Key Recommendations Guidelines

2006 HFSA Comprehensive Heart Failure Practice Guideline Key Recommendations

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Comprehensive Heart Failure Practice Guideline

Strength of Recommendation “Is recommended”

Part of routine care  Exceptions should be minimized

“Should be considered”

Majority of patients should receive intervention  Some discretion allowed

“May be considered”

Individualization of therapy is indicated

“Is not recommended”

Therapy should not be used

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Comprehensive Heart Failure Practice Guideline

Strength of Evidence A

Randomized controlled trials  May be assigned on results of 1 trial

B

Cohort and case control studies  Includes sub group analyses, metaanalyses, observational studies, registries

C

Expert opinion  Includes observational, epidemiological findings; in-practice safety reporting

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (3.1)

Heart Failure Prevention A careful and thorough clinical assessment, with appropriate investigation for known or potential risk factors, is recommended in an effort to prevent development of LV remodeling, cardiac dysfunction, and HF. Strength of Evidence = A

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (3.2)

HF Risk Factor Treatment Goals Risk Factor

Goal

Hypertension

Generally < 130/80

Diabetes

See ADA guidelines1

Hyperlipidemia

See NCEP guidelines2

Inactivity

20-30 min. aerobic 3-5 x wk.

Obesity

Weight reduction < 30 BMI

Alcohol

Men ≤ 2 drinks/day, women ≤ 1

Smoking

Cessation

Dietary Sodium

Maximum 2-3 g/day 1. Diabetes Care 2006; 29: S4-S42. 2. JAMA 2001; 285:2486-97. Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

Treating Hypertension to Prevent HF Aggressive blood pressure control: Decreases Decreases risk riskof of new newHF HF by by~~50% 50% 56% 56%in inDM2 DM2 Lancet 1991;338:1281:1281-5 (STOP-Hypertension). JAMA 1997;278:212-6 (SHEP). UKPDS Group. UKPDS 38. BMJ 1998;317:703-713.

Aggressive BP control in patients with prior MI: Decreases risk of new HF by ~ 80%

HFSA 2006 Practice Guideline (3.3-3.4)

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

Strength of Evidence = A

ACE inhibitors and beta blockers are recommended for all patients with prior MI. Strength of Evidence = A

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

Management of Patients with Known Atherosclerotic Disease But No HF Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest.

16 14 12 % MI, 10 Stroke, 8 CV Death 6 4 2 0

15 12

NEJM 2000;342:145-53 (HOPE). Lancet 2003;362:782-8 (EUROPA).

% MI, CV Death, Cardiac Arrest

Placebo

HOPE

Ramipril 22% rel. risk red. p < .001 0

1

2 Years

EUROPA

3

4

Placebo

9 6

Perindopril

3 0

20% rel. risk red. p = .0003 0

1

2 3 Years

4

5

Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF ≤ 40%) SAVE Study

0.3

Placebo

 All-cause mortality ↓ 19%  CV mortality ↓ 21%  HF development ↓ 37%  Recurrent MI ↓ 25%

0.2

Mortality Rate

Captopril 0.1

19% relative risk reduction p = 0.019 0 0 0.5 1 1.5 2 2.5 3 3.5 4

Years Pfeffer et al. NEJM 1992;327:669-77.

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 2001;357:1385-90.

HFSA 2006 Practice Guideline (4.8, 4.10)

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

Strength of Evidence = C

* Metrics to consider include the 6-minute walk test and NYHA functional class

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (4.18)

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 Strength of Evidence = B

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (7.1, 7.4)

Pharmacologic Therapy: ACE Inhibitors ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.

Strength of Evidence = A

ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.  Post MI

Strength of Evidence = B

 Non Post-MI

Strength of Evidence = C

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF SOLVD Prevention (Asymptomatic LVD)

CONSENSUS (Severe Heart Failure)

20%

death or HF hosp.

40%

mortality at 6 mos.

29%

death or new HF

31%

mortality at 1 year

27%

mortality at end of study

SOLVD Treatment (Chronic Heart Failure) 16%

mortality

 No difference in incidence of sudden cardiac death SOLVD Investigators. N Engl J Med 1992;327:685-91. SOLVD Investigators. N Engl J Med 1991;325:293-302. CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35.

