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Title: CCS HEART FAILURE WORKSHOP THE PRACTICAL MANAGEMENT OF HEART FAILURE


1
CCS HEART FAILURE WORKSHOP THE PRACTICAL
MANAGEMENT OF HEART FAILURE 2012 UPDATE

2
WELCOME!

3
Learning Objectives
  • At the conclusion of this workshop, participants
    will be able to
  • Review changes and updates for optimal management
    of chronic and acute heart failure updating 2006
    recommendations to 2012 context and environment
  • Discuss exercise for heart failure patients -
    where to begin, what to do and where to end and
  • Identify opportunities and challenges of surgery
    for patients with an ischemic etiology for heart
    failure.

4
Acute Heart Failure

5
What is heart failure?
  • Chronic Heart Failure (CHF)
  • Heart failure is a complex syndrome in which
    abnormal heart function results in, or increases
    the subsequent risk of, clinical symptoms and
    signs of low cardiac output and/or pulmonary or
    systemic congestion.
  • Acute Heart Failure Syndrome (AHF)
  • gradual or rapid change in heart failure signs
    and symptoms resulting in the need for urgent
    therapy

6
Classification of AHF
usually a hx of prog. worsening of known chronic
HF on Rx, and evidence of systemic/pulmonary
congestion.
high BP, /- preserved LV systolic fxn increased
sympathetic tone with ?HR, vasoconstriction may
be euvolaemic or only mildly hypervolemic, and
frequently with signs of pulmonary or systemic
congestion
Severe respiratory distress, ?RR, orthopnea,
rales. O2 sats lt90 RA prior to O2
Clinical and lab evidence of an ACS 15 of
patients with an ACS have signs and symptoms of
HF. Episodes of AHF are frequently assoc w/ or
precipitated by arrhythmia (bradycardia, AF, VT).
low output in absence of pulmonary congestion
with increased JVP, w/ or w/out HSM, and low LV
filling pressures
Usually sys BP lt90 mmHg or drop in MAP gt30 mmHg
and absent/low urine output. Organ hypoperfusion
and pulmonary congestion develop rapidly
ESC 2008
7
Has care evolved?
1950 1974 2012
Morphine Morphine Morphine?
Sedation
Oxygen Oxygen?
Dietary sodium restriction Dietary sodium restriction Dietary sodium restriction?
Strict bed rest Early mobilization
Digitalis Inotropes Avoid inotropes
Mercurial diuretics Diuretics ?Diuretics
Venesection Vasodilators ?Vasodilators
Harrisons Principles of Internal Medicine 1st
Edition (1950) Ramirez A et al. N Engl J Med
1974290(9)499-501
8
CASE 1
  • 74 year old female
  • 2 months worsening SOB/orthopnea
  • Presented to ED after Chinese food
  • Past Hx unclear, no meds
  • Physical exam
  • HR 98, BP 142/82, RR 28, temp 36.0C
  • JVP elevated, crackles, pulses 2, legs warm and
    LEE

9
CASE 1
  • 74 year old female
  • CXR pending
  • Labs pending

10
Question
  • prepare to provide your answer!

11
How confident are you that it is AHF?
  1. lt20
  2. 21-40
  3. 41-60
  4. 61-80
  5. gt80

12
How confident are you that it is AHF?
  1. lt20
  2. 21-40
  3. 41-60
  4. 61-80
  5. gt80

No right answer
13
AHF Dx Scoring systems
Predictor Points Our Case
Elevated NT-proBNP 4 ?
Interstitial edema on CXR 2 ?
Orthopnea 2 -
Absence of fever 2 2
Current loop diuretic use 1 -
Age gt 75 years 1 -
Rales on lung examination 1 1
Absence of cough 1 1
Interpretation 4
e.g. At a score of 9, PPV 92, NPV 82, sens 70,
spec 93
Baggish AL, et al. Am Heart J 2006 151 48-54. 
14
CASE 1
  • 74 year old female
  • CXR increased pulmonary markings c/w edema, no
    evidence of COPD
  • Labs troponin I 0.20
  • BNP 728 pg/ml
  • Creatinine 130

