CHF Guideline 2006

7/23/2019 CHF Guideline 2006

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ACC Heart Failure GuidelinesSlide Deck

Based on the ACC/AHA 2005 Guideline Update

for the Diagnosis and anage!ent of

Chronic Heart Failure in the Adult

"anuar# 200$



Supported by Medtronic, Inc.

Medtronic, Inc. was not involved in the development of this

slide deck and in no way influenced its contents.



%illia! &' A(raha!) D) FACC) FAHA

arshall H' Chin) D) *H) FAC*

Arthur ' Feld!an) D) *hD) FACC)

FAHA

Gar# S' Francis) D) FACC) FAHA

&heodore G' Ganiats) D

ariell "essup) D) FACC) FAHA

ar+in A' ,onsta!) D) FACC

Sharon Ann Hunt) D) FACC) FAHA) Chair

Donna ' ancini) D

,eith ichl) D) FAC*

"ohn A' -ates) D) FAHA

*eter S' .ahko) D) FACC) FAHA

arc A' Sil+er) D) FACC) FAHA

#nne %arner Ste+enson) D) FACC)

FAHA

Cl#de %' anc#) D) FACC) FAHA

ACC/AHA 2005 Guideline Update for the

anage!ent of *atients %ith Chronic Heart

Failure in the Adult

%riting Co!!ittee e!(ers



Class 1

Benefit >>> Risk

*rocedure/ &reat!entSH-UD (e

perfor!ed/ad!inistered

Class 11a

Benefit >> Risk Additional studies withfocused objectivesneeded

1& 1S .AS-3AB toperfor!

procedure/ad!inistertreat!ent

Class 11(

Benefit ≥ Risk Additional studies withbroad objectivesneeded; Additionalregistry data would behelpful

