Heart Failure Management Applying the ACC/AHA Chronic Heart Failure Guidelines

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Heart Failure Management Applying the ACC/AHA
Chronic Heart Failure Guidelines

• David Bragin Sánchez MD FACC
• Cardiomyopathy and Cardiac Transplant Specialist
• Intercontinental Hotel
• March 13 2007

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The Core
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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Patients With Current or Prior Symptoms of Heart
  Failure (HF)
• Left ventricle (LV) dysfunction
• Class I
• Drugs known to adversely affect the clinical
  status of patients with current or prior symptoms
  of HF and reduced left ventricle ejection
  fraction (LVEF) should be avoided or withdrawn
  whenever possible (e.g., nonsteroidal
  anti-inflammatory drugs, most antiarrhythmic
  drugs, and most calcium channel blocking drugs).
  (Level of Evidence B)
• 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. (Level of Evidence B)

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Stage C

• Class I
• Daily weight
• Influenza and pneumococcal vaccination
• Monitor potassium (4-5 mmol per L) and magnesium
• Emphasis on compliance with diet and medications
• Patient education and close supervision

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Stage C

• Class III
• Use of nutritional supplements as treatment for
  HF is not indicated in patients with current or
  prior symptoms of HF and reduced LVEF. (Level of
  Evidence C)
• 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. (Level of
  Evidence C)

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Beta Blockers
• Class I
• Beta-blockers (using 1 of the 3 proven to reduce
  mortality, i.e., bisoprolol, carvedilol, and
  sustained release metoprolol succinate) are
  recommended for all stable patients with current
  or prior symptoms of HF and reduced LVEF, unless
  contraindicated. (Level of Evidence A)

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Stage C

• Beta blockers
• Alleviate symptoms, improve clinical status,
  reduce risk of death and of hospitalization.
• Diuretics are needed to maintain sodium balance
  and prevent fluid retention that can accompany
  initiation of beta-blocker
• Should be given only if no or only minimal
  evidence of fluid retention
• Should not be totally withdrawn in acute
  decompensation
• Should be started before hospital discharge in
  all HF patients

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Class I
• Angiotensin converting enzyme inhibitors are
  recommended for all patients with current or
  prior symptoms of HF and reduced LVEF, unless
  contraindicated. (Level of Evidence A)
• Class III
• Routine combined use of an ACEI, ARB, and
  aldosterone antagonist is not recommended for
  patients with current or prior symptoms of HF and
  reduced LVEF. (Level of Evidence C)

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Stage C

• Not only interferes with RAS but potentates
  action of kinins and kinin-mediated prostaglandin
• Alleviate symptoms, improve clinical status,
  reduce risk of death and of hospitalization
• Contraindicated if angioedema or pregnant
• Fluid retention can blunt effects and fluid
  depletion can potentate adverse effects
  (Hypotension, hyperkalemia, renal failure)
• Cough. All other causes must be excluded

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Class I
• Angiotensin II receptor blockers approved for the
  treatment of HF are recommended in patients with
  current or prior symptoms of HF and reduced LVEF
  who are ACEI-intolerant. (Level of Evidence A)
• Class IIA
• Angiotensin II receptor blockers 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. (Level of
  Evidence A)
• Class IIB
• The addition of an ARB may be considered in
  persistently symptomatic patients with reduced
  LVEF who are already being treated with
  conventional therapy. (Level of Evidence B)

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Class I
• Aldosterone antagonist is reasonable in selected
  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 be less 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 be less than 5.0 mEq/L. (Level
  of Evidence B)

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Class I
• Diuretics and salt restriction are indicated in
  patients with current or prior symptoms of HF and
  reduced LVEF who have evidence of fluid
  retention. (Level of Evidence C)

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Stage C

• Inhibit reabsorption of sodium or chloride at
  specific sites in the renal tubule.
• Loop diuretics excrete up to 20-25 Na, enhance
  free water clearance and remain effective unless
  severe renal impairment.
• No long term studies effects on morbidity and
  mortality are not known
• Produce symptomatic relief more rapidly than any
  other drug.
• Risk of use is electrolyte depletion, hypotension
  and azotemia.

