Management of Congestive Heart Failure

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Management of Congestive Heart Failure

• Update - New Understanding
• Monday noon conference
• Chris Manasseh, MD
• March 4, 2002/March 10, 2003

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Learning Objectives

• Understand pathophysiology and rationale for
  treatment
• Review classification, clinical assessment and
  hemodynamic profile.
• Know the evidence for use of various medications
• Learn some principles in discharge planning for
  patients with CHF

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Pathophysiology of CHF

• ? Filling Pressures - Indicator is PCWP
• ? Perfusion - Indicator is Cardiac Index
• Cardiac Abnormalities
• Left ventricular chamber
• Remodeling
• Dilatation
• Reduction in myocyte shortening and wall motion

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Primary Response in CHFNeurohormonal Activation

• Renin-Angiotensin-Aldosterone System
• Sodium and water retention
• Sympathetic Nervous System
• peripheral vasoconstriction

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CHFTherapeutic Goals

• Reverse acute hemodynamic abnormalities
• Provide symptom relief
• Slow progression of disease
• Improve long term survival

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CHF ClassificationNew York Heart Association

• Class I - Asymptomatic
• Class II - Symptomatic with moderate exertion
• Class III - Symptomatic with mild exertion
• Class IV - Symptomatic with no exertion/or at rest

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CHF Clinical AssessmentLeft or right sided

• History
• Left sided
• Orthopnea
• Dyspnea
• Right sided
• Anorexia
• Abdominal distension
• Ankle edema

• Exam
• Left sided
• Rales
• Narrow pulse pressure
• Increasing S3
• Right sided
• Elevated JVP
• Hepato-jugular reflex
• Loud P2

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CHF Hemodynamic profile
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CHF pharmacotherapy

• Relief of symptoms
• Diuretics
• Digoxin
• Reduction in mortality/hospitalizations
• ACE Inhibitors
• Beta blockers
• Spironolactone
• Rescue in advanced failure
• Ionotropic infusions (dobutamine)
• Vasodilators

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Principles in selecting appropriate medications

• Reduction in
• Pre-load Diuretics
• After-load ACE Inhibitors
• Filling pressures Nitrates
• Restoring perfusion
• Inotropic agents
• Beta adrenergic receptor agents Dobutamine
• Phosphodiesterase inhibitors Milrinone

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Guidelines for use of ACE inhibitors in CHF

• Benefits of ACE Inhibitors in CHF are a Class
  effect
• Reduction in morbidity and mortality
• Reduction in hospitalization
• Favorable effects seen in patients at both ends
  of the spectrum
• Asymptomatic left ventricular systolic
  dysfunction
• Advanced heart failure patient in NYHA class IV
• Initial low doses, later up-titration to target
  dose as used in clinical trials in recommended

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ACE Inhibitors or ARBS in CHF

• Recommendation
• Continue to be agents of choice for blockade of
  RAAS in CHF
• Cornerstone of standard therapy for patients with
  LV systolic dysfunction
• Recent Trials
• ELITE-I Losartan 50 mg daily greater benefit
  than captopril 50 mg tid
• ELITE-II No comparative benefit from Losartan,
  trend for better outcome and fewer sudden deaths
  with captopril
• RESOLVD No major differences in efficacy of
  candesartan and enalapril, trend favoring
  enalapril during the study period of 43 weeks
• OPTIMAAL/VALIANT provide info about role of ACEI
  and ARB in post MI
• Reasonable option for combination of ACEI and ARB
• In severe hypertension since it reduces BP better
  than either agent alone, it also causes more
  vasodilatation

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Use of Digoxin in CHF

• Mechanism of action
• Positive inotropy, sympathoinhibitory effect with
  increased parasympathetic sensitivity
• Indication
• Symptomatic despite conventional Rx,even in
  patients with normal sinus rhythm
• Addition to ACEI and diuretics
• Now is part of triple drug standard therapy
• Evidence
• DIG Trial (Digoxin Investigation Group)
• Combined PROVED and Radiance trial
• Benefit
• Reduced hospitalizations and ER visits in
  patients at highest risk
• Improves exercise capacity
• decrease the need for co-intervention
• increasing dose of diuretics/ACEI OR adding new
  therapies

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Dosing of Digoxin in CHF

• No loading dose needed
• Starting dose and maintenance dose in CHF
• Normal sinus rhythm
• Normal renal function 0.25 mg daily
• Reduced renal function 0.125 mg daily
• Atrial fibrillation
• doses greater than 0.25 mg daily not recommended
• Measurement of SDC(Serum Digoxin Concentration)
• Sample for trough drawn more than 6 hours after
  dosing
• Initial once steady state reached, typically in
  2-3 weeks
• Subsequent
• significant change in renal function
• potentially interacting drug like amiodarone or
  verapamil is added
• suspected Digoxin toxicity

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Use of Dobutamine in CHF

• Indication
• Advanced CHF
• Patient selection
• Acute hemodynamic collapse
• Chronic Ionotropic Tune up
• High baseline BUN
• High dose diuretics with no effect
• Limitation
• Tachyphylaxis
• Tachyarrhythmia

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Use of Nitrates and Hydralazine in CHF