15
AHF Dx Scoring systems
Predictor Points Our Case
Elevated NT-proBNP 4 4
Interstitial edema on CXR 2 2
Orthopnea 2 -
Absence of fever 2 2
Current loop diuretic use 1 -
Age gt 75 years 1 -
Rales on lung examination 1 1
Absence of cough 1 1
Interpretation 10
e.g. At a score of 9, PPV 92, NPV 82, sens 70,
spec 93
Baggish AL, et al. Am Heart J 2006 151 48-54. 
16
CCS 2012
  • We recommend the use of a validated diagnostic
    scoring system for patients in whom the diagnosis
    of AHF is being considered (Strong
    Recommendation, Moderate Quality Evidence).
  • e.g. PRIDE score, Boston criteria
  • This recommendation places a relatively high
    value on evaluating the constellation of clinical
    findings in a patient with suspected AHF and less
    value on an individual physical examination
    finding, presenting symptom or investigation.

17
CCS 2012
  • We recommend that in the clinical scenario when
    the clinical diagnosis of AHF is of intermediate
    pre-test probability, NP level be obtained to
    rule-out (BNP lt100 pg/ml NT-proBNP lt300 pg/ml)
    or rule-in (BNP gt500 pg/ml NT-proBNP gt900 pg/ml
    if age 50-75 years, NT-proBNP gt1800 if age gt75
    years) AHF as the cause for the presenting
    symptoms suspicious of AHF
  • (Strong Recommendation, Moderate Quality
  • Evidence)

18
CCS 2012 Practical Tips
  • A precipitating cause for AHF should be sought.
  • An ECG and a chest x-ray should be performed
    within 2 hours of initial presentation.
  • Initial blood tests should include complete
    blood count, creatinine, blood urea nitrogen,
    glucose, sodium, potassium, and troponin.

19
CCS 2012 Practical Tips
  • A transthoracic echocardiogram should be
    performed within 72 hours of presentation.
  • For patients with a prior echocardiogram, another
    is not required unless there has been a
    significant change in clinical status requiring
    investigation, a lack of clinical response to
    appropriate therapy and/or it is greater than 12
    months since the prior echocardiogram.

20
CASE 2
  • 52 year old male with history of HF
  • Presented to ED after the Edmonton Oilers won the
    Stanley Cup
  • SOBOE, orthopnea
  • HR 98, BP 99/52, RR 24, temp 36.0c
  • JVP difficult to assess (thick neck)
  • crackles
  • pulses weak, legs cool and LEE
  • Trop 0.15

21
Question
  • prepare to provide your answer!

22
Where on this table does this pt fit?
1
2
Dry and Warm
Wet and Warm
Increasing Perfusion/ Cardiac Output
3
4
Dry and Cold
Wet and Cold
Increasing Congestion / PCWP
Adapted from Forrester, Am J Med 1978 Nohria et
al. JACC 2003 411797-804
23
Where on this table does this pt fit?
  1. Dry and Warm
  2. Wet and Warm
  3. Dry and Cold
  4. Wet and Cold

24
Where on this table does this pt fit?
1
2
Dry and Warm
Wet and Warm
Increasing Perfusion/ Cardiac Output
3
4
Dry and Cold
Wet and Cold
Increasing Congestion / PCWP
Adapted from Forrester, Am J Med 1978 Nohria et
al. JACC 2003 411797-804
25
Admit or discharge?
26
(No Transcript)
27
Treatment options?
28
CCS 2012 Oxygen
  • We recommend supplemental oxygen be considered
    for patients who are hypoxemic titrated to an
    oxygen saturation gt90 (Strong Recommendation,
    Moderate Quality Evidence).
  •  
  • Values and Preferences This recommendation
    places relatively higher value on the physiologic
    studies demonstrating potential harm with the use
    of excess oxygen in normoxic patients and less
    value on long-term clinical usage of supplemental
    oxygen without supportive data.