*rocedure/&reat!entA B C-3S1D.D

Class 111

Risk ≥ Benefit No additional studiesneeded

*rocedure/&reat!entshould 3-& (eperfor!ed/ad!inistered

S13C 1& 1S 3-&H*FU A3D A BHA.FU

shouldis reco!!endedis indicated

is useful/effecti+e/(eneficial

is reasona(lecan (e useful/effecti+e/

(eneficial

is pro(a(l# reco!!endedor indicated

!a#/!ight (e considered!a#/!ight (e reasona(leusefulness/effecti+eness is

unkno4n /unclear/uncertain or not4ell esta(lished

is not reco!!endedis not indicatedshould not

is notuseful/effecti+e/(eneficial

!a# (e har!ful

Appl#ing Classification of

.eco!!endations and e+el of +idence



e+el A

ultiple !"#$% population riskstrataevaluated

&eneralconsistency ofdirection and'agnitude ofeffect

Class 1

• .eco!!endation thatprocedure ortreat!ent isuseful/

effecti+e6 Sufficiente+idencefro! !ultiplerando!i7edtrials or !etaanal#ses

Class 11a

• .eco!!endation infa+or oftreat!ent orprocedure

(eing useful/effecti+e

6 So!econflictinge+idencefro! !ultiplerando!i7ed

trials or !etaanal#ses

Class 11(

• .eco!!endation8susefulness/efficac# less4ell

esta(lished6 Greaterconflictinge+idence fro!!ultiplerando!i7edtrials or !eta

anal#ses

Class 111

• .eco!!endation thatprocedure ortreat!ent notuseful/effecti+

e and !a# (ehar!ful

6 Sufficiente+idence fro!!ultiplerando!i7edtrials or !eta

anal#ses





e+el B

(i'ited !)#"% population riskstrataevaluated

Class 1

• .eco!!endation thatprocedure ortreat!ent isuseful/effecti+

e6 i!itede+idencefro! singlerando!i7edtrial or nonrando!i7ed

studies

Class 11a

• .eco!!endation in fa+orof treat!ent orprocedure(eing useful/

effecti+e6 So!econflictinge+idence fro!singlerando!i7edtrial or non

rando!i7edstudies

Class 11(

• .eco!!endation8susefulness/efficac# less4ellesta(lished

6 Greaterconflictinge+idence fro!singlerando!i7edtrial or nonrando!i7edstudies

Class 111


e and !a# (ehar!ful6 i!itede+idence fro!singlerando!i7edtrial or non

rando!i7edstudies







e+el C *ery li'ited !+# )% populationrisk strataevaluated

Class 1

• .eco!!endation thatprocedure ortreat!ent isuseful/

effecti+e6 -nl# e9pert

opinion) casestudies) orstandardofcare

Class 11a

• .eco!!endation in fa+orof treat!ent orprocedure(eing

useful/effecti+e

6 -nl# di+erginge9pert opinion)case studies)or standardofcare

Class 11(

• .eco!!endation8susefulness/efficac# less4ell

esta(lished6 -nl# di+erging

e9pert opinion)case studies)or standardofcare

Class 111


e and !a# (ehar!ful

6 -nl# e9pertopinion) casestudies) orstandardofcare



Heart Failure is a a:or and Gro4ing *u(lic

Health *ro(le! in the U'S'

• Appro9i!atel# 5 !illion patients in this countr# ha+eHF

• -+er 550)000 patients are diagnosed 4ith HF for the

first ti!e each #ear

• *ri!ar# reason for ;2 to ;5 !illion office +isits and

$'5 !illion hospital da#s each #ear

• 1n 200;) nearl# 5<)000 patients died of HF as a

pri!ar# cause



Heart Failure is *ri!aril# a

Condition of the lderl#

• &he incidence of HF approaches ;0 per ;000

population after age $5

• HF is the !ost co!!on edicare diagnosis

related group

• ore dollars are spent for the diagnosis and

treat!ent of HF than an# other diagnosis (#

edicare



Guideline Scope

Docu!ent focuses on =

• *re+ention of HF

• Diagnosis and !anage!ent of

chronic HF in the adult



Definition of Heart Failure

HF is a co!ple9 clinical s#ndro!e that can

result fro! an# structural or functionalcardiac disorder that i!pairs the a(ilit# of

the +entricle to fill 4ith or e:ect (lood'



>Heart Failure? +s' >Congesti+e Heart Failure?

Because not all patients ha+e +olu!e o+erload at

the ti!e of initial or su(se@uent e+aluation) theter! >heart failure? is preferred o+er the older

ter! >congesti+e heart failure'?



Causes of HF in %estern %orld

For a su(stantial proportion of patients)

causes are=

;' Coronar# arter# disease

2' H#pertension

<' Dilated cardio!#opath#





Stages of Heart Failure

At Risk for ,eart -ailure.

S&AG A High risk for de+eloping HF

S&AG B As#!pto!atic d#sfunction

,eart -ailure.

S&AG C *ast or current s#!pto!s of HF

S&AG D ndstage HF




• Designed to e!phasi7e pre+enta(ilit# of HF

• Designed to recogni7e the progressi+e

nature of d#sfunction




C-*3&) D- 3-& .*AC 3HA

CASSS

• 3HA Classes shift (ack/forth in indi+idualpatient in response to .9 and/or progression of

disease

• Stages progress in one direction due to cardiac

re!odeling











Stage A

*atients at High .isk for

De+eloping Heart Failure



Stage A &herap#

.eco!!ended &herapies to .educe .isk 1nclude:

• &reating kno4n risk factors h#pertension) dia(etes) etc'

4ith therap# consistent 4ith conte!porar# guidelines• A+oiding (eha+iors increasing risk i'e') s!oking

e9cessi+e consu!ption of alcohol) illicit drug use

• *eriodic e+aluation for signs and s#!pto!s of HF• entricular rate control or sinus rh#th! restoration• 3onin+asi+e e+aluation of function• Drug therap#

•Angiotensin Con+erting n7#!e 1nhi(itors AC1

•Angiotensin .eceptor Blockers A.Bs



Stage A &herap#

1n patients at high risk for de+eloping HF)

s#stolic and diastolic h#pertension should (e

controlled in accordance 4ith conte!porar#guidelines'

