ACC Heart Failure Guidelines Slide Deck Based on the ACC/AHA 2005 Guideline Update for the Diagnosis...

ACC Heart Failure GuidelinesSlide Deck

Based on the ACC/AHA 2005 Guideline Update

for the Diagnosis and Management of

Chronic Heart Failure in the Adult

January 2006

Supported by Medtronic, Inc.

Medtronic, Inc. was not involved in the development of this slide deck and in no way influenced its contents.

William T. Abraham, MD, FACC, FAHA

Marshall H. Chin, MD, MPH, FACP

Arthur M. Feldman, MD, PhD, FACC, FAHA

Gary S. Francis, MD, FACC, FAHA

Theodore G. Ganiats, MD

Mariell Jessup, MD, FACC, FAHA

Marvin A. Konstam, MD, FACC

Sharon Ann Hunt, MD, FACC, FAHA, Chair

Donna M. Mancini, MD

Keith Michl, MD, FACP

John A. Oates, MD, FAHA

Peter S. Rahko, MD, FACC, FAHA

Marc A. Silver, MD, FACC, FAHA

Lynne Warner Stevenson, MD, FACC, FAHA

Clyde W. Yancy, MD, FACC, FAHA

ACC/AHA 2005 Guideline Update for the Management of Patients With Chronic Heart

Failure in the Adult

Writing Committee Members

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended

or indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

Applying Classification of Recommendations and Level of Evidence

Level A

Multiple (3-5) population risk strata evaluated

General consistency of direction and magnitude of effect

Class I

• Recommen-dation that procedure or treatment is useful/ effective

• Sufficient evidence from multiple randomized trials or meta-analyses

Class IIa

• Recommen-dation in favor of treatment or procedure being useful/ effective

• Some conflicting evidence from multiple randomized trials or meta-analyses

Class IIb

• Recommen-dation’s usefulness/ efficacy less well established

• Greater conflicting evidence from multiple randomized trials or meta-analyses

Class III

• Recommen-dation that procedure or treatment not useful/effective and may be harmful

• Sufficient evidence from multiple randomized trials or meta-analyses


Level B

Limited (2-3) population risk strata evaluated

Class I

• Recommen-dation that procedure or treatment is useful/effective

• Limited evidence from single randomized trial or non-randomized studies

Class IIa

• Recommen-dation in favor of treatment or procedure being useful/ effective

• Some conflicting evidence from single randomized trial or non-randomized studies

Class IIb


• Greater conflicting evidence from single randomized trial or non-randomized studies

Class III

• Recommen-dation that procedure or treatment not useful/effective and may be harmful

• Limited evidence from single randomized trial or non-randomized studies



Level C Very limited (1-2) population risk strata evaluated

Class I

• Recommen-dation that procedure or treatment is useful/ effective

• Only expert opinion, case studies, or standard-of-care

Class IIa

• Recommen-dation in favor of treatment or procedure being useful/effective

• Only diverging expert opinion, case studies, or standard-of-care

Class IIb


• Only diverging expert opinion, case studies, or standard-of-care

Class III

• Recommend-ation that procedure or treatment not useful/effective and may be harmful

• Only expert opinion, case studies, or standard-of-care

Heart Failure is a Major and Growing Public Health Problem in the U.S.

Approximately 5 million patients in this country have HF

Over 550,000 patients are diagnosed with HF for the first time each year

Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year

In 2001, nearly 53,000 patients died of HF as a primary cause

Heart Failure is Primarily a Condition of the Elderly

The incidence of HF approaches 10 per 1000 population after age 65

HF is the most common Medicare diagnosis-related group

More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare

Guideline Scope

Document focuses on :

Prevention of HF

Diagnosis and management of

chronic HF in the adult

Definition of Heart Failure

HF is a complex clinical syndrome that canresult from any structural or functionalcardiac disorder that impairs the ability ofthe ventricle to fill with or eject blood.

“Heart Failure” vs. “Congestive Heart Failure”

Because not all patients have volume overload atthe time of initial or subsequent evaluation, theterm “heart failure” is preferred over the older term “congestive heart failure.”

