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Guideline Recommended Approach to the Evaluation and Management of Heart Failure

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Title: Guideline Recommended Approach to the Evaluation and Management of Heart Failure


1
Guideline Recommended Approach to the Evaluation
and Management of Heart Failure
  • William T. Abraham, MD, FACP, FACC
  • Professor of Medicine
  • Chief, Division of Cardiovascular Medicine
  • Associate Director, Davis Heart Lung Research
    Institute
  • The Ohio State University
  • Columbus, Ohio

2
ACC/AHA 2005 Guideline HF Stages
Heart Failure
At Risk for Heart Failure
  • Therapy Goals
  • All measures under Stages A and B
  • Dietary salt restriction
  • Therapy DrugsRoutine
  • Diuretics for fluid retention
  • ACEIs
  • ?-blockers
  • Therapy DrugsSelect Pts
  • Aldosterone antagonist
  • ARBs
  • Digitalis
  • Hydralazine/nitrates
  • Therapy DevicesSelect Pts
  • Biventricular pacing
  • Implantable defibrillators

Stage A At high risk for HF but without
structural heart disease or Sx of HF
Stage B Structural heart disease but without Sx
of HF
Stage C Structural heart disease with prior or
current Sx of HF
Stage D Refractory HF requiring specialized
inter-ventions
  • Therapy Goals
  • All measures under Stages A, B, and C
  • Discussion re appropriate level of care
  • Therapy Options
  • Compassionate end-of-life care/hospice
  • Extraordinary measures
  • Heart transplant
  • Chronic inotropes
  • Permanent mechanical support
  • Experimental surgery or drugs
  • Therapy Goals
  • Treat hypertension
  • Encourage smoking cessation
  • Treat lipid disorders
  • Encourage regular exercise
  • Discourage alcohol intake, illicit drug use
  • Control metabolic syndrome
  • Therapy Drugs
  • ACEI or ARB in appropriate patients for vascular
    disease or diabetes
  • Therapy Goals
  • All measures under Stage A
  • Therapy Drugs
  • ACEI or ARB in appropriate patients
  • ?-blockers in appropriate patients
  • Therapy Goals
  • All measures under Stages A and B
  • Dietary salt restriction
  • Therapy DrugsRoutine
  • Diuretics for fluid retention
  • ACEIs
  • ?-blockers
  • Therapy DrugsSelect Pts
  • Aldosterone antagonist
  • ARBs
  • Digitalis
  • Hydralazine/nitrates
  • Therapy DevicesSelect Pts
  • Biventricular pacing
  • Implantable defibrillators
  • Therapy Goals
  • All measures under Stages A, B, and C
  • Discussion re appropriate level of care
  • Therapy Options
  • Compassionate end-of-life care/hospice
  • Extraordinary measures
  • Heart transplant
  • Chronic inotropes
  • Permanent mechanical support
  • Experimental surgery or drugs
  • Therapy Goals
  • Treat hypertension
  • Encourage smoking cessation
  • Treat lipid disorders
  • Encourage regular exercise
  • Discourage alcohol intake, illicit drug use
  • Control metabolic syndrome
  • Therapy Drugs
  • ACEI or ARB in appropriate patients for vascular
    disease or diabetes
  • Therapy Goals
  • All measures under Stage A
  • Therapy Drugs
  • ACEI or ARB in appropriate patients
  • ?-blockers in appropriate patients

Hunt SA, Abraham WT, Chin MH, et al, J Am Coll
Cardiol, 2005
3
Heart Failure Prevention
Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
4
HF Risk Factor Treatment Goals
Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
5
Treating Hypertension to Prevent HF
  • Aggressive blood pressure control
  • Aggressive BP control in patients with prior MI

Decreases risk of new HF by 50 56 in DM2
Decreases risk of new HF by 80
Lancet 199133812811281-5 (STOP-Hypertension JAM
A 1997278212-6 (SHEP) UKPDS Group. UKPDS 38.
BMJ 1998317703-713
6
Prevention ACEI and Beta Blockers
  • ACE inhibitors are recommended for prevention of
    HF in patients at high risk for this syndrome,
    including those with
  • Coronary artery disease
  • Peripheral vascular disease
  • Stroke
  • Diabetes and another major risk factor
  • ACE inhibitors and beta blockers are recommended
    for all patients with prior MI

Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
7
Management of Patients with Known Atherosclerotic
Disease But No HF
Placebo
HOPE
  • Treatment with ACE inhibitors decreases the risk
    of CV death, MI, stroke, or cardiac arrest

Ramipril
22 rel. risk red. p
EUROPA
Placebo
Perindopril
20 rel. risk red. p .0003
NEJM 2000342145-53 (HOPE) Lancet 2003362782-8
(EUROPA)
8
Treatment of Post-MI Patients with Asymptomatic
LV Dysfunction (LVEF 40)
  • SAVE Study
  • All-cause mortality ?19
  • CV mortality ?21
  • HF development ?37
  • Recurrent MI ?25

Mortality Rate
Placebo
Captopril
19 rel. risk reduction p 0.019
Years
Pfeffer et al. NEJM 1992327669-77
9
The Additional Value of Beta Blockers Post-MI
CAPRICORN
  • Studied impact of beta blocker (carvedilol) on
    post-MI patients with LVEF 40 already
    receiving contemporary treatments, including
    revascularization, anticoagulants, ASA, and ACEI
  • All-cause mortality reduced (HR 0.077 p
    0.03)
  • Cardiovascular mortality reduced
    (HR 0.75 p .024)
  • Recurrent non-fatal MIs reduced (HR .59 p
    .014)

Dargie HJ. Lancet 20013571385-90
10
Heart Failure Patient Evaluation
  • Recommended evaluation for patients with a
    diagnosis of HF
  • Assess clinical severity and functional
    limitation by history, physical examination, and
    determination of functional class
  • Assess cardiac structure and function
  • Determine the etiology of HF
  • Evaluate for coronary disease and myocardial
    ischemia
  • Evaluate the risk of life threatening arrhythmia
  • Identify any exacerbating factors for HF
  • Identify co-morbidities which influence therapy
  • Identify barriers to adherence and compliance
  • Metrics to consider include the 6-minute walk
    test and NYHA functional class

Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
11
Evaluation Follow Up Assessments
  • Recommended Components of Follow-Up Visits
  • Signs and symptoms evaluated during initial visit
  • Functional capacity and activity level
  • Changes in body weight
  • Patient understanding of and compliance with
    dietary sodium restriction
  • Patient understanding of and compliance with
    medical regimen
  • History of arrhythmia, syncope, pre-syncope or
    palpitation
  • Compliance and response to therapeutic
    interventions
  • Exacerbating factors for HF, including worsening
    ischemic heart disease, hypertension, and new or
    worsening valvular disease

Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
12
Rationale for Evidence-Based Drug Selection in
Heart Failure
  • Within drug classes, agents may differ
    pharmacologically
  • These pharmacological differences may translate
    into differences in clinical outcomes
  • When multiple agents within a class produce
    discordant results on clinical outcomes, class
    effect cannot be presumed (e.g., ?-blockers)

