Transcript ACC Heart Failure Guideline Slide Set

ACC Heart Failure Guidelines
Slide Deck
Based on the ACC/AHA 2005 Guideline Update
for the Diagnosis and Management of
Chronic Heart Failure in the Adult
January 2006
Supported by Medtronic, Inc.
Medtronic, Inc. was not involved in the development of this
slide deck and in no way influenced its contents.
ACC/AHA 2005 Guideline Update for the
Management of Patients With Chronic Heart
Failure in the Adult
Writing Committee Members
Sharon Ann Hunt, MD, FACC, FAHA, Chair
William T. Abraham, MD, FACC, FAHA
Donna M. Mancini, MD
Marshall H. Chin, MD, MPH, FACP
Keith Michl, MD, FACP
Arthur M. Feldman, MD, PhD, FACC,
FAHA
John A. Oates, MD, FAHA
Gary S. Francis, MD, FACC, FAHA
Theodore G. Ganiats, MD
Peter S. Rahko, MD, FACC, FAHA
Marc A. Silver, MD, FACC, FAHA
Mariell Jessup, MD, FACC, FAHA
Lynne Warner Stevenson, MD, FACC,
FAHA
Marvin A. Konstam, MD, FACC
Clyde W. Yancy, MD, FACC, FAHA
Applying Classification of
Recommendations and Level of Evidence
Class I
Class IIa
Class IIb
Class III
Benefit >>> Risk
Benefit >> Risk
Additional studies with
focused objectives
needed
Benefit ≥ Risk
Additional studies with
broad objectives
needed; Additional
registry data would be
helpful
Risk ≥ Benefit
No additional studies
needed
Procedure/ Treatment
SHOULD be
performed/
administered
IT IS REASONABLE to
perform
procedure/administer
treatment
should
is recommended
is indicated
is useful/effective/
beneficial
is reasonable
can be useful/effective/
beneficial
is probably recommended
or indicated
Procedure/Treatment
MAY BE CONSIDERED
may/might be considered
may/might be reasonable
usefulness/effectiveness is
unknown
/unclear/uncertain or not
well established
Procedure/Treatment
should NOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY BE
HARMFUL
is not recommended
is not indicated
should not
is not
useful/effective/beneficial
may be harmful
Applying Classification of
Recommendations and Level of Evidence
Level A
Multiple (3-5)
population risk
strata
evaluated
General
consistency of
direction and
magnitude of
effect
Class I
Class IIa
• Recommendation that
procedure or
treatment is
useful/
effective
• Sufficient
evidence
from multiple
randomized
trials or
metaanalyses
• Recommendation in
favor of
treatment or
procedure
being useful/
effective
• Some
conflicting
evidence
from multiple
randomized
trials or metaanalyses
Class IIb
Class III
• Recommen• Recommendation’s
dation that
usefulness/
procedure or
efficacy less
treatment not
well
useful/effectiv
established
e and may be
• Greater
harmful
conflicting
• Sufficient
evidence from evidence from
multiple
multiple
randomized
randomized
trials or metatrials or metaanalyses
analyses
Applying Classification of
Recommendations and Level of Evidence
Level B
Limited (2-3)
population risk
strata
evaluated
Class I
• Recommendation that
procedure or
treatment is
useful/effecti
ve
• Limited
evidence
from single
randomized
trial or nonrandomized
studies
Class IIa
Class IIb
• Recommen• Recommendation’s
dation in favor
of treatment or usefulness/
efficacy less
procedure
well
being useful/
established
effective
• Greater
• Some
conflicting
conflicting
evidence from
evidence from
single
single
randomized
randomized
trial or nontrial or nonrandomized
randomized
studies
studies
Class III
• Recommendation that
procedure or
treatment not
useful/effectiv
e and may be
harmful
• Limited
evidence from
single
randomized
trial or nonrandomized
studies
Applying Classification of
Recommendations and Level of Evidence
Level C
Very limited (12) population
risk strata
evaluated
Class I
• Recommendation that
procedure or
treatment is
useful/
effective
• Only expert
opinion, case
studies, or
standard-ofcare
Class IIa
Class IIb
Class III
• Recommen• Recommen• Recommenddation in favor
dation’s
ation that
of treatment or
usefulness/
procedure or
procedure
efficacy less
treatment not
being
well
useful/effectiv
established
useful/effectiv
e and may be
e
harmful
• Only diverging
• Only diverging
expert opinion, • Only expert
expert opinion,
case studies,
opinion, case
case studies,
or standard-ofstudies, or
or standard-ofcare
standard-ofcare
care
Heart Failure is a Major and Growing Public
Health Problem in the U.S.