HFSA 2006 Practice Guideline (7.2)

Pharmacologic Therapy: Substitutes for ACEI It is recommended that other therapy be substituted for ACE inhibitors in the following circumstances:  In patients who cannot tolerate ACE inhibitors due to cough, ARBs are recommended. Strength of Evidence = A  The combination of hydralazine and an oral nitrate may be considered in such patients not tolerating ARBs. Strength of Evidence = C

 Patients intolerant to ACE inhibitors due to hyperkalemia or renal insufficiency are likely to experience the same side effects with ARBs. In these cases, the combination of hydralazine and an oral nitrate should be considered. Strength of Evidence = C

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (7.3, 7.4)

Pharmacologic Therapy: Beta Blockers Beta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%. Strength of Evidence = A

Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.  Post MI

Strength of Evidence = B

 Non Post-MI

Strength of Evidence = C

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD HF Severity

Target Dose (mg)

Outcome

Study

Drug

US Carvedilol1

carvedilol

mild/ moderate

6.2525 BID

↓ 48% disease progression (p= .007)

CIBIS-II2

bisoprolol

moderate/ severe

10 QD

↓ 34% mortality (p <.0001)

MERIT-HF3

metoprolol succinate

mild/ moderate

200 QD

↓ 34% mortality (p = .0062)

COPERNICUS4

carvedilol

severe

25 BID

↓ 35% mortality (p = .0014)

CAPRICORN5

carvedilol

post-MI LVD

25 BID

↓ 23% mortality (p =.031)

4. Packer M et al. N Engl J Med 2001;3441651-8. 1. Colucci WS et al. Circulation 1196;94:2800-6. 5. The CAPRICORN Investigators. Lancet 2001;357:1385-90. 2. CIBIS II Investigators. Lancet 1999;353:9-13. 3. MERIT-HF Study Group. Lancet 1999;353:2001-7.

HFSA 2006 Practice Guideline (7.5, 7.8)

Pharmacologic Therapy: Beta Blockers RECENT DECOMPENSATION OR EXACERBATION Beta blocker therapy is recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of IV diuretics and vasoactive agents. Whenever possible, beta blocker therapy should be initiated in the hospital at a low dose prior to discharge of stable patients. Strength of Evidence = B

Continuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment. Strength of Evidence = C 

If necessary, consider temporary dose reduction



Avoid abrupt discontinuation



Reinstate or gradually increase before discharge Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

COPERNICUS: Death, Hospitalization, or Study Drug Withdrawal in High Risk Patients % of Patients With Event

30

HR = 0.67 (CI = 0.47-0.96)

20 Placebo 10

0

Carvedilol

0

2 4 6 Weeks After Randomization

8

Krum H et al. JAMA 2003;289:754-6.

IMPACT-HF Primary End Point: Patients Receiving Beta Blocker at 60 Days Improvement 100

18%

91%

Patients (%)

P < .0001

75

73%

50 25 0 Carvedilol Predischarge Initiation (n=185)

Physician Discretion Postdischarge Initiation* (n=178) Gattis WA et al. JACC 2004;43:1534-41.

HFSA 2006 Practice Guideline (7.6)

Pharmacologic Therapy: Beta Blockers CONCOMITANT DISEASE Beta blocker therapy is recommended in the great majority of patients with LV systolic dysfunction—even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease.  Use with caution in patients with:  Diabetes with recurrent hypoglycemia

 Asthma or resting limb ischemia.  Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).  Not recommended in patients with asthma with active bronchospasm. Strength of Evidence = C

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

Diabetes and the Use of Beta Blockers for HF: Relative Risk for Mortality and Hospitalization for Heart Failure COPERNICUS (carvedilol)1

With diabetes Without diabetes MERIT-HF (ER metoprolol succinate)2

With diabetes Without diabetes 0

0.5

1.0

1.5

2.0

1. Mohacsi. Circulation. 2001;104(17):abstr 3551. 2. Hjalmarson. JAMA. 2000;283(10):1295.

HFSA 2006 Practice Guideline (11.8, 15.2)

Pharmacologic Therapy: Beta Blockers PRESERVED LVEF Beta blocker treatment is recommended in patients with HF and preserved LVEF who have: 

Prior MI

Strength of Evidence = A



Hypertension

Strength of Evidence = B



Atrial fib. requiring control of ventricular rate

Strength of Evidence = B

THE ELDERLY Beta-blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction. Strength of Evidence = B

In the absence of contraindications, these therapies are also recommended in the very elderly (age > 80 years). Strength of Evidence = C

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline

Pharmacologic Therapy: Beta Blocker Overview* General considerations

Initiate at low doses Up-titrate gradually, generally no sooner than at 2 week intervals Use target doses shown to be effective in clinical trials Aim to achieve target dose in 8-12 weeks Maintain at maximum tolerated dose

If symptoms worsen or other side effects appear

Adjust dose of diuretic or concomitant vasoactive med.