Causes of HF in Western World

For a substantial proportion of patients, causes are:

1. Coronary artery disease

2. Hypertension

3. Dilated cardiomyopathy

Stages of Heart Failure

At Risk for Heart Failure:

STAGE A High risk for developing HF

STAGE B Asymptomatic LV dysfunction

Heart Failure:

STAGE C Past or current symptoms of HF

STAGE D End-stage HF


• Designed to emphasize preventability of HF

• Designed to recognize the progressive nature of LV dysfunction


COMPLEMENT, DO NOT REPLACE NYHA CLASSES

• NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)

• Stages - progress in one direction due to cardiac remodeling

Stage A

Patients at High Risk for Developing Heart Failure

Stage A Therapy

Recommended Therapies to Reduce Risk Include:• Treating known risk factors (hypertension, diabetes, etc.)

with therapy consistent with contemporary guidelines• Avoiding behaviors increasing risk (i.e., smoking

excessive consumption of alcohol, illicit drug use)• Periodic evaluation for signs and symptoms of HF• Ventricular rate control or sinus rhythm restoration• Noninvasive evaluation of LV function• Drug therapy –

•Angiotensin Converting Enzyme Inhibitors (ACEI)•Angiotensin Receptor Blockers (ARBs)

Stage A Therapy

In patients at high risk for developing HF, systolic and diastolic hypertension should be controlled in accordance with contemporary guidelines.

In patients at high risk for developing HF, lipid disorders should be treated in accordancewith contemporary guidelines.

Using Therapy Consistent with Contemporary Guidelines

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Stage A Therapy

In patients at high risk for developing HF who have known atherosclerotic vascular disease, healthcare providers should follow current guidelines for secondary prevention.

For patients with diabetes mellitus (who are all at high risk for developing HF), blood sugar should be controlled in accordance with contemporary guidelines.




Stage A Therapy

Thyroid disorders should be treated in accordance with contemporary guidelines in patients at high risk for developing HF.



Stage A Therapy

Patients at high risk for developing HF should be counseled to avoid behaviors that may increase the risk of HF (e.g., smoking, excessive alcohol consumption, and illicit drug use).

Avoiding Behaviors That Increase Risk


Stage A Therapy

Healthcare providers should perform periodic evaluation for signs and symptoms of HF in patients at high risk for developing HF.

Periodic Evaluation for Signs and Symptoms


Stage A Therapy

Ventricular rate should be controlled or sinus rhythm restored in patients with supraventricular tachyarrhythmias who are at high risk for developing HF.

Ventricular Rate Control or Sinus Rhythm Restoration

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Stage A Therapy

Healthcare providers should perform a noninvasive evaluation of LV function (i.e.,LVEF) in patients with a strong family historyof cardiomyopathy or in those receiving cardiotoxic interventions.

Noninvasive Evaluation of LV Function


Stage A Therapy

ACEI can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors.

Angiotensin Converting EnzymeInhibitors (ACEI)


Stage A Therapy

ARBs can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors.

Angiotension Receptor Blockers(ARBs)


Stage A Therapy

Routine use of nutritional supplements solelyto prevent the development of structural heart disease should not be recommended for patients at high risk for developing HF.

Therapies NOT Recommended


Stage B

Patients with Asymptomatic LV Dysfunction

Stage B Therapy

Recommended Therapies:General Measures as advised for Stage A

•Drug therapy for all patients•ACEI or ARBs•Beta-Blockers

•ICDs in appropriate patients•Coronary revascularization in appropriate patients•Valve replacement or repair in appropriate patients

Stage B Therapy

All Class I recommendations for Stage A should apply to patients with cardiac structural abnormalities who have not developed HF. (Levels of Evidence: A, B, and C as appropriate)

Patients who have not developed HF symptoms should be treated according to contemporary guidelines after an acute MI.

General Measures



Stage B Therapy

Beta-blockers and ACEIs should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF.

ACEI should be used in patients with a reduced EF and no symptoms of HF, even if they have not experienced MI.

ACEI or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF.




Angiotensin Converting EnzymeInhibitors (ACEI)

Stage B Therapy

An ARB should be administered to post-MI patientswithout HF who are intolerant of ACEIs and have a low LVEF.

ACEIs or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF.

ARBs can be beneficial in patients with low EF andno symptoms of HF who are intolerant of ACEIs.

Angiotensin Receptor Blockers(ARBs)




Stage B Therapy

Beta-blockers and ACEIs should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF.

Beta-blockers are indicated in all patientswithout a history of MI who have a reducedLVEF with no HF symptoms.

Beta-Blockers



Stage B Therapy

Placement of an ICD is reasonable in patients withischemic cardiomyopathy who are at least 40 dayspost-MI, have an LVEF of 30% or less, are NYHAfunctional class I on chronic optimal medical therapy,and have reasonable expectation of survival with a good functional status for more than 1 year.

Placement of an ICD might be considered in patientswithout HF who have nonischemic cardiomyopathyand an LVEF less than or equal to 30% who are inNYHA functional class I with chronic optimal medicaltherapy and have a reasonable expectation of survivalwith good functional status for more than 1 year.

