Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
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Transcript of Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
2006 HFSA Comprehensive Heart Failure Practice Guideline
Key Recommendations
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Comprehensive Heart Failure Practice Guideline
Strength of Recommendation
“Is recommended”
“Should be considered”
“May be considered”
“Is not recommended”
Part of routine care Exceptions should be
minimized
Majority of patients should receive intervention Some discretion allowed
Individualization of therapy is indicated
Therapy should not be used
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Comprehensive Heart Failure Practice Guideline
Strength of Evidence
A
B
C
Randomized controlled trials May be assigned on results of 1 trial
Cohort and case control studies Includes sub group analyses, meta-
analyses, observational studies, registries
Expert opinion Includes observational, epidemiological
findings; in-practice safety reporting
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (3.1)
Heart Failure Prevention
Strength of Evidence = A
A careful and thorough clinical assessment, with appropriate investigation for known or potential risk factors, is recommended in an effort to prevent development of LV remodeling, cardiac dysfunction, and HF.
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (3.2)
HF Risk Factor Treatment Goals
Maximum 2-3 g/dayDietary Sodium
CessationSmoking
Men 2 drinks/day, women 1Alcohol
Weight reduction < 30 BMIObesity
20-30 min. aerobic 3-5 x wk.Inactivity
See NCEP guidelines2Hyperlipidemia
See ADA guidelines1Diabetes
Generally < 130/80Hypertension
GoalRisk Factor
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
1. Diabetes Care 2006; 29: S4-S42.2. JAMA 2001; 285:2486-97.
Treating Hypertension to Prevent HF
Aggressive blood pressure control:
Aggressive BP control in patients with prior MI:
Decreasesrisk of new HF
by ~ 80%
Decreasesrisk of new HF
by ~ 50%56% in DM2
Decreasesrisk of new HF
by ~ 50%56% in DM2
Lancet 1991;338:1281:1281-5 (STOP-Hypertension).JAMA 1997;278:212-6 (SHEP).UKPDS Group. UKPDS 38. BMJ 1998;317:703-713.
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (3.3-3.4)
Prevention—ACEI and Beta Blockers
ACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with:
Coronary artery disease
Peripheral vascular disease
Stroke
Diabetes and another major risk factorStrength of Evidence = A
ACE inhibitors and beta blockers are recommended for all patients with prior MI.
Strength of Evidence = A
Management of Patients with Known Atherosclerotic Disease But No HF
Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest.
Placebo
Ramipril
Placebo
Perindopril
20% rel. risk red. p = .0003
22% rel. risk red. p < .001
HOPE
EUROPA
NEJM 2000;342:145-53 (HOPE).
Lancet 2003;362:782-8 (EUROPA).
02468
10121416
0 1 2 3 4Years
% MI,Stroke,
CV Death
0
3
6
9
12
15
0 1 2 3 4 5Years
% MI,CV Death,
Cardiac Arrest
Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF 40%)
SAVE Study
All-cause mortality ↓ 19%
CV mortality ↓21%
HF development ↓ 37%
Recurrent MI ↓ 25%
Placebo
Captopril
Years
MortalityRate
19% relative risk reductionp = 0.019
Pfeffer et al. NEJM 1992;327:669-77.
0
0.1
0.2
0.3
0 0.5 1 1.5 2 2.5 3 3.5 4
The Additional Value of Beta Blockers Post-MI: CAPRICORN
Studied impact of beta blocker (carvedilol) on post-MI patients with LVEF 40% already receiving contemporary treatments, including revascularization, anticoagulants, ASA, and ACEI:
All-cause mortality reduced (HR = 0.077; p = 0.03)
Cardiovascular mortality reduced (HR = 0.75; p = .024)
Recurrent non-fatal MIs reduced (HR =.59; p = .014)
Dargie HJ. Lancet 2001;357:1385-90.
