HFSA 2010 Comprehensive Heart Failure Practice Guideline Key Recommendations.
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Transcript of HFSA 2010 Comprehensive Heart Failure Practice Guideline Key Recommendations.
HFSA 2010 Comprehensive Heart Failure Practice Guideline
Key Recommendations
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Comprehensive Heart Failure Practice Guideline Strength of Recommendation
“Is recommended”
“Should be considered”
“May be considered”
“Is not recommended”
Part of routine care
Exceptions should be minimized
Majority of patients should receive intervention
Some discretion allowed
Individualization of therapy is indicated
Therapy should not be used
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Comprehensive Heart Failure Practice Guideline
Strength of Evidence
A
B
C
Randomized controlled trials
May be assigned on results of 1 trial
Cohort and case control studies
Includes sub group analyses, meta-analyses, observational studies, registries
Expert opinion
Includes observational, epidemiological findings; in-practice safety reporting
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (3.1)
Heart Failure Prevention
A careful and thorough clinical assessment, with appropriate investigation for known or potential risk factors, is recommended in an effort to prevent development of LV remodeling, cardiac dysfunction, and HF. Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (3.2)
HF Risk Factor Treatment GoalsRisk Factor Goal
Hypertension Generally < 130/80
Diabetes See ADA guidelines1
Hyperlipidemia See NCEP guidelines2
Inactivity 20-30 min. aerobic 3-5 x wk.
Obesity Weight reduction < 30 BMI
Alcohol Men ≤ 2 drinks/day, women ≤ 1
Smoking Cessation
Dietary Sodium Maximum 2-3 g/day 1Diabetes Care 2006; 29: S4-S42
2JAMA 2001; 285:2486-97
Adapted from:
Treating Hypertension to Prevent HF
Aggressive blood pressure control:
Aggressive BP control in patients with prior MI:
Decreasesrisk of new HF
by ~ 80%
Decreasesrisk of new HF
by ~ 50%56% in DM2
Decreasesrisk of new HF
by ~ 50%56% in DM2
Lancet 1991;338:1281-5 (STOP-HypertensionJAMA 1997;278:212-6 (SHEP)UKPDS Group. UKPDS 38. BMJ 1998;317:703-713
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (3.3-3.4)
Prevention—ACEI and Beta Blockers
ACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with:
Coronary artery disease
Peripheral vascular disease
Stroke Diabetes and another major risk factor
Strength of Evidence = A
ACE inhibitors and beta blockers are recommended for all patients with prior MI.
Strength of Evidence = A
Management of Patients with Known Atherosclerotic Disease But No HF
Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest.
NEJM 2000;342:145-53 (HOPE)Lancet 2003;362:782-8
(EUROPA)
02468
10121416
0 1 2 3 4
Years
% MI,Stroke,
CV Death
0
3
6
9
12
15
0 1 2 3 4 5
Years
% MI, CV Death, Cardiac Arrest
Placebo
Ramipril
Placebo
Perindopril
20% rel. risk red. p = .0003
22% rel. risk red. p < .001
HOPE
EUROPA
Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF ≤ 40%)
SAVE Study
All-cause mortality ↓19%
CV mortality ↓21%
HF development ↓37%
Recurrent MI ↓25% 0
0.1
0.2
0.3
0 0.5 1 1.5 2 2.5 3 3.5 4
Placebo
Captopril
Years
MortalityRate
19% rel. risk reduction
p = 0.019
Pfeffer et al. NEJM 1992;327:669-77
The Additional Value of Beta Blockers Post-MI: CAPRICORN
Studied impact of beta blocker (carvedilol) on post-MI patients with LVEF ≤ 40% already receiving contemporary treatments, including revascularization, anticoagulants, ASA, and ACEI:
All-cause mortality reduced (HR = 0.077; p = 0.03)
Cardiovascular mortality reduced (HR = 0.75; p = .024)
Recurrent non-fatal MIs reduced (HR =.59; p = .014)
Dargie HJ. Lancet 2001;357:1385-90
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (4.8, 4.10)
Heart Failure Patient EvaluationRecommended evaluation for patients with a diagnosis of HF:
Assess clinical severity and functional limitation by history, physical examination, and determination of functional class*
Assess cardiac structure and function
Determine the etiology of HF
Evaluate for coronary disease and myocardial ischemia
Evaluate the risk of life threatening arrhythmia
Identify any exacerbating factors for HF
Identify co-morbidities which influence therapy Identify barriers to adherence and compliance Strength of Evidence = C
*Metrics to consider include the 6-minute walk test and NYHA functional class
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (4.19)
Evaluation—Follow Up AssessmentsRecommended Components of Follow-Up Visits
Signs and symptoms evaluated during initial visit
Functional capacity and activity level
Changes in body weight
Patient understanding of and compliance with dietary sodium restriction and medical regimen
History of arrhythmia, syncope, pre-syncope, palpitation, or ICD discharge
Adherence and response to therapeutic interventions
Exacerbating factors for HF, including worsening ischemic heart disease, hypertension, and new or worsening valvular disease Strength of Evidence = B
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.1, 7.7)
Pharmacologic Therapy: ACE Inhibitors
ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A
ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C
ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.