Internal Cardioverter Defibrillator (ICD)



Stage B Therapy

Coronary revascularization should berecommended in appropriate patientswithout symptoms of HF in accordancewith contemporary guidelines (seeACC/AHA Guidelines for the Managementof Patients With Chronic Stable Angina).

Coronary Revascularization


Stage B Therapy

Valve replacement or repair should berecommended for patients withhemodynamically significant valvularstenosis or regurgitation and nosymptoms of HF in accordance with contemporary guidelines.

Valve Replacement/Repair


Stage B Therapy

Digoxin should not be used in patients with low EF,sinus rhythm, and no history of HF symptoms,because in this population, the risk of harm is not balanced by any known benefit.

Use of nutritional supplements to treat structuralheart disease or to prevent the development of symptoms of HF is not recommended.

Calcium channel blockers with negative inotropiceffects may be harmful in asymptomatic patientswith low LVEF and no symptoms of HF after MI.





Stage C

Patients with Past or CurrentSymptoms of Heart Failure

Recommended Therapies:•General measures as advised for Stages A and B•Drug therapy for all patients

•Diuretics for fluid retention•ACEI•Beta-blockers

•Drug therapy for selected patients•Aldosterone Antagonists•ARBs•Digitalis•Hydralazine/nitrates

•ICDs in appropriate patients•Cardiac resynchronization in appropriate patients•Exercise Testing and Training

Stage C Therapy(Reduced LVEF with Symptoms)

Measures listed as Class I recommendations forpatients in stages A and B are also appropriate forpatients in Stage C. (Levels of Evidence: A, B, and C asappropriate)

Drugs known to adversely affect the clinical status ofpatients with current or prior symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatorydrugs, most antiarrhythmic drugs, and most calcium channel blocking drugs).

General Measures




Diuretics and salt restriction are indicated inpatients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention.

Diuretics



ACEIs are recommended for all patients withcurrent or prior symptoms of HF and reducedLVEF, unless contraindicated.

Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended forpatients with current or prior symptoms of HFand reduced LVEF.

Angiotensin Enzyme ConvertingInhibitors (ACEIs)




ARBs approved for the treatment of HF are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACEI-intolerant (see full text guidelines for information regarding patients with angioedema).

ARBs are reasonable to use as alternatives to ACEIs as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications.

Angiotensin Receptor Blockers (ARBs)




The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy.

Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patientswith current or prior symptoms of HF and reduced LVEF.

ARBs (cont’d)




Addition of an aldosterone antagonist is recommended inselected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should beless than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should beless than 5.0 mEq/L. Under circumstances where monitoring for hyperkalemia or renal dysfunction is notanticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists.

Routine combined use of an ACEI, ARB, and aldosteroneantagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.

Aldosterone Antagonists




Beta-blockers (using 1 of the 3 proven to reducemortality, i.e., bisoprolol, carvedilol, and sustainedrelease metoprolol succinate) are recommended forall stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated.

Beta-Blockers



Digitalis can be beneficial in patients withcurrent or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF.

Digitalis



The addition of a combination of hydralazine and anitrate is reasonable for patients with reduced LVEF who are already taking an ACEI and beta-blocker for symptomatic HF and who have persistent symptoms.

A combination of hydralazine and a nitrate might be

reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an ACEI or ARB because of drug intolerance, hypotension, or renal insufficiency.

Hydralazine and Isosorbide Dinitrate




An ICD is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia.

ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with ischemic heart disease who are at least 40 days post-MI, have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year.

Implantable Cardioverter-Defibrillators (ICDs)




ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with nonischemic cardiomyopathy who have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year.

Placement of an ICD is reasonable in patients with LVEF of 30% to 35% of any origin with NYHA functional class II or III symptoms who are taking chronic optimal medical therapy and who have reasonable expectation of survival with good functional status of more than 1 year.

ICDs (cont’d)III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII



Patients with LVEF less than or equal to 35%, sinusrhythm, and NYHA functional class III or ambulatoryclass IV symptoms despite recommended, optimalmedical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration greater than 120 ms, should receive

cardiac resynchronization therapy unless contraindicated.

Cardiac Resynchronization



Maximal exercise testing with or without measurement of respiratory gas exchange is recommended to facilitate prescription of an appropriate exercise program for patients presenting with HF.

Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of HF and reduced LVEF.

Exercise Testing and Training




Unproven/Not RecommendedDrugs and Interventions for HF

• Nutritional Supplements

• Hormonal Therapies

• Intermittent Intravenous

Positive Inotropic Therapy


Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of HF and reduced LVEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for Stage D).

