Transcript Heart Failure: Dx and Management

Heart Failure: ACC
Guidelines for Dx and
Management
Steven W. Harris MHS PAC
Epidemiology
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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
Epidemiology
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The incidence of HF approaches 10 per
1000 population after age 65
HF is the most common Medicare
diagnosis-related group
More dollars are spent for the diagnosis
and treatment of HF than any other
diagnosis by Medicare
ACC Guidelines
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Focus on :
Prevention of HF
Diagnosis and management of chronic HF
in the adult.
Definition
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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.
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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.”
• Use terms:
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Compensated Heart Failure: euvolemic
Decompensated Heart Failure: fluid overload
Etiology
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For a substantial proportion of patients,
causes are:
Coronary artery disease
Hypertension
Dilated cardiomyopathy
Signs and Symptoms
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Symptoms
 Decreased
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Perfusion:
Weakness
Fatigue
Confusion
Restlessness
Anxiety
Palpitations
Cold Extremities
Symptoms
 Increased
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LV preload:
DOE
PND
Cough: often positional
Wheeze
Orthopnea
Abdominal Distension
edema
Signs
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Increased Preload/Decreased perfusion
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Pedal edema
Hepatic congestion
JVD
Rales
Wheezing
S3
Tachycardia
Cyanosis
Cold extremities
New York Heart Association
Classes
NYHA I: no symptoms w/ physical activity,
but known disease
NYHA II: slight limitations, symptoms w/
normal activities, but able to walk 3 blocks
NYHA III: symptoms w. minimal activity and
marked limitation of activity
NYHA IV: symptoms at rest and any activity
Stages of Heart Failure
Designed to emphasize preventability of
HF through treatment therapies.
Designed to recognize the progressive
nature of LV dysfunction.
Stages of HF
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COMPLEMENT, DO NOT REPLACE NYHA
CLASSES
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NYHA Classes - shift back/forth in individual
patient (in response to Rx and/or
progression of disease)
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Stages - progress in one direction due to
cardiac remodeling
Stages of HF
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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
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.
16
14
12
% MI, 10
Stroke, 8
CV Death 6
4
2
0
15
Placebo
HOPE
Ramipril
22% rel. risk red. p < .001
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1
2
Years
EUROPA
3
4
Placebo
12
% MI,
CV Death,
Cardiac Arrest
NEJM 2000;342:145-53 (HOPE).
Lancet 2003;362:782-8 (EUROPA).
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Perindopril
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20% rel. risk red. p = .0003
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0
1
2
3
Years
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ARBS in Patients Not Taking ACE Inhibitors:
Val-HeFT & CHARM-Alternative
Val-HeFT
Valsartan
Survival %
90
80
Placebo
70
60
CHARM-Alternative
50
CV Death or HF Hosp %
100
Placebo
40
30
Candesartan
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10
p = 0.017
50
HR 0.77, p = 0.0004
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6
9 12 15 18 21 24 27
Months
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9
18
27
36
42
Months
Maggioni AP et al. JACC 2002;40:1422-4.
Granger CB et al. Lancet 2003;362:772-6.
COPERNICUS: Death, Hospitalization, or
Study Drug Withdrawal in High Risk Patients
% of Patients With Event
30
HR = 0.67 (CI = 0.47-0.96)
20
Placebo
10
Carvedilol
0
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2
4
6
Weeks After Randomization
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Krum H et al. JAMA 2003;289:754-6.
Stage A: at risk for HF
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Therapy
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Treat Hypertension
Encourage Smoking cessation
Treat lipid disorders
Encourage regular exercise
Discourage ETOH, drugs
Control Metabolic Syndrome
ACE or ARB in appropriate patents for vasc dz or
diabetes
Stage B: Structural disease/No Sx
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All measures under Stage A
ACE or ARB in appropriate patients
Beta-blockers in appropriate patients
ICDs in appropriate patients
Stage C: Structural Disease with
current or prior sx
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Therapy:
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All measures under Stages A and B
Routine Use
• ACE, Beta-blocker
• Diuretics for fluid retention
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Selected Patients
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Aldosterone antagonist
ARB
Digitalis
Hydralazine/nitrates
Devices: BI-V, ICD
Stage D: refractory HF
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All measures from stages A, B, C
Decision:
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Appropriate level of care
Compassionate end-of-life care
Transplant
Chronic Inotropes: neo, epi, dopamine.
Permanent Mechanical Support: LVAD
Experimental surgery /drugs.
Devices
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An implantable cardioverter-defibrillator
(ICD) for secondary prevention to prolong
survival in patients with a history of cardiac
arrest, ventricular fibrillation, or
hemodynamically destabilizing ventricular
tachycardia.
Devices
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An ICD for primary prevention to reduce
total mortality by preventing sudden cardiac
death (SCD) in patients with ischemic heart
disease who meet the following criteria: at
least 40 days post-myocardial infarction, an
LVEF 30 percent, New York Heart Association
functional class II or III symptoms despite
optimal chronic medical therapy, and a
reasonable expectation of survival with a
good functional status for more than one
year.
Devices
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An ICD for primary prevention to reduce
total mortality by preventing SCD in patients
with nonischemic cardiomyopathy who meet
the following criteria: an LVEF less than 30
percent, New York Heart Association
functional class II or III symptoms despite
optimal chronic medical therapy, and a
reasonable expectation of survival with a
good functional status for more than one
year.
Devices
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Cardiac resynchronization therapy,
unless contraindicated, in patients who
meet the following criteria: cardiac
dyssynchrony as defined by a QRS
duration >120 msec, LVEF 35 percent,
sinus rhythm, and New York Heart
Association functional class III or
ambulatory class IV symptoms despite
optimal chronic medical therapy.
Patient Surveilance
 MAWDS
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Medicine
Activity
Weight
Diet
Symptoms
CASE 1
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y/o female
DM
BP 146/84
LDL 150
Non-smoker
Exercises daily
Case 2
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y/o male
AWMI 1 year ago
EF 28%
Diabetic
BP 128/72
Smoker
DOE with strenuous activity
Case 3
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y/o male
DM
CHD, prior Inferior MI
EF 46%
BP 132/78
Walks daily. Unable to walk up inclines.
C/o LE edema and weight gain of 10 lbs
Case 4
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y/o female
H/o BRCA treated with adriamycin
BP 110/68 on ACE, Coreg
EF 30%
Non-diabetic
Symptoms with minimal activity
LBBB