If up-titration continues to be difficult

Prolong titration interval

Continue titration to target after symptoms return to baseline

Reduce target dose Consider referral to a HF specialist * Consult language of specific recommendations Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (7.10)

Pharmacologic Therapy: Angiotensin Receptor Blockers ARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency. Strength of Evidence = A

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative Val-HeFT Valsartan

Survival %

90

80

Placebo 70

60

CHARM-Alternative

50

CV Death or HF Hosp %

100

Placebo

40

30

Candesartan 20

10

p = 0.017 50

HR 0.77, p = 0.0004 0

0

3

6

9 12 15 18 21 24 27

Months

0

9

18

27

36

42

Months Maggioni AP et al. JACC 2002;40:1422-4. Granger CB et al. Lancet 2003;362:772-6.

HFSA 2006 Practice Guideline (7.14-7.15)

Pharmacologic Therapy: Aldosterone Antagonists An aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have: 

NYHA class IV HF (or class III, previously class IV) due to LV systolic dysfunction (LVEF ≤ 35%)

One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor or an ARB. Strength of Evidence = A Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

Aldosterone Antagonists in HF

Probability of Survival

RALES (Advanced HF)

EPHESUS (Post-MI)

1.00

1.00

0.90

0.90

0.80

Spironolactone

0.70

0.80

Placebo 0.70

0.60 0.50

Epleronone

Placebo

0.60 0.50

RR = 0.70 P < 0.001

0.40

RR = 0.85 P < 0.008

0.40 0 3 6 9 12 15 18 21 24 27 30 33 36

0 3 6 9 12 15 18 21 24 27 30 33 36

Months

Months Pitt B. N Engl J Med 1999;341:709-17. Pitt B. N Engl J Med 2003;348:1309-21.

HFSA 2006 Practice Guideline (7.16-7.18)

Aldosterone Antagonists and Renal Function Aldosterone antagonists are not recommended when:  Creatinine > 2.5mg/dL (or clearance < 30 mL/min)  Serum potassium> 5.0 mmol/L  Therapy includes other potassium-sparing diuretics Strength of Evidence = A

It is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 months Strength of Evidence = A

Supplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength of Evidence = A

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (7.19)

Pharmacologic Therapy: Hydralazine and Oral Nitrates A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with LV systolic dysfunction:  NYHA III or IV HF

Strength of Evidence = A

 NYHA II HF

Strength of Evidence = B

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

A-HeFT Outcomes End point Primary end point composite score

ISDN-HDZN Placebo (n=518) (n=532)

p

-0.1

-0.5

0.01

6.2

10.2

0.02

1st HF hospitalization (%)

16.4

24.4

0.001

Change in quality-of-life score at 6 months**

-5.5

-2.7

0.02

All-cause mortality (%)

Taylor AL et al. N Engl J Med 2004; 351;2049-2057.

A-HeFT All-Cause Mortality 43% Decrease in Mortality

100

Survival %

Fixed Dose ISDN/HDZN

95

90

Placebo P = 0.01

85 0

100

200

300

400

500

600

Days Since Baseline Visit Taylor AL et al. N Engl J Med 2004;351:2049-57.