29
CCS 2012 CPAP/BIPAP
  • We recommend CPAP or BIPAP not be used routinely
    (Strong Recommendation, Moderate Quality
    Evidence).
  • Values and Preferences This recommendation
    places high weight on RCT data with a
    demonstrated lack of efficacy and with safety
    concerns in routine use. Treatment with
    BIPAP/CPAP may be appropriate for patients with
    persistent hypoxia and pulmonary edema.

30
CASE 2
  • 52 year old male with history of HF
  • Presented to ED after the Edmonton Oilers won the
    Stanley Cup
  • SOBOE, orthopnea
  • HR 98, BP 99/52, RR 24, temp 36.0c
  • JVP difficult to assess (thick neck)
  • crackles
  • pulses weak, legs cool and LEE
  • Trop 0.15

31
Question
  • prepare to provide your answer!

32
How much diuretic will you give and how?
  1. IV lasix 20 mg bid
  2. IV lasix 40 mg bid
  3. IV lasix 80 mg bid
  4. IV lasix 10 mg/hour infusion
  5. Other choice

33
DOSE Study Design
Acute Heart Failure (1 symptom AND 1 sign) lt24
hours after admission
2x2 factorial randomization
Low Dose (1 x oral) Q12 IV bolus
High Dose (2.5 x oral) Q12 IV bolus
Low Dose (1x oral) Continuous infusion
High Dose (2.5 x oral) Continuous infusion
48 hours
1) Change to oral diuretics 2) continue current
strategy 3) 50 increase in dose
e.g. Home dose 40 mg BID Bolus 80 (low) 200
(high)
72 hours
Co-primary endpoints
Felker, NEJM 2011
60 days
Clinical endpoints
34
DOSE Co-Primary Endpoints
  • Efficacy
  • Patient Global Assessment by visual analog scale
    over 72 hours using area under the curve
  • Safety
  • Change in creatinine from baseline to 72 hours

35
DOSE patient global assessment
36
DOSE Death, Rehosp, ER visit
37
DOSE-AHF Conclusions
  • There was no statistically significant difference
    in global symptom relief or change in renal
    function at 72 hours for either
  • bolus vs. infusion or low vs. high
  • No clinical differencesbut
  • High was associated with favorable trends
  • Symptom relief (global assessment and dyspnea)
  • Weight loss and net volume loss
  • Proportion free from signs of congestion
  • Reduction in NT-proBNP

38
CCS 2012 Diuretics
  • We recommend intravenous diuretics be given as
    first line therapy for patients with congestion
    (Strong Recommendation, Moderate Quality
    Evidence).
  •  
  • We recommend for patients requiring intravenous
    diuretic therapy, furosemide may be dosed
    intermittently (e.g. twice daily) or as a
    continuous infusion (Strong Recommendation,
    Moderate Quality Evidence).

39
Diuretic dosing for ADHF
Creatinine clearance
Initial IV dose
Maintenance dose
Patient
60 mL/min/1.73m2
New-onset HF or no maintenance diuretic
therapyEstablished HF or chronic oraldiuretic
therapyNew-onset HF or no maintenance diuretic
therapyEstablished HF or chronic oraldiuretic
therapy
Lowest diuretic dosethat allows forclinical
stability isthe ideal dose
Furosemide 20-40 mg2-3 times dailyFurosemide
bolus equivalentto oral doseFurosemide 20-80
mg2-3 times dailyFurosemide bolus
equivalentto oral dose
lt 60 mL/min/1.73m2
Creatinine clearance is calculated from the
Cockroft-Gault or Modified Diet in Renal Disease
formula. See text for details. Intravenous
continuous furosemide at doses of 5 to 20mg/h is
also an option.
Practical Tips When Response to Diuretic is
Suboptimal
Reevaluate the need for additional diuresis by
assessing volume status Restrict NA/H2O intake
(and exercise caution reducing oral intake below
500 ml per 24 hours). Review diuretic dosing.
Higher bolus doses will be more effective than
more frequent lower doses. Diuretic infusions
(eg, furosemide 20-40 mg bolus then 5-20
mg/h) can be a useful strategy when other options
are not available. Add another type of diuretic
with different site of action (thiazides,
spironolactone). Thiazide diuretics (eg oral
metolazone 2.5-5 mg OB/BID or
hydrochlorothiazide 25-50 mg) are often given at
least 30 minutes before the loop diuretic to
enhance diuresis, although this is not required
to have an adequate effect. Consider
hemodynamic assessment and/or positive inotropic
agents if clinical evidence of poor perfusion
coexists with diuretic resistance. Refer for
hemodialysis, ultrafiltration, or other renal
replacement strategies if diuresis is impeded by
renal insufficiency.
40
Question
  • prepare to provide your answer!

