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1

CHRONIC CONGESTIVE HEART FAILURE American Heart
Association in collaboration with Sociedad
Española de Cardiología date
posted March, 2003
2
Committee on Post Graduate Education, Council on
Clinical Cardiology, American Heart
Association Developed in collaboration with the
Sociedad Española de Cardiología Prepared
by Ann F. Bolger, MD José López-Sendón, MD The
content of these slides is current as of March
2003 Future revisions will be posted on the
American Heart Association website
(www.americanheart.org).
3
The Problem (USA) 5,000,000 patients 6,500,00
0 hospital days / year 300,000 deaths / year
6 - 10 of people 65 years 5.4 of health
care budget (38 billion) Incidence x 2 in last
ten years
Gottdiener J et al. JACC 2000351628 Haldeman GA
et al. Am Heart J 1999137352 Kannel WB et al.
Am Heart J 1991121951 OConnell JB et al. J
Heart Lung Transplant 199313S107
4
Definition of heart failure
5
Suspected Heart Failure because of SYMPTOMS
and/or SIGNS
Assess presence of CARDIAC DISEASE by ECG, X-Ray
or BNP (if available)
NORMAL No Heart Failure
Tests abnormal
VENTRICULAR FUNCTION Imaging by
ECHO-Doppler, Nuclear angiography or MRI if
available
NORMAL No Heart Failure
Tests abnormal
Heart Failure Systolic / Diastolic Identify
etiology, evaluate severity, choose therapy
ESC HF guidelines 2001
6
HF Risk Factors No Heart disease No symptoms
A
Stages in the evolution of Heart Failure
B
Heart disease No symptoms
Asymptomatic LV dysfunction
C
Prior or current HF Symptoms
D
Refractory HF symptoms
AHA / ACC HF guidelines 2001
7
Hypertension Diabetes, Hyperchol. Family
Hx Cardiotoxins
A
Stages in the Evolution of Heart Failure Clinical
Characteristics
B
Heart disease (any)
Asymptomatic LV dysfunction Systolic / Diastolic
C
Dyspnea, Fatigue Reduced exercise tolerance
D
Marked symptoms at rest despite max. therapy
AHA / ACC HF guidelines 2001
8
Treat risk factors Avoid toxics ACE-i in selected
p.
A
Stages in the Evolution of Heart Failure
Treatment
B
ACE-i ? blockers
In selected patients
C
ACE-i ? blockers Diuretics / Digitalis
D
Palliative therapy Mech. Assist device Heart
Transplant
AHA / ACC HF guidelines 2001
9
Incidence n 5888 Age 65 y Follow-up
5.5 y 4 different locations in the US
INCIDENCE 19.3 / 1000 person-years
The Cardiovascular Health Study Gottdiener J et
al. JACC 2000351628
10
The Cardiovascular Health Study JACC 2000351628
Risk Factors
Coronary heart Disease
11
Direct Causes
1- Myocardial abnormalities (CHD!)2-
Hemodynamic overload3- Ventricular filling
abnormalities4- Ventricular dyssynergy5-
Changes in cardiac rhythm
12
Aggravating Factors

• Medications
• New heart disease
• Myocardial ischemia

• Endocarditis
• Obesity
• Hypertension
• Physical activity
• Dietary excess

• Pregnancy
• Arrhythmias (AF)
• Infections
• Thromboembolism
• Hyper/hypothyroidism

13
Initial / Ongoing Evaluation

• Identify heart disease
• Assess functional capacity (NYHA, 6 min walk, )
• Assess volume status (edema, rales, jugular,
  hepatomegaly, body weight)
• Lab assessment routine electrolytes, renal
  funct. Repeat ECHO, RX only if significant
  changes in functional status
• Assess prognosis

14
Prognosis
50

Post MI n196
40
Cardiac Mortality
30
31-35
20
36-45
10
46-53
54-60
60
0
LVEF
Brodie B. et al Am J Cardiol 1992691113
15

Treatment Objectives
(Cost)
16

• Treatment
• Prevention. Control of risk factors
• Life style
• Treat etiologic cause / aggravating factors
• Drug therapy
• Personal care. Team work
• Revascularization if ischemia causes HF
• ICD (Implantable Cardiac Defibrillator)
• Ventricular resyncronization
• Ventricular assist devices
• Heart transplant
• Artificial heart
• Neoangiogenesis, Gene therapy

