Transcript 2007 HF Guidelines - Canadian Cardiovascular Society

www.hfcc.ca
Recommendations on
Heart Failure: Update 2007
Prevention
Management during intercurrent illness
Treatment of acute decompensation
Use of biomarkers
Arnold JMO, Howlett JG, Dorian P et al. Can J Cardiol 2007;23(1):21-45.
Leadership. Knowledge. Community.
2
CCS HF Guidelines
• First CCS recommendations were published in 1994
with updates in 2001, 2003 and 2006
• New clinical trial evidence and meta-analyses were
critically reviewed by a multidisciplinary primary
panel whose recommendations and practical tips
were reviewed by a secondary panel
• Practical advice for specialists, family physicians,
nurses, pharmacists and others involved in HF care
• Goal is to translate best evidence-based therapies
into clinical practice with a measurable impact on
the health of HF patients in Canada
Arnold JMO, Liu P et al. Can J Cardiol 2006;22(1):23-45.
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
3
Proposed Timeline Through Five Development Cycles
Cycle 1
Cycle 2
Cycle 3
Cycle 4
Cycle 5
Heart
Failure
Heart
Failure
Heart
Failure
Heart
Failure
Heart
Failure
12 Months
12 Months
12 Months
12 Months
12 Months
Jan ‘05
Start
Jan ‘06
CJC Paper
Jan ‘07
Jan ‘08
Jan ‘09
Jan ‘10
CJC
CJC Paper
? Paper
Acute Coronary
Syndrome
Arnold JMO, Liu P, Demers C et al.
Can J Cardiol 2006;22(1):23-45.
? Arrhythmia
Arnold JMO, Howlett JG, Dorian P et al. Can J Cardiol 2007:23(1);21-45
© 2004 Canadian Cardiovascular Society
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Process and Purpose of 2007
HF Recommendations Update
• Priority challenges identified through the national HF
workshop program in 2006
• New evidence-based recommendations for
– Prevention of HF
– Management of HF during intercurrent illness
– Treatment of acute decompensated HF
– Use of biomarkers (eg BNP/NT-BNP) in HF care
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Consensus Conference Panelists 2007
Primary panelists:
J Malcolm O Arnold, Jonathan G Howlett, Anique Ducharme,
Justin Ezekowitz, Martin J Gardner, Nadia Giannetti,
Haissam Haddad, George A Heckman, Andrew Ignaszewski,
Debra Isaac, Philip Jong, Peter Liu, Elizabeth Mann,
Robert S McKelvie, Gordon W Moe, Kelly O’Halloran,
John D Parker, Heather J Ross, Errol J Sequeira,
Anna M Svendsen, Ross T Tsuyuki, Michel White
Secondary panelists:
Tom Ashton, Victor Huckell, Marie-Helene Leblanc,
Gary E Newton, Joel Niznick, Sherryn N Roth, Denis Roy,
Stuart Smith, Bruce A Sussex, Salim Yusuf
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Class of Recommendation and
Grade of Evidence
Evidence or general agreement that a given procedure or
treatment is beneficial, useful and effective.
Conflicting evidence or a divergence of opinion about the
usefulness or efficacy of a procedure or treatment.
Weight of evidence in favour of usefulness or efficacy.
Usefulness or efficacy is less well established by
evidence or opinion.
Evidence or general agreement that the procedure or
treatment is not useful or effective and in some cases
may be harmful.
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Class of Recommendation and
Grade of Evidence
Data derived from multiple randomized
trials or meta-analyses
Data derived from a single randomized
clinical trial or nonrandomized studies
Consensus of opinion of experts
and/or small studies
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Key Emphases in 2006
• Management of HF requires
• an accurate diagnosis
• aggressive treatment of known risk factors
(e.g. hypertension, diabetes)
• rational combination drug therapy
• Care should be individualized for each patient based on:
• symptoms
• clinical presentation
• disease severity
• underlying cause
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Key Emphases in 2006
• Patient and caregiver education should be tailored
and repeated
• Mechanical interventions (e.g. revascularization
and devices) should be available
• Collaboration is required among healthcare
professionals
• Access to primary, emergency and specialist care
must be timely
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Key Clinical Questions Addressed in 2007
• Which patients should be identified as being at high risk
of developing heart failure and which interventions
should be used?