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Class IIa
• Digitalis can be beneficial in patients with
  current or prior symptoms of HF and reduced LVEF
  to decrease hospitalizations for HF. (Level of
  Evidence B)
• Dose should be of 0.125-0.25mg QD, without
  loading and lower if patient is over age 70, has
  renal impairment or low lean body mass
• Serum levels are followed for purpose of toxicity
  and not to guide therapy

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Class IIa
• The addition of a combination of hydralazine and
  a nitrate is reasonable for patients with reduced
  LVEF who are already taking an ACEI and
  beta-blocker for symptomatic HF and who have
  persistent symptoms. (Level of Evidence A)

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Class I
• Implantable cardioverter-defibrillator therapy is
  recommended for primary prevention to reduce
  total mortality by a reduction in sudden cardiac
  death.
• LVEF less than or equal to 30
• NYHA functional class II or III symptoms while
  undergoing chronic optimal medical therapy
• Reasonable expectation of survival with a good
  functional status for more than 1 year

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Stage C

• Ischemic heart disease who are at least 40 days
  post-MI
• (Level of Evidence A)
• Nonischemic cardiomyopathy (Level of Evidence B)

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Stage C

• Class I CRT
• Patients with LVEF less than or equal to 35
• Sinus rhythm
• NYHA functional class III or ambulatory class IV
  symptoms despite optimal medical therapy
• QRS duration greater than 0.12 ms
• (Level of Evidence A)

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage C

• Class III
• 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. (Level of Evidence C)

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage D

• End stage heart disease
• Cardiac transplantation is currently the only
  established surgical approach to the treatment of
  refractory HF, but it is available to fewer than
  2500 patients in the United States each year
• Alternate surgical and mechanical approaches for
  the treatment of end-stage HF are under
  development

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage D

• Class III
• Routine intermittent infusions of positive
  inotropic agents are not recommended for patients
  with refractory end-stage HF. (Level of Evidence
  B)
• However, continuous intravenous support can
  provide palliation of symptoms as part of an
  overall plan to allow the patient to die with
  comfort at home

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Stage D

• Referral of patients with refractory end-stage HF
  to an HF program with expertise in the management
  of refractory HF is useful. (Level of Evidence
  A)
• 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.
  (Level of Evidence C)
• Patients with refractory end-stage HF and
  implantable defibrillators should receive
  information about the option to inactivate
  defibrillation. (Level of Evidence C)

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Stage D

• Class I
• Referral for cardiac transplantation in
  potentially eligible patients is recommended for
  patients with refractory end-stage HF. (Level of
  Evidence B)
• Class IIa
• Consideration of an LV assist device as permanent
  or destination therapy is reasonable in highly
  selected patients with refractory end-stage HF
  and an estimated 1-year mortality over 50 with
  medical therapy. (Level of Evidence B)

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Stage D

• Absolute indications for cardiac transplant
• For hemodynamic compromise due to HF
• Refractory cardiogenic shock
• Documented dependence on IV inotropic support to
  maintain adequate organ perfusion
• Peak VO2 less than 10 mL per kg per min with
  achievement of anaerobic metabolism
• Severe symptoms of ischemia that consistently
  limit routine activity and are not amenable to
  coronary artery bypass surgery or percutaneous
  coronary intervention
• Recurrent symptomatic ventricular arrhythmias
  refractory to all therapeutic modalities

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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Special populations

• High-risk ethnic minority groups (e.g., blacks,
  hispanics)
• Groups underrepresented in clinical trials (women
  and elderly)
• Should have clinical screening and therapy in a
  manner identical to that applied to the broader
  population.
• (Level of Evidence B)

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• Stage C
• Basic management
• Beta blockers
• ACE inhibitors
• ARB
• Aldosterone blocker
• Diuretics
• Digoxin
• Hydralazine/Nitrate
• Devices
• Inotropic agents

• Stage D
• Refractory HF
• Transplantation
• Subgroups
• HF with normal LVEF

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HF with preserved EF

• Control systolic and diastolic BP (Class I Level
  of evidence A)
• Control ventricular rate in atrial fibrillation
  (Class I Level of evidence C)
• Diuretics to control pulmonary congestion and
  peripheral edema (Class I Level of evidence C)
• Coronary revascularization patients with CAD in
  whom ischemia is judged to have effect on
  diastolic dysfunction (Class IIa Level of
  evidence C)

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