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

13
Effect of ?-Blockade on Outcome in Patients With
HF and Post-MI LVD
Target HF Dosage Study Drug Severity (mg)
Outcome US Carvedilol1 carvedilol
mild/ 6.25-25 ?48 disease progression moderat
e BID (P.007) CIBIS-II2 bisoprolol
moderate/ 10 QD ?34 mortality severe (P?.0001
) MERIT-HF3 metoprolol mild/ 200 QD ?34
mortality succinate moderate (P.0062) CO
PERNICUS4 carvedilol severe 25 BID ?35
mortality (P.0014) CAPRICORN5
carvedilol Post-MI LVD 25 BID
?23 mortality
(P.031)
1Colucci WS, et al. Circulation.
1996942800-2806. 2CIBIS II Investigators and
Committees. Lancet. 19993539-13. 3MERIT-HF
Study Group. Lancet. 19993532001-2007. 4Packer
M, et al. N Engl J Med. 20013441651-1658. 5The
CAPRICORN Investigators. Lancet.
20013571385-1390.
14
?-Blockers Differ in Their Long-Term Effects on
Mortality in HF
Bisoprolol1 Bucindolol2 Carvedilol3-5 Metoprolol
tartrate6 Metoprolol succinate7 Nebivolol8 Xamoter
ol9
Beneficial No effect Beneficial No
effect Beneficial No effect Harmful
1CIBIS II Investigators and Committees. Lancet.
19993539-13. 2The BEST Investigators. N Engl J
Med 2001 3441659-1667. 3Colucci WS, et al.
Circulation 1996942800-2806. 4Packer M, et al.
N Engl J Med 20013441651-1658. 5The CAPRICORN
Investigators. Lancet. 20013571385-1390.
6Waagstein F, et al. Lancet. 19933421441-1446.
7MERIT-HF Study Group. Lancet. 19993532001-2007.
8SENIORS Study Group. Eur Heart J. 2005
26215-225. 9The Xamoterol in Severe heart
Failure Study Group. Lancet. 19903361-6.
15
COMET Primary Endpoint of Mortality
Metoprolol mean dose 85 mg QD Coreg mean dose
42 mg QD.
Poole-Wilson PA, et al. Lancet. 20033627-13.
16
?-Blockers Stage C Heart Failure
  • Class I Indication ?-blockers (using 1 of 3
    proven to reduce mortality, ie, bisoprolol,
    carvedilol, and sustained-release metoprolol
    succinate) are recommended for all stable
    patients with current or prior symptoms of HF and
    reduced LVEF, unless contraindicated Level of
    Evidence A

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

17
CHARM and Val-HeFT Trials
  • Addition of candesartan1 or valsartan2 to ACEI
    and ?-blocker in NYHA functional Class II-III
  • 0-10 lower risk of death (P?.05)
  • 13-15 lower risk of death or hospitalization
    for HF in both trials (both P?.01)
  • Higher risk for hypotension, renal insufficiency,
    and hyperkalemia with ARB treatment

1Pfeffer MA, et al. Lancet. 2003362759-766.
2Cohn JN, et al. N Engl J Med. 20013451667-1675.

18
VALIANT ACE Inhibitor, Angiotensin Receptor
Blocker, or Both in Post-MI LVD
Combined Cardiovascular End Point
Death From Any Cause
.4
.4
.3
.3
.2
.2
Probability of Event
.1
.1
0
0
0
6
12
18
24
30
36
0
6
12
18
24
30
36
Months
Valsartan ? captopril
Valsartan
Captopril
Number at Risk
Valsartan
4,464
4,272
4,007
2,648
1,437
4,909
357
3,921
3,667
3,391
2,188
1,204
4,909
290
4,414
4,265
3,994
2,648
1,435
Valsartan ? captopril
4,885
382
3,887
3,646
3,391
2,221
1,185
4,885
313
4,428
4,241
4,018
2,635
1,432
Captopril
4,909
364
3,896
3,610
3,355
2,155
1,148
4,909
295
1Pfeffer MA et al. N Engl J Med.
20033491893-1906.
19
ARBs Stage C Heart Failure
  • Class I Indication ARBs approved for HF are
    recommended in patients with current or prior
    symptoms of HF and reduced LVEF who are ACEI
    intolerant Level of Evidence A
  • Class IIa Indication ARBs are reasonable to use
    as alternatives to ACEIs as first-line therapy
    for patients with mild to moderate HF and reduced
    LVEF, especially for patients already taking ARBs
    for other indications Level of Evidence A

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

20
ARBs Stage C Heart Failure (contd)
  • Class IIb Indication The addition of an ARB may
    be considered in persistently symptomatic
    patients with reduced LVEF who are already being
    treated with conventional therapy (ie, ACEI and
    ?-blocker) Level of Evidence B

