Heart Failure

1. Heart Failure Ben Starnes MD FACC Interventional Cardiology Arkansas Cardiology Baptist Health Heart Institute

2. Financial disclosures -None

3. Heart Failure • Moving away from the term Congestive Heart Failure

6. Heart Failure imposes a significantburden on the US healthcare system -Heart failure accounts for over 3.4 million visits to physician offices, hospital outpatient departments, and emergency departments1 -More than 1,000,000 hospitalizations occur with the primary diagnosis of heart failure2 -Over 6.5 million days are spent in US hospitals for heart failure3 • 1 Vital Health Statistics 13. 2004;157:1-70. • 2 AHA Heart Disease and Stroke Statistics 2010 Update. Circulation. 2010;121:e46-215. • 3 European Heart Journal Supplements; V.7; Suppl B; 2005; pB8.

7. Heart Failure is a Clinical Diagnosis Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41:1797-1804.

13. Heart Failure

17. Beta Blockers

18. Beta Blockers ACC Guidelines 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.

19. Heart Failure

20. Ace Inhibitors in severe heart failure

21. Ace Inhibitors in mild to moderate heart failure

22. Ace Inhibitors ACC Guidelines ACEIs are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated.

25. Aldosterone Antagonists

26. Aldosterone Antagonists

27. Aldosterone Antagonists

28. 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 Aldosterone Antagonists ACC guidelines 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.

32. SCD-HeFT

33. Amiodarone n=845 Placebo n=847 SCD-HeFT Protocol Inclusion criteria ICD implant n=829 40 months average follow- up • Optimize: B, ACE-I, Diuretics Bardy GH. Chapter Excerpt from Arrhythmia Treatment and Therapy. Woosley RL, Singh SN, editors. Marcel Dekker, 1st edition. 2000;323-42. SCD-HeFT Investigators Meeting, August 2001, data from most recent follow-up

36. 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 A 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 B Implantable Cardioverter-Defibrillators ICD therapy is indicated in patients with LVEF less than 35% due to prior MI who are at least 40 days post-MI and are in NYHA functional Class II or III. ICD therapy is indicated in patients with nonischemic DCM who have an LVEF less than or equal to 35% and who are in NYHA functional Class II or III. All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

45. 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 A Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure For patients who have left ventricular ejection fraction (LVEF) less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, cardiac resynchronization therapy (CRT) with or without an ICD is indicated for the treatment of New York Heart Association (NYHA) functional Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy. *All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

46. End Stage Heart Failure Ventricular assist Device -Bridge to transplant -Destination Therapy Cardiac Transplantation Palliative Care

47. Diastolic Heart Failure Heart failure with preserved LV systolic function Generally due to hypertension  left ventricular hypertrophy  impaired LV filling and decreased LV stroke volume

48. Diastolic Heart Failure Treatment: -Diuretics to relieve congestion -Beta Blockers/Calcium channel blockers to reduce heart rate and improve diastolic filling -Control blood pressure -Maintain sinus rhythm Atrial fibrillation leads to loss of atrial kick (20% of cardiac output)

49. Take Home Points Medical Therapy -Ace inhibitors/beta blockers -Aldosterone antogonist (LVEF <35) -Diuretics as needed -Digoxin last line Device therapy -ICD -Cardiac Resynchronization Therapy End Stage Heart Failure -Ventricular Assist Device/Heart Transplant