• What complications can occur in heart failure patients
during an intercurrent illness, how should these patients
be monitored and which medications may require a dose
adjustment or discontinuation?
• What are the best therapies, both drug and nondrug
strategies, for patients with acute heart failure?
• How can new biomarkers help in the treatment of heart
failure and when and how should BNP/NT-proBNP be
measured in heart failure patients?
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure Management
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Prevention of Heart Failure
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Goals of HF Prevention
Primary Prevention
• Prevent the development of asymptomatic or symptomatic
LV dysfunction in patients with risk factors but no history of
symptomatic HF
Secondary Prevention
• Reduce HF-related morbidity and mortality in patients who
already have symptomatic disease
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Risk Factors for HF Development
•
Hypertension*
•
Ischemic heart disease*
•
Diabetes*/metabolic syndrome
•
Hyperlipidemia*
•
Smoking*
•
Obesity
•
Older age
•
Male gender
•
Ethnicity
•
Physical inactivity
•
Heavy alcohol consumption
* Most important targets for prevention
•
•
•
•
•
•
•
•
•
•
•
Excessive salt intake
Cardiotoxic agents
Family history/genetics
Low ejection fraction*
Impaired diastolic function
Left ventricular hypertrophy
Elevated neurohormonal
biomarkers
Abnormal ECG
Increased cardiothoracic ratio
Microalbuminuria
Elevated resting heart rate
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Patients at Risk of Developing HF
• Clinical assessment is recommended in all patients to
identify known or potential risk factors for HF (eg
hypertension, IHD, diabetes, hyperlipidemia, smoking)
(Class I, Level C)
• All modifiable risk factors for HF, including those for CAD,
such as hypertension, diabetes mellitus and hyperlipidemia,
should be treated according to current national guidelines
Practical Tips
(Class I, Level A)
• Poor adherence to preventive measures is common.
Reassess regularly to ensure targets achieved/maintained
• Patients at high risk for HF should receive influenza vaccine
(yearly) and pneumococcal vaccine (if not in last 6 yrs)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Hypertension, LV Hypertrophy and HF Risk
• Presence of hypertension increases risk of HF
eg Framingham Study
• Presence of LVH increases risk of HF and risk is
independent of association with hypertension
• Treatment of hypertension clearly reduces risk of HF
eg BP Lowering Treatment Trialists’ Collaboration
Practical Tips
• BP goal <140/90mmHg in most individuals
• <130/80mmHg in diabetes and/or kidney disease and
perhaps in patients with multiple risk factors
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Ischemic Heart Disease and HF Risk
• 52% of HF diagnoses in general population
attributed to CAD
• 40% of patients who have experienced an MI will
develop HF over time
• 8-fold increase in risk of subsequent death when a
new MI occurs in patients with established HF
• 1/3 of all deaths in HF are preceded by an ischemic
event
• Target dyslipidemia, hypertension, diabetes, smoking.