• Addition to ACE Inhibitor therapy
• Nitrates relief of dyspnea by reducing ? filling
  pressures
• Hydralazine control persistent ? BP by its
  vasodilatory effect
• Substitution to ACE Inhibitors
• Patients intolerant to ACEI
• Patients with renal dysfunction
• Se Creatinine gt2.5
• Se K gt5.0

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Use of Spironolactone in CHFRALES (Randomized
Aldactone Evaluation Study)

• Summary of Trial
• 1663 patients for 2 years with EFlt35,Class 3/4
  of NYHA
• Excluded patients with Se. Cr.gt2.5 and Se. K gt5.0
• Results NNT 9
• ? Mortality risk by 30
• ? Combined risk of death and hospitalization by
  35
• Patient selection
• Receiving standard therapy with diuretics, ACEI,
  Digoxin and beta blockers, with K lt5 and
  Creatinine lt 2.5
• Recent/current Class IV CHF
• Dosing
• Starting at 12.5mg titrated to target of 25mg/day
• Consideration
• lowering/eliminating supplemental potassium
• when K gt5 change dose to every other day
• monitor K, 1st week of starting therapy and after
  change in dose

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Use of Beta blockers in CHF

• General Principles
• Agents
• Trials
• Conclusions
• Applications

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General Principles when considering Beta blockers
in CHF

• Safe in mild to moderate CHF when initiated at
  low doses and gradually up-titrated under close
  observation no sooner than every 2 weeks
• Improved LVEF in all trials that lasted at least
  3 months
• Wide variability on exercise tolerance
• Beta blockers with intrinsic sympathomimetic
  activity, like acebutolol and pindolol appear to
  have negative impact on survival and should not
  be used in heart failure patients
• Before initiating beta blocker therapy
• patients are treated with ACEI, Diuretics and
  Digoxin for at least 2 months
• patients are clinically stable for 2-4 weeks on
  standard therapy without acute decompensation or
  fluid overload

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Beta blockers in CHFAgents used in mortality
trials
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Use of beta blockers in CHFSummary of Trials
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Carvedilol in CHFCOPERNICUS

• Trial Carvedilol Prospective Randomized
  Cumulative Survival trial
• Summary
• 2289 patients with EFlt25 ,Class 3/4 of NYHA
• stopped abruptly after 6 months due to profound
  benefit
• Patient selection
• absence of Rales,edema,ascites
• on conventional therapy(diuretics, ACEI/ARB)
• Dosing
• Start at 3.125 mg bid
• Titrate every 2 weeks
• Target upto 50mg bid
• Conclusion Safety established in Class IV

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Beta blockers in CHFResults of trials
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Beta blockers in CHFConclusions from trials

• CIBIS Safety in Class II, III of NYHA
• COPERNICUS Safety in Class IV of NYHA
• Euvolemic
• Hemodynamically stable
• MOCHA Benefit of Carvedilol at lower dosages
• BEST Cannot assume that all beta blockers are
  equally effective in severe CHF
• Meta Analysis 10,000 patients from 18 trials
• Reduction in Mortality by 32
• Improvement in Ejection Fraction by 29

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Use of beta blockers in CHFPractical applications

• Patient selection
• Type of dysfunction - systolic
• NYHA Class II, III
• Standard therapy ACEI, diuretics digoxin
• Fluid status no evidence of overload
• Dosage selection
• Starting dose per trial regimen
• Titration frequency 2-4 weeks
• Target dose per trial regimen
• Monitor Heart rate, BP, Fluid status

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Adjusting beta blockers when clinical
decompensation occurs

• Indicators of worsening heart failure/fluid
  retention
• Increasing fatigue
• lower exercise tolerance
• weight gain
• When symptomatic deterioration occurs
• during up-titration go back to the last
  tolerated dose
• during stable maintenance continue same dose
• diet/medication non-compliance
• disease progression
• ischemia
• arrhythmia

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Recommendations for Anticoagulation in CHF

• All patients with CHF and Atrial fibrillation
  should be treated with warfarin, INR 2.0
  -3.0(Strength of evidence A)
• Consider using Warfarin for patients in sinus
  rhythm with LVEF lt35(Strength of evidence B)
• Benefit seen in SOLVD study

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Concern about using Aspirin with ACE Inhibitors
in CHF

• Potential negative therapeutic interaction
• ACEI augment bradykinin induced stimulation of
  prostaglandin synthesis which is blocked in the
  presence of ASA thereby potentially reducing
  benefits of ACEI
• Possible similar beneficial actions
• ACEI reduce ischemic events in CHF by its
  antithrombotic effect
• Aspirin has beneficial effects on ventricular
  remodeling
• No clear evidence of harm
• may be dose related
• dose of aspirin lt100 mg/day showed no interaction
  with ACEI

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Discharge plan for the HospitalizedCriteria

• Clinical status goals
• Achievement of dry weight
• Optimal BP range
• Walking without dyspnea or dizziness
• Stability goals
• Stable for 24 hour on oral regimen
• Renal function stable and improving
• Fluid status stable even on oral agents
• Blood pressure stable
• 48 hours off Ionotropic agents if used

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Discharge planPatient instructions

• Restriction
• Sodium
• Fluids
• Medication
• Schedule, flexible diuretic plan
• Effects
• Follow up
• Phone call within 3 days
• Clinic visit within 5-10 days