Title: CCS HEART FAILURE WORKSHOP THE PRACTICAL MANAGEMENT OF HEART FAILURE
1CCS HEART FAILURE WORKSHOP THE PRACTICAL
MANAGEMENT OF HEART FAILURE 2012 UPDATE
2WELCOME!
3Learning 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.
4Acute Heart Failure
5What 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
6Classification 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
7Has 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
8CASE 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
9CASE 1
- 74 year old female
- CXR pending
- Labs pending
10Question
- prepare to provide your answer!
11How confident are you that it is AHF?
- lt20
- 21-40
- 41-60
- 61-80
- gt80
12How confident are you that it is AHF?
- lt20
- 21-40
- 41-60
- 61-80
- gt80
No right answer
13AHF 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.
14CASE 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
15AHF 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.
16CCS 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.
17CCS 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)
18CCS 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.
19CCS 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.
20CASE 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
21Question
- prepare to provide your answer!
22Where 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
23Where on this table does this pt fit?
- Dry and Warm
- Wet and Warm
- Dry and Cold
- Wet and Cold
24Where 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
25Admit or discharge?
26(No Transcript)
27Treatment options?
28CCS 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.
29CCS 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.
30CASE 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
31Question
- prepare to provide your answer!
32How much diuretic will you give and how?
- IV lasix 20 mg bid
- IV lasix 40 mg bid
- IV lasix 80 mg bid
- IV lasix 10 mg/hour infusion
- Other choice
33DOSE 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
34DOSE 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
35DOSE patient global assessment
36DOSE Death, Rehosp, ER visit
37DOSE-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
38CCS 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).
39Diuretic 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.
40Question
- prepare to provide your answer!
41For a persistently symptomatic patient with HF,
what is next option?
- Higher dose lasix
- Different diuretic
- Add vasodilator
- Add inotropic agent
- Patience.
- Other choice
42CCS 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
43CCS 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.
44Do 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
46Conflict 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
47A 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.
48Question
- 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)
50CRT 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
51RAFT 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
52CRT Mortality reduction
Al-Majed et al, Annals of Internal Medicine 2011
53CRT HF Hosp reduction
Al-Majed et al, Annals of Internal Medicine 2011
54Medical 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
55Recommendation 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)
56Practical 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
57CRT 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
58Consider 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
59Importance 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
60Recommendation
- 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
61Practical 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
62The ACEI-ARB-MRA Dilemma
- Jonathan Howlett MD
- Disclosures at www.hfcc.ca
63Questions
- 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
67When 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.
68CHARM-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
692006 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)
70EMPHASIS 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
71EMPHASIS Primary Endpoint
72Patient 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
73Recommendation 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)
74Combination 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
75But we vote with our feet!
76Fonarow, Circulation 2011. p 1601-10
77CHF 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)
78Impact 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)
79Management 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
80Suggested 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?
81Should all patients with HFexercise and how?
82Question
- 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
84The 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.
85The 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.
86The 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
87Sinus tachycardia then multiple PVCs then VT
88Question
- prepare to provide your answer!
89Question 2. Select the best answer?
- She had ischemia and this should have been
investigated by another test - The adrenaline surge during the test lead to
ventricular tachycardia and the defibrillator
shocks were appropriate - The treadmill test should have been stopped
before her heart rate reached the programmed VT
zone so she would not receive shocks - She should not be allowed to reach this level of
exercise even if she did not have a defibrillator
anyway - 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)
92Treadmill 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(No Transcript)
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