Treat aggressively
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Diabetes Mellitus and HF Risk
• DM increases risk 2 to 4 fold compared to patients
without DM
• DM is well established risk factor for CAD/IHD
• DM may produce HF independently of CAD
(diabetic CM)
• While increased HbA1C is associated with
increased HF, no study to date has shown
improved glycemic control reduces HF
• Canadian Diabetes Association recommends
HbA1C ≤7.0% in most patients with DM
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Microalbuminuria and HF Risk
• Microalbuminuria is an independent risk factor
for HF
• In diabetes, microalbuminuria increases HF
risk 2-4 fold
• Clinical trial data are insufficient at present to
support the treatment of microalbuminuria as
a strategy to prevent HF
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Hyperlipidemia and HF Risk
• Elevated TG and elevated TC/HDL are
associated with increase in HF risk
• Statin therapy may reduce HF risk
Practical Tips
• Hyperlipidemia should be treated aggressively
• In patients at high risk for HF, target LDL may
be <2.0mmol/L
• Statins may be the preferred drug
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Smoking and HF Risk
• Smoking may account for 17% of new HF cases
• Smoking has a direct and independent relationship
with the development of asymptomatic ventricular
dysfunction
• Smoking cessation can reduce morbidity and
mortality by 30% within 2 years in patients with HF
Practical Tip
•
Smoking cessation is an important strategy to prevent HF
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Obesity and HF Risk
• Overweight (BMI > 25 kg/m2) and obesity (BMI > 30 kg/m2)
are independent risk factors for HF
• Overweight and obesity may lead to changes in LV structure
and function regardless of BP, age, sex and LV mass
• Improvement in LV function and HF can occur after bariatric
surgery in morbidly obese HF patients
Practical Tip
• Weight reduction in overweight or obese individuals
may is an important strategy to prevent HF
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Patients with Asymptomatic LV Dysfunction
• ACE inhibitors should be used in all asymptomatic
patients with LV dysfunction and LVEF <40%
(Class 1, Level A, LVEF <35%; Class I, Level B, LVEF 35-40%)
• Beta-blockers should be considered in all asymptomatic
patients with LV dysfunction and LVEF < 40%
(Class I, Level B, prior MI; Class IIa, Level C, no prior MI)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Screening for LV Dysfunction
• Community epidemiological studies document a
prevalence of 1-6% for impaired systolic function and
11-21% for isolated impaired diastolic function
• No consensus on optimal screening method to detect
asymptomatic LV dysfunction
Practical Tips
• Routine screening for asymptomatic LV dysfunction is
not recommended
• Selective screening may be considered for patients at
higher risk: IHD, hypertension, DM, certain ethnic
groups, elderly
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and
Intercurrent Illness
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Heart Failure and Cognitive Impairment
Recommendation
• Elderly or frail patients with HF who present with acute
illness should be assessed for evidence of delirium and,
before discharge, cognitive impairment
(Class IIa, Level C)
Practical Tip
• In a hospitalized elderly or frail patient with HF,
screening for chronic cognitive impairment is best
performed pre-discharge once the patient has been
stabilized
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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CSHA* Clinical Frailty Scale
* Canadian Study of Health and Aging
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Heart Failure and Comorbidities
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and Diabetes
Recommendation
• Treat elevated blood glucose to achieve:
- HbA1C ≤ 7.0%
- fasting/preprandial blood glucose 4.4 mmol/L to 7.0 mmol/L
(Class I, Level A)
Practical Tips
• Oral antidiabetic therapy should be individualized; no compelling
evidence exists to recommend one agent
over another
• Metformin may be considered a first-line agent if the eGFR
is > 30 mL/min but should be discontinued temporarily if renal
function worsens significantly
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Renal Dysfunction: Impact on HF
CV
events
eGFR
< 60 mL/min
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and Renal Dysfunction
Recommendations
• Patients with stable renal function, and serum creatinine
< 200 µmol/L, should receive standard therapy (ACE-I, ARB
or spironolactone). However, monitor potassium and
creatinine more frequently, especially with combination
therapy or acute dehydrating illness
(Class I, Level B)
• Patients with HF who continue to experience volume
overload or increasing serum creatinine should be assessed
for reversible causes (eg. NSAIDs, hypovolemia,
hypotension, urinary tract obstruction or infection)
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and Renal Dysfunction
Recommendations