41
For a persistently symptomatic patient with HF,
what is next option?
  1. Higher dose lasix
  2. Different diuretic
  3. Add vasodilator
  4. Add inotropic agent
  5. Patience.
  6. Other choice

42
CCS 2012 Vasodilators
  • We recommend the following intravenous
    vasodilators, titrated to systolic blood pressure
    (SBP) gt 100 mmHg, for relief of dyspnea in
    hemodynamically stable patients (SBP gt 100
    mmHg)
  • Nitroglycerin (Strong Recommendation, Moderate
    Quality Evidence)
  • Nesiritide (Weak Recommendation, High Quality
    Evidence)
  • Nitroprusside (Weak Recommendation, Low Quality
    Evidence).

AHA 2012 RELAX-AHF, CARRESS
43
CCS 2012 Inotropes
  • We recommend hemodynamically stable patients do
    not routinely receive inotropes like dobutamine,
    dopamine or milrinone (Strong Recommendation,
    High Quality Evidence).
  • Values and Preferences These recommendations for
    inotropes place high value on the potential harm
    demonstrated when systematically studied in
    clinical trials and less value on potential short
    term hemodynamic effects of inotropes.

44
Do I stop the beta-blockers on admission?
  • Cohorts suggest continuing beta-blockers
    advantageous
  • RCT B-CONVINCED
  • Keep vs. Stop strategy in known HF pts on
    beta-blockers
  • Keep was non-inferior to Stop.
  • Does not delay clinical improvement
  • Predicts staying on BB in the longer term

Eur Heart J 2009 302186-92
45
RESYNCHRONIZATION THERAPY and DEVICES

Anique Ducharme, MD MSc FRCPC
46
Conflict Disclosures
The speaker has received fees/honoraria from the
following sources Abbott vascular, Medtronic,
Merck, Otsuka, Pfizer, Sorin St-Jude
Medical None of the drugs, devices, or
treatment modalities mentionedin this
presentation are non approved indications.
Anique Ducharme, Institut de Cardiologie de
Montréal, Université de Montréal
47
A Case of Mild Heart Failure
  • 61 years old female, previous MI,
  • stable NYHA II, LVEF 25
  • On optimal dose of lisinopril, eplerone and
    bisoprolol, occasional diuretics
  • Has not been assessed for device Rx
  • BP 99/67 mmHg, HR 76 bpm
  • K, 4.7 mEq/L NT-proBNP 4500 pg/mL
  • EKG old anterior MI, LBBB QRS 155 ms.

48
Question
  • prepare to provide your answer!

49
  • You started treating this patient with mild
    symptoms of HF and low ejection fraction with
    epleronone as recommended. Dosage was increased
    up to 50 mg without side effects. What do you do
    next?
  • Angiotensin receptor blocker
  • ICD
  • CRT
  • CRT ICD (CRT-D)