All
Selected patients
17

Treatment Pharmacologic Therapy

• Diuretics
• ACE inhibitors
• Beta Blockers
• Digitalis
• Spironolactone
• Other

18
Diuretics Essential to control
symptoms secondary to fluid retention Prevent
progression from HT to HF Spironolactone
improves survival New research in progress
19
Diuretics
Thiazides Inhibit active exchange of Cl-Na in
the cortical diluting segment of the ascending
loop of Henle
Cortex
K-sparing Inhibit reabsorption of Na in
the distal convoluted and collecting tubule
Loop diuretics Inhibit exchange of Cl-Na-K in
the thick segment of the ascending loop of Henle
Medulla
Loop of Henle
Collecting tubule
20

• Diuretics. Indications
• 1. Symptomatic HF, with fluid retention
• Edema
• Dyspnea
• Lung Rales
• Jugular distension
• Hepatomegaly
• Pulmonary edema (Xray)

AHA / ACC HF guidelines 2001 ESC HF guidelines
2001
21

• Loop Diuretics / Thiazides. Practical Use
• Start with variable dose. Titrate to achieve dry
  weight
• Monitor serum K at frequent intervals
• Reduce dose when fluid retention is controlled
• Teach the patient when, how to change dose
• Combine to overcome resistance
• Do not use alone

22
Loop diuretics. Dose (mg)
Initial Maximum Bumetanide 0.5 to 1.0 / 12-24h
10 / day Furosemide 20 to 40 / 12-24h 400 /
day Torsemide 10 to 20 / 12-24h 200 / day
AHA / ACC HF guidelines 2001
23
Sharpe N. Heart failure. Martin Dunitz
200043 Kubo SH , et al. Am J Cardiol
1987601322 MRFIT, JAMA 19822481465 Pool
Wilson. Heart failure. Churchill Livinston
1997635
24

• Diuretic Resistance
• Neurohormonal activation
• Rebound Na uptake after volume loss
• Hypertrophy of distal nephron
• Reduced tubular secretion (renal failure,
  NSAIDs)
• Decreased renal perfusion (low output)
• Altered absortion of diuretic
• Noncompliance with drugs

Brater NEJM 1998339387 Kramer et al. Am J Med
199910690
25
Managing Resistance to Diuretics Restrict
Na/H2O intake (Monitor Natremia) Increase dose
(individual dose, frequency, i.v.) Combine
furosemide thiazide / spiro / metolazone
Dopamine (increase cardiac output) Reduce dose
of ACE-i Ultrafiltration
Motwani et al Circulation 199286439
26

ACE-i. Mechanism of Action
VASOCONSTRICTION
VASODILATATION
ALDOSTERONE
PROSTAGLANDINS
VASOPRESSIN
tPA
Kininogen
SYMPATHETIC
Kallikrein
Angiotensinogen
RENIN
BRADYKININ
Angiotensin I
A.C.E.
Kininase II
Inhibitor
ANGIOTENSIN II
Inactive Fragments
27
ACE-I. Clinical Effects

• Improve symptoms
• Reduce remodelling / progression
• Reduce hospitalization
• Improve survival

28
Mortality Reduction with ACE-i
Study ACE-i Clinical Seting CONSENSUS Enalapril CH
F SOLVD treatment Enalapril CHF AIRE Ramipril CHF
Vheft-II Enalapril CHF TRACE Trandolapril CHF /
LVD SAVE Captopril LVD SMILE Zofenopril High
risk HOPE Ramipril High risk
29
ACE-i
0.8
0.7
Placebo
0.6
Probabiilityof Death
p
0.5
0.4
p
0.3
Enalapril
0.2
0.1
0
0
12
11
10
9
8
7
6
5
4
3
2
1
CONSENSUS N Engl J Med 19873161429
Months
30
ACE-i
p 0.0036
Placebo n1284
Mortality
Enalapril n1285
n 2589 CHF - NYHA II-III - EF
48
0
6
12
24
18
30
36
42
SOLVD (Treatment)N Engl J M 1991325293
Months
31
ACE-i
30
Asymptomatic ventricular dysfunction post MI
Placebo
n1116
20
Mortality,
Captopril
n1115
10
n 2231 3 - 16 days post AMI EF 150 mg / day
² -19
p0.019
0
SAVE N Engl J Med 1992327669
4
3
0
1
2
Years
32
ACE-i
Placebo
30
20
Mortality
Ramipril
10
p 0.002
n 2006 HF after AMI