1n patients at high risk for de+eloping HF) lipid

disorders should (e treated in accordance

4ith conte!porar# guidelines'

Using &herap# Consistent 4ithConte!porar# Guidelines

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Stage A &herap#

1n patients at high risk for de+eloping HF 4ho

ha+e kno4n atherosclerotic +ascular disease)

healthcare pro+iders should follo4 currentguidelines for secondar# pre+ention'

For patients 4ith dia(etes !ellitus 4ho are all

at high risk for de+eloping HF) (lood sugar

should (e controlled in accordance 4ith

conte!porar# guidelines'


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Stage A &herap#

&h#roid disorders should (e treated in

accordance 4ith conte!porar# guidelines in

patients at high risk for de+eloping HF'


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Stage A &herap#

*atients at high risk for de+eloping HF should

(e counseled to a+oid (eha+iors that !a#

increase the risk of HF e'g') s!oking)e9cessi+e alcohol consu!ption) and illicit

drug use'

A+oiding Beha+iors &hat1ncrease .isk

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Stage A &herap#

Healthcare pro+iders should perfor! periodic

e+aluation for signs and s#!pto!s of HF inpatients at high risk for de+eloping HF'

*eriodic +aluation forSigns and S#!pto!s

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Stage A &herap#

entricular rate should (e controlled or sinus

rh#th! restored in patients 4ith

supra+entricular tach#arrh#th!ias 4ho are athigh risk for de+eloping HF'

entricular .ate Control or Sinus.h#th! .estoration

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Stage A &herap#

Healthcare pro+iders should perfor! a

nonin+asi+e e+aluation of function i'e')

F in patients 4ith a strong fa!il# histor#of cardio!#opath# or in those recei+ing

cardioto9ic inter+entions'

3onin+asi+e +aluation of Function

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Stage A &herap#

AC1 can (e useful to pre+ent HF in patients at

high risk for de+eloping HF 4ho ha+e a histor# of

atherosclerotic +ascular disease) dia(etes!ellitus) or h#pertension 4ith associated

cardio+ascular risk factors'

Angiotensin Con+erting n7#!e1nhi(itors AC1

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Stage A &herap#

A.Bs can (e useful to pre+ent HF in patients

at high risk for de+eloping HF 4ho ha+e a

histor# of atherosclerotic +ascular disease)dia(etes !ellitus) or h#pertension 4ith

associated cardio+ascular risk factors'

Angiotension .eceptor BlockersA.Bs

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Stage A &herap#

.outine use of nutritional supple!ents solel#

to pre+ent the de+elop!ent of structural heart

disease should not (e reco!!ended forpatients at high risk for de+eloping HF'

&herapies 3-& .eco!!ended

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Stage B

*atients 4ith As#!pto!atic

D#sfunction



Stage B &herap#

.eco!!ended &herapies:General easures as ad+ised for Stage A

•Drug therap# for all patients•AC1 or A.Bs

•BetaBlockers•1CDs in appropriate patients•Coronar# re+asculari7ation in appropriate patients•al+e replace!ent or repair in appropriate patients



Stage B &herap#

All Class 1 reco!!endations for Stage A

should appl# to patients 4ith cardiac

structural a(nor!alities 4ho ha+e notde+eloped HF' (evels of /vidence. A0 B0 and

C as appropriate%

*atients 4ho ha+e not de+eloped HF

s#!pto!s should (e treated according toconte!porar# guidelines after an acute 1'

General easures

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Stage B &herap#

Beta(lockers and AC1s should (e used in all

patients 4ith a recent or re!ote histor# of 1

regardless of F or presence of HF'

AC1 should (e used in patients 4ith a reduced F

and no s#!pto!s of HF) e+en if the# ha+e not

e9perienced 1'

AC1 or A.Bs can (e (eneficial in patients 4ith

h#pertension and H and no s#!pto!s of HF'

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Angiotensin Con+erting n7#!e

1nhi(itors AC1



Stage B &herap#

An A.B should (e ad!inistered to post1 patients

4ithout HF 4ho are intolerant of AC1s and ha+e a

lo4 F'

