CCS Heart Failure Management Guidelines & Surgical Revascularization Update

1. The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Rehabilitation and Exercise and Surgical Coronary Revascularization

2. Disclaimer The Canadian Cardiovascular Society (CCS) welcomes reuse of our educational slide deck for medical institution internal education or training (i.e. grand rounds, medical college/classroom education, etc.).  However, if the material is being used in an industry sponsored CME program, permission must be sought through our publisher Elsevier (www.onlinecjc.com). If your reuse request qualifies as medical institution internal education, you may reuse the material under the following conditions: • You must cite the Canadian Journal of Cardiology and the Canadian Cardiovascular Society as references. • You may not use any Canadian Cardiovascular Society logos or trademarks on any slides or anywhere in your presentation or publications. • Do not modify the slide content. • If repeating recommendations from the published guideline, do not modify the recommendation wording.

3. CCS Heart Failure Guidelines 2013 Update Primary Panel Gordon W. Moe, (Chair) Justin A. Ezekowitz, (Co-Chair) Eileen O’Meara Michael McDonald Jonathan G. Howlett Robert McKelvie Steve Fremes Anil Nigam Abdul Al-Hesayen Miroslaw Rajda George A. Heckman Vivek Rao Anique Ducharme Elizabeth Swiggum Adam Grzeslo Sean Virani Karen Harkness Estrellita Estrella-Holder Serge Lepage Vy Van Le Shelley Zieroth

4. CCS Heart Failure Guidelines 2013 Update Secondary Panel Simon Kouz J.Malcolm O. Arnold Tom Ashton Michel D’Astous Paul Dorian Nadia Giannetti Haissam Haddad Debra L. Isaac Marie-Hélène Leblanc Peter Liu Heather J. Ross Bruce Sussex Michel White

5. Surgical Coronary Revascularization

6. Recommendations - Surgical Coronary Revascularization in Heart Failure Values and Preferences: This recommendation places value upon identification of coronary artery disease, which may identify the cause of heart failure, have prognostic implications and require treatments aimed toward secondary vascular prevention.

7. Recommendations - Revascularization Procedures Assessment for Coronary Disease

8. Recommendations - Revascularization Procedures Assessment for Coronary Disease Values and Preferences: These recommendations place value on the need of coronary angiography to identify coronary artery disease amenable to revascularization. Available evidence suggests that coronary revascularization may provide quality of life and prognostic benefits to patients with heart failure and non-invasive imaging delineating high risk. In particular, patients with systolic heart failure due to ischemic heart disease may derive clinical benefit from coronary revascularization even in the absence of angina or reversible ischemia.

9. Practical Tips Revascularization Procedures Imaging • Several non-invasive methods for detection of coronary artery disease are in widespread use, including: • Dobutamine stress echocardiography (DSE) • perfusion cardiac magnetic resonance (CMR) • cardiac positron emission testing (PET) • nuclear stress imaging Local factors (availability, price, expertise, practice patterns) will determine the optimal strategy for imaging. 2. Non- invasive imaging modalities may provide critical information such as the amount and degree of ischemic or hibernating myocardium, and may be used to determine the likelihood of regional and global improvement in left ventricular systolic function following revascularization.

10. Practical Tips (cont’d) Revascularization Procedures Imaging 3. Patients with heart failure and reduced LVEF are more likely to experience significant improvement in LVEF following successful coronary revascularization if they demonstrate: a) Reversible ischemia or a large segment of viable myocardium (> 30% of the left ventricle) by nuclear stress testing/ viability study; b) Reversible ischemia or >7% hibernating myocardium on PET scanning; c) Reversible ischemia or > 20% of the left ventricle shown as viable by DSE; d) <50% wall thickness scarring as shown by late gadolinium enhancement by CMR.

11. Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care

12. Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care Values and Preferences: This recommendation reflects the preference that high risk revascularization is best performed in higher volume centers with significant experience, and known, published outcomes.

13. Practical Tip Revascularization Procedures Disease Management, Referral and Peri-operative Care Assessment for advanced heart failure therapies, by an appropriate team, should be performed prior to revascularization procedure in any patient with advanced heart failure

14. Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF

15. Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF

16. Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF Values and Preferences: These recommendations are based on data from RCTs on CABG and surgical ventricular restoration on patients with reduced systolic function and CAD. The recommendation on percutaneous coronary intervention is based on clinical need rather than RCT trial data.

17. Practical Tips Revascularization Procedures Surgical Revascularization for Patients with IHD and HF • In the setting of heart failure, angina and single territory coronary artery disease, PCI may be the treatment of first choice. However, PCI has not been shown to improve outcomes for patients with chronic stable heart failure, irrespective of underlying anatomy. • In contrast to the chronic stable patient with heart failure, urgent directed culprit vessel angioplasty continues to be the revascularization modality of choice for patients with acute coronary syndrome complicated by heart failure. • In highly selected cases, patients with advanced heart failure symptoms in association with large areas of dyskinetic and non-viable myocardium may experience clinical improvement with SVR or similar type procedures, when performed by experienced surgeons. • Mitral valve repair, when used concomitantly during CABG, may lead to clinical improvement in symptoms of heart failure in highly selected cases.

18. Recommendations - Revascularization Procedures Device Considerations in HF Patients Following Cardiac Surgery Values and Preferences: These recommendations reflect our support of and conformity with pre-existing cardiac device and rehabilitation guidelines statements.

