Transcript ACC/AHA 2005 Guideline Update for the Diagnosis and

ACC/AHA 2005 Guideline Update
for the Diagnosis and
Management of Chronic Heart
Failure in the adult
Sandra Rodriguez
Internal Medicine
TTUHSC
Introduction
Approximately 5 million patients in this
country have Heart Failure (HF)
550 000 are diagnosed annually with HF
The incidence has been increasing
– due to salvage of patients with Myocardial
Infarction (MI)
– due to better treatments
– due to recognition of HF with normal ejection
fraction (EF)
Death is about 40% at 5 years
– although has decreased in the last decade
Introduction
About 80% of patients hospitalized
with HF are more than 65 years old
Heart failure is the most common
Medicare hospital discharge
diagnosis
Educating patients regarding
diagnosis and prognosis is important
in helping them plan for their future
and is a crucial part of management
Definition of Heart Failure
Progressive clinical syndrome
characterized by specific symptoms in the
medical history and signs on the physical
examination.
Starts with cardiac remodeling and
progresses to impaired ability of the
ventricle to fill with or eject blood.
CAD, HTN, dilated cardiomyopathy and
valvular heart disease are the causes of
HF in most of the patients.
Classification of HF
At risk for heart failure
– Stage A: Patients with risk factors for
development of HF
Coronary artery disease (CAD, 2/3 of HF
patients)
Hypertension (HTN)
Diabetes Mellitus (DM)
Normal left ventricular (LV) function
– Stage B: Patients asymptomatic but
with LV hypertrophy (LVH) and/or
impaired LV function
Classification of HF
Heart Failure
– Stage C: Patients with current or past
symptoms of HF associated with
underlying structural disease
– Stage D: Patients with refractory HF
NYHA will be used for subjective
functional assessment of patients in
stages C and D
Classification of Heart Failure
Discordance between EF and
functional impairment
Ventricular distensibility
Valvular regurgitation
Pericardial restrain
Cardiac rhythm
Conduction abnormalities
Right Ventricular function
Pulmonary dynamics
Peripheral vascular resistance
Renal sodium handling
Neurohormonal and reflex autonomic
activity
Initial Clinical Assessment of HF
Class I
1. A thorough H & P to identify cardiac and
noncardiac disorders or behaviors that might
cause or accelerate HF
• Jugular venous distention and S3 are prognostic
2. Document history or current use of alcohol,
illicit drugs, alternative therapies,
chemotherapy drugs, family history of
cardiomyopathy
3. Assess Activities of daily living
4. Assess volume status, weight, BMI, BP
5. Laboratory evaluation, electrocardiogram and
chest radiograph
Initial Clinical Assessment of HF
Class I (continued)
6. Echocardiogram with Doppler
7. Radionuclide ventriculography
• provide highly accurate measurements of
LV and RV ejection fractions
8. Angiogram if angina or significant
ischemia in patients with impaired
ventricular function
9. Revascularization
• if significant ischemic chest pain or large
areas of ischemia
• left main disease in patients without chest
pain
Initial Clinical Assessment of HF
Class IIa
1. Angiogram if chest pain typical or atypical
that has not been evaluated before because
revascularization will be indicated if large
coronary disease is found
2. Angiogram if patient has known or suspected
CAD without angina
3. Noninvasive imaging to detect ischemia and
viability is reasonable
4. Maximal exercise testing w or w/o
measurement of respiratory gas exchange to
determine if dyspnea is secondary to HF
Initial Clinical Assessment of HF
Class IIa (continued)
5. Maximal exercise testing with gas exchange
to identify candidates for cardiac transplant
6. Screening for hemochromatosis, OSA, HIV,
rheumatologic diseases, amyloidosis, or
pheochromocytoma, Chagas
7. Endomyocardial biopsy if would influence
therapy
8. N-proBNP in whom clinical diagnosis is
uncertain
Initial Clinical Assessment of HF
Class IIb
1. In young patients with HF due to LV
dysfunction who do not have chest pain or
history of CAD, angiogram is reasonable to
exclude congenital coronary abnormalities
2. Noninvasive imaging to define the likelihood
of CAD in patients with HF and LV dysfunction
3. Holter monitoring if history of MI with HF to
document VT
4. CAD should be excluded whenever possible,
in DM or other states associated to silent
myocardial ischemia
Serial Clinical Assessment of HF
Class I
1. Assess ability to perform routine and
desired ADL’s, NYHA functional class
2. Volume status and weight
3. Diet and sodium intake, alcohol,
tobacco, illicit drugs, “alternative
therapies”, chemotherapy drugs
Serial Clinical Assessment of HF
Class IIa
– Repeat EF in patients with change in clinical
status or who have experienced event or
received treatment that might have a
significant effect on cardiac function
– Six minutes walk distance may have
prognostic significance and may help to assess
level of impairment
Class IIb
– Serial BNP’s to guide therapy not well
established
Prognostic variables
Decreasing LVEF.
