Guideline Management CHF

7/28/2019 Guideline Management CHF

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Dr. T. Heriansyah, SpJP

GUIDELINES FOR THE

DIAGNOSIS AND TREATMENT OFCHRONIC HEART FAILURE


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Definition

Heart Failure is pathophysiological

state in which an abnormality of

cardiac function is responsible for thefailure of the heart to pump blood at a

rate commensurate with the

requirements of the metabolizingtissues.

European Heart Journal (2001) 22, 1527-1560


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Diagnosis of C H F


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IDENTIFICATIONS OF HF PATIENTS

With a Syndrome of Decrease ExerciseTolerance

With a Syndrome of Fluid Retention

With No Symptoms or Symptoms of Another

Cardiac or Non Cardiac Disorder(MI, Arrythmias, Pulmonary or SystemicThromboembolic Events)


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SYMPTOMS AND SIGN

Breathlessness, Ankle Swelling, Fatique

Characteristic Symptoms

Peripheral Oedema, JVP , Hepatomegaly

Signs of Congestion of Systemic Veins

S3 , Pulmonary Rales , Cardiac Murmur


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E C G

A low Predictive Value

LAH and LVH May Be Associated wit LV Dysfunction Anterior Q-wave and LBBB a good predictors of EF

Detecting Arrhytmias as Causative of HF

CHEST X-RAY

A Part of Initial Diagnosis of HF Cardiomegaly, Pulmonary Congestion

Relationship Between Radiological Signs and

Haemodynamic Findings may Depend on the Duration

and Severity HF


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HAEMATOLOGY & BIOCHEMISTRY

A Part of Routine Diagnostic

Hb, Leucocyte, Platelets Electrolytes, Creatinine, Glucose, Hepatic Enzyme,

Urinalysis

TSH, C-RP, Uric Acid

ECHOCARDIOGRAPHY

The Preferred Methods Helpful in Determining the Aetiology

Follow Up of Patients Heart Failure


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PULMONARY FUNCTIONS

A Little Value in Diagnosis Heart Failure

Usefull in Excluding Respiratory Diseases

EXERCISE TESTING

Focused on Functional, Treatment Assessment andPrognostic


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STRESS ECHOCARDIOGRAPHY

For Detecting Ischaemia

Viability Study

NUCLEAR CARDIOLOGY

Not Recommended as a Routine Use

CMR( CARDIAC MAGNETIC RESONANCE IMAGING)

Recommenmded if Other Imaging Techniques not

Provided Diagnostic Answer


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INVASIVE INVESTIGATION

Elucidating the Cause and Prognostic Informations

Coronary Angiography :

in CADs Patients

Haemodynamic Monitoring :

To Assess Diagnostic and Treatment of HF

Endomyocardial Biopsy :

in Patients with Unexplained HF


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NATRIURETIC PEPTIDES

Cardiac Function (LV Function )

Plasma Natriuretic Peptide Concentration(Diagnostic Blood Use for HF)

Natriuretic Peptide :

Greatest Risk of CV Events

Natriuretic Peptide :

Improve Outcome in Patients withTreatment

Identify Pts. With Asymptomatic LV

Dysfunction (MI, CAD)


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Suspected Heart Failure Because

of symptoms and signs

Assess Presence of Cardiac Disease by ECG, X-Rayor NatriureticPeptides (Where Available)

Imaging by Echocardiography (NuclearAngiography or MRI Where Available)

Assess Etiology, Degree, PrecipitatingFactors and Type of Cardiac Dysfunction

Tests Abnormal

Tests Abnormal

Choose Therapy

ALGORITHM FOR THE DIAGNOSIS OF THE HF

If NormalHeart Failure

Unlikely

Additional Diagnosis TestsWhere Appropriate (e.g.Coronary Angiography)

If NormalHeart Failure

Unlikely

(ESC, 2001)