AC1s or A.Bs can (e (eneficial in patients 4ith

h#pertension and H and no s#!pto!s of HF'

A.Bs can (e (eneficial in patients 4ith lo4 F and

no s#!pto!s of HF 4ho are intolerant of AC1s'

Angiotensin .eceptor BlockersA.Bs

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Stage B &herap#

Beta(lockers and AC1s should (e used in all

patients 4ith a recent or re!ote histor# of 1

regardless of F or presence of HF'

Beta(lockers are indicated in all patients

4ithout a histor# of 1 4ho ha+e a reduced

F 4ith no HF s#!pto!s'

BetaBlockers

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Stage B &herap#

*lace!ent of an 1CD is reasona(le in patients 4ith

ische!ic cardio!#opath# 4ho are at least E0 da#s

post1) ha+e an F of <0 or less) are 3HA

functional class 1 on chronic opti!al !edical therap#)

and ha+e reasona(le e9pectation of sur+i+al 4ith agood functional status for !ore than ; #ear'

*lace!ent of an 1CD !ight (e considered in patients

4ithout HF 4ho ha+e nonische!ic cardio!#opath#

and an F less than or e@ual to <0 4ho are in3HA functional class 1 4ith chronic opti!al !edical

therap# and ha+e a reasona(le e9pectation of sur+i+al

4ith good functional status for !ore than ; #ear'

1nternal Cardio+erter Defi(rillator 1CD

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Stage B &herap#

Coronar# re+asculari7ation should (e

reco!!ended in appropriate patients

4ithout s#!pto!s of HF in accordance4ith conte!porar# guidelines see

ACC/AHA Guidelines for the anage!ent

of *atients %ith Chronic Sta(le Angina'

Coronar# .e+asculari7ation

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Stage B &herap#

al+e replace!ent or repair should (e

reco!!ended for patients 4ith

he!od#na!icall# significant +al+ular stenosis or regurgitation and no

s#!pto!s of HF in accordance 4ith

conte!porar# guidelines'

al+e .eplace!ent/.epair

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Stage B &herap#

Digo9in should not (e used in patients 4ith lo4 F)

sinus rh#th!) and no histor# of HF s#!pto!s)

(ecause in this population) the risk of har! is not

(alanced (# an# kno4n (enefit'

Use of nutritional supple!ents to treat structural

heart disease or to pre+ent the de+elop!ent of

s#!pto!s of HF is not reco!!ended'

Calciu! channel (lockers 4ith negati+e inotropiceffects !a# (e har!ful in as#!pto!atic patients

4ith lo4 F and no s#!pto!s of HF after 1'


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Stage C

*atients 4ith *ast or CurrentS#!pto!s of Heart Failure



.eco!!ended &herapies:

•General !easures as ad+ised for Stages A and B•Drug therap# for all patients

•Diuretics for fluid retention•AC1

•Beta(lockers•Drug therap# for selected patients•Aldosterone Antagonists•A.Bs•Digitalis

•H#drala7ine/nitrates•1CDs in appropriate patients•Cardiac res#nchroni7ation in appropriate patients•9ercise &esting and &raining

Stage C &herap#.educed F 4ith S#!pto!s

S C



easures listed as Class 1 reco!!endations for

patients in stages A and B are also appropriate for

patients in Stage C' !(evels of /vidence. A0 B0 and C as

appropriate%

Drugs kno4n to ad+ersel# affect the clinical status of

patients 4ith current or prior s#!pto!s of HF and

reduced F should (e a+oided or 4ithdra4n

4hene+er possi(le e'g') nonsteroidal antiinfla!!ator#

drugs) !ost antiarrh#th!ic drugs) and !ost calciu!channel (locking drugs'

General easures111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

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St C &h



Diuretics and salt restriction are indicated in

patients 4ith current or prior s#!pto!s of HF

and reduced F 4ho ha+e e+idence of fluidretention'

Diuretics

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St C &h



AC1s are reco!!ended for all patients 4ith

current or prior s#!pto!s of HF and reduced

F) unless contraindicated'