Approximately 5 million patients in this country have
HF

Over 550,000 patients are diagnosed with HF for the
first time each year

Primary reason for 12 to 15 million office visits and
6.5 million hospital days each year

In 2001, nearly 53,000 patients died of HF as a
primary cause
Heart Failure is Primarily a
Condition of the Elderly

The incidence of HF approaches 10 per 1000
population after age 65

HF is the most common Medicare diagnosisrelated group

More dollars are spent for the diagnosis and
treatment of HF than any other diagnosis by
Medicare
Guideline Scope
Document focuses on :

Prevention of HF

Diagnosis and management of
chronic HF in the adult
Definition of Heart Failure
HF is a complex clinical syndrome that can
result from any structural or functional
cardiac disorder that impairs the ability of
the ventricle to fill with or eject blood.
“Heart Failure” vs. “Congestive Heart Failure”
Because not all patients have volume overload at
the time of initial or subsequent evaluation, the
term “heart failure” is preferred over the older
term “congestive heart failure.”
Causes of HF in Western World
For a substantial proportion of patients,
causes are:
1.
Coronary artery disease
2.
Hypertension
3.
Dilated cardiomyopathy
Stages of Heart Failure
At Risk for 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
Stages of Heart Failure
• Designed to emphasize preventability of HF
• Designed to recognize the progressive
nature of LV dysfunction
Stages of Heart Failure
COMPLEMENT, DO NOT REPLACE NYHA
CLASSES
•
NYHA Classes - shift back/forth in individual
patient (in response to Rx and/or progression of
disease)
•
Stages - progress in one direction due to cardiac
remodeling
Stage A
Patients at High Risk for
Developing Heart Failure
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)
Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
I IIa IIb III
In patients at high risk for developing HF,
systolic and diastolic hypertension should be
controlled in accordance with contemporary
guidelines.
I IIa IIb III
In patients at high risk for developing HF, lipid
disorders should be treated in accordance
with contemporary guidelines.
Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
I IIa IIb III
In patients at high risk for developing HF who
have known atherosclerotic vascular disease,
healthcare providers should follow current
guidelines for secondary prevention.
I IIa IIb III
For patients with diabetes mellitus (who are all
at high risk for developing HF), blood sugar
should be controlled in accordance with
contemporary guidelines.
Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
I IIa IIb III
Thyroid disorders should be treated in
accordance with contemporary guidelines in
patients at high risk for developing HF.
Stage A Therapy
Avoiding Behaviors That
Increase Risk
I IIa IIb III
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).
Stage A Therapy
Periodic Evaluation for
Signs and Symptoms
I IIa IIb III
Healthcare providers should perform periodic
evaluation for signs and symptoms of HF in
patients at high risk for developing HF.
Stage A Therapy
Ventricular Rate Control or Sinus
Rhythm Restoration
I IIa IIb III
Ventricular rate should be controlled or sinus
rhythm restored in patients with
supraventricular tachyarrhythmias who are at
high risk for developing HF.
Stage A Therapy
Noninvasive Evaluation of
LV Function
I IIa IIb III
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.
Stage A Therapy
Angiotensin Converting Enzyme
Inhibitors (ACEI)
I IIa IIb III
ACEI 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.
Stage A Therapy
Angiotension Receptor Blockers
(ARBs)
I IIa IIb III
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.
Stage A Therapy
Therapies NOT Recommended
I IIa IIb III
Routine use of nutritional supplements solely
to prevent the development of structural heart
disease should not be recommended for
patients at high risk for developing HF.
Stage B
Patients with Asymptomatic
LV Dysfunction
Stage B Therapy
Recommended Therapies:
General Measures as advised for Stage A
•Drug therapy for all patients
•ACEI or ARBs
•Beta-Blockers
•ICDs in appropriate patients
•Coronary revascularization in appropriate patients
•Valve replacement or repair in appropriate patients