HFSA 2006 Practice Guideline (4.8, 4.10)
Heart Failure Patient EvaluationRecommended evaluation for patients with a diagnosis of HF: Assess clinical severity and functional limitation by history, physical
examination, and determination of functional class*
Assess cardiac structure and function
Determine the etiology of HF
Evaluate for coronary disease and myocardial ischemia
Evaluate the risk of life threatening arrhythmia
Identify any exacerbating factors for HF
Identify co-morbidities which influence therapy
Identify barriers to adherence and compliance Strength of Evidence = C
* Metrics to consider include the 6-minute walk test and NYHA functional class
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (4.18)
Evaluation—Follow Up AssessmentsRecommended Components of Follow-Up Visits Signs and symptoms evaluated during initial visit
Functional capacity and activity level
Changes in body weight
Patient understanding of and compliance with dietary sodium restriction
Patient understanding of and compliance with medical regimen
History of arrhythmia, syncope, pre-syncope or palpitation
Compliance and response to therapeutic interventions
Exacerbating factors for HF, including worsening ischemic heart disease, hypertension, and new or worsening valvular disease Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.1, 7.4)Pharmacologic Therapy: ACE Inhibitors
ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF 40%.
Strength of Evidence = A
ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C
ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF 40%. Post MI Strength of Evidence = B
Non Post-MI Strength of Evidence = C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
ACE Inhibitors in Heart Failure:From Asymptomatic LVD to Severe HF
SOLVD Prevention (Asymptomatic LVD)
20% death or HF hosp.
29% death or new HF
CONSENSUS (Severe Heart Failure)
40% mortality at 6 mos.
31% mortality at 1 year
27% mortality at end ofstudy
No difference in incidence of sudden cardiac death
SOLVD Investigators. N Engl J Med 1992;327:685-91.SOLVD Investigators. N Engl J Med 1991;325:293-302.CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35.
(Chronic Heart Failure)SOLVD Treatment
16% mortality
HFSA 2006 Practice Guideline (7.2)
Pharmacologic Therapy: Substitutes for ACEI
It is recommended that other therapy be substituted for ACE inhibitors in the following circumstances: In patients who cannot tolerate ACE inhibitors due to cough,
ARBs are recommended. Strength of Evidence = A
The combination of hydralazine and an oral nitrate may be considered in such patients not tolerating ARBs.
Strength of Evidence = C
Patients intolerant to ACE inhibitors due to hyperkalemia or renal insufficiency are likely to experience the same side effects with ARBs. In these cases, the combination of hydralazine and an oral nitrate should be considered.
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.3, 7.4)Pharmacologic Therapy: Beta Blockers
Beta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF 40%.
Strength of Evidence = A
Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF 40%. Post MI Strength of Evidence = B
Non Post-MI Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD
↓23% mortality (p =.031)25 BIDpost-MI LVD
carvedilolCAPRICORN5
↓35% mortality (p = .0014)25 BIDseverecarvedilolCOPERNICUS4
↓34% mortality (p = .0062)200 QDmild/ moderate
metoprololsuccinate
MERIT-HF3
↓34% mortality (p <.0001)10 QDmoderate/ severe
bisoprololCIBIS-II2
↓48% disease progression (p= .007)
6.25-25 BID
mild/ moderate
carvedilolUS Carvedilol1Outcome
Target Dose (mg)
HF SeverityDrugStudy
1. Colucci WS et al. Circulation 1196;94:2800-6. 2. CIBIS II Investigators. Lancet 1999;353:9-13.3. MERIT-HF Study Group. Lancet 1999;353:2001-7.
4. Packer M et al. N Engl J Med 2001;3441651-8. 5. The CAPRICORN Investigators. Lancet 2001;357:1385-90.
HFSA 2006 Practice Guideline (7.5, 7.8)
Pharmacologic Therapy: Beta Blockers
RECENT DECOMPENSATION OR EXACERBATION
Beta blocker therapy is recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of IV diuretics and vasoactive agents.
Whenever possible, beta blocker therapy should be initiated in the hospital at a low dose prior to discharge of stable patients.
Strength of Evidence = B
Continuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment. Strength of Evidence = C
If necessary, consider temporary dose reduction
Avoid abrupt discontinuation
Reinstate or gradually increase before discharge
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
0000
2020
1010
% o
f Pat
ient
s W
ith E
vent
% o
f Pat
ient
s W
ith E
vent
22 44 66 88
Carvedilol
Placebo
HR = 0.67 (CI = 0.47HR = 0.67 (CI = 0.47--0.96)0.96)
Weeks After RandomizationWeeks After Randomization
3030
COPERNICUS: Death, Hospitalization, or Study Drug Withdrawal in High Risk Patients
Krum H et al. JAMA 2003;289:754-6.