Worsening NYHA functional status.
Hyponatremia.
Decreased peak exercise O2 uptake.
Anemia.
Wide QRS.
Chronic hypotension.
Resting tachycardia.
Renal Insuficiency.
Refractory volume overload.
BNP levels inpatient may predict readmission and
death, and adverse events after MI.
Therapy for Stage A
Class I
– Systolic and diastolic HTN control
following JNC guidelines
It decreases risk of new HF by 50% in any
patient, and by 81% in patients who had
prior MI
The consequent LVH is an independent CV
risk factor as is age or SBP predicting MI,
stroke, sudden death or HF. (ALLHAT,
Fragmingham, SHEP)
– Lipid disorders control
Reduces likelihood of death and of HF in
patients with history of MI. (CARE, LIPID)
Therapy for Stage A
Class I (continued)
– DM control
DM modestly increases risk of HF for men, and
increases relative risk in women more than 3-fold
Microalbuminuria greater than 200 mg/dl is
associated with HF development and death. (SOLVD,
HOPE)
– Metabolic syndrome
Any 3 of abdominal adiposity, hypertriglyceridemia,
low HDL, HTN, and fasting hyperglycemia
Prevalence exceed 40% of population older than 40
years of age
Obesity and insulin resistance are important risk
factors for the development of HF
Therapy for Stage A
Class I (continued)
– Tobacco, amphetamines and illicit drugs
cessation and alcohol moderate use
– Ventricular rate control or sinus rhythm
restoration
– Thyroid disorders treatment
– Secondary atherosclerotic disease
prevention
ACEI now class IIa due to failure to find
significant reduction in new onset HF in
patients with CVD
Therapy for Stage A
Class IIa:
– ACE Inhibitors to prevent HF in patients
with history of atherosclerotic disease,
DM, or HTN. Level A
– ARB to prevent HF in patient with
history of atherosclerotic disease, DM or
HTN. Level C.
Therapy for Stage B
Class I: All for Stage A plus:
– BB and ACEI for all post MI patients reduces
the risk of reinfarction or death when initiated
even days or weeks after the event
(CAPRICORN, AIRE, SAVE, ISIS-4)
– BB and ACEI for all reduced LVEF patients
regardless history of MI or HF symptoms
– Long term ACEI delay onset of HF symptoms
and decrease the risk of death and
hospitalization for HF in asymptomatic patients
with reduced LVEF due or not to MI (SOLVD,
FEST)
– Use the BB that were employed in the large HF
trials.