HFSA 2006 Practice Guideline (7.23)

Pharmacologic Therapy: Diuretics Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by:  Congestive symptoms  Signs of elevated filling pressures Strength of Evidence = A

Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF. Strength of Evidence = B

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (7.23)

Loop Diuretics Agent

Initial Daily Dose

Max Total Daily Dose

Elimination: Duration of Renal – Met. Action

Furosemide

20-40mg qd or bid

600 mg

65%R-35%M 4-6 hrs

Bumetanide

0.5-1.0 mg qd or bid

10 mg

62%R/38%M 6-8 hrs

Torsemide

10-20 mg qd

200 mg

20%R-80%M 12-16 hrs

Ethacrynic acid

25-50 mg qd or bid

200 mg

67%R-33%M 6 hrs

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (7.23)

Potassium-Sparing Diuretics Agent

Initial Daily Dose

Max Total Daily Dose

Elimination

Duration of Action

Spironolactone

12.5-25 mg qd

50 mg

Metabolic

48-72 hrs

Eplerenone

25-50 mg qd

100 mg

Renal, Metabolic

Unknown

Amiloride

5 mg qd

20 mg

Renal

24 hrs

Triamterene

50-75 mg bid

200 mg

Metabolic

7-9 hrs

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (7.24)

Pharmacologic Therapy: Diuretics  Restoration of normal volume status may require multiple adjustments.  Once a diuretic effect is achieved with short-acting loop diuretics, increase frequency to 2-3 times a day if necessary, rather than increasing a single dose. Strength of Evidence = B  Oral torsemide may be considered in patients exhibiting poor absorption of oral medication or erratic diuretic effect. Strength of Evidence = C

 IV administration of diuretics may be necessary. Strength of Evidence = A

 Diuretic refractoriness may represent patient noncompliance, a direct effect of diuretic use on the kidney, or progression of underlying dysfunction. Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (9.1, 9.4)

Device Therapy: Prophylactic ICD Placement In patients on optimal medical therapy (ideally 3-6 months) with or without concomitant coronary artery disease (including a prior MI > 1 month ago): 

Prophylactic ICD placement should be considered in those with NYHA II-III HF (LVEF ≤ 30%)



Prophylactic ICD placement may be considered in those with NYHA II-III HF (LVEF 31-35%) Strength of Evidence = A

Concomitant placement should be considered in NYHA IIIIV patients undergoing implantation of a biventricular pacing device. Strength of Evidence = B Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

MADIT II: Prophylactic ICD in Ischemic LVD (LVEF ≤30%) Probability of Survival

1.0 .9

.7

Conventional Therapy

.6 0

Number at Risk Defibrillator Conventional

Defibrillator

.8

0

1

2

3

4

110 (.78) 65 (.69)

9 3

Year 742 490

503 (.91) 329 (.90)

274 (.84) 170 (.78)

Moss AJ et al. N Engl J Med 2002;346:877-83.

ICD Therapy in the SCD-HeFT Trial: Mortality by Intention-to-Treat .4

HR

97.5% Cl

P Value

Amiodarone vs Placebo

1.06

.86-1.30

.53

ICD vs Placebo

.77

.62-.96

.007

Mortality

.3

22% .2

17% Amiodarone

.1

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 2005;352:225-37.

HFSA 2006 Practice Guideline (9.7)

Device Therapy: Biventricular Pacing Biventricular pacing therapy should be considered for patients with all of the following:  Sinus rhythm  A widened QRS interval (≥120 ms)  Severe LV systolic dysfunction (LVEF ≤ 35% with LV dilation > 5.5 cm)  Persistent, moderate-to-severe HF (NYHA III) despite optimal medical therapy. Strength of Evidence = A

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

CRT Improves Quality of Life and NYHA Functional Class Average Change in Score (MLWHF)

NYHA: Proportion Improving by 1 or More Class

0

80

-5

*

*

*

60

-10

(%) 40

-15

* ICD MI RA CL E

TA K

*

CO N

IC

SR

*

CD

*

MU ST

MI RA C

LE

-20

Control

CRT

* P < .05

20 0

MIRACLE CONTAK MIRACLE CD ICD

Abraham WT et al. Circulation 2003;108:2596-2603.

CRT in Patients with Advanced HF and a Prolonged QRS Interval: COMPANION Primary End Point: All-Cause Mortality

Death or Hospitalization Due to HF

Risk of all-cause mortality reduced by 19% in group with CRT and ICD (p =.014) Risk of death or hospitalization from HF reduced by 34% in ICD group and by 40% in ICD-CRT group (p < .001) Bristow MR et al. N Engl J Med 2004;350:2140-50.

Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF % Event-Free Survival

100

75

CRT

50

Medical Therapy

25 HR = 0.64 (95% CI = .48-.85) p = .0019 0

Number at risk CRT Medical Therapy

0 409 404

500 376 365

351 321

Days 213 192

1,000 89 71

1,500 8 5

Cleland JG et al. N Engl J Med 2005;352:1539-49.

