, to modify clinical management provides further clinical benefit |
Cardiac hs-troponins | Myocyte death | Acute and chronic HF | Very sensitive marker predicting higher risk of CV events regardless of aetiology | Optimization of therapy in patients with elevated hs-cTn should be more aggressive | Prognostication improves only for mortality and use to modify therapy has not been tested |
ST2 | Fibrosis/inflammation/immunity | Acute and chronic HFrEF, HFpEF, and previously low EF recovered | Additional prognostic value beyond NPs suspected low week-to-week variations | Could provide additional value for short and long term prognostication, regardless of LVEF | Unclear if using ST2 in acute HF to modify therapies improves clinical outcomes |
Galectin-3 | Cardiac and vascular fibrosis | Incident HF, HFrEF and HFpEF | Early detection of risk and long term prognostication in HF | Preventive measures and therapy optimization based on levels could improve outcomes | Recent study showed ST2 superior to galectin-3 in a multivariable prediction model |
Clinical Trials That Might Influence Practice
Mineralocorticoid receptor antagonists in HFpEF
- 1.We suggest that in individuals with HFpEF, an increased NP level, serum potassium < 5.0 mmol/L, and an estimated glomerular filtration rate (eGFR) ≥ 30 mL/min, a mineralocorticoid receptor antagonist like spironolactone should be considered, with close surveillance of serum potassium and creatinine (Weak Recommendation; Low-Quality Evidence).
Combined angiotensin/neprilysin inhibition in HFrEF
- 1.We recommend that in patients with mild to moderate HF, an EF < 40%, an elevated NP level or hospitalization for HF in the past 12 months, a serum potassium < 5.2 mmol/L, and an eGFR ≥ 30 mL/min and treated with appropriate doses of guideline-directed medical therapy should be treated with LCZ696 in place of an ACE inhibitor or an angiotensin receptor blocker, with close surveillance of serum potassium and creatinine (Conditional Recommendation; High-Quality Evidence).
Clinical implications
Conclusions
Supplementary Material
- Supplemental Table S1
References
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Article Info
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Footnotes
The disclosure information of the authors and reviewers is available from the CCS website: www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgment in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.
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- ErratumCanadian Journal of CardiologyVol. 32Issue 3
- PreviewIn the article, “The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: Anemia, Biomarkers, and Recent Therapeutic Trial Implications” by Moe et al., published in the January issue (Can J Cardiol 2015; 31:3-16), there is an error on page 12. The recommendation on combined angiotensin/neprilysin inhibition in HFrEF should state an EF of ≤ 40%. A corrected recommendation is provided here.
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