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

21
Trials With Aldosterone Antagonist
Primary Endpoint All-Cause Mortality
Aldosterone Antagonist
Hazard
Log-rank
Trial
Placebo
Ratio
P Value
.85
EPHESUS
554/3,319
478/3,313
.008
(.75, .96)
.70
RALES
284/822
386/841
(.60, .82)
Pitt B. N Engl J Med. 20033481309-1321. Pitt B.
N Engl J Med. 1999341709-717.
22
Aldosterone Antagonists Stage C Heart Failure
  • Class I Indication Addition of an aldosterone
    antagonist is reasonable in selected patients
    with moderately severe to severe symptoms of HF
    and reduced LVEF who can be carefully monitored
    for preserved renal function and normal potassium
    concentration Level of Evidence B

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

23
A-HeFT All-Cause Mortality
Taylor AL, et al. N Engl J Med.
20043512049-2057.
24
Nitrates/Hydralazine Stage C Heart Failure
  • Class IIa Indication The addition of isosorbide
    dinitrate and hydralazine to a standard medical
    regimen for HF, including ACEIs and ?-blockers,
    is reasonable and can be effective in blacks with
    NYHA functional Class III or IV HF Level of
    Evidence A
  • Class IIb Indication A combination of
    hydralazine and a nitrate might be reasonable in
    patients with current or prior symptoms of HF and
    a reduced LVEF who cannot be given an ACEI or ARB
    because of drug intolerance, hypotension, or
    renal insufficiency Level of Evidence C

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

25
Cardiac Resynchronization Therapy Weight of
Evidence
  • ?4,000 patients evaluated in randomized
    controlled trials
  • Consistent improvement in quality of life,
    functional status, and exercise capacity
  • Strong evidence of reverse remodeling
  • ? LV volumes and dimensions
  • ? LVEF
  • ? Mitral regurgitation
  • Reduction in HF and all-cause morbidity and
    mortality

Abraham WT. Circulation. 20031082596-2603.
26
CRT Improves Quality of Life and NYHA Functional
Class
()
PAbraham et al. 2003.
27
CARE-HF Effect of CRT Without an ICD on
All-Cause Mortality
Cleland JG, et al. N Engl J Med.
20053521539-1549.
28
CRT Stage C Heart Failure
  • Class I Indication Patients with LVEF ?35,
    sinus rhythm, and NYHA functional Class III or
    ambulatory Class IV symptoms despite recommended
    optimal medical therapy and who have cardiac
    dysynchrony, which is currently defined as a QRS
    ?120 msec, should receive CRT, unless
    contraindicated Level of Evidence A

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

29
MADIT II Effect of Prophylactic ICD in Ischemic
LVD (LVEF ?30)
Moss AJ, et al. N Engl J Med. 2002346877-883.
30
SCD-HeFT Enrollment Scheme
Bardy GH, et al. N Engl J Med. 2005352225-237.
31
SCD-HeFT Trial Mortality by Intention-to-Treat
.4
.3
22
.2
Mortality
17
.1
Amiodarone
ICD Therapy
Placebo
0
0
6
12
18
24
30
36
42
48
54
60
Months of Follow-Up
Bardy GH, et al. N Engl J Med. 2005352225-237.
32
ICDs Stage C Heart Failure
  • Class I Indication An ICD is recommended as
    secondary prevention to prolong survival in
    patients with current or prior symptoms of HF and
    reduced LVEF who have a history of cardiac
    arrest, ventricular fibrillation, or hemodynamic
    destabilizing ventricular tachycardia Level of
    Evidence A
  • Class I Indication ICD therapy is recommended
    for primary prevention to reduce total mortality
    by reducing sudden cardiac death in patients with
    ischemic heart disease who are at least 40 days
    post-MI, have an LVEF ?30 with NYHA functional
    Class II or III symptoms while undergoing chronic
    optimal medical therapy, and have a reasonable
    expectation of survival Level of Evidence A

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

33
ICDs Stage C Heart Failure (contd)
  • Class I Indication ICD therapy is recommended
    for primary prevention to reduce total mortality
    by a reduction in sudden cardiac death in
    patients with nonischemic cardiomyopathy who have
    an LVEF ?30, with NYHA functional Class II or
    III symptoms while undergoing chronic optimal
    medical therapy, and have a reasonable
    expectation of survival Level of Evidence B
  • Class IIa Indication Placement of an ICD is
    reasonable in patients with an LVEF of 30 to 35
    of any origin with NYHA functional Class II or
    III symptoms who are taking chronic optimal
    medical therapy and who have a reasonable
    expectation of survival Level of Evidence B

Hunt SA, Abraham WT, Chin MH, et al., Circulation
and JACC, Sept. 2005 Available beginning August
15, 2005 at www.acc.org and www.americanheart.org.