50
CRT in Patients with Mild HF SymptomsMADIT-CRT
1820 pts, mostly NYHA II, CRTICD vs ICD
alone Low risk population, annual mortality
3 40 reduction in HF events in CRT-ICD group
Moss et al, NEJM 2009
51
RAFT Death or HF hospitalization
Outcome ICD (N904) ICD-CRT (N894) Hazard ratio (95 CI) P value
Primary outcome Primary outcome Primary outcome Primary outcome Primary outcome
Death or hospitalization for HF 363 (40.3) 297 (33.2) 0.75 (0.64-0.87) lt0.001
Secondary outcomes Secondary outcomes Secondary outcomes Secondary outcomes Secondary outcomes
Death from any cause 236 (26.1) 186 (20.8) 0.75 (0.62-0.91) 0.003
Hospitalization for HF 236 (26.1) 174 (19.5) 0.68 (0.56-0.83) lt0.001
1800 pts, 80 NYHA II CRT-D vs ICD Median
follow-up 40 months
Tang AS, et al. N Engl J Med 2010
52
CRT Mortality reduction
Al-Majed et al, Annals of Internal Medicine 2011
53
CRT HF Hosp reduction
Al-Majed et al, Annals of Internal Medicine 2011
54
Medical Therapy in Perspective
RAFT 1800 pts, 80 NYHA II CRT-D vs ICD median
f/u 40 months
25 reduction in mortality
Zannad et al, N Engl J Med, 2010
Tang et al, N Engl J Med 2010
55
Recommendation 2011 (Update)
  • We recommend the use of CRT in combination with
    an ICD for HF patients on optimal medical therapy
    with NYHA II HF symptoms, LVEF lt 30, and QRS
    duration gt 150 ms.
  • (Strong Recommendation, High Quality Evidence)

56
Practical tips
  • QRSgt 150 ms based on a subgroup analysis of
    MADIT-CRT and RAFT studies
  • Most LBBB are gt150 msec
  • The selection of patients should be
    individualized and based on risk features

57
CRT for Everyone?Maybe not
  • Not everyone will benefit
  • Non-response is 30 depending on the
    definition of
  • Death
  • Hospitalization
  • Failure to improve 1 NYHA functional class
  • Failure to improve peak VO2 or 6 min walk
    distance
  • Absence of reverse remodelling (LVESV or EF)
  • Absence of improvement in dyssynchrony

58
Consider Risks vs Benefits Real World
N 1081 ICD replacements
N 713 Upgrade Procedures
Krahn et al, Ont ICD Database Circulation 2011
Poole et al, REPLACE Registry Circulation 2010
59
Importance of Patient Selection
  • Much uncertainty persists
  • Narrow QRS with mechanical dyssynchrony
  • LV dysfunction and chronic RV pacing
  • Atrial fibrillation and LBBB
  • Right bundle branch block
  • Asymptomatic patients
  • Class IV/Stage D patients

Real World Patient Population
60
Recommendation
  • Routine CRT implantation is not currently
    recommended for patients with heart failure and
    narrow QRS (lt120 ms)
  • Patients enrolled in CRT studies who show benefit
    have a QRS duration gt150ms, on average. The
    benefit in patients with QRS 120ms to 150ms is
    less clear
  • Echocardiography derived parameters of
    dyssynchrony cannot be recommended on a routine
    basis since clinical utility has not been
    established

Practical tips
61
Practical tip
  • The use of CRT may prevent worsening in patients
    with LV systolic dysfunction who require
    permanent pacing and who are expected to have a
    high burden of ventricular pacing

62
The ACEI-ARB-MRA Dilemma
  • Jonathan Howlett MD
  • Disclosures at www.hfcc.ca

63
Questions
  • prepare to provide your answers!

64
  • Case 1.
  • 34 year old female with NYHA FC II HF with LVEF
    29
  • BP 130/70, HR 63, Na 139, Creat 100, K 4.0
  • On BB, ACE, diuretic target doses.
  • Which drug should you start next?
  • ARB
  • Aldo Inhibitor
  • Neither
  • Does not matter, going for device anyway

65
  • Case 2.
  • 64 year old female with NYHA FC I HF with LVEF
    29
  • BP 160/70, HR 63, Na 139, Creat 100, K 4.2
  • On BB, ACE, CCB, diuretic target doses.
  • Which drug should you start next?
  • ARB
  • Aldo Inhibitor
  • Neither
  • Both

66
  • Case 3.
  • 84 year old female with NYHA FC IIIb HF with LVEF
    29
  • BP 100/70, HR 70, Na 139, Creat 160, K 4.7
  • On BB, ACE, Digoxin, diuretic optimal doses.
  • Which drug should you start next?
  • ARB
  • Aldo Inhibitor
  • Neither- I will use nitrates preferentially
  • Both