IMPACT-HF Primary End Point:Patients Receiving Beta Blocker at 60 Days
CarvedilolPredischarge Initiation
(n=185)
Physician DiscretionPostdischarge Initiation*
(n=178)
18%18%ImprovementImprovement
Gattis WA et al. JACC 2004;43:1534-41.
91%
73%
0
25
50
75
100
Patie
nts
(%)
P < .0001
HFSA 2006 Practice Guideline (7.6)
Pharmacologic Therapy: Beta Blockers
CONCOMITANT DISEASE
Beta blocker therapy is recommended in the great majority of patients with LV systolic dysfunction—even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease.
Use with caution in patients with: Diabetes with recurrent hypoglycemia Asthma or resting limb ischemia.
Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).
Not recommended in patients with asthma with active bronchospasm. Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Diabetes and the Use of Beta Blockers for HF: Relative Risk for Mortality and Hospitalization for Heart Failure
0 0.5 1.0 1.5 2.0
COPERNICUS (carvedilol)1
With diabetes
Without diabetesMERIT-HF (ER metoprolol succinate)2
With diabetes
Without diabetes
1. Mohacsi. Circulation. 2001;104(17):abstr 3551.
2. Hjalmarson. JAMA. 2000;283(10):1295.
HFSA 2006 Practice Guideline (11.8, 15.2)
Pharmacologic Therapy: Beta Blockers
PRESERVED LVEFBeta blocker treatment is recommended in patients with HF and preserved LVEF who have: Prior MI Strength of Evidence = A
Hypertension Strength of Evidence = B
Atrial fib. requiring control of ventricular rate Strength of Evidence = B
THE ELDERLYBeta-blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction.
Strength of Evidence = B
In the absence of contraindications, these therapies are alsorecommended in the very elderly (age > 80 years). Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline
Pharmacologic Therapy: Beta Blocker Overview*
Prolong titration interval
Reduce target dose
Consider referral to a HF specialist
If up-titration continues to be difficult
Adjust dose of diuretic or concomitant vasoactive med.
Continue titration to target after symptoms return to baseline
If symptoms worsen or other side effects appear
Initiate at low doses
Up-titrate gradually, generally no sooner than at 2 week intervals
Use target doses shown to be effective in clinical trials
Aim to achieve target dose in 8-12 weeks
Maintain at maximum tolerated dose
General considerations
* Consult language of specific recommendations
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.10)
Pharmacologic Therapy: Angiotensin Receptor Blockers
ARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency.
Strength of Evidence = A
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-AlternativeVal-HeFT
Valsartan
Placebo
p = 0.017
Months
Surv
ival
%
CV
Dea
th o
r HF
Hos
p % Placebo
Candesartan
CHARM-Alternative
HR 0.77, p = 0.0004
MonthsMaggioni AP et al. JACC 2002;40:1422-4.Granger CB et al. Lancet 2003;362:772-6.
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 270
10
20
30
40
50
0 9 18 27 36 42
HFSA 2006 Practice Guideline (7.14-7.15)
Pharmacologic Therapy:Aldosterone Antagonists
An aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have: NYHA class IV HF (or class III, previously class IV)
due to LV systolic dysfunction (LVEF 35%)
One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor or an ARB. Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Aldosterone Antagonists in HFRALES (Advanced HF) EPHESUS (Post-MI)
Spironolactone
Placebo
Months
RR = 0.70P < 0.001
Epleronone
Placebo
RR = 0.85P < 0.008
Pitt B. N Engl J Med 1999;341:709-17.Pitt B. N Engl J Med 2003;348:1309-21.
