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Heart Failure Guidelines

Heart Failure Guidelines. Patrice M. Schneider RN BSN Heart Failure Coordinator South Jersey Heart Group Lourdes Cardiology Services. Background. NHLBI estimates that @ any given time: 35% of pts with heart failure are NYHA I 35% of pts with heart failure are NYHA II

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Heart Failure Guidelines

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  1. Heart Failure Guidelines Patrice M. Schneider RN BSN Heart Failure Coordinator South Jersey Heart Group Lourdes Cardiology Services

  2. Background • NHLBI estimates that @ any given time: • 35% of pts with heart failure are NYHA I • 35% of pts with heart failure are NYHA II • 25% of pts with heart failure are NYHA III • 5% of pts with heart failure are NYHA IV • Therefore > 85% pf pts with heart failure are treated primarily in the ambulatory setting

  3. CONGESTIVE HEART FAILUREScope of the Problem in U.S. • Prevalence of CHF: > 3,000,000 in U.S. • Worldwide >15,000,000 • Incidence of CHF: > 400,000/year in U.S. • Most common hospital discharge diagnosis in patients over 65 years old • Mortality of CHF: Approx 200,000/yr in U.S. • Cost of CHF: > $ 7 Billion/yr for Hospital Care • All of above are likely to increase with population aging

  4. Etiology of Heart Failure What causes heart failure? • The loss of a critical quantity of functioning myocardial cells after injury to the heart due to: • Ischemic Heart Disease • Hypertension • Infections (e.g., viral myocarditis, Chagas’ disease) • Toxins (e.g., alcohol or cytotoxic drugs) • Valvular Disease • Prolonged Arrhythmias • Peripartum • Idiopathic Cardiomyopathy

  5. Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class A B C D High risk of developing HF Structural heart disease but without symptoms of HF Structural heart disease with HF symptoms, either prior or current Refractory HF requiring specialized interventions I II–III IV Asymptomatic HF No symptoms Mild and Moderate HF Symptoms upon mild to moderate exertion Severe HF Symptomsat rest ACC/AHAHF Stage NYHAFunctionalClass

  6. Challenging Tradition • NYHA class changes over time • Increasing evidence that heart failure is a cellular disease • Despite symptomatic improvement neurohormonal, cytokine and cellular changes continue to occur and allow heart failure to progress • Ejection Fraction (EF) does not correlate with functional capacity (NYHA class)

  7. Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional Class A B C D High risk of developing HF Structural heart disease but without symptoms of HF Structural heart disease with HF symptoms, either prior or current Refractory HF requiring specialized interventions I II–III IV Asymptomatic HF No symptoms Mild and Moderate HF Symptoms upon mild to moderate exertion Severe HF Symptomsat rest ACC/AHAHF Stage NYHAFunctionalClass

  8. Stages of Heart Failure

  9. Evaluation of The Patient With Cardiomyopathy • Historical Data • Etiology • Duration of symptoms • ECG Findings • Biochemical parameters • Levels of various neurohormones • Measurement of effect of NH activation • Hemodynamic parameters • Initial • After tailored therapy • Exercise Capacity • Trends • Risk of sudden deterioration

  10. Insults Ischemia Tachycardia High PVC burden Viral Thyroid disease Unclear etiology Peripartum Idiopathic HIV Infiltrative Hemachromatosis Sarcoidosis amyloid Etiology of Cardiomyopathy • Abnormal loading conditions • Valvular disease • Hypertention • Shunts • Toxins • Chemotherapeutics • Cobalt/heavy metal • Acohol • Genetic • familial • Muscular dystrophies • Mitochondrial disorders • Hypertrophic • ARVD

  11. Historical Data & Prognosis • Duration of illness • Shorter duration of illness associated with a greater likelihood of spontaneous improvement • Patients with recent onset (<6-7 months require close clinical surveillance) • But signs of hemodynamic instability • Or end organ underperfusion Stevenson AM J Med 1987 Steimle JACC 1994

  12. New York Heart Association Functional Classification • I. No limitations of physical activity, no symptoms with ordinary activities • II. Mild/slight limitation, symptoms with ordinary activities • Moderate/marked limitation, symptoms with less than ordinary activities • IV. Severe limitation, symptoms of heart failure at rest • Symptoms: Dyspnea or fatigue Adapted from Criteria Committee of the New York Heart Association, 1994.

  13. Exercise Capacity • NYHA (Gradman Card Clinics 1994) • Annual mortality • NYHA I 5% • NYHA II 3-25 % • NYHA III 10-45% • NYHA IV 50-77% • Some overlap II/III likely related to differences in classification from center to center, subjective interpretation, II, predominantly better than III

  14. Exercise Capacity • 6 minute walk test (6MWT) • Assess day-to-day efforts at submax exertion • Measures distance an individual able to traverse over 6 minute period • In moderate heart failure 6MWT has been shown to be • Inversely related to QOL score • Inversely related to NYHA • Predictive or mortality in moderate HF • In Severe HF (< 300 meters) • Correlate to Peak VO2 • Predictive of 6 month event-free survival • But not long term (>6 month) survival Cahalin Chest 1996

  15. Trends Serial determination of LVEF may enhance prognostic value Mortality @ 1 year < - 5 29% >10 13 % * Prognosis and CMP Survival based on change in EF 1.0 > 10 .50 < - 5 24 48 72 Months V-HeFT I and II data

