Congestive Heart Failure:Guideline Based

Management from Stage A to D

ACC/AHA Practice Guideline Update 2005

Christine NardiLoyola University Cardiology

July 27, 2007

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

Total estimated cost of HF treatmentin the U.S. in 2005?

$27.9 billion

Hospital Discharges for CHF

Definition of Heart Failure HF is a complex clinical syndrome that can

result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.

Manifests as Dyspnea and fatigue

Limits exercise tolerance Fluid retention

Pulmonary congestion and peripheral edema

Causes of HF in the Western World Coronary artery disease Hypertension Dilated cardiomyopathy

Ischemic Post-viral Etoh-related Genetic

Valvular heart disease

Initial Assessment History and Physical

History PMHx of HTN, CAD, DM, thyroid disease, valvular

disease, chemotherapy or XRT, PVD, OSA, rheumatic heart disease

Functional status Social history: tobacco, etoh, illicits Family history: HF, CAD, SCD

Physical Vitals (admission weight) Cardiopulmonary exam, volume assessment

Initial Assessment Labs: CMP, CBC, Mg, U/A 12 lead EKG, CXR Assessment of ventricular function

2-D echo with Doppler MUGA if poor echo windows

BNP when diagnosis is unclear

Guideline Scope

Current ACC/AHA guidelines focus on : Prevention of HF Diagnosis and management of chronic HF in the adult

Stage AHigh Risk for developing

Heart failure

Stage BAsymptomatic LV dysfunction

Stage CPast or current

Symptoms of HF

Stage DEnd-stage HF

Stages of HF: ACC/AHA

Class Isymptoms at activity levels thatwould limit normal individuals

Class IIsymptoms of HF with

ordinary exertionClass III

symptoms of HF with lessthan ordinary exertion

Class IVSymptoms of HF at rest

NYHA Functional Class

Stages of Heart Failure

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

Goals of Therapy Improve symptoms and quality of life Slow the progression of cardiac and

peripheral destruction Reduce mortality

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

Levels of Evidence A: data from multiple randomized trials B: data from one randomized trial or non-

randomized studies C: no data just consensus opinion of

experts

Stage APatients at High Risk for Developing Heart Failure

Patients at risk for HF HTN DM CAD Obesity Metabolic syndrome Exposure to cardiotoxins Family history of cardiomyopathy

Stage A Risk factor modification Diet and exercise plans Patient and family education Tobacco cessation Discourage alcohol and illicit drug use ACE inhibition in appropriate patient

population

Stage A Non-invasive measurement of LV function Periodic evaluation for signs and

symptoms of heart failure Ventricular rate control and sinus rhythm

restoration

Stage BPatients with Asymptomatic

LV Dysfunction

Stage B

Valvedisease LVH

PreviousMI

LVremodeling

Acute infarct (hours)

Infarct expansion

(hours to days)Global remodeling (days to months)

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 CPatients 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)

ACE-I Trials in Symptomatic HF

Mortality % Mortality %ACE-I Control RR

Chronic HFCONSENSUS 1 39 54 0.56SOLVD Treatment 35 40 0.82Post-MISAVE 20 25 0.81AIRE 17 23 0.73TRACE 35 42 0.78Avg mortality 21% 25% 16%

IAACE-I should be used in

all patients with reduced EF,unless contraindicated

or unable to tolerate them.

IAACE inhibitors should be

titrated to doses used in clinicaltrials, as tolerated,with concomitant

up-titration of beta-blockers

Beta-blockers in HF

carvedilol

Metoprolol XL

bisoprolol

IABeta-blockers

(carvedilol and metoprolol XL) should be used

in all stable patients with reducedEF, unless contraindicated

Starting and Target Doses for Beta-blockers in Heart FailureAgent Starting

DoseTarget Dose<75kg

Target Dose>75kg

MetoprololCR/XL

12.5-25mg po daily

200mg po daily

200mg po daily

Bisoprolol 1.25mg po daily

5mg po daily

10mg po daily

Carvedilol 3.125mg po twice daily

25mg po twice daily

50mg po twice daily

IBBeta-blockers should be initiated

at very low doses, followed by gradualincrements, in patients who have no orminimal evidence of fluid retention and

have not required recent treatmentwith an IV inotropic agent

ARB Trials in Symptomatic HF

ELITE I/II OPTIMAAL VALIANT ValHeFT CHARMpatients NYHA II-IV AMI/CHF AMI/CHF NYHA II-IV NYHA II-IV

Study design Losartan or captopril

Losartan or captopril

Valsartan, captopril or both

Valsartan and ACEI

Candesartan and ACEI

Beta-blocker 16% 79% 70% 35% 55%

mortality No difference

Captopril better

No difference

No difference

No difference

HF hosp No difference

Captopril better

Both better Both better Both better

other Losartan better tolerated

Losartan better tolerated

Increased creatinine with both

Increased mortality with beta-blockers

Decreased mortality with b-blockers; increased K and Cr with both

IAARB are recommended in patients

with current or prior symptomswith low EF who are ACE-I intolerant

IIbBAddition of ARB may be considered

in persistently symptomaticpatients who are already on

conventional therapy

RALES (Randomized Aldactone Evaluation Study) 1663 patients

NYHA class III-IV 10% beta-blockers KCl discouraged

Exclusion: K>5.0 or Cr>2.5

Spironolactone 25mg daily

Drug held for K>6.0 or Cr>4.0

Pitt et al. NEJM 1999:341:709.