0
30
24
12
18
0
6
AIRE Lancet 1993342821
Months
33
ACE-i. Indications

• Symptomatic heart failure
• Asymptomatic ventricular dysfunction
• - LVEF
• Selected high risk subgroups

AHA / ACC HF guidelines 2001 ESC HF guidelines
2001
34

• ACE-i. Practical Use
• Start with very low dose
• Increase dose if well tolerated
• Renal function serum K after 1-2 w
• Avoid fluid retention / hypovolemia (diuretic
  use)
• Dose NOT determined by symptoms
• Combine to overcome resistance
• Do not use alone

35
ACE-i. Dose (mg) Initial Maximum Captopril
6.25 / 8h 50 / 8h Enalapril 2.5 / 12 h 10 to
20 / 12h Fosinopril 5 to 10 / day 40 /
day Lisinopril 2.5 to 5.0 / day 20 to 40 /
day Quinapril 10 / 12 h 40 / 12 h Ramipril 1.25
to 2.5 / day 10 / day
AHA / ACC HF guidelines 2001
36

• ACE-I. Adverse Effects
• Hypotension (1st dose effect)
• Worsening renal function
• Hyperkalemia
• Cough
• Angioedema
• Rash, ageusia, neutropenia,

37

• ACE-I. Contraindications
• Intolerance (angioedema, anuric renal fail.)
• Bilateral renal artery stenosis
• Pregnancy
• Renal insufficiency (creatinine 3 mg/dl)
• Hyperkalemia ( 5,5 mmol/l)
• Severe hypotension

38
ß-Adrenergic Blockers Mechanism of action

• Density of ß1 receptors
• Inhibit cardiotoxicity of catecholamines
• Neurohormonal activation
• HR
• Antiischemic
• Antihypertensive
• Antiarrhythmic
• Antioxidant, Antiproliferative

39

ß-Adrenergic Blockers Clinical Effects

• Improve symptoms (only long term)
• Reduce remodelling / progression
• Reduce hospitalization
• Reduce sudden death
• Improve survival

40
ß-Adrenergic Blockers
1.0
1.0
Carvedilol (n696)
0.9
0.9
Survival
Placebo (n398)
p
0.8
0.8
0.7
0.7
Risk reduction 65
I-II HF
0.6
0
50
100
150
200
250
300
350
400
Days
US Carvedilol HF NEJM 1996 334 1349-55
41
ß-Adrenergic Blockers
1
Bisoprolol 11.8
0.9
0.8
P
Survival
Placebo 17.3
ICCC NYHA III-IV
0.7
n2647
0.6
Annual Mortality bisoprolol8.2 placebo12
Mean Follow-up 1.4 years
0.5
0
600
400
200
800
CIBIS-II Lancet 19993539
Days
42
ß-Adrenergic Blockers
Placebo
15
p0.0062
Mortality
Metoprolol
10
5
Risk Reduction 34
NYHA II-IV N3991
0
0
3
6
9
12
15
18
21
MERIT-HF Lancet 1999 353 2001
Months
43
ß-Adrenergic Blockers
100
90
80
Survival
Carvedilol
70
p0.00014 35 RR
60
Placebo
N 2289 III-IV NYHA
50
24
0
20
16
12
8
4
28
Months
COPERNICUS NEJM 20013441651
44

ß-Adrenergic Blockers
1
HR 0.77 (0.60 - 0.98) p0.95
0.9
Carvedilol 116 / 975 (12)
Survival
0.85
0.8
Placebo 151 / 984 (15)
LVD / HF Post AMI
0.75
0.7
0
0.5
1
1.5
2
2.5
Years
CAPRICORN Lancet 20013571385
45
ß-Adrenergic Blockers Indications

• Symptomatic heart failure
• Asymptomatic ventricular dysfunction
• - LVEF
• After AMI

AHA / ACC HF guidelines 2001 ESC HF guidelines
2001
46
ß-Adrenergic Blockers When to start

