2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure  Justin A. Ezekowitz, MBBCh, Eileen O'Meara, MD, Michael A. McDonald, MD, Howard Abrams, MD, Michael Chan, MBBS, Anique Ducharme, MD, Nadia Giannetti, MD, Adam Grzeslo, MD, Peter G. Hamilton, MBBCh, George A. Heckman, MD, Jonathan G. Howlett, MD, Sheri L. Koshman, Pharm D, Serge Lepage, MD, Robert S. McKelvie, MD, Gordon W. Moe, MD, Miroslaw Rajda, MD, Elizabeth Swiggum, MD, Sean A. Virani, MD, Shelley Zieroth, MD, Abdul Al-Hesayen, MD, Alain Cohen-Solal, MD, Michel D'Astous, MD, Sabe De, MD, Estrellita Estrella-Holder, RN, Stephen Fremes, MD, Lee Green, MD, Haissam Haddad, MD, Karen Harkness, RN, Adrian F. Hernandez, MD, Simon Kouz, MD, Marie-Hélène LeBlanc, MD, Frederick A. Masoudi, MD, Heather J. Ross, MD, Andre Roussin, MD, Bruce Sussex, MBBS  Canadian Journal of Cardiology  Volume 33, Issue 11, Pages 1342-1433 (November 2017) DOI: 10.1016/j.cjca.2017.08.022 Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 1 Algorithm for the diagnosis of heart failure in the ambulatory care setting. For patients with heart failure, a history, physical exam, and initial investigations should be supplemented with natriuretic peptides and/or imaging tests. ∗Natriuretic peptides are not available in all jurisdictions in Canada. ‡Includes systolic as well as diastolic parameters (eg, numeric left ventricular ejection fraction, transmitral and pulmonary venous flow patterns, or mitral annulus velocities); a preserved ejection function on a routine echocardiogram does not rule out the clinical syndrome of heart failure and therefore clinical judgement is required if other indicators point to heart failure as a diagnosis. A lower BNP cutoff for suspecting heart failure in the ambulatory setting facilitates earlier implementation of guideline-directed care. BNP, B-type natriuretic peptide; CBC, complete blood count; CMR, cardiac magnetic resonance; CT, computed tomography; MIBI, myocardial perfusion scan; MUGA, multigated acquisition scan; NT-proBNP, N-terminal propeptide B-type natriuretic peptide. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 2 General guidance as to the workup to identify the most probable etiology for a patient's heart failure (HF). At all stages, a thorough clinical history and physical exam should aid in the selection of additional investigations. A detailed family history is invaluable, especially in patients who are younger or do not have an obvious etiology. Testing should be placed in context of the pretest probability, availability, and expertise of the test. More common etiologies (eg, coronary artery disease, hypertension) should be considered first, and further testing should be encouraged if another etiology is suspected in addition to a more common etiology (eg, hemachromatosis in a patient with known coronary artery disease). ∗Patients might have mixed etiology of HF. A detailed medical and family history might guide investigations and should be completed in all patients (see Recommendation 19 in section 5. Diagnosis of HF). Direct testing on the basis of pretest probability, availability, and expertise. ARVC, arrhythmogenic right ventricular cardiomyopathy; CAD, coronary artery disease; CBC, complete blood count; CMP, cardiomyopathy; CMR, cardiac magnetic resonance; ECG, electrocardiogram; HCM, hypertrophic cardiomyopathy; HFmEF, heart failure with a midrange ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HTN, hypertension; Hx, history; LV, left ventricle; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy; NP, natriuretic peptide; PPCM, peripartum cardiomyopathy; Rx, prescription; TSH, thyroid-stimulating hormone. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 3 Algorithm for the use of natriuretic peptides in different heart failure (HF)-related clinical scenarios. Clinical evaluation and the risks and benefits of the action suggested should be considered. BNP, B-type natriuretic peptide; NT-proBNP, N-terminal propeptide B-type natriuretic peptide. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 4 Therapeutic approach to patients with symptoms of heart failure (HF) and a reduced ejection fraction. ∗Sacubitril or valsartan. ‡Refer to Table 5. ACEi, angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; ARNI, angiotensin receptor-neprilysin inhibitor; BB, β-blocker; bpm, beats per minute; CRT, cardiac resynchronization therapy; HR, heart rate; ICD, implantable cardioverter defibrillator; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; NYHA, New York Heart Association; SR, sinus rhythm. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 5 Referral pathway for device therapy in patients with heart failure; the referral pathway for devices should be guided by many factors as outlined in the figure, as well as patient preferences, goals, and comorbidity. CRT, cardiac resynchronization therapy; ECG, electrocardiogram; ICD, implantable cardioverter-defibrillator; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 6 The approach to assessment for coronary artery disease in patients with heart failure. All patients with heart failure are expected to undergo noninvasive measurement of systolic function (not included in this algorithm). PCI, percutaneous coronary intervention. ∗Some centres might additionally perform noninvasive imaging, especially when coronary anatomy is not optimal. †If imaging indicates features of high risk, progression to coronary angiography is expected. ‡Noninvasive imaging might be performed in certain centres for risk stratification or diagnosis. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 7 Decision regarding coronary revascularization in patients with heart failure. It is recommended that surgical and interventional cardiology consultation be considered early in this process. ∗Coronary anatomy suitable for CABG includes: multivessel disease > 70% stenosis; left main stem stenosis > 50%; or diabetes with left anterior descending artery stenosis > 70%. †In selected cases in which there is noninvasive imaging evidence of extensive cardia ischemia, PCI might be considered. CABG, coronary artery bypass grafting; IC, intracoronary; LVEF, left ventricular ejection fraction; MV, mitral valve; PCI, percutaneous coronary intervention; TAVI, transcatheter aortic valve implantation. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 8 Diagnosis of heart failure in the acute care setting. If acute heart failure (AHF) is suspected, the initial work-up may be supplemented by natriuretic peptide testing and/or an AHF diagnosis score. ∗ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) or other scoring system. BNP, B-type natriuretic peptide; CBC, complete blood count; Cr, creatinine; ECG, electrocardiogram; NT-proBNP, N-terminal propeptide B-type natriuretic peptide. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 9 Treatment algorithm for acute heart failure. Decisions regarding the additional use of inotropes or vasodilators should be done in consultation with individuals with experience and expertise in the management of patients with acute heart failure, and placed in clinical context. ∗See Table 27 for dosing. BiPAP, bilevel positive airway pressure; CPAP, continuous positive airway pressure; I.V., intravenous; MAP, mean arterial pressure; PA, pulmonary artery; SBP, systolic blood pressure; SL, sublingual. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 10 Stepped pharmacological care; treatment algorithm for patients with heart failure (HF) and volume overload. At each decision, clinical assessment should include an assessment of symptoms, volume assessment, and appropriate monitoring of vital signs, electrolytes, and creatinine. Daily weights are more easily and accurately assessed than urine output. ∗Assumes: (1) volume assessment with each step; (2) monitoring of electrolytes, renal function, symptoms, and vital signs; (3) daily weights; and (4) urine output not often accurate or obtainable. †Titrate progressively, according to the degree of hypervolemia, furosemide doses, and creatinine/kidney function. I.V., intravenous. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 11 Outpatient diuretic management algorithm for patients with heart failure. At each decision, clinical assessment should include an assessment of symptoms, volume assessment, and appropriate monitoring of vital signs, electrolytes, and creatinine. Daily weights are more easily and accurately assessed than urine output. Reassess serum potassium and creatinine 3-5 days after each diuretic dose change, earlier if concerned, other medication changes, or significant volume changes. Lowest dose of a diuretic that allows for optimal symptoms is the ideal dose. Dose reductions or increases should take into account previous response if known, and clinical scenario. See section 7.4.2. Initial and Ongoing Treatment and Canadian Cardiovascular Society Apps for further practical guidance. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions

Figure 12 Referral and follow-up frequency for patients with heart failure (HF). Recommended initial referral wait time and follow-up frequency. ∗Visit frequency might increase during medication titration. ACEi/ARB, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker; ACS, acute coronary syndrome; COPD, chronic obstructive pulmonary disease; ED, emergency department; EF, ejection fraction; ICD, implantable cardioverter defibrillator; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NYHA, New York Heart Association. Canadian Journal of Cardiology 2017 33, 1342-1433DOI: (10.1016/j.cjca.2017.08.022) Copyright © 2017 Canadian Cardiovascular Society Terms and Conditions