Stage B Therapy
General Measures
I IIa IIb III
All Class I recommendations for Stage A
should apply to patients with cardiac
structural abnormalities who have not
developed HF. (Levels of Evidence: A, B, and
C as appropriate)
I IIa IIb III
Patients who have not developed HF
symptoms should be treated according to
contemporary guidelines after an acute MI.
Stage B Therapy
Angiotensin Converting Enzyme
Inhibitors (ACEI)
I IIa IIb III
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.
I IIa IIb III
ACEI should be used in patients with a reduced EF
and no symptoms of HF, even if they have not
experienced MI.
I IIa IIb III
ACEI or ARBs can be beneficial in patients with
hypertension and LVH and no symptoms of HF.
Stage B Therapy
Angiotensin Receptor Blockers
(ARBs)
I IIa IIb III
An ARB should be administered to post-MI patients
without HF who are intolerant of ACEIs and have a
low LVEF.
I IIa IIb III
I IIa IIb III
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.
Stage B Therapy
Beta-Blockers
I IIa IIb III
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.
I IIa IIb III
Beta-blockers are indicated in all patients
without a history of MI who have a reduced
LVEF with no HF symptoms.
Stage B Therapy
Internal Cardioverter Defibrillator (ICD)
I IIa IIb III
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.
I IIa IIb III
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 in
NYHA functional class I with chronic optimal medical
therapy and have a reasonable expectation of survival
with good functional status for more than 1 year.
Stage B Therapy
Coronary Revascularization
I IIa IIb III
Coronary revascularization should be
recommended in appropriate patients
without symptoms of HF in accordance
with contemporary guidelines (see
ACC/AHA Guidelines for the Management
of Patients With Chronic Stable Angina).
Stage B Therapy
Valve Replacement/Repair
I IIa IIb III
Valve replacement or repair should be
recommended for patients with
hemodynamically significant valvular
stenosis or regurgitation and no
symptoms of HF in accordance with
contemporary guidelines.
Stage B Therapy
Therapies NOT Recommended
I IIa IIb III
I IIa IIb III
I IIa IIb III
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 inotropic
effects may be harmful in asymptomatic patients
with low LVEF and no symptoms of HF after MI.
Stage C
Patients with Past or Current
Symptoms of Heart Failure
Stage C Therapy
(Reduced LVEF with Symptoms)
Recommended Therapies:
•General measures as advised for Stages A and B
•Drug therapy for all patients
•Diuretics for fluid retention
•ACEI
•Beta-blockers
•Drug therapy for selected patients
•Aldosterone Antagonists
•ARBs
•Digitalis
•Hydralazine/nitrates
•ICDs in appropriate patients
•Cardiac resynchronization in appropriate patients
•Exercise Testing and Training
Stage C Therapy
(Reduced LVEF with Symptoms)
General Measures
I IIa IIb III
Measures listed as Class I recommendations for
patients in stages A and B are also appropriate for
patients in Stage C. (Levels of Evidence: A, B, and C as
appropriate)
I IIa IIb III
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 calcium
channel blocking drugs).
Stage C Therapy
(Reduced LVEF with Symptoms)
Diuretics
I IIa IIb III
Diuretics and salt restriction are indicated in
patients with current or prior symptoms of HF
and reduced LVEF who have evidence of fluid
retention.
Stage C Therapy
(Reduced LVEF with Symptoms)
Angiotensin Enzyme Converting
Inhibitors (ACEIs)
I IIa IIb III
ACEIs are recommended for all patients with
current or prior symptoms of HF and reduced
LVEF, unless contraindicated.
I IIa IIb III
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.
Stage C Therapy
(Reduced LVEF with Symptoms)
Angiotensin Receptor Blockers (ARBs)
I IIa IIb III
ARBs approved for the treatment of HF are
recommended in patients with current or prior
symptoms of HF and reduced LVEF who are ACEIintolerant (see full text guidelines for information
regarding patients with angioedema).
I IIa IIb III
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.
Stage C Therapy
(Reduced LVEF with Symptoms)
ARBs (cont’d)
I IIa IIb III
I IIa IIb III
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.
Stage C Therapy