Prob
abili
ty o
f Sur
viva
l
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 3 6 9 12 15 18 21 24 27 30 33 360.40
0.50
0.60
0.70
0.80
0.90
1.00
0 3 6 9 12 15 18 21 24 27 30 33 36Months
HFSA 2006 Practice Guideline (7.16-7.18)Aldosterone Antagonists and Renal Function
Aldosterone antagonists are not recommended when: Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
Serum potassium> 5.0 mmol/L
Therapy includes other potassium-sparing diureticsStrength of Evidence = A
It is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 months
Strength of Evidence = A
Supplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.19)
Pharmacologic Therapy:Hydralazine and Oral Nitrates
A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with LV systolic dysfunction: NYHA III or IV HF Strength of Evidence = A
NYHA II HF Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
A-HeFT Outcomes
0.02-2.7-5.5Change in quality-of-life score at 6 months**
0.00124.416.41st HF hospitalization (%)
0.0210.26.2All-cause mortality (%)
0.01-0.5-0.1 Primary end point composite score
pPlacebo (n=532)
ISDN-HDZN (n=518)
End point
Taylor AL et al. N Engl J Med 2004; 351;2049-2057.
A-HeFT All-Cause MortalitySu
rviv
al %
Days Since Baseline Visit
43% Decrease in Mortality
Fixed Dose ISDN/HDZN
Placebo
P = 0.01
Taylor AL et al. N Engl J Med 2004;351:2049-57.
85
90
95
100
0 100 200 300 400 500 600
HFSA 2006 Practice Guideline (7.23)
Pharmacologic Therapy: Diuretics
Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by: Congestive symptoms
Signs of elevated filling pressuresStrength of Evidence = A
Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF.
Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.23)
Loop Diuretics
6 hrs67%R-33%M200 mg25-50 mg qdor bid
Ethacrynicacid
12-16 hrs20%R-80%M200 mg10-20 mg qdTorsemide
6-8 hrs62%R/38%M10 mg0.5-1.0 mg qd or bid
Bumetanide
4-6 hrs65%R-35%M600 mg20-40mg qdor bid
Furosemide
Duration of Action
Elimination: Renal – Met.
Max Total Daily Dose
Initial Daily Dose
Agent
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.23)
Potassium-Sparing Diuretics
7-9 hrsMetabolic200 mg50-75 mg bid
Triamterene
24 hrsRenal20 mg5 mg qdAmiloride
UnknownRenal, Metabolic
100 mg25-50 mg qd
Eplerenone
48-72 hrsMetabolic50 mg12.5-25 mg qd
Spironolactone
Duration of Action
EliminationMax Total Daily Dose
Initial Daily Dose
Agent
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.24)
Pharmacologic Therapy: Diuretics Restoration of normal volume status may require multiple
adjustments.
Once a diuretic effect is achieved with short-acting loop diuretics, increase frequency to 2-3 times a day if necessary, rather than increasing a single dose. Strength of Evidence = B
Oral torsemide may be considered in patients exhibiting poor absorption of oral medication or erratic diuretic effect.
Strength of Evidence = C
IV administration of diuretics may be necessary. Strength of Evidence = A
Diuretic refractoriness may represent patient noncompliance, a direct effect of diuretic use on the kidney, or progression ofunderlying dysfunction.
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (9.1, 9.4)
Device Therapy:Prophylactic ICD Placement
In patients on optimal medical therapy (ideally 3-6 months) with or without concomitant coronary artery disease (including a prior MI > 1 month ago): Prophylactic ICD placement should be considered in
those with NYHA II-III HF (LVEF 30%)
Prophylactic ICD placement may be considered in those with NYHA II-III HF (LVEF 31-35%)
Strength of Evidence = A
Concomitant placement should be considered in NYHA III-IV patients undergoing implantation of a biventricular pacing device. Strength of Evidence = B
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
MADIT II: Prophylactic ICD in Ischemic LVD (LVEF 30%)
365 (.69)170 (.78)329 (.90)490Conventional9110 (.78)274 (.84)503 (.91)742Defibrillator
Number at Risk
0 1 2 3
.7
.8
.9
1.0Pr
obab
ility
of S
urvi
val
ConventionalTherapy
Defibrillator
Year
.6
04
Moss AJ et al. N Engl J Med 2002;346:877-83.
ICD Therapy in the SCD-HeFT Trial: Mortality by Intention-to-Treat
.007.62-.96.77ICD vs Placebo.53.86-1.301.06Amiodarone vs Placebo
P Value97.5% ClHR
Months of Follow-Up
Mor
talit
y
0 6 12 18 24 30 36 42 48 54 600
.1
.2
.3
.4
Amiodarone
ICD TherapyPlacebo
17%
22%
Bardy GH et al. N Engl J Med 2005;352:225-37.