Therapy for Stage B
Class I: All for Stage A plus (continued):
– ARB post-MI if ACEI intolerant
– Revascularization even w/o symptoms in
patients with reduced LVEF (CASS)
– Valvular repair should be considered if severe
aortic or mitral valve stenosis or regurgitation
regardless of symptoms and even when VF is
impaired
– In severe AR hydralazine and nifedipine might
delay need for surgery but doesn’t reduce
death or risk of HF
Therapy for Stage B
Class IIa:
– ACEI or ARB in HTN with LVH (LIFE)
– ICD in ischemic CMP, at least 40 days post-MI,
with EF 30% or less, on optimal medical
therapy, NYHA class I, with more than 1 year
of expected survival (MADIT-II)
Class IIb:
– ICD in nonischemic CMP, with EF 30% or less,
NYHA class I, on optimal medical therapy, with
more than 1 year of expected survival
Therapy for Stage C
With reduced LVEF:
– Class I recommendations
Measures as for Stages A and B
Diuretics and salt restriction
ACEI in all patients, unless contraindicated,
captopril, enalapril, fosinopril, quinapril
(CONSENSUS, ATLAS)
BB: Bisoprolol, carvedilol, or SR metoprolol
in all patients, unless contraindicated
(CIBIS, COMET, CAPRICORN, IMPACT,
MERIT-HF)
Therapy for Stage C
With reduced LVEF:
–Class I recommendations:
ARB: Candesartan or valsartan (CHARM,
Val-HeFT)
Discontinue NSAID’s, most antiarrhymic
drugs (CAST, PROMISE, SWORD, CHFSTAT), and most calcium channel blockers
Maximal exercise testing to guide exercise
program
Exercise training
ICD if history of cardiac arrest, VF, or
unstable VT
Therapy for Stage C
With reduced LVEF:
– Class I recommendations:
ICD in nonischemic cardiomyopathy, EF 30% or less,
NYHA II or III on optimal therapy, >1yr life
expectancy
CRT in pts with QRS wider than 120msecs, with EF
35% or less, sinus rhythm and NYHA III or IV in spite
of optimal medical therapy (MIRACLE)
Aldosterone antagonist if Cr 2.5 mg/dl or less in men,
2.0 or less in women, and potassium less than 5.0
mEq/L
– 30% relative risk death reduction in heart failure
– 35% reduction in heart failure hospitalization when
added to ACEI therapy for patients Class III or
IV(RALES).
Therapy for Stage C
With reduced LV function:
– Class IIa:
ARB as alternative for ACEI as first line therapy
(CHARM, STRETCH)
Digitalis can decrease hospitalizations for HF
(PROVED, RADIANCE)
Hydralazine and nitrate if persistent symptoms after
ACEI and BB
ICD if EF 30 to 35% of any origen, NYHA II or III
– Class IIb:
Hydralazine and nitrate in patients intolerant to ACEI
or ARB’s
Addition of and ARB to conventional therapy
(RESOLVED)
Board-type Questions
The only antiarrhythmic agents that
have not shown to decrease
survival are:
1.
2.
3.
4.
Amiodarone and milrinone
Procainamide and milrinone
Propafenone and flecainide
Amiodarone and dofetilide
Board-type Questions
Which is the only false statement
regarding diuretics:
1. Produce symptomatic benefit more
rapidly than any other HF drug.
2. Are the only drugs that can adequately
control fluid retention.
3. Should be used with an ACEI or ARB
plus BB in most patients with HF.
4. Decrease morbidity and mortality.
Board-type Question
Of the following recommendations for HF
which have demonstrated to improve
morbidity and mortality?
1. Routine combined use of an ACEI, ARB, and
Aldosterone antagonist. (Level C).
2. CCB with negative inotropic effects.
3. Long term use of an infusion of a positive
inotropic drug.
4. Hormonal therapies and nutritional
suplements.
5. Use of bisoprolol, or carvedilol or SR
metoprolol.
Board-type Question
49-years-old man, for yearly PE, found
cardiomegaly in CXR. All ROS is negative
as well as the PE. All lab values are
normal. Echocardiogram showed EF
40%, angiogram is normal, what to do
next?
1.
2.
3.
4.
5.
No treatment, f/u in 6 months.
Carvedilol titrate up to 25mg BID.
Start Atenolol plus Valsartan.
Start Enalapril BID plus SR metoprolol.
Start Losartan once a day.