“NOT another CHF overview”

1. “NOT another CHF overview” A few pearls extracted from the guidelines and applied to clinical care Richard Garmany MD

2. Disclosures • None • Unless otherwise noted, all slides reference the 2009 Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults, Circulation. 2009;119: 1977-2016

3. Objectives 1. Understand the role of guidelines based care in the management of a complex condition such as heart failure2. Appreciate the role of at least one diagnostic study, medication, and intervention in the management of the heart failure patient3. Think about the critical importance of a multidisciplinary approach in improving outcomes in patients with heart failure

4. Non-objectives • Detailed epidemiology, pathogenesis, natural history, diagnosis, or management outside of guideline based care • Coverage of all Guideline based care • Detailed Performance Measures • Appropriate use criteria • I do not have a simple strategy to manage this condition, prevent readmissions for heart failure patients, or dramatically reduce cost of care

5. Definition Clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or eject blood Primary manifestations are dyspnea/fatigue and fluid retention, both can impair functional capacity

6. The syndrome • May result from abnormalities of the pericardium, myocardium, endocardium, and vasculature • Most heart failure results from dysfunction of the left ventricular myocardium • this includes those with both normal and abnormal LV size and systolic function

7. The syndrome • May result from abnormalities of the pericardium, myocardium, endocardium, and vasculature • Most heart failure results from dysfunction of the left ventricular myocardium • this includes those with both normal and abnormal LV size and systolic function • Cardiomyopathy ≠ Heart Failure

8. The syndrome • No single diagnostic test! • Diagnosis largely based on history and physical exam

9. Stages in the Development of Heart Failure

10. Stages in the Development of Heart Failure

11. New York Heart Association Functional Classification Class I:No symptoms with ordinary activity Class II:Slight limitation of physical activity Class III:Marked limitation of physical activity Class IV:Symptoms at rest or with minimal exertion

12. Common Causes • Coronary Artery Disease • Hypertension • Dilated cardiomyopathy • Valvular heart disease • Arrhythmias

13. Diagnostic evaluation of patient should be focused on:

14. Diagnostic evaluation of patient should be focused on: • Coronary Artery Disease • Hypertension • Dilated cardiomyopathy • Valvular heart disease • Arrhythmias

15. Practice Guidelines • ACC/AHA 2009 update of 2005 guidelines • Other societies overlap • Consensus of expert opinion • Graded into level of evidence A-C • Various Populations and Settings • Initial evaluation • Follow Up assessment • Patients with reduced left ventricular systolic function • End Stage Heart failure • Hospitalized patients

16. Practice Guidelines • Patients/Situations NOT SPECIFICALLY covered • Heart failure with normal left ventricular systolic function • The very elderly as a group • Multiple comorbidities

17. Guide to the guidelines • Class I : Should be performed • Class IIa : It is reasonable to perform procedure or administer treatment • Class IIb : Procedure or treatment may be considered • Class III : Should NOT be performed, not helpful and may be harmful

18. Initial and Serial Assessment of Patients Presenting with Heart FailureClass I Guidelines • History and Physical • Disorders that may contribute • Drugs and alcohol • Functional status • Weight, volume status, blood pressure • General labs: CBC, CMP, Lipids, TSH • EKG and CXR

19. Initial and Serial Assessment of Patients Presenting with Heart FailureClass I Guidelines • Echocardiogram • Coronary angiogram • in all patients with angina or evidence of significant ischemia unless they are not candidates for revascularization of any kind

20. Initial and Serial Assessment of Patients Presenting with Heart FailureParaphrased Class IIa Guidelines • Angiography is reasonable if there is any real suspicion for coronary disease • Screening for “zebras” (HIV, hemochromatosis, etc) • Measurement of BNP in the urgent care or ER setting when the diagnosis is uncertain

21. Serial Clinical AssessmentClass I GuidelinesEach clinical visit: • Assessment of ability to perform activities of daily living • Assessment of volume status and weight • History for Tobacco, ETOH, Drugs, Na intake

22. Serial Clinical AssessmentClass IIa Guidelines • Repeat Echo • Change in clinical status • Clinical event or recovery from event • Treatment given that might have significant effect on cardiac function

23. Guidelines for Patients with Reduced Left Ventricular Systolic Function

24. Class I Guidelines for Patients with Reduced Left Ventricular Systolic Function • Diuretics and Salt restriction for volume overload

25. Class I Guidelines for Patients with Reduced Left Ventricular Systolic Function • Avoid NSAIDS and Non-Vasoselective calcium channel blockers (Verapamil, Diltiazem, Nifedipine) • ACE Inhibitors, ARB if intolerant • Beta Blockers • Carvedilol • Metoprolol Succinate • Bisoprolol

