HF Guideline Slide 2006

8/3/2019 HF Guideline Slide 2006

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ACC Heart Failure GuidelinesSlide Deck

Based on the ACC/AHA 2005 Guideline Update

for the Diagnosis and Management of

Chronic Heart Failure in the Adult

January 2006


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Supported by Medtronic, Inc.

Medtronic, Inc. was not involved in the development of this

slide deck and in no way influenced its contents.


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William T. Abraham, MD, FACC, FAHA

Marshall H. Chin, MD, MPH, FACP

Arthur M. Feldman, MD, PhD, FACC,

FAHA

Gary S. Francis, MD, FACC, FAHA

Theodore G. Ganiats, MD

Mariell Jessup, MD, FACC, FAHA

Marvin A. Konstam, MD, FACC

Sharon Ann Hunt, MD, FACC, FAHA, Chair

Donna M. Mancini, MD

Keith Michl, MD, FACP

John A. Oates, MD, FAHA

Peter S. Rahko, MD, FACC, FAHA

Marc A. Silver, MD, FACC, FAHA

Lynne Warner Stevenson, MD, FACC,

FAHA

Clyde W. Yancy, MD, FACC, FAHA

ACC/AHA 2005 Guideline Update for the

Management of Patients With Chronic Heart

Failure in the AdultWriting Committee Members


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Class IBenefit >>> Risk

Procedure/ TreatmentSHOULD be

performed/administered

Class IIaBenefit >> RiskAdditional studies withfocused objectivesneeded

IT IS REASONABLE toperform

procedure/administertreatment

Class IIbBenefit RiskAdditional studies withbroad objectivesneeded; Additionalregistry data would behelpful

Procedure/TreatmentMAY BE CONSIDERED

Class IIIRisk BenefitNo additional studiesneeded

Procedure/Treatmentshould NOT beperformed/administered

SINCE IT IS NOTHELPFUL AND MAY BEHARMFUL

shouldis recommendedis indicatedis useful/effective/beneficial

is reasonablecan be useful/effective/beneficialis probably recommendedor indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness isunknown /unclear/uncertainor not well established

is not recommendedis not indicatedshould notis notuseful/effective/beneficialmay be harmful

Applying Classification of

Recommendations and Level of Evidence


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Level A

Multiple (3-5)population riskstrataevaluated

Generalconsistency ofdirection andmagnitude ofeffect

Class I

Recommen-dation thatprocedure ortreatment isuseful/effective Sufficientevidence frommultiplerandomizedtrials or meta-analyses

Class IIa

Recommen-dation in favorof treatment orprocedurebeing useful/effective Someconflictingevidence frommultiplerandomizedtrials or meta-

analyses

Class IIb

Recommen-dationsusefulness/efficacy lesswellestablished Greaterconflictingevidence frommultiplerandomizedtrials or meta-

analyses

Class III

Recommen-dation thatprocedure ortreatment notuseful/effectiveand may beharmful Sufficientevidence frommultiplerandomizedtrials or meta-

analyses




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Level B

Limited (2-3)population riskstrataevaluated

Class I

Recommen-dation thatprocedure ortreatment isuseful/effectiv

e Limitedevidence fromsinglerandomizedtrial or non-randomized

studies

Class IIa

Recommen-dation in favorof treatment orprocedurebeing useful/

effective Someconflictingevidence fromsinglerandomizedtrial or non-

randomizedstudies

Class IIb

Recommen-dationsusefulness/efficacy lesswell established

Greaterconflictingevidence fromsinglerandomized trialor non-randomized

studies

Class III

Recommen-dation thatprocedure ortreatment notuseful/effective

and may beharmful Limitedevidence fromsinglerandomized trialor non-

randomizedstudies




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Level C

Very limited (1-2) populationrisk strataevaluated

Class I

Recommen-dation thatprocedure ortreatment is

useful/effective Only expertopinion, casestudies, orstandard-of-care

Class IIa

Recommen-dation in favorof treatment orprocedure

beinguseful/effective Only divergingexpert opinion,case studies, orstandard-of-care

Class IIb

Recommen-dationsusefulness/efficacy less

well established Only divergingexpert opinion,case studies, orstandard-of-care

Class III

Recommend-ation thatprocedure ortreatment not

useful/effectiveand may beharmful Only expertopinion, casestudies, orstandard-of-care


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Heart Failure is a Major and Growing Public

Health Problem in the U.S.

y Approximately 5 million patients in this country have

HF

y Over 550,000 patients are diagnosed with HF for the

first time each year

y Primary reason for 12 to 15 million office visits and

6.5 million hospital days each year

y In 2001, nearly 53,000 patients died of HF as a

primary cause


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Heart Failure is Primarily a

Condition of the Elderly

y The incidence of HF approaches 10 per 1000

population after age 65

y HF is the most common Medicare diagnosis-

related group

y More dollars are spent for the diagnosis and

treatment of HF than any other diagnosis by

Medicare


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Guideline Scope

Document focuses on :

y

Prevention of HFy Diagnosis and management of

chronic HF in the adult


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Definition of Heart Failure

HF is a complex clinical syndrome that can

result from any structural or functionalcardiac disorder that impairs the ability of

the ventricle to fill with or eject blood.