67
When to Use ARBs as Add-on Therapy?
  • In patients with persistent HF symptoms, and who
    are at increased risk of HF hospitalization,
    despite optimal treatment with ACE inhibitors and
    beta-blockers (Class I, Level A)

CHARM Proportion of patients with CV death or
hospital admission for CHF
Val-HeFT Probability of freedom from combined
endpoint (All-cause mortality, cardiac arrest
with resuscitation, hospitalization for worsening
HF, or therapy with intravenous inotropes or
vasodilators)
Pfeffer MA et al. Lancet 2003363759-66.

Cohn JN et al. N Engl J Med 20013451667-75.
Arnold JMO et al. Can J Cardiol 200622(1)23-45.
68
CHARM-Added Permanent study drug discontinuations
Percent of patients
Placebo
Candesartan
24.2
25
What are the effects of Spiro?
20
18.3
15
10
7.8
4.5
4.1
5
3.4
3.1
0.7
0
Hypo-tension
Increased creatinine
Increasedpotassium
AE/lab. abnorm.
p0.0003
p0.079
p0.0001
plt0.0001
69
2006 Recommendation
  • Patients with LVEF ? 30 and severe symptoms
    despite optimized other therapies(Class I, Level
    B)
  • Or with AHF with an LVEF less than 30 following
    acute myocardial infarction(Class IIa, level B)

70
EMPHASIS Baseline Characteristics
Characteristic Eplerenone (N1364) Placebo (N1373)
Mean age yr 68.7 (7.7) 68.6 (7.6)
Female sex 22.7 21.9
Ischemic heart disease 70 68
Blood pressure mm Hg 124 17/75 10 12417/7510
Atrial fibrillation or flutter 30 32
Diabetes mellitus no. () 34 29
Serum Creatinine mg/dl 1.14 (0.30) 1.16 (0.31)
Estimated GFR ml/min/1.73 m2 71.2 (21.9) 70.4 (21.7)
lt 60 ml/min/1.73 m2 no. () 32 35
Serum Potassium mmol/liter 4.3 (0.4) 4.3 (0.4)
Zannad, NEJM 2011 36411-21
71
EMPHASIS Primary Endpoint
72
Patient Follow-up and Dosing
Eplerenone Placebo
Discontinuations in surviving patients () 16.3 16.6
Discontinuations for AE n () 188 (13.8) 222 (16.2)
Mean dose at month 5 (mg/day) 39.1 13.8 40.8 12.9
p 0.09
73
Recommendation 2011
  • We recommend that an aldosterone receptor
    blocking agent such as eplerenone be considered
    for patients with mild to moderate (NYHA II) HF,
    aged gt 55 years with LV systolic dysfunction
    (LVEF lt 30, or if LVEF is 30 and 35 with QRS
    duration gt130 ms), and recent hospitalization for
    CVD or elevated BNP/NT-pro-BNP levels, who are on
    standard HF therapy
  • (Strong Recommendation, High-Quality
    Evidence)

74
Combination RAAS Blockade- OptionsAdd an ARB
  • Mean BP reduction 5-7 / 3-5 mmHg
  • Mean ? in creatinine lt 30 umol/L
  • Mean ? in potasssium 0.3 Mmol/L
  • Reduction in CHF/CV Death in Mild/mod HF
  • Evidence with triple therapy

Combination RAAS BlockadeAdd Spironolactone
  • Mean BP reduction -1 to 5/ _13 mmHg
  • Mean ? in creatinine lt 50 umol/L
  • Mean ? in potasssium 0.5- 0.9 Mmol/L
  • Trials stopped early in enhanced moderate HF
  • No evidence in triple therapy