Use of nutritional supplements as treatment for HF is not indicated in patients with current or prior symptoms of HF and reduced LVEF.

Unproven/Not Recommended Drugs and Interventions




Calcium channel blocking drugs are not indicated as

routine treatment for HF in patients with current or prior symptoms of HF and reduced LVEF.

Hormonal therapies other than to replete deficiencies are not recommended and may be harmful to patients with current or prior symptoms of HF and reduced LVEF.

Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patientswith current or prior symptoms of HF and reduced LVEF.

Unproven/Not Recommended Drugs and Interventions





Recommended Therapies for Routine Use:•Treating known risk factor (hypertension) with therapy

consistent with contemporary guidelines•Ventricular rate control for all patients•Drugs for all patients -

•Diuretics•Drugs for appropriate patients –

•ACEI•ARBs•Beta-Blockers•Digitalis

•Coronary revascularization in selected patients•Restoration/maintenance of sinus rhythm in

appropriate patients

Stage C Therapy(Normal LVEF with Symptoms)

Differential Diagnosis in Patient with HF and Normal LVEF with Symptoms

• Incorrect diagnosis of HF• Inaccurate measurement of

LVEF• Primary valvular disease• Restrictive (infiltrative)

cardiomyopathies• Amyloidosis, sarcoidosis,

hemochromatosis• Pericardial constriction• Episodic or reversible LV

systolic dysfunction• Severe hypertension,

myocardial ischemia

• HF associated with high metabolic demand (high-output states)

• Anemia, thyrotoxicosis, arteriovenous fistulae

• Chronic pulmonary disease with right HF

• Pulmonary hypertension associated with pulmonary vascular disorders

• Atrial myxoma• Diastolic dysfunction of

uncertain origin• Obesity

Physicians should control systolic and diastolic hypertension in patients with HF and normal LVEF, in accordance with published guidelines.

Treating known risk factors - Hypertension



Physicians should control ventricular rate in patients with HF and normal LVEF and atrialfibrillation.

Ventricular Rate Control



Physicians should use diuretics to controlpulmonary congestion and peripheral edema inpatients with HF and normal LVEF.

Diuretics



Coronary revascularization is reasonable in patients with HF and normal LVEF and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function.

Coronary Revascularization



Restoration and maintenance of sinus rhythm in patients with atrial fibrillation and HF and normal LVEF might be useful to improve symptoms.

Restoration/Maintenance of Sinus Rhythm



The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF.

Angiotensin Enzyme ConvertingInhibitors (ACEIs)




Angiotensin Receptor Blockers (ARBs)




Beta-Blockers



The usefulness of digitalis to minimize symptoms of HF in patients with HF and normal LVEF is not well established.

Digitalis



Stage D

Patients with Refractory End-Stage HF

Stage D Therapy

Recommended Therapies Include:•Control of fluid retention •Referral to a HF program for appropriate pts•Discussion of options for end-of-life care•Informing re: option to inactivate defibrillator•Device use in appropriate patients•Surgical therapy –

•Cardiac transplantation•Mitral valve repair or replacement•Other

•Drug Therapy –•Positive inotrope infusion as palliation in appropriate patients

Stage D Therapy

Meticulous identification and control of fluid retention is recommended in patients with refractory end-stage HF.

Control of Fluid Retention


Stage D Therapy

Referral of patients with refractory end-stage HF to an HF program with expertise in the management of refractory HF is useful.

Referral to an HF Program


Stage D Therapy

Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory end-stage HF persist despite application of all recommended therapies.

Discussion of Options for End-of-Life Care


Stage D Therapy

Patients with refractory end-stage HF andimplantable defibrillators should receive information about the option to inactivate defibrillation.

Inform on option to inactivate defibrillation


Stage D Therapy

Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF.

The effectiveness of mitral valve repair or replacement is not established for severe secondary mitral regurgitation in refractory end-stage HF.

Surgical Therapy




Stage D Therapy

Consideration of an LV assist device as permanentor “destination” therapy is reasonable in highly selected patients with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy.

Pulmonary artery catheter placement may be reasonable to guide therapy in patients with refractory end-stage HF and persistently severe symptoms.

Device Use


Stage D Therapy

Continuous intravenous infusion of a positive inotropic agent may be considered for palliation of symptoms in patients with refractory end-stage HF.

Routine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF.

Medical TherapyIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII


Stage D Therapy

Partial left ventriculectomy is not recommended inpatients with nonischemic cardiomyopathy and refractory end-stage HF.

Routine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF.




ACC Heart Failure Guidelines Slide Deck Based on the ACC/AHA 2005 Guideline Update for the Diagnosis...

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