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Aims of treatment

1. Preventiona) Prevention and/or controlling of diseases leading

to cardiac dysfunction and heart failure

b) Prevention of progression to heart failure once

cardiac dysfunction is established

2. Morbidity

Maintenance or improvement in quality of life

3. MortalityIncreased duration of life

Guidelines for the diagnosis and treatment of chronic heart failure



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Management outline

Establish that the patient has HF. Ascertain presenting features: pulmonary oedema, exertional

breathlessness, fatigue, peripheral oedema

Assess severity of symptoms

Determine aetiology of heart failure

Identify precipitating and exacerbating factors

Identify concomitant diseases

Estimate prognosis

Anticipate complications

Counsel patient and relatives

Choose appropriate management

Monitor progress and manage accordingly




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Treatment options

Non-pharmacological management

General advice and measures

Exercise and exercise training

Pharmacological therapy

Angiotensin-converting enzyme (ACE) inhibitors

Diuretics

Beta-adrenoceptor antagonists

Aldosterone receptor antagonists

Angiotensin receptor antagonists

Cardiac glycosides Vasodilator agents (nitrates/hydralazine)

Positive inotropic agents

Anticoagulation

Antiarrhythmic agents

Oxygen

Devices and surgery Revascularization (catheter interventions and surgery), other forms of surgery

Pacemakers

Implantable cardioverter defibrillators (ICD)

Heart transplantation, ventricular assist devices, artificial heart

Ultrafiltration, haemodialysis




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Pharmacological therapy


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Angiotensin-Converting Enzyme Inhibitors

Recommended as first-line therapy.

Should be uptitrated to the dosages shown to beeffective in the large, controlled trials, and nottitrated based on symptomatic improvement.

Moderate renal insufficiency and a relatively low bloodpressure (serum creatinine 250 mol.l-1 and systolicBP 90 mmHg) are not contraindications.

Absolute contraindications: bilateral renal arterystenosis and angioedema.




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Diuretics

Essential for symptomatic treatment when

fluid overload is present and manifest.

Always be administered in combination

with ACE inhibitors if possible.




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Recommended in advanced HF (NYHA III-IV),

in addition to ACE inhibition and diuretics to

improve survival and morbidity

Aldosterone Receptor Antagonists - Spironolactone




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ARBs could be considered in patients who donot tolerateACE inhibitors for symptomatictreatment.

It is unclear whether ARBs are as effective asACE inhibitors for mortality reduction.

In combination with ACE inhibition, ARBs mayimprove heart failure symptoms and reducehospitalizations for worsening heart failure.

Angiotensin II Receptor Antagonists




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indicated in atrial fibrillation and any degree ofsymptomatic heart failure.

A combination of digoxin and beta-blockade

appears superior than either agent alone.

In sinus rhythm, digoxin is recommended toimprove the clinical status of patients with

persisting heart failure despite ACE inhibitor anddiuretic treatment.

Cardiac Glycosides




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No specific role for vasodilators in the treatment of HF

Used as adjunctive therapy for angina or concomitanthypertension.

In case of intolerance to ACE inhibitors ARBs are

preferred to the combination hydralazinenitrates.

HYDRALAZINE-ISOSORBIDE DINITRATE

Hydralazine (up to 300 mg) in combination with ISDN (up to 160

mg) without ACE inhibition may have some beneficial effect on

mortality, but not on hospitalization for HF.

Nitrates may be used for the treatment ofconcomitant angina or

relief ofacute dyspnoea.

Vasodilator Agents In Chronic Heart Failure

Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560


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Commonly used to limit severe episodes ofHF or as a bridge to heart transplantationin end-stage HF.

Repeated or prolonged treatment with oralinotropic agents increases mortality.

Currently, insuffcient data are available to

recommend dopaminergic agents for heartfailure treatment.

Positive Inotropic Therapy




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Recommendation

1. All pts with HF and AF should be treated with

warfarin unless contraindicated.

2. Patients with LVEF 35% or less.

Anticoagulation

HFSA Guidelines for Management of Patients With Heart Failure Caused by Left

Ventricular Systolic Dysfunction - Pharmacological Approaches 2000


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Antiplatelet Drugs

Recommendation

There is insufficient evidence concerning thepotential negative therapeutic interaction

betweenASA and ACE inhibitors.

Antiplatelet agent for pts with HF who haveunderlyingCAD.

HFSA Guidelines for Management of Patients With Heart Failure Caused by LeftVentricular Systolic Dysfunction - Pharmacological Approaches 2000


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No indication for the use of antiarrhythmic agents in HF

Indications for antiarrhythmic drug therapy include AF(rarely flutter), non-sustained or sustained VT.

CLASS I ANTIARRHYTHMICS

should be avoided

CLASS II ANTIARRHYTHMICS

Beta-blockers reduce sudden death in heart failure

CLASS III ANTIARRHYTHMICS

Amiodarone is the only antiarrhythmic drug withoutclinically relevant negative inotropic effects.

