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CSI Position Statement on Management of HF in India 2017

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Dr Santanu Guha, Kolkata    05 January 2018

  1. The commonest etiology is CAD followed by idiopathic dilated cardiomyopathy. RHD still contributes 10% of the disease burden.
  2. There is a need for a statement on HF as it is emerging as an important public health problem in India.
  3. The purpose of CSI position statement on HF is to provide a single document for the whole country which provides the latest available data from India and also serves as a reference regarding the latest clinical literature. It is recommendary in nature and carries no statutory status.
  4. The CSI position statement recommends nonpharmacological therapy including lifestyle modifications, exercise rehabilitation and vaccination.
  5. The natriuretic peptides represent the gold standard biomarkers in HF. BNP or NT-proBNP “guided therapy” is not routinely recommended in India.
  6. Pharmacological management of chronic HFrEF recommends ACEI/ARB/ARNI, BB, MRA in all patients; diuretics in symptomatic patients and use of hydralazine, ivabradine and digoxin as complementary.
  7. Statins are not recommended to be initiated, unless the patient is already on statin. Carnitine/CoQ/intermittent inotropes/CCB-verapamil/diltiazm are not to be used. All patients with prior or current symptoms of HFrEF regardless of aetiology should be started on ACEI, unless contraindicated.
  8. Replacement of ACEI with ARNI should be considered in patients who remain symptomatic despite optimal therapy with an ACEI, b-blocker and MRA. In patients who are tolerating ACEI (or ARB) well, replacement by ARNI may be considered on an individual basis.
  9. Use of beta blockers (bisoprolol, metoprolol succinate extended release or carvedilol) is recommended for all patients with current/prior symptoms of HFrEF in absence of contraindications.
  10. Patients with prior or current symptoms of chronic HFrEF who are intolerant to ACEI (due to cough) are candidates for ARBs.
  11. b blockers and ACEIs can be initiated together as soon as the diagnosis of HFrEF is made.
  12. Diuretics should be used in HFrEF patients who have evidence of fluid retention and are usually combined with an ACEI (or ARB), beta blocker and MRAs.
  13. Ivabradine can be considered for symptomatic HF patients who are in sinus rhythm and have resting HR >70 bpm despite maximally tolerated doses of BB, ACEI (ARB) and MRA. Optimal use of device therapy in our country will require better risk stratification methods or lowering of initial device cost.
  14. Surgery for HF comprises of mitral valve reconstruction, external support, myocyte restoration and replacement, ventricle restoration, revascularization, mechanical support and heart transplantation.
  15. CRT can be considered for patient with LVEF <35% and are undergoing placement of a new or replacement pacemaker implantation. It should not be considered in patients whose comorbidities limit expected survival to <1 year; HF with non-LBBB pattern with QRS <150 ms.
  16. Preventing or delaying onset of HF is a feasible task and should be a priority for our country because of cost-effectiveness. It can be achieved either by targeting those at high risk or promoting healthy lifestyle for entire population.

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