• In stable patients who are not oliguric but have increasing
serum creatinine levels (> 30% from previously stable
baseline), the dose of diuretics, ACE-I, ARBs and
spironolactone may be reduced until renal function
stabilizes
(Class I, Level C)
• In patients with oliguria who are hemodynamically stable,
diuretics, ACE-I, ARBs, spironolactone and non-HF drugs
that impair renal function should be reviewed daily
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
33
Heart Failure and Renal Dysfunction
Recommendation
• Routine use of ACE-I, ARBs or spironolactone in the
setting of severe renal dysfunction (serum creatinine
> 250 µmol/L or an increase of > 50% from baseline) is
not recommended due to a lack of evidence for efficacy
in HF patients
(Class IIa, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and Renal Dysfunction
Recommendations
• Indications for the use of digoxin should be
re-evaluated in patients with severe renal dysfunction
• Adjust dose to maintain trough level of < 1 nmol/L
• If patients have rapid deterioration in renal function,
withhold digoxin and re-evaluate once renal function
has stabilized
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and Renal Dysfunction
Recommendation
• In patients not responding adequately to > 240 mg
intravenous furosemide daily, treatment options include:
○
More frequent or higher doses of intravenous
boluses of diuretic
(Class IIb, Level C)
○
Combination with thiazide diuretic, eg,
hydrochlorothiazide or metolazone
(Class IIA, Level B)
○
Continuous intravenous furosemide infusion
(Class IIa, Level B)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure with Renal Dysfunction
Practical Tips
• Serum creatinine increased by > 30% of baseline value over
several days OR oliguria and rising serum creatinine
Repeat careful daily assessments of volume status
and clinical perfusion including
– body weight
– urine output
– BP
– serum electrolytes
– serum creatinine
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure with Renal Dysfunction
Practical Tips
• In the setting of worsening renal function, follow patients closely
• Volume-overloaded patients who do not respond to bolus IV
furosemide may respond better to continuous infusion
• In highly selected cases, under experienced supervision,
hypertonic saline with high-dose loop diuretic or intermittent slow
continuous venovenous ultrafiltration may be considered
• When diuretics are reduced (especially in the setting of a
combination ACE inhibitor, ARB or spironolactone) serum
electrolytes should be rechecked within 2 to 4 weeks to assess
serum potassium
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and Anemia
Recommendation
• In patients with anemia (plasma hemoglobin
< 110 g/L or hematocrit < 35%)
– Evaluate for underlying causes such as chronic blood
loss or other inflammatory illness
– Treat iron, vitamin B12 or folate deficiencies
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and Anemia
Practical Tips
• There is insufficient evidence to support the routine use of bone
marrow-stimulating drugs to increase hemoglobin levels in HF
• If plasma hemoglobin < 90 g/L is associated with increased
symptoms of HF, blood transfusion or a bone marrowstimulating agent may be considered if advanced symptoms are
present and after substrate deficiencies have been corrected
• If anemia is severe, patient should be assessed by a physician
experienced in its diagnosis and management. Underlying
causes should be treated, using intravenous means if
necessary
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Heart Failure and
Acute Intercurrent Medical Illness
Recommendations
• Continue beta-blockers and ACE-I at their usual dose during
acute intercurrent illness (eg, pneumonia, exacerbation of COPD,
other systemic infection, etc), unless they are not tolerated
(eg, if significant reactive airways disease is present)
(Class IIa, Level C)
•
In a life-threatening complication, beta-blockers and ACE-I or
ARBs may be discontinued abruptly, but
– Generally, the dose should be decreased by one-half, and the
patient should be reassessed
– Dose should be uptitrated to the previous well-tolerated dose
as soon as safely possible
(Class IIa, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
41
Heart Failure and
Acute Intercurrent Medical Illness
Recommendations
• Initiate beta blockers as soon as possible after diagnosis
of HF, including during the index hospitalization, provided
that the patient is clinically stable Clinicians should not
wait until hospital discharge to start a beta blocker in
stablized patients
(Class I, Level B)
• Continue beta blockers in patients hospitalized with acute
HF unless they develop cardiogenic shock, refractory
volume overload or symptomatic bradycardia
(Class IIa, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
42
Heart Failure and
Acute Dehydrating Illness
Recommendations
• Patients with an acute dehydrating illness should undergo
prompt evaluation including measurement of:
○ serum electrolytes
○ blood urea nitrogen
○ creatinine
even if not clinically volume-overloaded or volume-depleted.