Antiarrhythmics




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ACC/AHA A New Approach To The Classification of HF

Stage Descriptions Examples

A Patient who is at high risk fordeveloping HF but has no

structural disorderof the heart.

Hypertension; CAD; DM;rheumatic fever; cardiomyopathy.

B Patient with a structural disorder

of the heart but who has neverdeveloped symptoms of HF.

LV hypertrophy or fibrosis;

LV dilatation; asymptomatic VHD;MI.

C patient with past or current

symptoms of HF associated with

underlying structural heart

disease.

Dyspnea or fatigue ec LV systolic

dysfunction; asymptomatic

patients with HF.

D Patient with end-stage disease Frequently hospitalized pts ; pts

awaiting heart transplantation etc

ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001


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Stage A Stage B Stage C Stage D

Pts with :

Hypertension

CAD

DM

Cardiotoxins

FHx CM

THERAPY Treat Hypertension

Stop smoking

Treat lipid disorders

Encourage regular

exercise

Stop alcohol

& drug use

ACE inhibition

Pts with :

Previous MI

LV systolic

dysfunction

Asymptomatic

Valvular disease

THERAPY All measures under

stage A

ACE inhibitor

Beta-blockers


stage A

Drugs for routine use:

diuretic

ACE inhibitor

Beta-blockers

digitalis


stage A,B and C

Mechanical assist

device Heart transplantation

Continuous IV

inotrphic infusions for

palliation

Pts who have

marked symptoms

at rest despite

maximal medical

therapy.

Pts with :

Struct. HD

Shortness of

breath and fatigue,

reduce exercise

tolerance

Struct.

Heart

Disease

Develop

Symp.of

HF

Refract.

Symp.of

HF at rest

Stages in The Evolution of HF and Recommended Therapy by Stage

ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001


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Chronic Heart FailureChoice ofPharmacological Therapy

LV systolic dysfunction ACE inhibitor Diuretic Beta-blockerAldosterone

Antagonist

Asymptomatic LV

dysfunctionIndicated Not indicated Post MI Not indicated

Symptomatic HF (NYHA II) IndicatedIndicated if

Fluid retentionIndicated Not indicated

Worsening HF (NYHA III-IV) IndicatedIndicated

comb. diuretic

IndicatedIndicated

End-stage HF (NYHA IV) IndicatedIndicated

comb. diuretic

IndicatedIndicated



A

Ch i il Ch i f


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Chronic Heart FailureChoice ofPharmacological Therapy

LV systolic dysfunction

Angiotensin

II receptorantagonists

Cardiac glycosides

Vasodilator

(hydralazine/

isosorbide

dinitrate)

Potassium -sparing

diuretic

Asymptomatic LV

dysfunctionNot indicated With AF Not indicated Not indicated

Symptomatic HF (NYHA II)

If ACE inhibitors

are not tolerated

and not on beta-blockade

(a) when AF

(b) when improved

from more severeHF in sinus

rhythm

If ACE inhibitors

and angiotensin

II antagonistsare not

tolerated

If persisting

hypokalaemia

Worsening HF (NYHA III-IV)

If ACE inhibitors

are not tolerated

and not on beta-

blockade

indicated

If ACE inhibitors

and angiotensin

II antagonists

are not

tolerated

If persisting

hypokalaemia

End-stage HF (NYHA IV)If ACE inhibitors

are not tolerated

and not on beta-

blockade

indicated

If ACE inhibitorsand angiotensin

II antagonists

are not

tolerated

If persisting

hypokalaemia

Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560

B


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Intervention


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Pts with heart failure ofischaemic origin revascularization

symtomatic improvement.

A strong negative correlation of operative mortality and LVEF,

a low LVEF (


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Conclusion

DIAGNOSIS OF HEART FAILURE

Clinical Signs and Symptoms

Echocardiography (LVEF) The PreferredMethod

Natriuretic Peptide Helpful in The Diagnosis

Process

Additional Test Should be PerfomedWhere Diagnosis Doubt Persist


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Conclusion

Management of HF must be starting fromtheearlier stage (AHA/ACC stage A).

Treatment at each stage can reduce

morbidity and mortality.

Before initiatingtherapy :

Established the correct diagnose. Consider management outline.


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Th k Y U

PREVENTION

IS BETTER THANTREATMENT

NO MATTER WHAT,

Guideline Management CHF

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