• Patient stable
• No physical evidence of fluid retention
• No need for i.v. inotropic drugs
• Start ACE-I / diuretic first
• No contraindications
• In hospital or not

47
ß-Adrenergic Blockers Dose (mg)
Initial Target Bisoprolol 1.25 / 24h 10 /
24h Carvedilol 3.125 / 12h 25 / 12h Metoprolol
tartrate 6.25 / 12h 75 / 12h Metoprolol
succinnate 12,5-25 / 24h 200 / 24h

• Start Low, Increase Slowly
• Increase the dose every 2 - 4 weeks

48
ß-Adrenergic Blockers Adverse Effects

• Hypotension
• Fluid retention / worsening heart failure
• Fatigue
• Bradycardia / heart block

• Review treatment (/-diuretics, other drugs)
• Reduce dose
• Consider cardiac pacing
• Discontinue beta blocker only in severe cases

49
ß-Adrenergic Blockers Contraindications

• Asthma (reactive airway disease)
• AV block (unless pacemaker)
• Symptomatic hypotension / Bradycardia
• Diabetes is NOT a contraindication

50
Digitalis
-
Na-K ATPase
Na-Ca Exchange
Na
K
Na
Ca
Ca
Myofilaments
K
Na
CONTRACTILITY
51
Digitalis. Mechanism of Action Blocks Na / K
ATPase Ca Inotropic effect Natriuresis
Neurohormonal control
NEJM 1988318358
52
Digitalis. Clinical Effects

• Improve symptoms
• Modest reduction in hospitalization
• Does not improve survival

53

Digitalis
Mortality
Placebo n3403
p 0.8
N6800 NYHA II-III
Digoxin n3397
0
48
12
24
36
DIG N Engl J Med 1997336525
Months
54
Digitalis. Indications When no adequate
response to ACE-i diuretics beta-blockers
AHA / ACC Guidelines 2001 In combination with
ACE-i diuretics if persisting symptoms ESC
Guidelines 2001 AF, to slow AV conduction Dose
0.125 to 0.250 mg / day
55
Digoxin. Contraindications

• Digoxin toxicity
• Advanced A-V block without pacemaker
• Bradycardia or sick sinus without PM
• PVCs and VT
• Marked hypokalemia
• W-P-W with atrial fibrillation

56

Aldosterone Inhibitors
ALDOSTERONE
Spironolactone
-
Competitive antagonist of the aldosterone
receptor (myocardium, arterial walls, kidney)

• Retention Na
• Retention H2O
• Excretion K
• Excretion Mg2

• Collagen
• deposition
• Fibrosis
• - myocardium
• - vessels

Edema
Arrhythmias
57
Spironolactone
Annual Mortality Aldactone 18 Placebo 23
Survival
Aldactone
N 1663 NYHA III-IV Mean follow-up 2 y
p
RALES NEJM 1999341709
Placebo
months
58

• Spironolactone. Indications
• Recent or current symptoms despite ACE-i,
  diuretics, dig. and b-blockers
• AHA / ACC HF guidelines 2001
• Recommended in advanced heart failure (III-IV),
  in addition to ACE-i and diuretics
• Hypokalemia
• ESC HF guidelines 2001

59

• Spironolactone. Practical use
• Do not use if hyperkalemia, renal insuf.
• Monitor serum K at frequent intervals
• Start ACE-i first
• Start with 25 mg / 24h
• If K 5.5 mmol/L, reduce to 25 mg / 48h
• If K is low or stable consider 50 mg / day
• New studies in progress

60

• Other Drugs. (only in selected patients)
• Inotropics refractory HF
• Nitrates ischemia, angina, pulmonary congestion
• ARB Contraindications to ACE-i
• Antiarrhythmics (only amiodarone) H risk
  arrhyth.
• Anticoagulants High risk of embolysm
• Ca channel blockers (only amlodipine) ischemia

61

Angiotensin II Receptor Blockers (ARB)
RENIN
Angiotensin IANGIOTENSIN II

Angiotensinogen
ACE
Other pathways
AT1 Receptor Blockers
RECEPTORS
AT1
AT2
Vasoconstriction
Proliferative Action
Vasodilatation
Antiproliferative Action
62
Angiotensin II Receptor Blockers (ARB)