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Heart Failure vs. Congestive Heart Failure

Because not all patients have volume overload at

the time of initial or subsequent evaluation, theterm heart failure is preferred over the older

term congestive heart failure.


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Causes of HF in Western World

For a substantial proportion of patients,

causes are:

1. Coronary artery disease

2. Hypertension

3. Dilated cardiomyopathy


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Stages of Heart Failure

At Riskfor Heart Failure:

STAGE A High risk for developing HF

STAGE B Asymptomatic LV dysfunction

Heart Failure:

STAGE C Past or current symptoms of HF

STAGE D End-stage HF


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Designed to emphasize preventability of HF

Designed to recognize the progressive

nature of LV dysfunction


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COMPLEMENT, DO NOT REPLACE NYHA

CLASSES

NYHA Classes - shift back/forth in individualpatient (in response to Rx and/or progression of

disease)

Stages - progress in one direction due to cardiac

remodeling


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Stage A

Patients at High Risk for

Developing Heart Failure


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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)


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Stage A Therapy

In patients at high risk for developing HF,

systolic and diastolic hypertension should be

controlled in accordance with contemporaryguidelines.

In patients at high risk for developing HF, lipid

disorders should be treated in accordance

with contemporary guidelines.

Using Therapy Consistent withContemporary Guidelines

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Stage A Therapy

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 sugarshould be controlled in accordance with

contemporary guidelines.





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Stage A Therapy

Thyroid disorders should be treated in

accordance with contemporary guidelines inpatients at high risk for developing HF.




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Stage A Therapy

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).

Avoiding Behaviors ThatIncrease Risk



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Stage A Therapy

Healthcare providers should perform periodic

evaluation for signs and symptoms of HF inpatients at high risk for developing HF.

Periodic Evaluation forSigns and Symptoms



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Stage A Therapy

Ventricular rate should be controlled or sinus

rhythm restored in patients with

supraventricular tachyarrhythmias who are at

high risk for developing HF.

Ventricular Rate Control or SinusRhythm Restoration

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Stage A Therapy

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.

Noninvasive Evaluation ofLV Function



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Stage A Therapy

ACEI can be useful to prevent HF in patients at

high risk for developing HF who have a history of

atherosclerotic vascular disease, diabetesmellitus, or hypertension with associated

cardiovascular risk factors.

Angiotensin Converting EnzymeInhibitors (ACEI)



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Stage A Therapy

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.

Angiotension Receptor Blockers(ARBs)



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Stage A Therapy

Routine use of nutritional supplements solely

to prevent the development of structural heart

disease should not be recommended forpatients at high risk for developing HF.

Therapies NOT Recommended



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Stage B

Patients with Asymptomatic

LV Dysfunction


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Stage B Therapy

Recommended Therapies:

General Measures as advised for Stage A

Drug therapy for all patients

ACEI or ARBs

Beta-BlockersICDs in appropriate patients

Coronary revascularization in appropriate patients

Valve replacement or repair in appropriate patients


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Stage B Therapy

All Class I recommendations for Stage A

should apply to patients with cardiac

structural abnormalities who have notdeveloped HF. (Levels ofEvidence: A, B, and

C as appropriate)

Patients who have not developed HF

symptoms should be treated according tocontemporary guidelines after an acute MI.

General Measures




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Stage B Therapy

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.




Angiotensin Converting EnzymeInhibitors (ACEI)


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Stage B Therapy

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.

Angiotensin Receptor Blockers(ARBs)





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Stage B Therapy

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.

Beta-Blockers




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Stage B Therapy

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 inNYHA functional class I with chronic optimal medical

therapy and have a reasonable expectation of survival

with good functional status for more than 1 year.

Internal Cardioverter Defibrillator (ICD)




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Stage B Therapy

Coronary revascularization should be

recommended in appropriate patients

without symptoms of HF in accordancewith contemporary guidelines (see

ACC/AHA Guidelines for the Management

of Patients With Chronic Stable Angina).

Coronary Revascularization



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Stage B Therapy

Valve replacement or repair should be

recommended for patients with

hemodynamically significant valvularstenosis or regurgitation and no

symptoms of HF in accordance with

contemporary guidelines.