  16. Prognosis and CMP • Trends • Decrease in EF • Decrease in exercise capacity • Increase in left ventricular diastolic dimension • Risk of sudden Deterioration • Non-revascularizable coronary lesion with a high ischemic burden • Increase in number of arrhythmic events

  17. Treatment Chronic Systolic Heart Failure

  18. Vasodilator Therapy Ace-inhibitors & H/I B-Blockers ARBs Aldosterone Inhibitors DT OHT CRT

  19. Reduction in Mortality with ACE-I & B-Blocker therapy SOLVD II/III CONSENSUS IV MERIT HF II/III US CARVEDILOL II/III COPERNICUS IIIB 40 % 1 yr 34 % 1 yr 65% ½ yr 35% 10 mos 16% 3 yr B-Blocker ACE-I

  20. Which BB should we use? • US CARVEDILOL Trial • Coreg • Target 25 mg bid • Caveats • > 70 kg: 50 mg bid • Able to decrease vasodilator to allow uptitration to maximal dose • MERIT-HF Trial • Metoprolol Succinate • Target: 150 mg daily • Caveat • Metoprolol Tartrate is inferior (however it was underdosed in the trial) • CIBIS II Trial • Bisoprolol • Target: approximately 7.5 mg daily • Asthmatics

  21. Changes in LVEF Cardiovascular hospitalizations  0.4 8 P<.001 P=.01 7  6 0.3  5 Mean number/subject LVEF (EF units) 0.2 4   3  2 0.1 1 0 0 Placebo 6.25 mg bid 12.5 mg bid 25 mg bid Placebo 6.25 mg bid 12.5 mg bid 25 mg bid Carvedilol Carvedilol Carvedilol Dose-Response Trial (MOCHA): Effect on Ejection Fraction and Morbidity Patients receiving diuretics, ACE inhibitors, ± digoxin; follow-up duration 6 months; placebo (n=84), carvedilol (n=261). Adapted from Bristow et al, 1996. P<.05 vs placebo

  22. Mortality in the placebo arm of Val-HeFT by treatment group: 23-month mean follow-up Slide courtesy of J. Cohn

  23. ARBs ELITE II 3152 NYHA III-IV Losartan 50 mg QD vs Capoten 50 mg TID No difference in mortality, well tolerated Pitt et al. Lancet 2000;355;1582-1587 Val-HeFT 5010 NYHA II-IV Valsartan 160 mg BID vs placebo No difference in mortality Significant decrease in morbidity & mortality Cohn et al. NEJM 2001;345:1667-75 Death Hospitalizations for CHF* Cardiac arrest Intravenous therapy Triple therapy adverse effect on mortality CHARM –added 2548 II-IV Candesartan 24 mg QD vs Placebo all on ACE-I Significant decrease in CVd and HF admit McMurray The LANCET 2003:362;767

  24. Where Does Hydralazine/Isosorbide Fit in? • ACE-I or ARB intolerant • ACE-I or ARB are supperior • But if intolerant due to • Cough • Hyperkalemia, renal insufficiency • Angioedema • BIDIL (V-HeFT Trial) • AA who still have NYHA II-IV HF despite • ACE/ARB and BB • ON TOP of baseline therapy, not instead of • 3 times a day

  25. RALES Trial 1663 NYHA III-IV 25 mg Aldactonevs Placebo 30% reduction in death* Progressive HF SCD 35% reduction in hospitalization Significant improvement in NYHA functional class Pitt et al. NEJM 1999;341:709 EPHESUS Trial 6632 pts 3-14 d after AMI, EF < 40% And sign of HF Or DM with or without signs of HF 50 mgQDEplerenonevs placebo Significant reduction in: Death 14 % v 17% CVd/hosp 27% v 30% SCD 4.9% vs 6% Pitt NEJM 2003;348:1309 Aldosterone Inhibitors

  26. Sinus node AV node Stimulation therapy Ventricular Resynchronization • Ventricular dyssynchrony • 30 - 50% CHF patients with IVCD • As QRS widens • Mortality increases • Electrical delay translates to mechanical delay/dyssynchrony • Improved • A-V synchrony • Interventricular synchrony • Intraventricular synchrony • Positive remodeling • Reduction in heart failure and all-cause morbidity and mortality Conduction block Abraham WT and Hayes DL, Circulation 2003; 108:2596-2603

  27. Chronic Heart Failure • NYHA I • ACE-inhibitor- SOLVD Prevention Trial • NYHA II/III • ACE-I – SOLVD, V-HeFT II • Hydralazine/ISDN – V-HeFT • B-Blocker – MERIT-HF, US Carvedilol, • Angiotensin Receptor Blocker- Val-HeFT, CHARM • NYHA IV • ACE-I- CONSENSUS • B-Blocker- COPERNICUS • NYHA III/IV • Aldosterone Blocker – RALES • Resynchronization therapy (EF <35%, QRS > 130ms) • Post-AMI • ACE-I SAVE Trial • B-Blocker CAPRICORN Trial • Eplerenone EPHESUS Trial

  28. Mechanism of Death in HF Other 11% Other 15% Other 24% SCD 33% SCD 59% SCD 64% HF 26% HF 12% HF 56% NYHA IV NYHA II NYHA III HF = mortality secondary to worsening heart failure SCD = sudden cardiac death MERIT-HF Study Group. Lancet 1999

  29. Ultimate Goal Delay progression of heart failure or death to the point where good quality and quantity of life is achieved

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