34
Evidence-Based Treatment Across the Continuum of
LVD and HF
For all indicated patients. Abraham WT, 2005.
35
Acute Decompensated Heart Failure Treatment
Goals for Hospitalized Patients
  • Improve symptoms, especially congestion and
    low-output symptoms
  • Optimize volume status
  • Identify etiology
  • Identify precipitating factors
  • Optimize chronic oral therapy minimize side
    effects
  • Identify who might benefit from revascularization
  • Education patients concerning medication and HF
    self-assessment
  • Consider enrollment in a disease management
    program

Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
36
Overview of Treatment Options for Patients with
Acute Decompensated HF
  • Fluid and sodium restriction
  • Diuretics, especially loop diuretics
  • Ultrafiltration/renal replacement therapy
    (in selected patients only)
  • Parenteral vasodilators
    (nitroglycerin, nitroprusside, nesiritide)
  • Inotropes (milrinone or dobutamine)

See recommendations for stipulations and
restrictions.
Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
37
Discharge Criteria for Hospitalized ADHF Patients
  • Recommended prior to discharge for all patients
    with HF
  • Exacerbating factors addressed
  • Near optimum fluid status achieved
  • Transition from IV to oral diuretic completed
  • Near optimum pharmacologic therapy achieved
  • Follow-up clinic visit scheduled, usually 7-10
    days
  • Should be considered prior to discharge for
    patients with advanced HF or a history of
    recurrent admissions
  • Oral regimen stable for 24 hours
  • No IV inotrope or vasodilator for 24 hours
  • Ambulation before discharge to assess functional
    capacity
  • Plans for post-discharge management
  • Referral to a disease management program

Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
38
Predictors of Mortality Based on Analysis of
ADHERE Database
  • Classification and Regression Tree (CART)
    analysis of ADHERE data shows
  • Three variables are the strongest predictors of
    mortality in hospitalized ADHF patients

BUN 43 mg/dL Systolic blood pressure mmHg Serum creatinine 2.75 mg/dL
Fonarow GC et al. JAMA 2005293572-80
39
Heart Failure Patient Education
  • It is recommended that patients with HF and their
    family members or caregivers receive
    individualized education and counseling that
    emphasizes self-care.
  • This education and counseling should be delivered
    by providers using a team approach.
  • Teaching should include skill building and target
    behaviors

Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
40
The Potential Impact of Effective Education on
Patient Compliance
Kravitz et al. Arch Int Med 19931531869-78
41
Sample Target Behavior Be Able to Read and
Understand Food Labels
Labels from cups of soup
42
Heart Failure Disease Management
  • Patients recently hospitalized for HF and other
    patients at high risk should be considered for
    referral to a comprehensive HF disease management
    program that delivers individualized care

43
HF Disease Management and the Risk of Readmission
Risk Ratio
Summary RR 0.76 (95 CI .68-.87) Summary RR for
randomized only 0.75 (CI .60-.95)
44
End-of-Life Care in Heart Failure
  • End-of-life care should be considered in patients
    who have advanced, persistent HF with symptoms at
    rest despite repeated attempts to optimize
    pharmacologic and non-pharmacologic therapy, as
    evidenced by one or more of the following
  • Frequent hospitalizations (3 or more per year)
  • Chronic poor quality of life with inability to
    accomplish activities of daily living
  • Need for intermittent or continuous intravenous
    support
  • Consideration of assist devices as destination
    therapy

Adams KF, Lindenfeld J, et al. HFSA 2006
Comprehensive Heart Failure Guideline. J Card
Fail 200612e1-e122
45
Heart Failure A Practical Approach to Treatment
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