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Heart Failure: Get With The Guidelines Update

Heart Failure: Get With The Guidelines Update. Jeffrey A. Hershey, M.D. Assistant Professor of Medicine Emory University. Disclosures. None. An asymptomatic 48y.o. male Steelers fan with HTN and DM.

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Heart Failure: Get With The Guidelines Update

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  1. Heart Failure: Get With The Guidelines Update Jeffrey A. Hershey, M.D. Assistant Professor of Medicine Emory University

  2. Disclosures • None

  3. An asymptomatic 48y.o. male Steelers fan with HTN and DM • A. Should undergo an MMPI evaluation and enroll in an extensive counselling program. • B. Should be forced to sit through all 8 Browns home games to develop real character. • C. Should be referred to hospice and let go as there is no hope. • D. Has stage A HF and should be aggressively treated for HTN and DM. Psych evaluation may be beneficial.

  4. Objectives • To become familiar with the signs and symptoms of heart failure • To be able to differentiate between HF and COPD • To review the latest updates in HF • To review the new classifications of stages of heart failure along with implications for treatment

  5. Heart Failure is a Major and Growing Public Health Problem in the U.S. • Approximately 5 million patients in this country have HF • Over 550,000 patients are diagnosed with HF for the first time each year • Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year • In 2001, nearly 53,000 patients died of HF as a primary cause

  6. Heart Failure is Primarily a Condition of the Elderly • The incidence of HF approaches 10 per 1000 population after age 65 • HF is the most common Medicare diagnosis-related group • More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare

  7. Heart Failure 2007Disease Management • Several large randomized controlled trials suggest that participation in HF disease management programs lead to significant long – term survival benefit • Nurse driven programs have decreased hospitalization rates • May not improve functional capacity, reduce cost or health care utilization

  8. Heart Failure 2007Disease Management • Pre-discharge teaching sessions have resulted in improved clinical outcomes, increased self-care measure adherence and reduced cost of health care • Led to the ACC / AHA Get-with-the Guidelines initiative • Clinical performance measures from JCAHO

  9. Heart Failure 2007 • ACC/AHA Guidelines • Available for download at www.acc.org under clinical statements/guidelines HF • Get-with-the-Guidelines samples also available from Oregon Project • Office tools also available

  10. Guideline Scope Document focuses on : • Prevention of HF • Diagnosis and management of chronic HF in the adult

  11. “Heart Failure” vs. “Congestive Heart Failure” • Because not all patients have volume overload at • the time of initial or subsequent evaluation, the • term “heart failure” is preferred over the older • term “congestive heart failure.”

  12. Causes of HF in Western World • For a substantial proportion of patients, causes are: • Coronary artery disease • Hypertension • Dilated cardiomyopathy

  13. Stages of Heart Failure At Risk for Heart Failure: STAGE AHigh risk for developing HF • STAGE B Asymptomatic LV dysfunction • Heart Failure: • STAGE CPast or current symptoms of HF • STAGE DEnd-stage HF

  14. Stages of Heart Failure • COMPLEMENT, DO NOT REPLACE NYHA CLASSES • NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease) • Stages - progress in one direction due to cardiac remodeling

  15. Stage A Patients at High Risk for Developing Heart Failure

  16. Stage A Therapy • Recommended Therapies to Reduce Risk Include: • Treating known risk factors (hypertension, diabetes, etc.) • with therapy consistent with contemporary guidelines • Avoiding behaviors increasing risk (i.e., smoking • excessive consumption of alcohol, illicit drug use) • Periodic evaluation for signs and symptoms of HF • Ventricular rate control or sinus rhythm restoration • Noninvasive evaluation of LV function • Drug therapy – • Angiotensin Converting Enzyme Inhibitors (ACEI) • Angiotensin Receptor Blockers (ARBs)

  17. Stage A Therapy Using Therapy Consistent with Contemporary Guidelines • In patients at high risk for developing HF, • systolic and diastolic hypertension should be • controlled in accordance with contemporary • guidelines. • In patients at high risk for developing HF, lipid • disorders should be treated in accordance • with contemporary guidelines.

  18. Stage A Therapy Using Therapy Consistent with Contemporary Guidelines • In patients at high risk for developing HF who • have known atherosclerotic vascular disease, • healthcare providers should follow current • guidelines for secondary prevention. • For patients with diabetes mellitus (who are all • at high risk for developing HF), blood sugar • should be controlled in accordance with • contemporary guidelines.

  19. Stage A Therapy Using Therapy Consistent with Contemporary Guidelines • Thyroid disorders should be treated in • accordance with contemporary guidelines in • patients at high risk for developing HF.