HR 0.70p<0.001

IBAldosterone antagonists may be added

in selected patients with moderatelysevere to severe symptoms with low EF who

can be carefully monitored for renalfunction and potassium

EPHESUS: Eplerenone for LV Dysfunction after MI Selective aldosterone blocker in 6632 patients Post-MI day 3-14, EF<40%, and CHF Exclusion: Cr>2.5, K>5.0 Median follow-up 16 months

Rate of deathfrom cardiovascular causes or hospitalizationor cardiovascularevents

Pitt et al. NEJM 2003;348:1309.

IBAddition of an aldosterone

antagonist in patients after an acute MI,with HF signs and symptoms,

and an EF<40%

Hydralazine/Isordil

Taylor et al. NEJM 2004;351:2049.

Study RR at 2 yearsV-Heft I Hydralazine/isordil

vs. placebo34 (p=0.028)

V-Heft II Hydralazine/isordil vs. enalapril

28 (p=0.016)

AA-Heft

IIbCCombination hydralazine/isordil may be

reasonable in patients with low EFand current or prior symptoms who

cannot be given ACEI or ARB becauseof renal insufficiency or intolerance

IIaAAddition of hydralazine/isordil is

reasonable in patients with low EFwho are already

on ACEI and beta-blocker who havepersistent symptoms

Digoxin: Improvement in symptoms but not survival Digitalis investigation

group 6800 patients EF<45% Past or current

symptoms of HF On ACEI and diuretics

NEJM 1997;336:525.

All-cause mortality

Death or hospitalization for worsening HF

IIaBDigitalis can be beneficial in patients

with low EF and current or priorsymptoms to decrease hospitalizations for HF

ICDs for secondary prevention IA: an ICD is recommended for survivors of

cardiac arrest, VF or hemodynamically unstable VT who have low EF and current or prior symptoms

ICDs for primary prevention MADIT II 1232 patients EF<30% Prior MI Conventional tx vs.

ICD Death from any cause

was the primary endpoint

HR 0.69p=0.016

IAAn ICD is recommended for patients

with an ischemic cardiomyopathywho are at least 40d post MI,

LVEF<30%, NYHA class II-IV on optimal medical therapy with an

expected survival of >1 year

Moss et al. NEJM 2002;346:12.

ICDs for primary prevention SCD-Heft 2521 patients

52% ICM 48% non-ICM

NYHA II-III EF<35% Placebo Amiodarone ICD

Bardy et el. NEJM 2005;352:3.

IAAn ICD is recommended for patientswith non-ischemic cardiomyopathy,

LVEF<30%, NYHA class II-IV on optimal medical therapy with an

expected survival of >1 year

CRT: Cardiac Resynchronization Therapy

CRT: Cardiac Resynchronization Therapy MIRACLE EF<35% QRS>130ms Endpoints: death or

hospitalization for CHF

CRT reduces all-cause mortality but not sudden death.

Abraham et al. NEJM 2002;346:24.

IAPatients with EF<35%, NSR, NYHA III-IVdespite optimal medical management

who have a QRS>120ms should receive resynchronization therapy

unless contraindicated

Unproven/Not RecommendedDrugs and Interventions for HF

• Nutritional Supplements• Hormonal Therapies• Intermittent Intravenous Positive Inotropic Therapy

Stage C Therapy(Reduced LVEF with Symptoms)

Additional recommendations Diuretics and salt restriction for fluid retention Routine exercise Treatment with warfarin if HF + AF, h/o TIA/CVA,

h/o DVT/PE, recent anterior wall MI or MI with LV thrombus

NSAIDS and calcium-channel blockers should be avoided

Routine combination of ACE-I, ARB and aldosterone antagonist is not recommended

Beta Blocker

Diuretics for fluid retention

Aldosterone antagonists in select patient

Digoxin to reducehospitalizations

Hydralazine/nitrate or ARB ifBP allows + sxs

Bi-v pacing if sxs

ACE-I (or ARB if ACE intolerant)

Regular exercise programSodium restriction

ICD

Stage C: Diastolic dysfunction, normal EF with symptoms Close to 50% of all patients with HF have a

preserved EF Lack of evidence-based medicine to guide

treatment

Diastolic Dysfunction

Diastolic Dysfunction

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

Stage DPatients with Refractory End-Stage HF

Stage D Limited options High mortality Frequent hospitalizations Consume tremendous resources for care

Stage D Heart Failure

Options

Heart transplantChronic inotropesPermanent device

Experimental surgery/drugs

CompassionateEnd-of-life care/

hospice

Inotropes: ACC/AHA Guidelines 2005 Milrinone and dobutamine Not recommended except for in hospital

use for decompensated heart failure or cardiogenic shock

Not recommended for chronic use except for palliative care to improve quality of life

Home use for end-stage heart failure

Heart Failure Pearls Use IV Lasix (instead of oral) for inpatients

Lowers pulmonary pressures, rapid symptom relief Use nitropaste in the ED

Lowers pulmonary pressures, rapid symptom relief Be aggressive in patients with normal EF, good BP

and normal renal function Go slowly in patients with HCM, cor pulmonale,

severe AS and low EF Preload dependent

Closely monitor renal function Don’t be afraid of beta-blockers

Heart Failure Pearls Titrate up quickly on ACE-I, ARB and

hydralazine/isordil while inpatient Titrate up slowly on beta-blockers as an

outpatient Rate control is critical Stay ahead on electrolyte replacement Check weights, I/Os, telemetry on patients daily Review the echo with a friendly cardiology fellow Review fluid, salt restrictions and medication

compliance with patients at each outpatient visit

Questions?