• Candesartan, Eprosartan, Irbesartan
• Losartan, Telmisartan, Valsartan
• Efficacy not equal / superior to ACE-I
• Not indicated with beta blockers
• Indicated in patients intolerant to ACE-I

AHA / ACC HF guidelines 2001 ESC HF guidelines
2001
63
Angiotensin II Receptor Blockers (ARB)
1.0
Valsartan

0.9
Survival
Placebo

0.8
P 0.8
0.7

0
3
6
9
12
21
18
15
24
27
Val-HeFT AHA 2000
Months
64

Vasodilators
Venous Vasodilatation
VENOUS Nitrates Molsidomine
MIXED Calcium antagonists a-adrenergic
Blockers ACE-I, ARBs K channel
activators Nitroprusside
ARTERIAL Minoxidil Hydralazine
Arterial Vasodilatation
65

NITRATESHEMODYNAMIC EFFECTS
1- VENOUS VASODILATATION
Preload2- Coronary vasodilatation Myocardial
perfusion 3- Arterial vasodilatation
Afterload 4- Others
Pulmonary congestionVentricular sizeVent. Wall
stressMVO2
66

Nitrates
0.7
Placebo (273)Prazosin (183)Hz ISDN (186)
0.6
0.5
Probabilityof Death
0.4
0.3
0.2
0.1
0
0
6
12
18
24
30
36
42
VHefT-1 N Engl J Med 19863141547
Months
67
Nitrate Hydralazine
0.75
n 804
HZ ISDN
0,54
Probability of death
0.50
0.47
p 0.016
0,48
0.36
0.42
Enalapril
0.25
0.31
0.25
0.13
0.18
0.09
p 0.08
0
60
0
12
24
48
36
V-HeFT IIN Engl J Med 1991 325303
Months
68
Nitrates. Clinical Use

• CHF with myocardial ischemia
• Orthopnea and paroxysmal nocturnal dyspnea
• In acute CHF and pulmonary edemaNTG sl / iv
• Nitrates Hydralazine in intolerance
• to ACE-I (hypotension, renal insufficiency)

69

• Positive Inotropes
• Digitalis
• Sympathomimetics
• Catecholamines
• B-adrenergic agonists
• Phosphodiesterase inhibitors
• Amrinone, Milrinone, Enoximone
• Calcium sensitizers
• Levosimendan, Pimobendan

70
Positive Inotropic Therapy

• May increase mortality
• Exception Digoxin, Levosimendan
• Use only in refractory CHF
• NOT for use as chronic therapy

71
Drugs to Avoid (may increase symptoms, mortality)

• Inotropes, long term / intermittent
• Antiarrhythmics (except amiodarone)
• Calcium antagonists (except amlodipine)
• Non-steroidal antiinflammatory drugs (NSAIDS)
• Tricyclic antidepressants
• Corticosteroids
• Lithium

ESC HF guidelines 2001
72
NEW DRUGS (ongoing research)
1. New neurohormonal modulators 2. New
inotropics 3. Gene therapy 4. Myocyte transplant
and mitosis 5. Neoangiogenesis / Growth factors
73
New Drugs (ongoing research)

• 1. New neurohormonal modulators
• Beta-blockers
• Aldosterone receptor antagonists
• Angiotensin II receptor antagonists
• Endothelin inhibitors
• Vasopresin inhibitors
• Natriuretic Peptides
• Endopeptidase inhibitors
• Vasopeptidase inhibitors

74

• Other Drugs (ongoing research)
• Erythropoietin
• Ranolazine
• Matrix metalloproteinases
• Growth Hormone
• L-Thyroxine
• Inhibitors of carnitine palmitoyltransferse-I
• Dopamine-?-hyydroxylase inhibitors
• Antithrombotics

75

• Refractory End-Stage HF
• Review etiology, treatment aggrav. factors
• Control fluid retention
• Resistance to diuretics
• Ultrafiltration ?
• iv inotropics / vasodilators during
  decompensation
• Consider resynchronization
• Consider mechanical assist devices
• Consider heart transplantation

76

• Heart Transplant. Indications
• Refractory cardiogenic shock
• Documented dependence on IV inotropic support to
  maintain adequate organ perfusion
• Peak VO2
• Severe symptoms of ischemia not amenable to
  revascularization
• Recurrent symptomatic ventricular arrhythmias
  refractory to all therapeutic modalities
• Contraindications age, severe comorbidity

77

• Heart Failure and Myocardial Ischemia
• Coronary HD is the cause of 2/3 of HF
• Segmental wall motion abnormalities are not
  specific if ischemia
• Angina coronary angio and revascularization
• No angina
• Search for ischemia and viability in all ?
• Coronary angiography in all ?