Valve Replacement/Repair



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Stage B Therapy

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 inotropiceffects may be harmful in asymptomatic patients

with low LVEF and no symptoms of HF after MI.


III IIaIIaIIa

IIbIIbIIb

IIIIIIIII

III IIaIIaIIa

IIbIIbIIb

IIIIIIIII

III IIaIIaIIa

IIbIIbIIb

IIIIIIIII

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IIbIIbIIb

IIIIIIIII




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Stage C

Patients with Past or CurrentSymptoms of Heart Failure


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Recommended Therapies:General measures as advised for Stages A and B

Drug therapy for all patients

Diuretics for fluid retention

ACEI

Beta-blockersDrug therapy for selected patients

Aldosterone Antagonists

ARBs

Digitalis

Hydralazine/nitratesICDs in appropriate patients

Cardiac resynchronization in appropriate patients

Exercise Testing and Training

Stage C Therapy(Reduced LVEF with Symptoms)


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Measures listed as Class I recommendations for

patients in stages A and B are also appropriate for

patients in Stage C. (Levels ofEvidence: 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 calciumchannel blocking drugs).

General Measures





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Diuretics and salt restriction are indicated in

patients with current or prior symptoms of HF

and reduced LVEF who have evidence of fluidretention.

Diuretics




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ACEIs are recommended for all patients with

current or prior symptoms of HF and reducedLVEF, unless contraindicated.

Routine combined use of an ACEI, ARB, and

aldosterone antagonist is not recommended forpatients with current or prior symptoms of HF

and reduced LVEF.

Angiotensin Enzyme ConvertingInhibitors (ACEIs)





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ARBs approved for the treatment of HF are

recommended in patients with current or prior

symptoms of HF and reduced LVEF who are ACEI-

intolerant (see full text guidelines for informationregarding 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.






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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.

ARBs (contd)





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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 orequal 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.

Aldosterone Antagonists





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Beta-blockers (using 1 of the 3 proven to reduce

mortality, i.e., bisoprolol, carvedilol, and sustained

release metoprolol succinate) are recommended forall stable patients with current or prior symptoms of

HF and reduced LVEF, unless contraindicated.

Beta-Blockers




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Digitalis can be beneficial in patients with

current or prior symptoms of HF and reduced

LVEF to decrease hospitalizations for HF.

Digitalis




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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 priorsymptoms of HF and reduced LVEF who cannot be

given an ACEI or ARB because of drug intolerance,

hypotension, or renal insufficiency.

Hydralazine and Isosorbide Dinitrate





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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.

Implantable Cardioverter-Defibrillators (ICDs)





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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 undergoingchronic 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 IIor 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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Patients with LVEF less than or equal to 35%, sinus

rhythm, and NYHA functional class III or ambulatory

class IV symptoms despite recommended, optimalmedical therapy and who have cardiac

dyssynchrony, which is currently defined as a QRS

duration greater than 120 ms, should receive cardiac

resynchronization therapy unless contraindicated.

Cardiac Resynchronization




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Maximal exercise testing with or without

measurement of respiratory gas exchange is

recommended to facilitate prescription of an

appropriate exercise program for patientspresenting with HF.

Exercise training is beneficial as an adjunctive

approach to improve clinical status in ambulatory

patients with current or prior symptoms of HF andreduced LVEF.

Exercise Testing and Training





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Unproven/Not RecommendedDrugs and Interventions for HF

Nutritional Supplements

Hormonal Therapies Intermittent Intravenous

Positive Inotropic Therapy



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Long-term use of an infusion of a positive inotropic

drug may be harmful and is not recommended for

patients with current or prior symptoms of HF and

reduced LVEF, except as palliation for patients withend-stage disease who cannot be stabilized with

standard medical treatment (see recommendations

for Stage D).

Use of nutritional supplements as treatment for HF

is not indicated in patients with current or priorsymptoms of HF and reduced LVEF.

Unproven/Not Recommended Drugs and Interventions





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Calcium channel blocking drugs are not indicated as

routine treatment for HF in patients with current or

prior symptoms of HF and reduced LVEF.

Hormonal therapies other than to replete

deficiencies are not recommended and may be

harmful to patients with current or prior symptoms

of HF and reduced LVEF.

Routine combined use of an ACEI, ARB, andaldosterone antagonist is not recommended for

patientswith current or prior symptoms of HF and

reduced LVEF.