19. Practical Tips Revascularization Procedures Device Considerations in HF Patients Following Cardiac Surgery • During surgical revascularization, consideration can be given to implantation of epicardial left ventricular leads to facilitate biventricular pacing in eligible patients who may be candidates for cardiac resynchronization therapy, especially if the coronary sinus anatomy is known to be unfavourable for lead placement. • Patients with heart failure and who have successful surgical coronary revascularization can be referred to a cardiac rehabilitation program.

20. Approach to Assessment for Coronary Artery Disease in Patients with Heart Failure

21. Decision Regarding Coronary Revascularization in Heart Failure

22. Exercise Training and Heart Failure

23. Recommendations - Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure Values and Preferences: This recommendation places a high value on improvements in non-morbid outcomes and recognizes that not all patients will be able to participate in a structured exercise training program due to patient preferences or availability of resources.

24. Recommendations - Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure Values and Preferences: This recommendation places a high value on clinician’s assessment of both the clinical stability of a patient and their appropriateness to start exercise, recognizing that most patients will be eligible to participate.

25. Practical Tip Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure Adherence to an Exercise Program • Frequent reinforcement, including letters, phone calls and home visits, may enhance adherence to exercise. • Identifying and addressing patient-specific barriers may aid in the uptake of exercise for patients. • Once a home-based program is initiated, more frequent follow-up visits and occasional supervised “refresher” sessions to answer questions, review concerns or modify the training program may give patients the guidance needed to ensure that home-based cardiac rehabilitation is successful.

26. Recommendations - Rehabilitation and Exercise in HF Cardiac Rehabilitation Programs for Patients with Recently Decompensated or Advanced Heart Failure Values and Preferences: This recommendation places high value on initiating mobilization and therapy early (even if only limited exercises are prescribed) in order to prevent further decline of muscle function, improve function during day to day activities and provide a baseline from which to add further exercise modalities.

27. Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation Programs for Patients with Recently Decompensated or Advanced Heart Failure Selected patients may benefit from limited exercise therapy, such as lower-extremity or inspiratory muscle strengthening, directed towards alleviating symptom of muscle fatigue.

28. Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation in Heart Failure with Preserved Ejection Fraction • Until data specific for patients with heart failure and preserved ejection fraction are available, exercise programs using a similar approach to patients with impaired systolic function may be considered in patients with heart failure and preserved ejection fraction.

29. Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation in Patients with Cardiac Resynchronization Therapy and Implantable Cardioverter Defibrillators Exercise training is safe and not associated with an increased risk of ICD therapy. The maximal target HR should be at least 20 beats below the ICD intervention heart rate to avoid inappropriate ICD shocks.

30. Practical Tip Rehabilitation and Exercise in HF Exercise in Frail Senior with Heart Failure • Frail seniors with heart failure should be offered multi-component (endurance and resistance, balance) tailored exercise programs appropriate for their comorbidities.

31. Recommendations - Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in Heart Failure Values and Preferences: This recommendation places a high value on using commonly available measurements to assist in developing the exercise prescription. The priority is safety, hence, if a patient has a history of ICD discharges, exercise should be avoided if a short loss of consciousness is dangerous, i.e. swimming and activities associated with an increased risk of falling.

32. Practical Tip Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF Strength Training For strength training, the use of light (5-10 lbs) free weights for 10-20 repetitions 2 to 3 times per week may improve muscle tone and strength.

33. Practical Tip Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF Interval Training Interval training sessions should use 15-30s exercise intervals (RPE 3-5) with rest intervals of equal duration and may last 15-30 seconds.

34. Practical Tips Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF Aerobic Exercise Training Intensity The Modified Borg RPE scale and % HRmax are easier to use in practice than equations based on heart rate reserve (HRR) or measurement of peak VO2.

35. Sing – Talk –Gasp Test Maximal 10 very, very hard9 87 very hard65 hard4 somewhat hard3 moderate2 easy1 very easy0.5 very, very easy0 nothing at all Rate of Perceived Exertion (RPE)* Gasp: breathing heavily Talk: enough breath to carry a conversation Sing: Enough breath to sing *Modified Scale adapted by Borg

36. Table: Exercise Modalities According to Clinical Scenario Discharged with Heart Failure NYHA I-III NYHA IV Flexibility Exercises Recommended Recommended Recommended Aerobic Exercises • Walk • Treadmill • Ergocycle • Swimming • Selected population only • Supervision by an expert team needed (see text) • Suggested modality • Selected population only • Supervision by an expert team needed (see text) • Continuous training: • Moderateintensity: • RPE scale 3-5,or • 65-855 HRmax, or • 50-75% peak VO2 • Moderateintensityaerobicintervalmaybeincorporated in selected patients • Intervals of 15-30 seconds with a RPE scale of 3-5 • Restintervals of 15-30 seconds • Intensity • Starting with 2-3 days/week • Goal: 5 days/week • Frequency • Selected population only • Supervision by an expert team needed (see text) • Selected population only • Supervision by an expert team needed (see text) • Starting with 10-15 minutes • Goal: 30 minutes Isometric/Resistance Exercises • Intensity • 10-20 repetitions of 5-10 pounds free weights • 2-3 days/week • Frequency