(Reduced LVEF with Symptoms)
Aldosterone Antagonists
I IIa IIb III
I IIa IIb III
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.
Stage C Therapy
(Reduced LVEF with Symptoms)
Beta-Blockers
I IIa IIb III
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.
Stage C Therapy
(Reduced LVEF with Symptoms)
Digitalis
I IIa IIb III
Digitalis can be beneficial in patients with
current or prior symptoms of HF and reduced
LVEF to decrease hospitalizations for HF.
Stage C Therapy
(Reduced LVEF with Symptoms)
Hydralazine and Isosorbide Dinitrate
I IIa IIb III
I IIa IIb III
The addition of a combination of hydralazine and a
nitrate is reasonable for patients with reduced
LVEF who are already taking an ACEI and betablocker for symptomatic HF and who have
persistent symptoms.
A combination of hydralazine and a nitrate might be
reasonable in patients with current or prior
symptoms of HF and reduced LVEF who cannot be
given an ACEI or ARB because of drug intolerance,
hypotension, or renal insufficiency.
Stage C Therapy
(Reduced LVEF with Symptoms)
Implantable CardioverterDefibrillators (ICDs)
I IIa IIb III
I IIa IIb III
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.
Stage C Therapy
(Reduced LVEF with Symptoms)
ICDs (cont’d)
I IIa IIb III
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 undergoing
chronic optimal medical therapy, and who have
reasonable expectation of survival with a good functional
status for more than 1 year.
I IIa IIb III
Placement of an ICD is reasonable in patients with LVEF
of 30% to 35% of any origin with NYHA functional class II
or 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.
Stage C Therapy
(Reduced LVEF with Symptoms)
Cardiac Resynchronization
I IIa IIb III
Patients with LVEF less than or equal to 35%, sinus
rhythm, and NYHA functional class III or ambulatory
class IV symptoms despite recommended, optimal
medical 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.
Stage C Therapy
(Reduced LVEF with Symptoms)
Exercise Testing and Training
I IIa IIb III
Maximal exercise testing with or without
measurement of respiratory gas exchange is
recommended to facilitate prescription of an
appropriate exercise program for patients
presenting with HF.
I IIa IIb III
Exercise training is beneficial as an adjunctive
approach to improve clinical status in ambulatory
patients with current or prior symptoms of HF and
reduced LVEF.
Stage C Therapy
(Reduced LVEF with Symptoms)
Unproven/Not Recommended
Drugs and Interventions for HF
• Nutritional Supplements
• Hormonal Therapies
• Intermittent Intravenous
Positive Inotropic Therapy
Stage C Therapy
(Reduced LVEF with Symptoms)
Unproven/Not Recommended Drugs and Interventions
I IIa IIb III
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 with
end-stage disease who cannot be stabilized with
standard medical treatment (see recommendations
for Stage D).
I IIa IIb III
Use of nutritional supplements as treatment for HF
is not indicated in patients with current or prior
symptoms of HF and reduced LVEF.
Stage C Therapy
(Reduced LVEF with Symptoms)
Unproven/Not Recommended Drugs and Interventions
I IIa IIb III
Calcium channel blocking drugs are not indicated as
routine treatment for HF in patients with current or
prior symptoms of HF and reduced LVEF.
I IIa IIb III
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.
I IIa IIb III
Routine combined use of an ACEI, ARB, and
aldosterone antagonist is not recommended for
patientswith current or prior symptoms of HF and
reduced LVEF.
Stage C Therapy
(Normal LVEF with Symptoms)
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 •Diuretics
•Drugs for appropriate patients –
•ACEI
•ARBs
•Beta-Blockers
•Digitalis
•Coronary revascularization in selected patients
•Restoration/maintenance of sinus rhythm in
appropriate patients
Differential Diagnosis in Patient with HF and
Normal LVEF with Symptoms
• Incorrect diagnosis of HF
• Inaccurate measurement of
LVEF
• Primary valvular disease
• Restrictive (infiltrative)
cardiomyopathies
• Amyloidosis, sarcoidosis,
hemochromatosis
• Pericardial constriction
• Episodic or reversible LV
systolic dysfunction
• Severe hypertension,
myocardial ischemia
• HF associated with high
metabolic demand (highoutput states)
• Anemia, thyrotoxicosis,
