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

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage C

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage CPatients 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patients with current or prior symptoms of HF and reduced left ventricle ejection fraction (LVEF) should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs).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 weightInfluenza and pneumococcal vaccinationMonitor potassium (4-5 mmol per L) and magnesiumEmphasis on compliance with diet and medicationsPatient education and close supervision

Stage C

Class IIIUse 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

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage C

Beta BlockersClass 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 blockersAlleviate 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-blockerShould 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

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage CClass 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 IIIRoutine 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 prostaglandinAlleviate symptoms, improve clinical status, reduce risk of death and of hospitalizationContraindicated if angioedema or pregnantFluid retention can blunt effects and fluid depletion can potentate adverse effects (Hypotension, hyperkalemia, renal failure)Cough. All other causes must be excluded

Stage C

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage CClass 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 IIAAngiotensin 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 IIBThe 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

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage CClass IClass IAldosterone antagonist is reasonable Aldosterone antagonist is reasonable in selected patients with moderately in selected patients with moderately severe to severe symptoms of HF and severe to severe symptoms of HF and reduced LVEF who can be carefully reduced LVEF who can be carefully monitored for preserved renal monitored for preserved renal function and normal potassium function and normal potassium concentration. Creatinine should be concentration. Creatinine should be less than or equal to 2.5 mg/dL in less than or equal to 2.5 mg/dL in men or less than or equal to 2.0 men or less than or equal to 2.0 mg/dL in women and potassium mg/dL in women and potassium should be less than 5.0 mEq/L. should be less than 5.0 mEq/L. (Level (Level of Evidence: B)of Evidence: B)

Stage C

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage C

Class IDiuretics 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 CInhibit 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 knownProduce symptomatic relief more rapidly than any other drug.Risk of use is electrolyte depletion, hypotension and azotemia.

Stage C

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage C

Class IIaDigitalis 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 massSerum levels are followed for purpose of toxicity and not to guide therapy

Stage C

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage C

Class IIaThe addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACEI and beta-blocker for symptomatic HF and who have persistent symptoms. (Level of Evidence: A)

Stage C

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage CClass 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 therapyReasonable 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 CClass I CRTPatients with LVEF less than or equal to 35%Sinus rhythmNYHA 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

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage C

Class IIILong-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

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage D

End stage heart diseaseCardiac 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 yearAlternate surgical and mechanical approaches for the treatment of end-stage HF are under development

Stage C

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage D

Class IIIRoutine 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 DReferral 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

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

Stage DClass I

Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF. (Level of Evidence: B)

Class IIaConsideration of an LV assist device as permanent or “destination” therapy is reasonable in highly selected patients with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy. (Level of Evidence: B)

Stage DAbsolute indications for cardiac transplant

For hemodynamic compromise due to HF Refractory cardiogenic shockDocumented dependence on IV inotropic support to maintain adequate organ perfusionPeak 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 interventionRecurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities

Stage C

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

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

Basic management

Beta blockers

ACE inhibitors

ARB

Aldosterone blocker

Diuretics

Digoxin

Hydralazine/Nitrate

Devices

Inotropic agents

Stage D

Refractory HF

Transplantation

Subgroups

HF with normal LVEF

HF with preserved EFControl 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)