75
But we vote with our feet!
76
Fonarow, Circulation 2011. p 1601-10
77
CHF Clinics Increased use of EBM versus
Community- the First 1933 Patients
EB Therapy First visit from Community(n 1155) Previously seen in clinic(n 778) P value
Age (SD) 62 (16) 63 (14) ns
LVEF (SD) 30 (14) 31 (14) ns
ACE inhibitor () 79 81 ns
ACE inhibitor( at target) 25 60 0.01
Diuretic () 49 66 0.01
Beta Blocker () 49 58 0.01
Aldo Antagonist () 15 30 0.01
J Card Fail, Volume 7, Issue 3 Suppl 2, p.90
(2001)
78
Impact of HF Clinic Care on LVEF in Canadians
with HF
  • 21 Clinics with data from 1999-2010
  • 599 patients with LVEF data at 0, 1,2 years
  • 74 male, 63 ischemic etiology

Measurement Baseline Assessment (SD) Year 1 follow up (SD) Year 2 follow up (SD) P value baseline to 2 years (SD)
LVEF 32 (14) 38 (15) 38 (14) plt 0.001
Improve by gt 20 baseline 30 (14) 31 (14) plt 0.001
Improve by gt10 ACE inhibitor () 79 81 plt 0.001
ACE use 54 69 69 plt 0.001
ACE or ARB 70 93 95 plt 0.001
Beta blocker use 63 85 85 plt 0.001
Aldo Antagonist 21 35 45 Plt 0.001
Eur Heart J 201132 (suppl 1)
79
Management of Patients with HF and Acute
Intercurrent Medical Illness
  • HF patients with an acute dehydrating illness of
    any kind should undergo prompt evaluation
    (electrolytes, BUN, Crcl).
  • If diarrhea or vomiting occurs, the aldosterone
    blocker should be stopped until resolution.
  • Caution is also necessary when there are other
    potential causes of dehydration, including
    increase in diuretic dose.

Canadian Cardiovascular Society Consensus
Conference recommendations update 2007 American
College of Cardiology Foundation/American Heart
Association practice guidelines 2009
80
Suggested addition.
  • Most of the time, the Aldosterone Antagonist is
    the way to go
  • Monitoring is the most important aspect of Rx
  • Triple therapy is discouraged outside special
    circumstances
  • Role for ARBs if
  • Very high BP
  • Difficulty with K high
  • Cannot tolerate AA due to side effects
  • Osteoarthritis?

81
Should all patients with HFexercise and how?
  • Eileen OMeara, M.D.

82
Question
  • prepare to provide your answer!

83

EXERCISE TRAINING IN CHRONIC HEART FAILURE
  • QUESTION 1. TRUE OR FALSE?
  • All patients with stable New York Heart
    Association (NYHA) class I-III should be
    considered for enrolment in a tailored exercise
    training program, in order to improve exercise
    tolerance and quality of life.
  • True
  • False

84
The benefits of rehabilitation in HF
  • It is now well recognized that exercise-based
    cardiac rehabilitation programs for patients with
    HF improve exercise capacity, skeletal and
    respiratory muscle function, quality of life,
    autonomic function, biomarkers, and reduce
    depressive symptoms as well as cardiovascular
    risk factors.

Piepoli MF et al. Eur J Heart Fail 2011 13(4)
347357. Vanhees L et al. Eur J Cardiovasc Prev
Rehabil 2011.
Based on the results of prior studies of exercise
training, the Canadian Cardiovascular Society has
adopted recommendations that physical activity be
considered for stable patients with systolic
dysfunction.
Canadian Cardiovascular Society consensus
conference recommendations on heart failure 2006
diagnosis and management. Can J Cardiol
200622(1)2345.
85
The HF-ACTION trial
  • The HF-ACTION trial demonstrated no significant
    reduction in the combined endpoint of all-cause
    mortality or hospitalization (hazard ratio, 0.93
    95 confidence interval, 0.841.02 P0.13).
  • After adjusting for 4 covariables associated with
    an increase in the primary endpoint and for HF
    etiology, exercise training was found to reduce
    the incidence of all-cause mortality or all-cause
    hospitalization by 11 (HR, 0.89 95 CI,
    0.810.99 P 0.03).
  • exercise training conferred modest but
    statistically significant improvements in
    self-reported health status.

