ch f management

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DEFINITION of HEART FAILURE

Heart Failure is a pathophysiological state in which anabnormality of cardiac function to pump the blood at arate commensurate with requirements of metabolizing

tissue.

Guidelines for the diagnosis and treatment of chronic heart failure

European Heart Journal (2001) 22, 1528



Epidemiology

Europe The prevalence of symptomatic HF range from 0.4-2%.10 million HF pts in 900 million total population

USAnearly 5 million HF pts.± 500,000 pts are D/ HF for the 1 st time each year.Last 10 years number of hospitalizations has

increased.Nearly 300,000 patients die of HF each year.


European Heart Journal (2001) 22, 1527-1560

ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001



Aims of treatment

1. Prevention a) Prevention and/or controlling of diseases leading

to cardiac dysfunction and heart failureb) Prevention of progression to heart failure once

cardiac dysfunction is established2. Morbidity

Maintenance or improvement in quality of life

3. Mortality Increased duration of life





Management outline

Establish that the patient has HF. Ascertain presenting features: pulmonary oedema, exertionalbreathlessness, fatigue, peripheral oedema

Assess severity of symptoms

Determine aetiology of heart failure

Identify precipitating and exacerbating factors

Identify concomitant diseases

Estimate prognosis

Anticipate complications

Counsel patient and relatives

Choose appropriate management

Monitor progress and manage accordingly





New York Heart Association (NYHA)Classification of Heart Failure

Class – INo limitation : ordinary physical exercise doesnot cause undue fatigue, dyspnoea or palpita-tions.

Class – II

Slight limitation of physical activity : comfor-

table at rest but ordinary activity results infatigue, dyspnoea, or palpitation.

Class - IIIMarked limitation of physical activity : comfor-table at rest but less than ordinary activityresults in symptoms.

Class - IVUnable to carry out any physical activity with-out discomfort : symptoms of heart failure arepresent even at rest with increased discomfortwith any physical activity.

Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1531



ACC/AHA – A New Approach To The Classification of HF

Stage Descriptions Examples

A Patient who is at high risk for developing HF but has nostructural disorder of the heart.

Hypertension; CAD; DM;rheumatic fever; cardiomyopathy.

B Patient with a structural disorder

of the heart but who has never developed symptoms of HF.

LV hypertrophy or fibrosis;

LV dilatation; asymptomatic VHD;MI.

C patient with past or currentsymptoms of HF associated withunderlying structural heartdisease .

Dyspnea or fatigue ec LV systolicdysfunction; asymptomaticpatients with HF.

D Patient with end-stage disease Frequently hospitalized pts ; ptsawaiting heart transplantation etc




Algorithm for the Diagnosis of Heart FailureSuspected Heart Failure

Because of symptoms and signs

Assess presence of cardiac diseases by ECG, X-ray orNatriuretic peptide (where available)

Test Abnormal

Imaging by Echocardiography(Nuclear angiography or MRI

Where available)

Test Abnormal

Assess etiology, degree, precipitating Factors and type of cardiac dysfunction

Choose Therapy

NormalHeart Failure

Unlickely

NormalHeart Failure

Unlickely

Additonal diagnosis testswhere appropriate

(e.g. coronary angiography)


European Heart Journal (2001) 22, 1530



Stage A Stage B Stage C Stage D

Pts with :• Hypertension• CAD• DM• Cardiotoxins• FHx CM

THERAPY• Treat Hypertension• Stop smoking•

Treat lipid disorders• Encourage regular exercise

• Stop alcohol& drug use

• ACE inhibition

Pts with :• Previous MI• LV systolic

dysfunction• Asymptomatic

Valvular disease

THERAPY• All measures under

stage A•

ACE inhibitor • Beta-blockers


stage A•

Drugs for routine use:• diuretic• ACE inhibitor • Beta-blockers• digitalis


stage A,B and C• Mechanical assist

device• Heart transplantation• Continuous IV

inotrphic infusions for palliation

Pts who havemarked symptomsat rest despitemaximal medicaltherapy.

Pts with :

• Struct. HD

• Shortness of breath and fatigue,reduce exercisetolerance

Struct.HeartDisease

DevelopSymp.of

HF

Refract.Symp.ofHF at rest

Stages in the evolution of HF and recommended therapy by stage




Treatment options

Non-pharmacological managementGeneral advice and measuresExercise and exercise training

Pharmacological therapy Angiotensin-converting enzyme (ACE) inhibitorsDiureticsBeta-adrenoceptor antagonists

Aldosterone receptor antagonists Angiotensin receptor antagonistsCardiac glycosidesVasodilator agents (nitrates/hydralazine)Positive inotropic agents

Anticoagulation Antiarrhythmic agentsOxygen

Devices and surgeryRevascularization (catheter interventions and surgery), other forms of surgeryPacemakersImplantable cardioverter defibrillators (ICD)Heart transplantation, ventricular assist devices, artificial heartUltrafiltration, haemodialysis

Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560



Pharmacological therapy



Angiotensin-converting enzyme inhibitors

Recommended as first-line therapy.