78

• Supraventricular Arrhythmias
• Risk of embolization (AF)
• Anticoagulation in AF
• Systolic diastolic dysfunction
• Digoxin, beta blockers
• Amiodarone if b-blocker ineffective/ contraind.
• Conversion to sinus rhythm in all ?
• ongoing research

79

• Ventricular Arrhythmias / Sudden Death
• Antiarrhythmics ineffective (may increase
  mortality)
• Amiodarone do not improve survival
• ?-blockers reduce all cause mortality and SD
• Control ischemia
• Control electrolyte disturbances
• ICD (Implantable Cardiac Defibrillator)
• In secondary prevention of SD
• In sustained, hemodynamic destabilizing VT
• Ongoing research will establish new indications

80

• Diastolic Heart Failure
• Incorrect diagnosis of HF
• Inaccurate measurement of LVEF
• Primary valvular disease
• Restrictive (infiltrative) cardiomyopathies
  (Amyloidosis)
• Pericardial constriction
• Episodic or reversible LV systolic dysfunction
• Severe hypertension, ischemia
• High output states Anemia, thyrotoxicosis, etc
• Chronic pulmonary disease with right HF
• Pulmonary hypertension
• Atrial myxoma
• LV Hypertrophy
• Diastolic dysfunction of uncertain origin

81

• Diastolic Heart Failure
• Treat as HF with low LVEF
• Control
• Hypertension
• Tachycardia
• Fluid retention
• Myocardial ischemia
• Ongoing research

82
HEART FAILURE MODELS
CONGESTIVE - Digoxin, Diurétics
HEMODYNAMIC - Vasodilators
NEUROHUMORAL - ACE inhibitors, ?- Blockers,
Spironolactone
IMMUNOLOGICAL - Cytokine inhibitors
83
TREATMENT STRATEGIES
Symptom relief
Vasodilators Inotropics
Diuretics
Neurohumoral activation ACE-is,
?-blockers Spironolatone ARBs?, ANP? ET-1?
Prevention of disease progression
Anti-remodeling strategies
Gene therapy?
Reversal of HF
Mann. Circulation 1999 100 999-1008
84
AHA / ACC Recommendations for the Evaluation of
Patients Class I 1. Thorough history and physical
examination 2. Patients ability to perform
desired activities 3. Volume status (fluid
retention, edema) 4. Lab blood count,
electrolytes, creatinine, glucose, 5. Initial
12-lead ECG and chest radiograph 7. Initial 2-D
ECHO or radionuclide ventriculography to
assess left ventricular systolic function 8.
Coronary arteriography in patients with angina
AHA / ACC HF guidelines 2001 http//www.americanh
eart.org/presenter.jhtml?identifier11841
85

• AHA / ACC
• Recommendations for the Evaluation of Patients
• Class III
• 1. Routine endomyocardial biopsy
• 2. Routine Holter monitoring
• or signal-averaged electrocardiography.
• 3. Repeat coronary arteriography or noninvasive
  testing
• for ischemia in patients with already excluded
• coronary artery disease
• 4. Routine measurement of norepinephrine or
  endothelin

AHA / ACC HF guidelines 2001 http//www.americanh
eart.org/presenter.jhtml?identifier11841
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• AHA / ACC
• Recommendations for Patients at High Risk of
  Developing HF
• (Stage A)
• Class I
• 1. Control of systolic and diastolic hypertension
  
• 2. Treatment of lipid disorders
• 3. Control other risk factors (e.g., smoking,
  alcohol, drugs)
• 4. ACE inhibition in patients with a history of
  atherosclerotic
• vascular disease, diabetes mellitus, or
  hypertension
• 5. Control of ventricular rate in
  supraventricular arrhythmias
• 6. Treatment of thyroid disorders
• 7. Periodic evaluation for signs and symptoms of
  HF