HFSA 2006 Practice Guideline (9.7)
Device Therapy:Biventricular Pacing
Biventricular pacing therapy should be consideredfor patients with all of the following: Sinus rhythm
A widened QRS interval (120 ms)
Severe LV systolic dysfunction (LVEF 35% with LV dilation > 5.5 cm)
Persistent, moderate-to-severe HF (NYHA III) despite optimal medical therapy.
Strength of Evidence = A
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
CRT Improves Quality of Life and NYHA Functional Class
(%)
Abraham WT et al. Circulation 2003;108:2596-2603.
Average Change in Score (MLWHF)
-20
-15
-10
-5
0
MIR
ACLE
MUS
TIC
SRCO
NTAK
CD
MIR
ACLE
ICD
* P < .05Control CRT
* ** *
NYHA: Proportion Improving by 1 or More Class
0
20
40
60
80
MIRACLE CONTAKCD
MIRACLEICD
**
*
CRT in Patients with Advanced HF and a Prolonged QRS Interval: COMPANION
Bristow MR et al. N Engl J Med 2004;350:2140-50.
Primary End Point: All-Cause Mortality
Death or Hospitalization Due to HF
Risk of all-cause mortality reduced by 19%in group with CRT and ICD (p =.014)Risk of death or hospitalization from HFreduced by 34% in ICD group and by 40% inICD-CRT group (p < .001)
Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF
571192321365404Medical Therapy889213351376409CRT
Number at risk0 500 1,000 1,500
25
50
75
100
% E
vent
-Fre
e Su
rviv
al
Medical Therapy
CRT
Days0
HR = 0.64 (95% CI = .48-.85)p = .0019
Cleland JG et al. N Engl J Med 2005;352:1539-49.
HFSA 2006 Practice Guideline (11.1-11.2)
HF with Preserved LVEF—Diagnosis
Careful attention to differential diagnosis is recommendedin patients with HF and preserved LVEF.
Treatments may differ based on cardiac disorder.
Evaluation for ischemic disease and inducible myocardial ischemia should be included.
Recommended diagnostic tools: Echocardiography
Electrocardiography
Stress imaging (via exercise or pharmacologic means, using myocardial perfusion or echocardiographic imaging)
Strength of Evidence = C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Figure 11.1. Diagnostic Categories of Heart Failure with Preserved LVEF
Figure courtesy of Marvin Konstam MD and Marvin Kronenberg MD.
Heart Failure with Preserved LVEF
Dilated LVDilated LV NonNon--dilated LVdilated LV
Valvular diseaseValvular diseaseAR; MRAR; MR
No valvular No valvular diseasedisease
High output HFHigh output HFIncreased thicknessIncreased thickness Normal thicknessNormal thickness Right Ventricular Dysfunction*Right Ventricular Dysfunction*
Mitral obstructionMitral obstructionMS; Atrial myxomaMS; Atrial myxoma
Normal or Increased Normal or Increased QRS voltage QRS voltage
Hypertrophic diseaseHypertrophic disease
No mitral No mitral obstructionobstruction
Pulmonary Pulmonary HypertensionHypertension
Hypertensive Hypertensive HxHx or PEor PE
HypertensiveHypertensive--hypertrophichypertrophiccardiomyopathycardiomyopathy
Isolated or Isolated or predominant RVMIpredominant RVMI
Low QRS voltageLow QRS voltageInfiltrative myopathyInfiltrative myopathy
No Aortic valve No Aortic valve diseasedisease
Inducible ischemiaInducible ischemiaIntermittent/activeIntermittent/active
ischemiaischemia
No inducible ischemiaNo inducible ischemiaFibrotic; collagenFibrotic; collagen--vascular;vascular;Restrictive CM; carcinoid; Restrictive CM; carcinoid;
Reconsider diagnosis of HFReconsider diagnosis of HF
No pericardial No pericardial diseasedisease
Pericardial diseasePericardial diseaseTamponade /ConstrictionTamponade /Constriction
Aortic valve diseaseAortic valve diseaseAortic stenosisAortic stenosis
No Hypertensive No Hypertensive HxHx or or PEPE
Hypertrophic Hypertrophic cardiomyopathycardiomyopathy
LVEF=left ventricular ejection fraction; HF=heart failure; QRS=electrocardiographic ventricular depolarization; AR= aortic regurgitation; MR=mitral regurgitation; MS=mitral stenosis; RVMI=right ventricular myocardial infarction; Hx=history; PE= physical examination.