  20. Stage A Therapy Avoiding Behaviors That Increase Risk • Patients at high risk for developing HF should • be counseled to avoid behaviors that may • increase the risk of HF (e.g., smoking, • excessive alcohol consumption, and illicit • drug use).

  21. Stage A Therapy Periodic Evaluation for Signs and Symptoms • Healthcare providers should perform periodic • evaluation for signs and symptoms of HF in • patients at high risk for developing HF.

  22. Stage A Therapy Ventricular Rate Control or Sinus Rhythm Restoration IIa IIa IIa IIa IIb IIb IIb IIb III III III III • Ventricular rate should be controlled or sinus • rhythm restored in patients with • supraventricular tachyarrhythmias who are at • high risk for developing HF. I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B

  23. Stage A Therapy Noninvasive Evaluation of LV Function • Healthcare providers should perform a • noninvasive evaluation of LV function (i.e., • LVEF) in patients with a strong family history • of cardiomyopathy or in those receiving • cardiotoxic interventions.

  24. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I A Stage A Therapy Angiotensin Converting Enzyme Inhibitors (ACEI) • ACEI can be useful to prevent HF in patients at • high risk for developing HF who have a history of • atherosclerotic vascular disease, diabetes • mellitus, or hypertension with associated • cardiovascular risk factors.

  25. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I C Stage A Therapy Angiotension Receptor Blockers (ARBs) • ARBs can be useful to prevent HF in patients • at high risk for developing HF who have a • history of atherosclerotic vascular disease, • diabetes mellitus, or hypertension with • associated cardiovascular risk factors.

  26. Stage A Therapy Therapies NOT Recommended • Routine use of nutritional supplements solely • to prevent the development of structural heart • disease should not be recommended for • patients at high risk for developing HF.

  27. Stage B Patients with Asymptomatic LV Dysfunction

  28. Stage B Therapy • Recommended Therapies: • General Measures as advised for Stage A • Drug therapy for all patients • ACEI or ARBs • Beta-Blockers • ICDs in appropriate patients • Coronary revascularization in appropriate patients • Valve replacement or repair in appropriate patients

  29. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I Stage B Therapy General Measures • All Class I recommendations for Stage A • should apply to patients with cardiac • structural abnormalities who have not • developed HF. (Levels of Evidence: A, B, and • C as appropriate) • Patients who have not developed HF • symptoms should be treated according to • contemporary guidelines after an acute MI.

  30. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Stage B Therapy Angiotensin Converting Enzyme Inhibitors (ACEI) • Beta-blockers and ACEIs should be used in all • patients with a recent or remote history of MI • regardless of EF or presence of HF. • ACEI should be used in patients with a reduced EF • and no symptoms of HF, even if they have not • experienced MI. • ACEI or ARBs can be beneficial in patients with • hypertension and LVH and no symptoms of HF.

  31. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B B IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I C Stage B Therapy Angiotensin Receptor Blockers (ARBs) • An ARB should be administered to post-MI patients • without HF who are intolerant of ACEIs and have a • low LVEF. • ACEIs or ARBs can be beneficial in patients with • hypertension and LVH and no symptoms of HF. • ARBs can be beneficial in patients with low EF and • no symptoms of HF who are intolerant of ACEIs.

  32. Stage B Therapy Beta-Blockers • Beta-blockers and ACEIs should be used in all • patients with a recent or remote history of MI • regardless of EF or presence of HF. • Beta-blockers are indicated in all patients • without a history of MI who have a reduced • LVEF with no HF symptoms.

  33. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Stage B Therapy Internal Cardioverter Defibrillator (ICD) • Placement of an ICD is reasonable in patients with • ischemic cardiomyopathy who are at least 40 days • post-MI, have an LVEF of 30% or less, are NYHA • functional class I on chronic optimal medical therapy, • and have reasonable expectation of survival with a • good functional status for more than 1 year. • Placement of an ICD might be considered in patients • without HF who have nonischemic cardiomyopathy • and an LVEF less than or equal to 30% who are in • NYHA functional class I with chronic optimal medical • therapy and have a reasonable expectation of survival • with good functional status for more than 1 year.

  34. Stage B Therapy Coronary Revascularization • Coronary revascularization should be • recommended in appropriate patients • without symptoms of HF in accordance • with contemporary guidelines (see • ACC/AHA Guidelines for the Management • of Patients With Chronic Stable Angina).

  35. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Stage B Therapy Valve Replacement/Repair • Valve replacement or repair should be • recommended for patients with • hemodynamically significant valvular • stenosis or regurgitation and no • symptoms of HF in accordance with • contemporary guidelines.