AHA / ACC HF guidelines 2001 http//www.americanh
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• AHA / ACC
• Recommendations for Patients at High Risk of
  Developing HF
• (Stage A)
• Class IIa
• 1. Noninvasive evaluation of left ventricular
  function in
• patients with a strong family history of
  cardiomyopathy
• or in those receiving cardiotoxic
  interventions
• Class III
• 1. Exercise to prevent the development of HF
• 2. Reduction of dietary salt beyond that which is
  prudent
• 3. Routine testing to detect left ventricular
  dysfunction
• 4. Routine use of nutritional supplements

AHA / ACC HF guidelines 2001 http//www.americanh
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88

• AHA / ACC
• Recommendations for Patients With Asymptomatic
• Left Ventricular Systolic Dysfunction (Stage B)
• Class I
• ACE inhibition in patients with previous AMI
• ACE inhibition in patients with a reduced LVEF
• Beta-blockade in patients with a recent AMI
• Beta-blockade in patients with a reduced LVEF
• Valve repair for significant valvular stenosis /
  regurgitation
• Regular evaluation for signs and symptoms of HF
• Also Class I recommendations for patients in
  Stage A

AHA / ACC HF guidelines 2001 http//www.americanh
eart.org/presenter.jhtml?identifier11841
89
AHA / ACC Recommendations for Patients With
Asymptomatic Left Ventricular Systolic
Dysfunction (Stage B) Class IIb 1. Systemic
vasodilators in severe aortic regurgitation Class
III 1. Digoxin in patients in sinus rhythm 2.
Reduction of dietary salt beyond that which is
prudent 3. Exercise to prevent the development of
HF 4. Routine use of nutritional supplements
AHA / ACC HF guidelines 2001 http//www.americanh
eart.org/presenter.jhtml?identifier11841
90
AHA / ACC Recommendations for Treatment of
Symptomatic Left Ventricular Systolic Dysfunction
(Stage C) Class I 1. Diuretics in patients with
fluid retention. 2. ACE inhibition in all
patients 3. Beta-blockers in all stable
patients 4. Digitalis for the treatment of
symptoms of HF 5. Withdrawal of drugs adversely
affecting clin. status (most antiarrhythmics,
most calcium channel blockers, nonsteroidal
anti-inflammatory drugs, )
AHA / ACC HF guidelines 2001 http//www.americanh
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AHA / ACC Recommendations for Treatment of
Symptomatic Left Ventricular Systolic Dysfunction
(Stage C) Class IIa 1. Spironolactone in patients
with recent or current Class IV symptoms 2.
Exercise training to improve clinical status 3.
Angiotensin receptor blockade in patients who
cannot be given ACE-I because of cough or
angioedema 4. Hydralazine and a nitrate in
patients who cannot be given ACE-i because of
hypotension or renal insufficiency
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• AHA / ACC
• Recommendations for Treatment of Symptomatic Left
• Ventricular Systolic Dysfunction (Stage C)
• Class IIb
• 1. Addition of angiotensin receptor blocker to
  ACE-i
• 2. Addition of a nitrate to ACE-I in patients
• Class III
• 1. Long-term intermittent use inotropics infusion
  
• 2. Use of angiotensin blocker instead of ACE-i
• 3. Use of angiotensin blocker before a
  beta-blocker
• 4. Use of Ca channel blocker for HF
• 5. Routine use of nutritional supplements

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AHA / ACC Recommendations for Patients With
Refractory End-Stage HF (Stage D) Class I 1.
Meticulous identification and control of fluid
retention 2. Referral for cardiac transplantation
in eligible patients 3. Referral to an HF
program 4. Other class I recommendations for
Stages A, B, and C
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• AHA / ACC
• Recommendations for Patients With Refractory
• End-Stage HF (Stage D)
• Class IIb
• 1. Pulmonary artery catheter to guide therapy
• 2. Mitral valve repair for severe secondary
  mitral regurg.
• 3. Continuous infusion of inotropics for symptoms
• Class III
• 1. Partial left ventriculectomy
• 2. Routine intermittent infusions of inotropics

AHA / ACC HF guidelines 2001 http//www.americanh
eart.org/presenter.jhtml?identifier11841