Post MI Strength of Evidence = B
Non Post-MI Strength of Evidence = C
Adapted from:
ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF
SOLVD Prevention (Asymptomatic LVD)
20% death or HF hosp.
29% death or new HF
CONSENSUS (Severe Heart Failure)
40% mortality at 6 mos.
31% mortality at 1 year
27% mortality at end of study
No difference in incidence of sudden cardiac death
SOLVD Investigators. N Engl J Med 1992;327:685-91SOLVD Investigators. N Engl J Med 1991;325:293-302CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35
(Chronic Heart Failure)SOLVD Treatment
16% mortality
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ACE Inhibitors Used in Clinical Trials
Generic Name Trade Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Captopril Capoten 6.25 mg tid 50 mg tid 122.7 mg/day
Enalapril Vasotec 2.5 mg bid 10 mg bid 16.6 mg/day
Fosinopril Monopril 5-10 mg qd 80 mg qd N/A
Lisinopril Zestril, Prinivil
2.5-5 mg qd 20 mg qd 4.5 mg/day, 33.2 mg/day*
Quinapril Accupril 5 mg bid 80 mg qd N/A
Ramipril Altace 1.25-2.5 mg qd 10 mg qd N/A
Trandolapril Mavik 1 mg qd 4 mg qd N/A
*No mortality difference between high and low dose groups, but 12% lower risk of death or hospitalization in high dose group vs. low dose group.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.2)
Pharmacologic Therapy: Substitutes for ACEI
It is recommended that other therapy be substituted for ACE inhibitors in the following circumstances:
In patients who cannot tolerate ACE inhibitors due to cough, ARBs are recommended. Strength of Evidence = A
The combination of hydralazine and an oral nitrate may be considered in such patients not tolerating ARBs.
Strength of Evidence = C
Patients intolerant to ACE inhibitors from hyperkalemia or renal insufficiency are likely to experience the same side effects with ARBs. In these cases, the combination of hydralazine and an oral nitrate should be considered. Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.6, 7.7)
Pharmacologic Therapy: Beta Blockers
Beta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A
Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.
Post MI Strength of Evidence = B
Non Post-MI Strength of Evidence = C
Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD
Study Drug
HF Severity
Target Dose (mg)
Outcome
US Carvedilol1 carvedilol mild/ moderate
6.25- 25 BID
↓48% disease progression (p= .007)
CIBIS-II2 bisoprolol moderate/ severe
10 QD ↓34% mortality (p <.0001)
MERIT-HF3 metoprolol succinate
mild/ moderate
200 QD ↓34% mortality (p = .0062)
COPERNICUS4 carvedilol severe 25 BID ↓35% mortality (p = .0014)
CAPRICORN5 carvedilol post-MI LVD
25 BID ↓23% mortality (p =.031)
1Colucci WS et al. Circulation 1196;94:2800-6. 2CIBIS II Investigators. Lancet 1999;353:9-13.3MERIT-HF Study Group. Lancet 1999;353:2001-7. 4Packer M et al. N Engl J Med 2001;3441651-8. 5The CAPRICORN Investigators. Lancet 2001;357:1385-90.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.8)
Pharmacologic Therapy: Beta Blockers
RECENT DECOMPENSATION
Beta blocker therapy is recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of IV diuretics and vasoactive agents.