Unproven/Not Recommended Drugs and Interventions






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Recommended Therapies for Routine Use:Treating known risk factor (hypertension) with therapy

consistent with contemporary guidelines

Ventricular rate control for all patients

Drugs for all patients -

DiureticsDrugs for appropriate patients

ACEI

ARBs

Beta-Blockers

DigitalisCoronary revascularization in selected patients

Restoration/maintenance of sinus rhythm in

appropriate patients

Stage C Therapy(Normal LVEF with Symptoms)


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Differential Diagnosis in Patient with HF and

Normal LVEF with Symptoms

Incorrect diagnosis of HF

Inaccurate measurement ofLVEF

Primary valvular disease

Restrictive (infiltrative)

cardiomyopathies Amyloidosis, sarcoidosis,

hemochromatosis

Pericardial constriction

Episodic or reversible LVsystolic dysfunction

Severe hypertension,myocardial ischemia

HF associated with highmetabolic demand (high-output states)

Anemia, thyrotoxicosis,arteriovenous fistulae

Chronic pulmonarydisease with right HF

Pulmonary hypertensionassociated withpulmonary vasculardisorders

Atrial myxoma

Diastolic dysfunction ofuncertain origin

Obesity


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Physicians should control systolic and

diastolic hypertension in patients with HF andnormal LVEF, in accordance with published

guidelines.

Treating known risk factors -Hypertension




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Physicians should control ventricular rate in

patients with HF and normal LVEF and atrial

fibrillation.

Ventricular Rate Control




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Physicians should use diuretics to control

pulmonary congestion and peripheral edema in

patients with HF and normal LVEF.

Diuretics




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Coronary revascularization is reasonable in

patients with HF and normal LVEF and

coronary artery disease in whom symptomaticor demonstrable myocardial ischemia is

judged to be having an adverse effect on

cardiac function.

Coronary Revascularization




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Restoration and maintenance of sinus rhythm

in patients with atrial fibrillation and HF and

normal LVEF might be useful to improve

symptoms.

Restoration/Maintenanceof Sinus Rhythm



S C


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The use of beta-adrenergic blocking agents, ACEIs,

ARBs, or calcium antagonists in patients with HF

and normal LVEF and controlled hypertension mightbe effective to minimize symptoms of HF.

Angiotensin Enzyme ConvertingInhibitors (ACEIs)



St C Th


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St C Th


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Beta-Blockers



St C Th


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The usefulness of digitalis to minimize

symptoms of HF in patients with HF and normal

LVEF is not well established.

Digitalis




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Stage D

Patients with Refractory End-Stage HF

St D Th


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Stage D Therapy

Recommended Therapies Include:Control of fluid retention

Referral to a HF program for appropriate pts

Discussion of options for end-of-life care

Informing re: option to inactivate defibrillator

Device use in appropriate patientsSurgical therapy

Cardiac transplantation

Mitral valve repair or replacement

Other

Drug Therapy Positive inotrope infusion as palliation

in appropriate patients

St D Th


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Stage D Therapy

Meticulous identification and control of fluid

retention is recommended in patients with

refractory end-stage HF.

Control of FluidRetention


St D Th


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Stage D Therapy

Referral of patients with refractory end-stage

HF to an HF program with expertise in the

management of refractory HF is useful.

Referral to an HF Program


Stage D Therapy


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Stage D Therapy

Options for end-of-life care should be

discussed with the patient and family when

severe symptoms in patients with refractory

end-stage HF persist despite application of all

recommended therapies.

Discussion of Options forEnd-of-Life Care


Stage D Therapy


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Stage D Therapy

Patients with refractory end-stage HF and

implantable defibrillators should receive

information about the option to inactivate

defibrillation.

Inform on option toinactivate defibrillation


Stage D Therapy


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Stage D Therapy

Referral for cardiac transplantation in

potentially eligible patients is recommended for

patients with refractory end-stage HF.

The effectiveness of mitral valve repair or

replacement is not established for severe

secondary mitral regurgitation in refractory

end-stage HF.

Surgical Therapy



Stage D Therapy


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Stage D Therapy

Consideration of an LV assist device as

permanentordestination therapy is

reasonable in highly selected patients with

refractory end-stage HF and an estimated1-year mortality over 50% with medical therapy.

Pulmonary artery catheter placement may be

reasonable to guide therapy in patients with

refractory end-stage HF and persistently severesymptoms.

Device Use


Stage D Therapy


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Stage D Therapy

Continuous intravenous infusion of a positive

inotropic agent may be considered for

palliation of symptoms in patients with

refractory end-stage HF.

Routine intermittent infusions of positive

inotropic agents are not recommended for


Medical TherapyIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII


Stage D Therapy


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Stage D Therapy

Partial left ventriculectomy is not

recommended inpatients with nonischemic

cardiomyopathy and refractory end-stage HF.

Routine intermittent infusions of positive

inotropic agents are not recommended for





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