OConnor CM et al. JAMA 2009 301
14391450. Flynn KE et al. JAMA 2009 301
14511459.
86
The case of Madame T
  • 2007 42 y.o. patient presents with EF 38 and
    sustained VT. No significant CAD on angio.
  • Diagnosis Familial cardiomyopathy
  • 2007 - A defibrillator is implanted i.e.
    secondary prevention and medical therapy is
    optimized
  • 2008 EF increased to 45
  • 2010 EF is 50 on echocardiogram
  • 2010 Amiodarone is stopped since patient fears
    the side effects and EF is now  normalized 
  • She undergoes a treadmill test prior to exercise
    training in November 2010

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Sinus tachycardia then multiple PVCs then VT
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Question
  • prepare to provide your answer!

89
Question 2. Select the best answer?
  1. She had ischemia and this should have been
    investigated by another test
  2. The adrenaline surge during the test lead to
    ventricular tachycardia and the defibrillator
    shocks were appropriate
  3. The treadmill test should have been stopped
    before her heart rate reached the programmed VT
    zone so she would not receive shocks
  4. She should not be allowed to reach this level of
    exercise even if she did not have a defibrillator
    anyway
  5. She should have been on amiodarone or a higher
    dose of beta-blockers

90

PATIENT EVALUATION PRIOR TO AN EXERCISE PROGRAM
  • The following should be obtained prior to a
    tailored exercise training program
  • An assessment of clinical status by a clinician
    experienced in the management of heart failure
    patients should be completed
  • Establish if the patient has an ICD and if yes,
    verify if previous shocks have been delivered and
    note the programmed VT zone
  • Exercise test (evaluate ischemia, arrhythmias,
    rate responses of patients with pacemakers, and
    determine training heart rate ranges)
  • Non-cardiac causes of dyspnea or musculoskeletal
    disorders may limit exercise tolerance and
    should be evaluated

 
91

Madame T Actions and Reactions
  • She complained to the hospital authorities and
    had to receive the help of a psychologist to cope
    with the fear of defibrillator shocks.
  • The technician was unaware of how to prepare a
    patient with a defibrillator for a treadmill test
    and the attending physician should have
    supervised more closely in preparation for the
    test.
  • A written protocol was made to ensure that this
    would not happen again. The patient was satisfied
    with the procedure.
  • She began training again about 1 year later and
    still sees her cardiologist in that same
    hospital.
  • Current EF is 45 (July 2012 echocardiogram)

92
Treadmill test protocol for patients with
defibrillators
  • The indication for the treadmill test should be
    clearly described and the patient must be flagged
    as having a defibrillator
  • Defibrillator programmation will be verified
    immediately prior to the treadmill test
  • Maximal HR will be the programmed HR for VT
    therapy minus 20 beats per minute. The test
    should be stopped immediately as that HR is
    reached.
  • All pharmacological treatments should be
    continued (especially beta-blockers and
    antiarrhythmics)
  • No adjustment to the defibrillator programmation
    should be made in view of the treadmill test

93

Exercise Training in Stable HF is SAFE
  • A stepwise approach to exercise training in
    stable HF is suggested, including
  • Cardiopulmonary/exercise testing is used for
    safety assessment and exercise prescription.
  • Initial supervision ensures safety of the
    prescribed program and may help patients
    understand their limits. For patients who prefer
    home-based exercise, after a minimum of 6-8
    supervised sessions, exercise training may
    continue with a home-based program.

94

Aerobic Exercise Training Prescription
Moderate-intensity continuous aerobic exercise
training at rate of perceived exertion (RPE) 3-5
(Figure), 65-85 maximum heart rate, and 50-75
peak V02 is recommended in HF patients
 
Exercise program schedule in stable patients
should begin with aerobic exercise training,
10-15 minutes in duration, 2-3 days per week
frequency, before gradually increasing training
to a target of 30 minutes, 5 days per week.
Walking, treadmill, and stationary cycling can be
chosen as primary training modes.
Moderate-intensity aerobic interval training may
be incorporated into the ET program in selected,
stable HF patients.
95
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96
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97
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