Whenever possible, beta blocker therapy should be initiated in the hospital at a low dose prior to discharge of stable patients. Strength of Evidence = B
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.11)
Pharmacologic Therapy: Beta Blockers
SYMPTOMATIC EXACERBATION
Continuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment, unless they develop cardiogenic shock, refractory volume overload, or symptomatic bradycardia. Strength of Evidence = C
Temporary dose reduction may be considered
Avoid abrupt discontinuation
Reinstate or gradually increase prior to discharge
Titrate dose to previously tolerated dose as soon as possible
Adapted from:
00
00
2020
1010
% o
f P
atie
nts
Wit
h E
ve
nt
% o
f P
atie
nts
Wit
h E
ve
nt
22 44 66 88
CarvedilolCarvedilol
PlaceboPlacebo
HR = 0.67 (CI = 0.47-0.96)HR = 0.67 (CI = 0.47-0.96)
Weeks After RandomizationWeeks After Randomization
3030
Krum et al. JAMA 2003;289
COPERNICUS: Death, Hospitalization, or Study Drug Withdrawal in High Risk Patients
Krum H et al. JAMA 2003;289:754-6
IMPACT-HF Primary End Point:Patients Receiving Beta Blocker at 60 Days
91%
73%
0%
25%
50%
75%
100%
Pat
ient
s
P<.0001
CarvedilolPredischarge Initiation
(n=185)
Physician DiscretionPostdischarge Initiation*
(n=178)
18%18%ImprovementImprovement
Gattis WA et al. JACC 2004;43:1534-41
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.9)
Pharmacologic Therapy: Beta Blockers
CONCOMITANT DISEASE
Beta blocker therapy is recommended in the great majority of patients with HF and reduced LVEF—even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease.
Use with caution in patients with: Diabetes with recurrent hypoglycemia Asthma or resting limb ischemia.
Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).
Not recommended in patients with asthma with active bronchospasm. Strength of Evidence = C
Diabetes and the Use of Beta Blockers for HF: Relative Risk for Mortality and Hospitalization for Heart Failure
0 0.5 1.0 1.5 2.0
COPERNICUS (carvedilol)1
With diabetes
Without diabetes
MERIT-HF (ER metoprolol succinate)2
With diabetes
Without diabetes
Mohacsi. Circulation. 2001;104(17):abstr 3551.
Hjalmarson. JAMA. 2000;283(10):1295.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (11.8, 15.2)
Pharmacologic Therapy: Beta Blockers
PRESERVED LVEF
Beta blocker treatment is recommended in patients with HF and preserved LVEF who have:
Prior MI Strength of Evidence = A
Hypertension Strength of Evidence = B
Atrial fib. requiring control of ventricular rate Strength of Evidence = B
THE ELDERLY
Beta-blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction.
Strength of Evidence = B
In the absence of contraindications, these therapies are also recommended in the very elderly (age > 80 years).
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline
Pharmacologic Therapy: Beta Blocker Overview*
General considerations
Initiate at low doses
Up-titrate gradually, generally no sooner than at 2 week intervals
Use target doses shown to be effective in clinical trials
Aim to achieve target dose in 8-12 weeks
Maintain at maximum tolerated dose
If symptoms worsen or other side effects appear
Adjust dose of diuretic or concomitant vasoactive med.
Continue titration to target after symptoms return to baseline
If up-titration continues to be difficult
Prolong titration interval
Reduce target dose
Consider referral to a HF specialist
*Consult language of specific recommendations
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Beta Blockers Used in Clinical Trials
Generic Name Trade Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Bisoprolol Zebeta 1.25 mg qd 10 mg qd 8.6 mg/day
Carvedilol Coreg 3.125 mg bid 25 mg bid 37 mg/day
Carvedilol Coreg CR 10 mg qd 80 mg qd
Metoprolol succinate CR/XL
Toprol XL 12.5-25 mg qd 200 mg qd 159 mg/day
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.3)
Pharmacologic Therapy: Angiotensin Receptor Blockers
ARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency.