  36. Stage B Therapy Therapies NOT Recommended • Digoxin should not be used in patients with low EF, • sinus rhythm, and no history of HF symptoms, • because in this population, the risk of harm is not • balanced by any known benefit. • Use of nutritional supplements to treat structural • heart disease or to prevent the development of • symptoms of HF is not recommended. • Calcium channel blockers with negative inotropic • effects may be harmful in asymptomatic patients • with low LVEF and no symptoms of HF after MI.

  37. Stage C Patients with Past or Current Symptoms of Heart Failure

  38. Stage C Therapy (Reduced LVEF with Symptoms) • Recommended Therapies: • General measures as advised for Stages A and B • Drug therapy for all patients • Diuretics for fluid retention • ACEI • Beta-blockers • Drug therapy for selected patients • Aldosterone Antagonists • ARBs • Digitalis • Hydralazine/nitrates • ICDs in appropriate patients • Cardiac resynchronization in appropriate patients • Exercise Testing and Training

  39. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I Stage C Therapy (Reduced LVEF with Symptoms) General Measures • Measures listed as Class I recommendations for • patients in stages A and B are also appropriate for • patients in Stage C. (Levels of Evidence: A, B, and C as • appropriate) • Drugs known to adversely affect the clinical status of • patients with current or prior symptoms of HF and • reduced LVEF should be avoided or withdrawn • whenever possible (e.g., nonsteroidal anti-inflammatory • drugs, most antiarrhythmic drugs, and most calcium • channel blocking drugs).

  40. Stage C Therapy (Reduced LVEF with Symptoms) Diuretics • Diuretics and salt restriction are indicated in • patients with current or prior symptoms of HF • and reduced LVEF who have evidence of fluid • retention.

  41. Stage C Therapy (Reduced LVEF with Symptoms) Angiotensin Enzyme Converting Inhibitors (ACEIs) • ACEIs are recommended for all patients with • current or prior symptoms of HF and reduced • LVEF, unless contraindicated. • Routine combined use of an ACEI, ARB, and • aldosterone antagonist is not recommended for • patients with current or prior symptoms of HF • and reduced LVEF.

  42. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I A Stage C Therapy (Reduced LVEF with Symptoms) Angiotensin Receptor Blockers (ARBs) • ARBs approved for the treatment of HF are • recommended in patients with current or prior • symptoms ofHF and reduced LVEF who are ACEI- • intolerant (see full text guidelines for information • regarding patients with angioedema). • 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.

  43. Stage C Therapy (Reduced LVEF with Symptoms) ARBs (cont’d) • The addition of an ARB may be considered in • persistently symptomatic patients with reduced • LVEF who are already being treated with • conventional therapy. • Routine combined use of an ACEI, ARB, and • aldosterone antagonist is not recommended for • patientswith current or prior symptoms of HF and • reduced LVEF.

  44. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Stage C Therapy (Reduced LVEF with Symptoms) Aldosterone Antagonists • Addition of an aldosterone antagonist is recommended 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. Creatinine should be • less than or equal to 2.5 mg/dL in men or less than or • equal to 2.0 mg/dL in women and potassium should be • less than 5.0 mEq/L. Under circumstances where • monitoring for hyperkalemia or renal dysfunction is not • anticipated to be feasible, the risks may outweigh the • benefits of aldosterone antagonists. • Routine combined use of an ACEI, ARB, and aldosterone • antagonist is not recommended for patients with current • or prior symptoms of HF and reduced LVEF.

  45. Stage C Therapy (Reduced LVEF with Symptoms) Beta-Blockers Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., 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.

  46. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Stage C Therapy (Reduced LVEF with Symptoms) Digitalis Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF.

  47. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Stage C Therapy (Reduced LVEF with Symptoms) Hydralazine and Isosorbide Dinitrate • The addition of a combination of hydralazine and a • nitrate is reasonable for patients with reduced • LVEF who are already taking an ACEI and beta- • blocker for symptomatic HF and who have • persistent symptoms. • A combination of hydralazine and a nitrate might be • reasonable in patients with current or prior • symptoms of HF and reduced LVEF who cannot be • given an ACEI or ARB because of drug intolerance, • hypotension, or renal insufficiency.

  48. Stage C Therapy (Reduced LVEF with Symptoms) Implantable Cardioverter- Defibrillators (ICDs) 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 hemodynamically destabilizing ventricular tachycardia. ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with ischemic heart disease who are at least 40 days post-MI, have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year.

  49. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B B Stage C Therapy (Reduced LVEF with Symptoms) ICDs (cont’d) 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 less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. Placement of an ICD is reasonable in patients with 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 reasonable expectation of survival with good functional status of more than 1 year.

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