arteriovenous fistulae
• Chronic pulmonary
disease with right HF
• Pulmonary hypertension
associated with
pulmonary vascular
disorders
• Atrial myxoma
• Diastolic dysfunction of
uncertain origin
• Obesity
Stage C Therapy
(Normal LVEF with Symptoms)
Treating known risk factors Hypertension
I IIa IIb III
Physicians should control systolic and
diastolic hypertension in patients with HF and
normal LVEF, in accordance with published
guidelines.
Stage C Therapy
(Normal LVEF with Symptoms)
Ventricular Rate Control
I IIa IIb III
Physicians should control ventricular rate in
patients with HF and normal LVEF and atrial
fibrillation.
Stage C Therapy
(Normal LVEF with Symptoms)
Diuretics
I IIa IIb III
Physicians should use diuretics to control
pulmonary congestion and peripheral edema in
patients with HF and normal LVEF.
Stage C Therapy
(Normal LVEF with Symptoms)
Coronary Revascularization
I IIa IIb III
Coronary revascularization is reasonable in
patients with HF and normal LVEF and
coronary artery disease in whom symptomatic
or demonstrable myocardial ischemia is
judged to be having an adverse effect on
cardiac function.
Stage C Therapy
(Normal LVEF with Symptoms)
Restoration/Maintenance
of Sinus Rhythm
I IIa IIb III
Restoration and maintenance of sinus rhythm
in patients with atrial fibrillation and HF and
normal LVEF might be useful to improve
symptoms.
Stage C Therapy
(Normal LVEF with Symptoms)
Angiotensin Enzyme Converting
Inhibitors (ACEIs)
I IIa IIb III
The use of beta-adrenergic blocking agents, ACEIs,
ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF.
Stage C Therapy
(Normal LVEF with Symptoms)
Angiotensin Receptor Blockers (ARBs)
I IIa IIb III
The use of beta-adrenergic blocking agents, ACEIs,
ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF.
Stage C Therapy
(Normal LVEF with Symptoms)
Beta-Blockers
I IIa IIb III
The use of beta-adrenergic blocking agents, ACEIs,
ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF.
Stage C Therapy
(Normal LVEF with Symptoms)
Digitalis
I IIa IIb III
The usefulness of digitalis to minimize
symptoms of HF in patients with HF and normal
LVEF is not well established.
Stage D
Patients with Refractory End-Stage HF
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 patients
•Surgical therapy –
•Cardiac transplantation
•Mitral valve repair or replacement
•Other
•Drug Therapy –
•Positive inotrope infusion as palliation
in appropriate patients
Stage D Therapy
Control of Fluid
Retention
I IIa IIb III
Meticulous identification and control of fluid
retention is recommended in patients with
refractory end-stage HF.
Stage D Therapy
Referral to an HF Program
I IIa IIb III
Referral of patients with refractory end-stage
HF to an HF program with expertise in the
management of refractory HF is useful.
Stage D Therapy
Discussion of Options for
End-of-Life Care
I IIa IIb III
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.
Stage D Therapy
Inform on option to
inactivate defibrillation
I IIa IIb III
Patients with refractory end-stage HF and
implantable defibrillators should receive
information about the option to inactivate
defibrillation.
Stage D Therapy
Surgical Therapy
I IIa IIb III
Referral for cardiac transplantation in
potentially eligible patients is recommended for
patients with refractory end-stage HF.
I IIa IIb III
The effectiveness of mitral valve repair or
replacement is not established for severe
secondary mitral regurgitation in refractory
end-stage HF.
Stage D Therapy
Device Use
I IIa IIb III
I IIa IIb III
Consideration of an LV assist device as
permanentor “destination” therapy is
reasonable in highly selected patients with
refractory end-stage HF and an estimated
1-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 severe
symptoms.
Stage D Therapy
Medical Therapy
I IIa IIb III
Continuous intravenous infusion of a positive
inotropic agent may be considered for
palliation of symptoms in patients with
refractory end-stage HF.
I IIa IIb III
Routine intermittent infusions of positive
inotropic agents are not recommended for
patients with refractory end-stage HF.
Stage D Therapy
Therapies NOT Recommended
I IIa IIb III
I IIa IIb III
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
patients with refractory end-stage HF.