Strength of Evidence = A
ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 27
Val-HeFT
Valsartan
Placebo
p = 0.017
Months
Su
rviv
al %
0
10
20
30
40
50
0 9 18 27 36
CV
Dea
th o
r H
F H
osp
%
Placebo
Candesartan
CHARM-Alternative
HR 0.77, p = 0.0004
Months
Maggioni AP et al. JACC 2002;40:1422-4
Granger CB et al. Lancet 2003;362:772-6
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Angiotensin Receptor Blockers Used in Clinical Trials
Generic Name Trade Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Candesartan Atacand 4-8 mg qd 32 mg qd 24 mg/day
Losartan Cozaar 12.5-25 mg qd 150 mg qd 129 mg/day
Valsartan Diovan 40 mg bid 160 mg bid 254 mg/day
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.14-7.15)
Pharmacologic Therapy: Aldosterone Antagonists
An aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have:
NYHA class IV HF (or class III, previously class IV) HF from
reduced LVEF (≤ 35%)
One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor (or ARB) and a beta blocker.
Adapted from:
Strength of Evidence = A
Aldosterone Antagonists in HF
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 3 6 9 12 15 18 21 24 27 30 33 36
RALES (Advanced HF)
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 3 6 9 12 15 18 21 24 27 30 33 36
EPHESUS (Post-MI)
Spironolactone
Placebo
Months
RR = 0.70P < 0.001
Eplerenone
Placebo
RR = 0.85P < 0.008
Pitt B. N Engl J Med 1999;341:709-17Pitt B. N Engl J Med 2003;348:1309-21
Pro
bab
ility
of
Su
rviv
al
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.16-7.18)
Aldosterone Antagonists and Renal Function
Aldosterone antagonists are not recommended when:
Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
Serum potassium> 5.0 mmol/L
Therapy includes other potassium-sparing diuretics Strength of Evidence = A
It is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 months
Strength of Evidence = A
Supplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.19)
Pharmacologic Therapy:Hydralazine and Oral Nitrates
A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with HF and reduced LVEF: NYHA III or IV HF Strength of Evidence = A
NYHA II HF Strength of Evidence = B
A-HeFT Outcomes
End point
ISDN-HDZN (n=518)
Placebo (n=532)
p
Primary end point composite score
-0.1 -0.5 0.01
All-cause mortality (%) 6.2 10.2 0.02
1st HF hospitalization (%) 16.4 24.4 0.001
Change in quality-of-life score at 6 months**
-5.5 -2.7 0.02
Taylor AL et al. N Engl J Med 2004; 351;2049-57
A-HeFT All-Cause Mortality
85
90
95
100
0 100 200 300 400 500 600
Survival %
Days Since Baseline Visit
43% Decrease in Mortality
Fixed Dose ISDN/HDZN
Placebo
P = 0.01
Taylor AL et al. N Engl J Med 2004;351:2049-57
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.23)
Pharmacologic Therapy: Diuretics
Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by:
Congestive symptoms
Signs of elevated filling pressures Strength of Evidence = A
Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF.
Strength of Evidence = B
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.24)
Pharmacologic Therapy: Diuretics Restoration of normal volume status may require multiple
adjustments.
Once a diuretic effect is achieved with short-acting loop diuretics, increase frequency to 2-3 times a day if necessary, rather than increasing a single dose. Strength of Evidence = B
Oral torsemide may be considered in patients exhibiting poor absorption of oral medication or erratic diuretic effect.
Strength of Evidence = C
IV administration of diuretics may be necessary. Strength of
Evidence = A
Diuretic refractoriness may represent patient nonadherence, a direct effect of diuretic use on the kidney, or progression of underlying dysfunction.
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Loop Diuretics
Agent Initial Daily Dose
Max Total Daily Dose
Elimination: Renal – Met.
Duration of Action
Furosemide 20-40mg qd or bid
600 mg 65%R-35%M 4-6 hrs
Bumetanide 0.5-1.0 mg qd or bid
10 mg 62%R/38%M 6-8 hrs
Torsemide 10-20 mg qd 200 mg 20%R-80%M 12-16 hrs
Ethacrynic acid
25-50 mg qd or bid
200 mg 67%R-33%M 6 hrs
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Potassium-Sparing Diuretics
Agent Initial Daily Dose
Max Total Daily Dose
Elimination Duration of Action
Spironolactone 12.5-25 mg qd
50 mg Metabolic 48-72 hrs
Eplerenone 25-50 mg qd
100 mg Renal, Metabolic
Unknown
Amiloride 5 mg qd 20 mg Renal 24 hrs
Triamterene 50-75 mg bid
200 mg Metabolic 7-9 hrs
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (9.1, 9.4)
Device Therapy:Prophylactic ICD Placement
Prophylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms: Ischemic etiology Strength of Evidence = A
Non-ischemic etiology Strength of Evidence = B
In patients who are undergoing implantation of a biventricular pacing device, use of a device that provides defibrillation should be considered. Strength of Evidence = B
Decisions should be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions, ideally after 3-6 mos. of optimal medical therapy.