HFSA 2006 Practice Guideline (11.1-11.2)

HF with Preserved LVEF—Diagnosis Careful attention to differential diagnosis is recommended in patients with HF and preserved LVEF. Treatments may differ based on cardiac disorder. Evaluation for ischemic disease and inducible myocardial ischemia should be included. Recommended diagnostic tools:  Echocardiography  Electrocardiography  Stress imaging (via exercise or pharmacologic means, using myocardial perfusion or echocardiographic imaging) Strength of Evidence = C Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

Figure 11.1. Diagnostic Categories of Heart Failure with Preserved LVEF Heart Failure with Preserved LVEF Dilated LV

Valvular disease AR; MR

NonNon-dilated LV

No valvular disease High output HF

Normal or Increased QRS voltage Hypertrophic disease

No Aortic valve disease

No Hypertensive Hx or PE Hypertrophic cardiomyopathy

Increased thickness

Low QRS voltage Infiltrative myopathy

Aortic valve disease Aortic stenosis

Normal thickness

Mitral obstruction MS; Atrial myxoma

No mitral obstruction

Pericardial disease Tamponade /Constriction

Hypertensive Hx or PE

Inducible ischemia Intermittent/active ischemia

HypertensiveHypertensive-hypertrophic cardiomyopathy

LVEF=left ventricular ejection fraction; HF=heart failure; QRS=electrocardiographic ventricular depolarization; AR= aortic regurgitation; MR=mitral regurgitation; MS=mitral stenosis; RVMI=right ventricular myocardial infarction; Hx=history; PE= physical examination.

Right Ventricular Dysfunction*

Pulmonary Hypertension

Isolated or predominant RVMI

No pericardial disease

No inducible ischemia Fibrotic; collagencollagen-vascular; Restrictive CM; carcinoid; Reconsider diagnosis of HF

* Some patients with right ventricular dysfunction have LV dysfunction due to ventricular interaction.

Figure courtesy of Marvin Konstam MD and Marvin Kronenberg MD. Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (12.3, Table 12.3) Acute Decompensated Heart Failure (ADHF)— 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 • Educate patients concerning medication and HF self-assessment • Consider enrollment in a disease management program Strength of Evidence = C Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 Practice Guideline (12.5-12.18)

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.

HFSA 2006 Practice Guideline (12.23, Table 12.7)

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

Strength of Evidence =C

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

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 BUN>>43 43mg/dL mg/dL Systolic Systolic blood bloodpressure pressure<<115 115mmHg mmHg Serum Serumcreatinine creatinine>>2.75 2.75mg/dL mg/dL Fonarow GC et al. JAMA 2005;293:572-80.

HFSA 2006 Practice Guideline (8.1)

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. Strength of Evidence = B

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

The Potential Impact of Effective Education on Patient Compliance Noncompliance rate when patients . . . Recall MD advice

Don’t recall advice

Medications

8.7%

66.7%

Diet

23.6%

55.8%

Activity

76.4%

84.5%

Smoking

60.0%

90.4%

Alcohol

60.0%

81.8% Kravitz et al. Arch Int Med 1993;153:1869-78.

Sample Target Behavior: Be Able to Read and Understand Food Labels

Labels from cups of soup

HFSA 2006 Practice Guideline (8.7)

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. Strength of Evidence = A

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HF Disease Management and the Risk of Readmission 1.1

Risk Ratio

Ekman

1 0.9 0.8 0.7

J aarsma Cline

Lasater

Stewart Rich

Rauh

Venner

0.6 Naylor

0.5

Fonarow

Summary RR = 0.76 (95% CI .68-.87) Summary RR for randomized only = 0.75 (CI = .60-.95)

HFSA 2006 Practice Guideline (8.13)

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 nonpharmacologic 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 Strength of Evidence = C

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

Evidence-Based Treatment Across the Continuum of Systolic LVD and HF Control Volume Diuretics Renal Replacement Therapy*

Improve Clinical Outcomes Aldosterone ACEI β-Blocker Antagonist or ARB or ARB CRT ± an ICD* HDZN/ISDN*

*In selected patients

Treat Residual Symptoms Digoxin