26. Class I Guidelines for Patients with Reduced Left Ventricular Systolic Function (Continued) • Should Receive Implanted Defibrillators • Survivors of cardiac arrest or symptomatic sustained VT • EF 35% or less, on good chronic medical therapy, NYHA class II or III symptoms and expected survival of greater than one year • Should receive Biventricular pacing with or without a defibrillator • EF 35% or less, class III or IV symptoms, on optimal medical therapy, with a QRS duration greater than 120 msec

27. Class I Guidelines for Patients with Reduced Left Ventricular Systolic Function (Continued) • Aldosterone antagonists • Selected patients with moderate to severe symptoms • In patients who can be closely monitored only for renal function and K levels • Cr 2.5 or less for Men • Cr 2.0 or less for women • Potassium < 5

28. Class IIa Guidelines for Patients with Reduced Left Ventricular Systolic Function • Afib: rate or rhythm control is ok • Exercise stress testing to facilitate exercise prescription (not for detection of ischemia) • ARB as first line treatment • Digoxin to decrease hospitalizations • Combination hydralazine/nitrates for patients on beta blockers and ACE with ongoing sx

29. Class III Guidelines for Patients with Reduced Left Ventricular Systolic Function • Combination of ACE, ARB, and Aldosterone antagonist • Calcium channel blockers • Long term infusions • Nutritional supplements • Hormonal therapies, other than to replete deficiencies

30. End Stage Heart Failure Class I • Control of fluid retention • Referral to transplant/LVAD/ Heart failure center • Discussion of end of life issues • Option to inactivate defibrillators

31. Guidelines for Hospitalized Patients • Ominous event • 50% risk of readmission at 6 months • 25-35% risk of death at 6 months

32. Guidelines for Hospitalized Patients • Precipitating factors • Noncompliance (Meds, Na, Diet) • Untreated hypertension • Atrial fibrillation • Acute myocardial ischemia • Recent addition of negative inotropic agents (nifedipine, verapamil, diltiazem, beta blockers) • NSAID use • Infections • ETOH or drug use • Endocrine abnormalities (Hyper or Hypothyroidism, DM) • Pulmonary emboli

33. Guidelines for Hospitalized PatientsClass I • Evaluate perfusion, volume status, factors that may cause the exacerbation, chronicity, association with preserved ejection fraction • Identification of ischemia with EKG and Enzymes • BNP for distinguishing other causes of dyspnea • Use of Intravenous loop diuretics at baseline oral dose or higher • Daily electrolytes during IV diuresis • For low EF continue ACE, BB unless hemodynamically unstable • If not on ACE or BB, start in hospital if indicated • Discharge “systems of care”

34. How does this apply to a patient?Consult from Teaching Service: • 59 year old woman with known CAD, obesity, DM, COPD, very low baseline activity • Jehovah's Witness • 2 weeks after anginal sx with increased dyspnea • Elevated enzymes, Echo with EF 30%

35. Meds at time of consult • 1. Aspirin 81 mg daily. • 2. Lipitor 40 mg daily. • 3. Lovenox 40 mg subcu daily. • 4. Lasix 40 mg twice daily. • 5. Insulin. • 6. Prinivil 40 mg daily. • 7. Metformin 1000 mg twice daily. • 8. Lopressor 25 mg twice daily.

36. Evaluation • Moderate volume overload • Normal blood pressure • Free of active anginalsx • Poor CABG candidate

37. Assessment/Treatment • Systolic HF • Recent MI • To cath lab: • 1. Three-vessel coronary disease with acute appearing stenosis of the right coronary artery and minimal right collateralization. • 2. Stable yet high-grade appearing disease in both her large OM and diagonal with complete occlusion of her LAD. • Declined CABG, angioplasty to RCA with plan for outpatient assessment of viability • Follow up arranged 1 week with new PCP, 4 weeks with cardiology, immediately with Cardiac Rehab

38. Course • Admitted with a TIA 4 weeks later • EF 40-45% • Admitted 7 weeks later with angina, cough declined surgical evaluation, concerned about blood • Switched to ARB • Antianginal meds intensified • Never saw new PCP or cardiologist, prefers f/u through her chronic mid level provider

39. Who is responsible for Readmissions? • Hospital • Cardiologist • The primary hospital service • The outpatient midlevel provider • The patient • More than one of the above!

40. Conclusion CHF: • ACE • Aldactone • B-Blocker • Dig • Diuretic Phil Mohler, Prudent Prescriber April 2013

41. Conclusion CHF: In all heart failure think: • ACE • Aldactone • B-Blocker • Dig • Diuretic • Volume Status • Hypertension • Diabetes • Coronary Artery Disease • Ejection Fraction

42. Conclusion CHF: In all heart failure think: • ACE • Aldactone • B-Blocker • Dig • Diuretic • Volume Status • Hypertension • Diabetes • Coronary Artery Disease • Ejection Fraction • In heart failure with reduced systolic function think: • Carvedilol • Ace Inhibitors • ICD