Strength of Evidence = C
Adapted from:
MADIT II: Prophylactic ICD in Ischemic LVD (LVEF 30%)
Moss AJ, et al. N Engl J Med. 2002;346;877-883.
365 (.69)170 (.78)329 (.90)490Conventional9110 (.78)274 (.84)503 (.91)742Defibrillator
Number at Risk
0 1 2 3
.7
.8
.9
1.0P
rob
abil
ity
of
Su
rviv
al
ConventionalTherapy
Defibrillator
Year
.6
04
Moss AJ et al. N Engl J Med 2002;346:877-83
ICD Therapy in the SCD-HeFT Trial: Mortality by Intention-to-Treat
HR 97.5% Cl P Value
Amiodarone vs Placebo 1.06 .86-1.30 .53
ICD vs Placebo .77 .62-.96 .007
Months of Follow-Up
Mo
rtal
ity
0 6 12 18 24 30 36 42 48 54 600
.1
.2
.3
.4
Amiodarone
ICD Therapy
Placebo
17%
22%
Bardy GH et al. N Engl J Med 2005;352:225-37
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (9.7)
Device Therapy:Biventricular Pacing
Biventricular pacing therapy is recommended for patients with all of the following:
Sinus rhythm
A widened QRS interval (≥120 ms)
Severe LV systolic dysfunction (LVEF < 35%)
Persistent, moderate-to-severe HF (NYHA III) despite optimal medical therapy.
Strength of Evidence = A
CRT Improves Quality of Life and
NYHA Functional ClassAverage Change in Score
(MLWHF)
-20
-15
-10
-5
0
Control CRT
* * * *
*P<.05
NYHA: Proportion Improving by 1 or More Class
0
20
40
60
80
MIRACLE CONTAKCD
MIRACLEICD
Control CRT
**
*
(%)
Abraham WT et al. Circulation 2003;108:2596-603
CRT in Patients with Advanced HF and a Prolonged QRS Interval: COMPANION
Bristow MR et al. N Engl J Med 2004;350:2140-50
Primary End Point: All-Cause Mortality
Death or Hospitalization Due to HF
Risk of all-cause mortality reduced by 19%in group with CRT and ICD (p =.014)Risk of death or hospitalization from HFreduced by 34% in ICD group and by 40% inICD-CRT group (p < .001)
Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF
571192321365404Medical Therapy
889213351376409CRT
Number at risk
0 500 1,000 1,500
25
50
75
100
% E
ve
nt-
Fre
e S
urv
ival
Medical Therapy
CRT
Days
0
HR = 0.64 (95% CI = .48-.85)p = .0019
Cleland JG et al. N Engl J Med 2005;352:1539-49
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (11.1-11.2)
HF with Preserved LVEF—Diagnosis
Careful attention to differential diagnosis is recommended in patients with HF and preserved LVEF.
Treatments may differ based on cardiac disorder.
Evaluation for ischemic disease and inducible myocardial ischemia should be included.
Recommended diagnostic tools:
Echocardiography
Electrocardiography
Stress imaging (via exercise or pharmacologic means, using myocardial perfusion or echocardiographic imaging)
Cardiac catheterization
Adapted from:
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Figure 11.3. Diagnostic Algorithmfor HF with Preserved LVEF
HF with Preserved LVEF
Dilated LV Non-dilated LV
Valvular diseaseAR, MR
No valvular dis.High output HF
Increasedthickness
NormalThickness
Right vent.dysfunction
Pulmonaryhypertension
Isolated pre-dominant RVMI
No mitralobstruction
Mitral obstructionMS, atrial myxoma
Pericardial dis.Tamponade Constriction
No pericardial disease
Inducible ischemiaIntermittent/active
ischemia
Normal or increased QRS
Hypertrophic dis.