Should be uptitrated to the dosages shown to beeffective in the large, controlled trials, and nottitrated based on symptomatic improvement.

Moderate renal insufficiency and a relatively low bloodpressure (serum creatinine < 250 µmol.l -1 and systolicBP > 90 mmHg) are not contraindications .

Absolute contraindications : bilateral renal arterystenosis and angioedema.





Diuretics

Essential for symptomatic treatment when

fluid overload is present and manifest. Always be administered in combination

with ACE inhibitors if possible.





Recommended in advanced HF (NYHA III-IV),

in addition to ACE inhibition and diuretics to

improve survival and morbidity

Aldosterone receptor antagonists - spironolactone





The RALES mortality trial Low dose spironolactone (12.5 – 50 mg) on topof an ACE inhibitor and a loop diuretic improved survival of patients in advancedheart failure (NYHA class III or IV).

Aldosterone receptor antagonists - spironolactone



Recommended for the treatment of all ptswith stable , mild, moderate and severe heartfailure on standard treatment, unless there is

a contraindication.

Patients with LV systolic dysfunction, with or without symptomatic HF, following an AMIlong-term betablockade is recommended in addition to ACE inhibitor.

Beta-adrenoceptor antagonists





Carvedilol(n=696)

Placebo(n=398)

Survival

Days0 50 100 150 200 250 300 350 400

1.0

0.9

0.8

0.7

0.6

0.5

Risk reduction = 65%P<0.001

Packer et al (1996)

Lancet (1999)0 200 400 600 800

1.0

0.8

0.6

0

Bisoprolol

Placebo

Time after inclusion (days)

P<0.0001

Survival

Risk reduction = 34%

The MERIT-HF Study Group (1999)Months of follow-up

Mortality %

0 3 6 9 12 15 18 21

20

15

10

5

0

Placebo

Metoprolol CR/XL

P=0.0062

Risk reduction = 34%

US Carvedilol Study

-Blockers in CHF -All-cause Mortality

CIBIS-II MERIT-HF



% S u r v

i v a l

0 0

3 6 9 12 15 18 21

Months

100

90

80

60

70

P=0.00013

Carvedilol

Placebo

COPERNICUS

All-cause mortality



Beta-adrenoceptor antagonists

CIBIS II, MERIT HF, US CARVEDILOL AND COPERNICUS study

Reduction in total mortality, cardiovascular mortality, sudden death and death due toprogression of heart failure in patients in func.class II-IV.

reduces hospitalizations

improves the functional class and leads toless worsening of heart failure.



ARBs could be considered in patients who do nottolerate ACE inhibitors for symptomatictreatment.

It is unclear whether ARBs are as effective as ACE inhibitors for mortality reduction.

In combination with ACE inhibition, ARBs mayimprove heart failure symptoms and reducehospitalizations for worsening heart failure.

Angiotensin II receptor antagonists





VAL-H

Patients were randomized to placebo or valsartan on top of standard therapy.

The results showed no difference in overallmortality , but a reduction in the combined end-

point all-cause mortality or morbidity expressed as hospitalization because of worsening heart failure.

Angiotensin II receptor antagonists



indicated in atrial fibrillation and any degree of symptomatic heart failure.

A combination of digoxin and beta-blockadeappears superior than either agent alone.

In sinus rhythm, digoxin is recommended toimprove the clinical status of patients withpersisting heart failure despite ACE inhibitor anddiuretic treatment.

Cardiac glycosides





DIG trial

Long-term digoxin did not improve survival .

The primary benefit and indication for digoxinin heart failure is to reduce symptoms andimprove clinical status decrease the risk of

hospitalization for heart failure without animpact on survival.

Cardiac glycosides



No specific role for vasodilators in the treatment of HF

Used as adjunctive therapy for angina or concomitanthypertension.

In case of intolerance to ACE inhibitors ARBs arepreferred to the combination hydralazine – nitrates.

HYDRALAZINE-ISOSORBIDE DINITRATE

Hydralazine (up to 300 mg) in combination with ISDN (up to 160mg) without ACE inhibition may have some beneficial effect on

mortality, but not on hospitalization for HF.Nitrates may be used for the treatment of concomitant angina or relief of acute dyspnoea .

Vasodilator agents in chronic heart failure




Commonly used to limit severe episodes of HF or as a bridge to heart transplantation in end-stage HF.

Repeated or prolonged treatment with oralinotropic agents increases mortality.

Currently, insuffcient data are available to

recommend dopaminergic agents for heartfailure treatment.

Positive inotropic therapy





POSITIVE INOTROPHIC AGENTSDobutaminMilrinoneLevosimendan

DOPAMINERGIC AGENTSIbopamine is not recommended for the treatment of chronic HF due to systolic LV dysfunction.