Follow patients carefully until they return to their previous state
of health
(Class IIa, Level C)
• In an acute dehydrating illness with risk of worsening renal
function, spironolactone may be temporarily withheld because
hyperkalemia is more common in this setting
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
43
Heart Failure and
Acute Intercurrent Medical Illness
Recommendations
• Consider colchicine (or oral or intra-articular steroid)
for treatment of acute gout
(Class IIa, Level C)
• In noncardiac surgery requiring general anesthesia,
patients with HF should be evaluated preoperatively
by a physician experienced in HF management
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Acute Heart Failure
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Presentation of Acute Heart Failure (AHF)
Rapid onset of appropriate signs and symptoms:
• Reduced cardiac output
• Decreased tissue perfusion
• Increased pulmonary/peripheral congestion
• Dyspnea with minimal exertion
• Orthopnea/PND
• Cough
• Increasing abdominal girth
• Peripheral edema
• Fatigue associated with systolic or diastolic
dysfunction, valve dysfunction, or cardiac rhythm
abnormalities
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Clinical Presentation of AHF
• De novo
• Decompensation of known HF
• Hypertension
• Pulmonary edema
• Cardiogenic shock
• High output failure (anemia, thyrotoxicosis,
arrhythmia, Paget’s disease)
• Predominant right-heart failure (elevated JVP,
peripheral edema, ascites)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Clinical Presentation of AHF
Data from ADHERE database (Acute Decompensated
Heart Failure National Registry in the US)
• Dyspnea in 89% of patients at presentation
• Rales in 68%
• Peripheral edema in 66%
• SBP <90mmHg in <2%
Adams KF Jr, Fonarow GC, Emerman CL, et al; ADHERE Scientific Advisory
Committee and Investigators. Am Heart J 2005;149:209-16.
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Clinical Evaluation of Acute HF
Recommendation
• Perform thorough clinical evaluation including assessment of
perfusion and volume status (cold or warm, wet or dry)
(Class IIa, Level C)
Nohria A et al. J Am Coll Cardiol 2003;41:1797-804. Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Clinical Evaluation of Acute HF
Recommendations
• Initial investigations should include
○ Renal function, lytes, CBC, troponin
○ ECG
○ CXR
○ Echocardiogram (if recent results unavailable)
○ BNP if diagnosis remains uncertain
• A precipitating cause should be sought in all patients
(Class I, Level C)
•
Serum albumin, D-dimer, liver and thyroid function,
arterial blood gas may be useful in selected patients
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Initial Management of AHF
Recommendations
• Measure vital signs frequently until patient is stable
(BP, HR, O2 sat)
(Class IIa, Level C)
• Monitor fluid balance including urine output (may
require bladder catheterization)
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
51
Initial Management of AHF
Recommendations
• Patients in shock or with significant renal dysfunction
require lab investigations (especially serum electrolytes,
renal function) regularly in first 24 h
(Class I, Level C)
• Patients in cardiogenic shock or who require pressors
may require invasive monitoring with arterial or CVP lines
(Class IIb, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
52
Medical Treatment of AHF
Recommendations
• Identify and promptly correct underlying/ precipitating
cause when possible
(Class I, Level B)
• Give oxygen initially to all patients with acute HF and
hypoxia
(Class I, Level C)
• If hypoxemia persists despite increasing incremental
fraction of oxygen, consider CPAP, BIPAP or
endotracheal intubation
(Class IIa, Level B)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
53
Medical Treatment of AHF
Recommendations
• Intravenous diuretics should be given as first-line therapy
for patients with acute HF and congestion
(Class I, Level B)
• Consider vasodilators for patients with dyspnea at rest
(Class I, Level C)
• Reserve positive inotropes for patients in cardiogenic