Low QRS voltageInfiltrative myopathy
No aortic valve disease
Aortic valve dis.Aortic stenosis
No hypertensive history of PE
HCM, Fabry dis.
Hypertensive history of PE
Hypertensive-HCM
Some patients with RV dysfunction have LV dysfunction due to ventricular interaction.
No inducible ischemia, fibrotic, collagen-Vascular, RCM, cardinoid, diabetes,Radiation or chemotherapy induced heart disease, infiltrative disease, co-morbid conditions, reconsider diagnosisof HF
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (12.3, Table 12.3) Acute Decompensated Heart Failure (ADHF)—
Treatment Goals for Hospitalized Patients
• Improve symptoms, especially congestion and low-output symptoms
• Optimize volume status
• Identify etiology
• Identify precipitating factors
• Optimize chronic oral therapy; minimize side effects
• Identify who might benefit from revascularization
• Education patients concerning medication and HF self-assessment
• Consider enrollment in a disease management program
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (12.5-12.20) Overview of Treatment Options for Patients with
Acute Decompensated HF
Fluid and sodium restriction
Diuretics, especially loop diuretics
Ultrafiltration/renal replacement therapy (in selected patients only)
Parenteral vasodilators * (nitroglycerin, nitroprusside, nesiritide)
Inotropes * (milrinone or dobutamine)*See recommendations for stipulations and restrictions.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (12.25, Table 12.7)Discharge Criteria for Hospitalized ADHF Patients
Recommended prior to discharge for all patients with HF:
Exacerbating factors addressed
Near optimum fluid status and pharmacologic therapy achieved
Transition from IV to oral diuretic completed
Patient education completed with clear discharge instructions
Follow-up clinic visit scheduled, usually 7-10 days
Should be considered prior to discharge for patients with advanced HF or a history of recurrent admissions:
Oral regimen stable for 24 hours
No IV inotrope or vasodilator for 24 hours
Ambulation before discharge to assess functional capacity
Plans for post-discharge management
Referral for disease management, if available
Strength of Evidence =C
Adapted from:
Predictors of Mortality Based on Analysis of ADHERE Database
Classification and Regression Tree (CART) analysis of ADHERE data shows:
Three variables are the strongest predictors of mortality in hospitalized ADHF patients:
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
Fonarow GC et al. JAMA 2005;293:572-80
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (8.1)
Heart Failure Patient Education
It is recommended that patients with HF and their family members or caregivers receive individualized education and counseling that emphasizes self-care.
This education and counseling should be delivered by providers using a team approach.
Teaching should include skill building and target behaviors.
Strength of Evidence = B
Adapted from:
The Potential Impact of Effective Education on Patient Compliance
Nonadherence rate when patients . . .
Recall MD advice Don’t recall advice
Medications 8.7% 66.7%
Diet 23.6% 55.8%
Activity 76.4% 84.5%
Smoking 60.0% 90.4%
Alcohol 60.0% 81.8%
Kravitz et al. Arch Int Med 1993;153:1869-78
Sample Target Behavior: Be Able to Read and Understand Food Labels
Labels from cups of soup
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (8.7)
Heart Failure Disease Management
Patients recently hospitalized for HF and other patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care.
Strength of Evidence = A
Adapted from:
HF Disease Management and the Risk of Readmission
Cline
J aarsma
Rich
Naylor
Stewart
Rauh
Lasater
Ekman
Venner
Fonarow0.5
0.6
0.7
0.8
0.9
1
1.1
RiskRatio
Summary RR = 0.76 (95% CI .68-.87)Summary RR for randomized only = 0.75 (CI = .60-.95)
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (8.13)
End-of-Life Care in Heart Failure
End-of-life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic, device, and other therapies, as evidenced by one or more of the following:
HF hospitalization Strength of Evidence = C
Chronic poor quality of life with inability to accomplish activities of daily living
Strength of Evidence = C
Need for continuous IV inotropic therapy support Strength of Evidence = C
Evidence-Based Treatment Across the Continuum of Systolic LVD and HF
Control Volume Improve Clinical Outcomes
DiureticsRenal ReplacementTherapy*
Digoxin
-BlockerACEIor ARB
AldosteroneAntagonist
or ARB
Treat Residual Symptoms
CRT an ICD*
HDZN/ISDN**In selected patients