Intravenous dopamine is used for the sort-termcorrection of haemodynamic disturbances of severeepisodes of worsening HF.

Positive inotropic therapy





No indication for the use of antiarrhythmic agents in HF

Indications for antiarrhythmic drug therapy include AF(rarely flutter), non-sustained or sustained VT.

CLASS I ANTIARRHYTHMICS

should be avoidedCLASS II ANTIARRHYTHMICS Beta-blockers reduce sudden death in heart failureCLASS III ANTIARRHYTHMICS

Amiodarone is the only antiarrhythmic drug withoutclinically relevant negative inotropic effects.

Antiarrhythmics





Recommendation

1. All pts with HF and AF should be treated withwarfarin unless contraindicated.

2. Patients with LVEF 35% or less.

Anticoagulation

HFSA Guidelines for Management of Patients With Heart Failure Caused by Left

Ventricular Systolic Dysfunction - Pharmacological Approaches 2000



Antiplatelet Drugs

Recommendation

There is insufficient evidence concerning thepotential negative therapeutic interaction between ASA and ACE inhibitors.

Antiplatelet agent for pts with HF who haveunderlying CAD.

HFSA Guidelines for Management of Patients With Heart Failure Caused by LeftVentricular Systolic Dysfunction - Pharmacological Approaches 2000



Chronic heart failure — choice of pharmacological therapy

LV systolic dysfunction ACE inhibitor Diuretic Beta-blockerAldosteroneAntagonist

Asymptomatic LVdysfunction Indicated Not indicated Post MI Not indicated

Symptomatic HF (NYHA II) Indicated Indicated ifFluid retention

Indicated Not indicated

Worsening HF (NYHA III-IV) IndicatedIndicated

comb. diureticIndicated

Indicated

End-stage HF (NYHA IV) Indicated Indicatedcomb. diuretic

Indicated Indicated



A



Chronic heart failure — choice of pharmacological therapy

LV systolic dysfunction

Angiotensin

II receptorantagonists

Cardiac glycosides

Vasodilator(hydralazine/

isosorbidedinitrate)

Potassium -sparingdiuretic

Asymptomatic LVdysfunction Not indicated With AF Not indicated Not indicated

Symptomatic HF (NYHA II)

If ACE inhibitorsare not toleratedand not on beta-

blockade

(a) when AF(b) when improved

from more severeHF in sinusrhythm

If ACE inhibitorsand angiotensin

II antagonistsare nottolerated

If persisting

hypokalaemia

Worsening HF (NYHA III-IV)

If ACE inhibitorsare not toleratedand not on beta-

blockade

indicated


II antagonistsare not

tolerated

If persistinghypokalaemia

End-stage HF (NYHA IV)If ACE inhibitorsare not toleratedand not on beta-

blockade

indicated


II antagonistsare not

tolerated

If persistinghypokalaemia


B



Intervention



Pts with heart failure of ischaemic origin revascularization symtomatic improvement.

A strong negative correlation of operative mortality and LVEF,

a low LVEF (<25%) was associated with increasedoperative mortality . Advance HF symptoms (NYHA IV)resulted in a greater mortality rate.

Off pump coronary revascularization may lower the surgical

risk for HF.

Heart Transplantation is an accepted mode of treatment for end-stage HF.

RevascularizationSurgical

Non Surgical





Care and Follow-up

Recommended components of programs

use a team approachvigilant follow-up, first follow-up within 10 days of dischargedischarge planningincreased access to health careoptimizing medical therapy with guidelinesintense education and counselling inpatient andoutpatient

strategies address barriers to complianceearly attention to signs and symptomsflexible diuretic regimen




Resume

Pharmacological Treatment :

I. Asymptomatic Systolic LV dysfunction :• ACE Inhibitor • -Blocker (in CAD)

II. Symptomatic Systolic LV dysfunctionA. No fluid retention

ACE Inhibitor -Blocker

If ischaemia (+) nitrate / revascularizationB. Fluid retention

Diuretic ACE Inhibitor (ARBs if not tolerated)

-Blocker ± Digitalis



Resume

III. Worsening HFStandard treatment : ACE Inhibitor, -Blocker Diuretic : doses + loop diureticLow dose spironolactoneDigitalisConsider :

» Revascularization» Valve surgery» Heart transplant

IV. End-stage HFIntermittent inotrophic supportCirculatory support (IABP, Ventr.Assist Devices)Haemofiltration on dialysis

briddging to heart transplantation



Conclusion

Management of HF must be starting fromthe earlier stage (AHA/ACC stage A).Treatment at each stage can reduce

morbidity and mortality.

Before initiating therapy :

Established the correct diagnose.Consider management outline.



ConclusionNon pharmacolgical intervention are helpfull in :

improving quality of lifereducing readmissionlowering cost.

Organize multi-disciplinary care :HF clinic, HF nurse specialist, pts telemonitoring.Health care system.

To optimize HF management Treatment should be according to the Guidelines,intensive education, and behavioral change efforts.

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