shock and/or volume overload with diuretic resistance and
use short-term to stablize patient. In hypotensive patients
(SBP 90 mmHg), dobutamine is preferred over milrinone
(Class I, Level C
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
54
Medical Treatment of AHF
Recommendations
• ACE-I are not recommended routinely in the first few hours of
AHF. They should be introduced when the patient is stabilized
(Class I, Level B)
• CCBs are not recommended in AHF; specifically, diltiazem and
verapamil are to be avoided in AHF with systolic dysfunction
(Class III, Level B)
• Diltiazem may be used in AHF with preserved systolic
dysfunction in the setting of AF with rapid ventricular response
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
55
Treatment of AHF
Recommendations
• In patients with refractory HF despite medical therapy,
an intra-aortic balloon pump may be considered
(Class IIb, Level B)
• Patients who remain in cardiogenic shock and have a
low comorbid burden should be transferred early to a
tertiary care centre in which circulatory mechanical
support and transplantation are available
(Class I, Level C)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Management of AHF
Practical Tips
• Vasodilators, including nitroglycerin (sl or iv), oral
nitrates, intravenous nitroprusside and neseritide may
be useful in patients with AHF + SBP > 100 mmHg
• Patients in cardiogenic shock but who are expected
to recover with support or are candidates for heart
transplant should be considered for ECMO and VAD
support
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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Treatment Algorithm for Acute HF
Erratum. Can J Cardiol 2006;22(3):271.
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Biomarkers in Heart Failure
59
Biomarker:
Definition and Expectation
“A characteristic that is objectively measured and
evaluated as an indicator of normal biological
processes, pathogenic processes, or pharmacologic
responses to a therapeutic intervention”
- NIH working group 2001
A cardiac biomarker can enhance clinicians’ abilities to
optimally manage patients with a cardiac disorder.
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
60
Elevated BNP Predictive of HF
BNP is secreted by ventricular myocytes in response to excessive stretch
BNP Trial – ROC curves
for BNP predicting
diagnosis of CHF
in patients with or
without CHF history
Strunk A et al. Am J Med 2006;119:69:e1-11.
61
NT-proBNP Complements Clinical Judgment
Moe GW et al. Circulation 2007;115(24):3103-10.
62
BNP/NT-proBNP in Heart Failure
Recommendations
• BNP or NT-proBNP should be measured to help confirm or
rule out a diagnosis of HF in the acute or ambulatory care
setting in patients in whom the clinical diagnosis is in doubt
(Class I, Level A)
• Measurement may also be considered in patients with
known HF for prognostic stratification
(Class IIa, Level A)
• Sequential measurement of BNP/NT-proBNP levels may
be considered to guide therapy in HF patients
(Class IIb, Level B)
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
63
BNP/NT-proBNP in Heart Failure
Practical Tips
• Biomarkers such as BNP and NT-proBNP are
complementary to, but do not replace, good clinical
evaluation
• No compelling factors favor the use of BNP versus NTproBNP
• The choice of assay is dictated by
– availability
– clinician’s familiarity and ability to interpret the results
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
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BNP and NT-proBNP In HF
Cut Points for HF Diagnosis
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.
65
Looking Forward
• HF knowledge has grown exponentially in the last
two decades
• Many additional clinical trials, planned or in
progress, will add to current knowledge and guide
therapy: further updates to recommendations are
planned (next is Jan 2008)
• A national health care strategy for HF would assist
in ensuring implementation of recommendations
• For Updates visit www.hfcc.ca
Arnold JMO, Howlett JG, et al. Can J Cardiol 2007;23(1):21-45.