* Some patients with right ventricular dysfunction have LV dysfunction due to ventricular interaction.
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (12.3, Table 12.3)Acute Decompensated Heart Failure (ADHF)—
Treatment Goals for Hospitalized Patients
• Improve symptoms, especially congestion and low-output symptoms
• Optimize volume status
• Identify etiology
• Identify precipitating factors
• Optimize chronic oral therapy; minimize side effects
• Identify who might benefit from revascularization
• Educate patients concerning medication and HF self-assessment
• Consider enrollment in a disease management program
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (12.5-12.18)Overview of Treatment Options for Patients with
Acute Decompensated HF
Fluid and sodium restriction
Diuretics, especially loop diuretics
Ultrafiltration/renal replacement therapy (in selected patients only)
Parenteral vasodilators *(nitroglycerin, nitroprusside, nesiritide)
Inotropes * (milrinone or dobutamine)*See recommendations for stipulations and restrictions.
HFSA 2006 Practice Guideline (12.23, Table 12.7)Discharge Criteria for Hospitalized ADHF Patients
Recommended prior to discharge for all patients with HF: Exacerbating factors addressed
Near optimum fluid status achieved
Transition from IV to oral diuretic completed
Near optimum pharmacologic therapy achieved
Follow-up clinic visit scheduled, usually 7-10 days
Should be considered prior to discharge for patients with advanced HF or a history of recurrent admissions:
Oral regimen stable for 24 hours
No IV inotrope or vasodilator for 24 hours
Ambulation before discharge to assess functional capacity
Plans for post-discharge management
Referral to a disease management program Strength of Evidence =C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Predictors of Mortality Based on Analysis of ADHERE Database
Classification and Regression Tree (CART) analysis of ADHERE data shows:
Three variables are the strongest predictors of mortality in hospitalized ADHF patients:
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
Fonarow GC et al. JAMA 2005;293:572-80.
HFSA 2006 Practice Guideline (8.1)
Heart Failure Patient Education
It is recommended that patients with HF and their family members or caregivers receive individualized education and counseling that emphasizes self-care.
This education and counseling should be delivered by providers using a team approach.
Teaching should include skill building and target behaviors.
Strength of Evidence = B
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
The Potential Impact of Effective Education on Patient Compliance
81.8%60.0%Alcohol
90.4%60.0%Smoking
84.5%76.4%Activity
55.8%23.6%Diet
66.7%8.7%Medications
Don’t recall adviceRecall MD advice
Noncompliance rate when patients . . .
Kravitz et al. Arch Int Med 1993;153:1869-78.
Sample Target Behavior: Be Able to Read and Understand Food Labels
Labels from cups of soup
HFSA 2006 Practice Guideline (8.7)
Heart Failure Disease Management
Patients recently hospitalized for HF and other patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care.
Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HF Disease Management and the Risk of Readmission
ClineJ aarsma
Rich
Naylor
Stewart
Rauh
Lasater
Ekman
Venner
Fonarow0.5
0.6
0.7
0.8
0.9
1
1.1
RiskRatio
Summary RR = 0.76 (95% CI .68-.87)Summary RR for randomized only = 0.75 (CI = .60-.95)
HFSA 2006 Practice Guideline (8.13)
End-of-Life Care in Heart Failure
End-of-life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic and nonpharmacologic therapy, as evidenced by one or more of the following: Frequent hospitalizations (3 or more per year)
Chronic poor quality of life with inability to accomplish activities of daily living
Need for intermittent or continuous intravenous support
Consideration of assist devices as destination therapyStrength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Evidence-Based Treatment Across the Continuum of Systolic LVD and HF
Control Volume Improve Clinical Outcomes
DiureticsRenal ReplacementTherapy*
Digoxin
-BlockerACEIor ARB
AldosteroneAntagonist
or ARB
Treat Residual Symptoms
CRT an ICD*
HDZN/ISDN**In selected patients