Transcript Heart Failure Management Applying the ACC/AHA Chronic

Heart Failure Management
Applying the ACC/AHA Chronic
Heart Failure Guidelines
David Bragin Sánchez MD FACC
Cardiomyopathy and Cardiac
Transplant Specialist
Intercontinental Hotel
March 13 2007
The Core
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Patients With Current or Prior Symptoms of
Heart Failure (HF)
Left ventricle (LV) dysfunction
Class I
Drugs known to adversely affect the clinical status of
patients with current or prior symptoms of HF and
reduced left ventricle ejection fraction (LVEF) should
be avoided or withdrawn whenever possible (e.g.,
nonsteroidal
anti-inflammatory
drugs,
most
antiarrhythmic drugs, and most calcium channel
blocking drugs). (Level of Evidence: B)
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. (Level of Evidence: B)
Stage C
Class I
Daily weight
Influenza and pneumococcal vaccination
Monitor potassium (4-5 mmol per L) and
magnesium
Emphasis on compliance with diet and
medications
Patient education and close supervision
Stage C
Class III
Use of nutritional supplements as treatment
for HF is not indicated in patients with
current or prior symptoms of HF and reduced
LVEF. (Level of Evidence: C)
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. (Level of
Evidence: C)
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Beta Blockers
Class I
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.
(Level
of
Evidence: A)
Stage C
Beta blockers
Alleviate symptoms, improve clinical status,
reduce risk of death and of hospitalization.
Diuretics are needed to maintain sodium balance
and prevent fluid retention that can accompany
initiation of beta-blocker
Should be given only if no or only minimal
evidence of fluid retention
Should not be totally withdrawn in acute
decompensation
Should be started before hospital discharge in all
HF patients
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Class I
Angiotensin converting enzyme inhibitors are
recommended for all patients with current or
prior symptoms of HF and reduced LVEF,
unless contraindicated. (Level of Evidence: A)
Class 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. (Level of Evidence: C)
Stage C
Not only interferes with RAS but potentates
action of kinins and kinin-mediated
prostaglandin
Alleviate symptoms, improve clinical status,
reduce risk of death and of hospitalization
Contraindicated if angioedema or pregnant
Fluid retention can blunt effects and fluid
depletion can potentate adverse effects
(Hypotension, hyperkalemia, renal failure)
Cough. All other causes must be excluded
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Class I
Angiotensin II receptor blockers approved for the
treatment of HF are recommended in patients with
current or prior symptoms of HF and reduced LVEF who
are ACEI-intolerant. (Level of Evidence: A)
Class IIA
Angiotensin II receptor blockers 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.
(Level of Evidence: A)
Class IIB
The addition of an ARB may be considered in persistently
symptomatic patients with reduced LVEF who are already
being treated with conventional therapy. (Level of
Evidence: B)
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Class I
Aldosterone antagonist is reasonable 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. (Level of
Evidence: B)
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Class I
Diuretics and salt restriction are
indicated in patients with current or
prior symptoms of HF and reduced
LVEF who have evidence of fluid
retention. (Level of Evidence: C)
Stage C
Inhibit reabsorption of sodium or chloride
at specific sites in the renal tubule.
Loop diuretics excrete up to 20-25% Na,
enhance free water clearance and remain
effective unless severe renal impairment.
No long term studies effects on morbidity
and mortality are not known
Produce symptomatic relief more rapidly
than any other drug.
Risk of use is electrolyte depletion,
hypotension and azotemia.
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Class IIa
Digitalis can be beneficial in patients with
current or prior symptoms of HF and reduced
LVEF to decrease hospitalizations for HF. (Level
of Evidence: B)
Dose should be of 0.125-0.25mg QD, without
loading and lower if patient is over age 70, has
renal impairment or low lean body mass
Serum levels are followed for purpose of toxicity
and not to guide therapy
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Class IIa
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. (Level of
Evidence: A)
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Class I
Implantable cardioverter-defibrillator therapy
is recommended for primary prevention to
reduce total mortality by a reduction in
sudden cardiac death.
LVEF less than or equal to 30%
NYHA functional class II or III symptoms
while undergoing chronic optimal medical
therapy
Reasonable expectation of survival with a
good functional status for more than 1 year
Stage C
Ischemic heart disease who are at
least 40 days post-MI
(Level of Evidence: A)
Nonischemic cardiomyopathy
(Level of Evidence: B)
Stage C
Class I CRT
Patients with LVEF less than or
equal to 35%
Sinus rhythm
NYHA functional class III or
ambulatory class IV symptoms
despite optimal medical therapy
QRS duration greater than 0.12 ms
(Level of Evidence: A)
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage C
Class 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. (Level of Evidence: C)
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage D
End stage heart disease
Cardiac transplantation is currently the
only established surgical approach to the
treatment of refractory HF, but it is
available to fewer than 2500 patients in the
United States each year
Alternate
surgical
and
mechanical
approaches for the treatment of end-stage
HF are under development
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage D
Class III
Routine intermittent infusions of positive
inotropic agents are not recommended for
patients with refractory end-stage HF.
(Level of Evidence: B)
However, continuous intravenous support
can provide palliation of symptoms as part
of an overall plan to allow the patient to
die with comfort at home
Stage D
Referral of patients with refractory end-stage HF
to an HF program with expertise in the
management of refractory HF is useful. (Level of
Evidence: A)
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.
(Level of Evidence: C)
Patients with refractory end-stage HF and
implantable
defibrillators
should
receive
information about the option to inactivate
defibrillation. (Level of Evidence: C)
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Stage D
Class I
Referral for cardiac transplantation in
potentially eligible patients is recommended
for patients with refractory end-stage HF.
(Level of Evidence: B)
Class IIa
Consideration of an LV assist device as
permanent or “destination” therapy is
reasonable in highly selected patients with
refractory end-stage HF and an estimated 1year mortality over 50% with medical
therapy. (Level of Evidence: B)
Stage D
Absolute indications for cardiac transplant
For hemodynamic compromise due to HF
Refractory cardiogenic shock
Documented dependence on IV inotropic support to
maintain adequate organ perfusion
Peak VO2 less than 10 mL per kg per min with
achievement of anaerobic metabolism
Severe symptoms of ischemia that consistently limit
routine activity and are not amenable to coronary
artery bypass surgery or percutaneous coronary
intervention
Recurrent symptomatic ventricular arrhythmias
refractory to all therapeutic modalities
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
Special populations
High-risk ethnic minority groups
(e.g., blacks, hispanics)
Groups underrepresented in clinical
trials (women and elderly)
Should have clinical screening and
therapy in a manner identical to
that applied to the broader
population.
(Level of Evidence: B)
Stage C
Stage D
Basic management
Refractory HF
Beta blockers
Transplantation
ACE inhibitors
Subgroups
ARB
HF with normal LVEF
Aldosterone blocker
Diuretics
Digoxin
Hydralazine/Nitrate
Devices
Inotropic agents
HF with preserved EF
Control systolic and diastolic BP (Class I
Level of evidence A)
Control
ventricular
rate
in
atrial
fibrillation (Class I Level of evidence C)
Diuretics
to
control
pulmonary
congestion and peripheral edema (Class I
Level of evidence C)
Coronary revascularization patients with
CAD in whom ischemia is judged to have
effect on diastolic dysfunction (Class IIa
Level of evidence C)