.outine co!(ined use of an AC1) A.B) and

aldosterone antagonist is not reco!!ended for patients 4ith current or prior s#!pto!s of HF

and reduced F'

Angiotensin n7#!e Con+erting1nhi(itors AC1s

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St C &h



A.Bs appro+ed for the treat!ent of HF are

reco!!ended in patients 4ith current or prior

s#!pto!s of HF and reduced F 4ho are AC1

intolerant see full te9t guidelines for infor!ationregarding patients 4ith angioede!a'

A.Bs are reasona(le to use as alternati+es to AC1s

as firstline therap# for patients 4ith !ild to

!oderate HF and reduced F) especiall# for

patients alread# taking A.Bs for other indications'

Angiotensin .eceptor Blockers A.Bs111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

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St C &h



&he addition of an A.B !a# (e considered in

persistentl# s#!pto!atic patients 4ith reduced

F 4ho are alread# (eing treated 4ith

con+entional therap#'


aldosterone antagonist is not reco!!ended for

patients4ith current or prior s#!pto!s of HF and

reduced F'

A.Bs cont8d111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


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Stage C &herap#



Addition of an aldosterone antagonist is reco!!ended in

selected patients 4ith !oderatel# se+ere to se+ere

s#!pto!s of HF and reduced F 4ho can (e

carefull# !onitored for preser+ed renal function and

nor!al potassiu! concentration' Creatinine should (e

less than or e@ual to 2'5 !g/d in !en or less than ore@ual to 2'0 !g/d in 4o!en and potassiu! should (e

less than 5'0 !@/' Under circu!stances 4here

!onitoring for h#perkale!ia or renal d#sfunction is not

anticipated to (e feasi(le) the risks !a# out4eigh the

(enefits of aldosterone antagonists'

.outine co!(ined use of an AC1) A.B) and aldosterone

antagonist is not reco!!ended for patients 4ith current

or prior s#!pto!s of HF and reduced F'

Aldosterone Antagonists

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Stage C &herap#



Beta(lockers using ; of the < pro+en to reduce

!ortalit#) i'e') (isoprolol) car+edilol) and sustained

release !etoprolol succinate are reco!!ended for

all sta(le patients 4ith current or prior s#!pto!s of

HF and reduced F) unless contraindicated'

BetaBlockers

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111






Stage C &herap#



Digitalis can (e (eneficial in patients 4ith

current or prior s#!pto!s of HF and reduced

F to decrease hospitali7ations for HF'

Digitalis111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



&he addition of a co!(ination of h#drala7ine and a

nitrate is reasona(le for patients 4ith reduced

F 4ho are alread# taking an AC1 and (eta

(locker for s#!pto!atic HF and 4ho ha+epersistent s#!pto!s'

A co!(ination of h#drala7ine and a nitrate !ight (e

reasona(le in patients 4ith current or priors#!pto!s of HF and reduced F 4ho cannot (e

gi+en an AC1 or A.B (ecause of drug intolerance)

h#potension) or renal insufficienc#'

H#drala7ine and 1sosor(ide Dinitrate

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



An 1CD is reco!!ended as secondar# pre+ention to

prolong sur+i+al in patients 4ith current or prior

s#!pto!s of HF and reduced F 4ho ha+e a histor# of

cardiac arrest) +entricular fi(rillation) or he!od#na!icall#

desta(ili7ing +entricular tach#cardia'

1CD therap# is reco!!ended for pri!ar# pre+ention to

reduce total !ortalit# (# a reduction in sudden cardiac

death in patients 4ith ische!ic heart disease 4ho are at

least E0 da#s post1) ha+e an F less than or e@ual to

<0) 4ith 3HA functional class 11 or 111 s#!pto!s 4hileundergoing chronic opti!al !edical therap#) and ha+e

reasona(le e9pectation of sur+i+al 4ith a good functional

status for !ore than ; #ear'

1!planta(le Cardio+erter

Defi(rillators 1CDs

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



1CD therap# is reco!!ended for pri!ar# pre+ention to

reduce total !ortalit# (# a reduction in sudden cardiac

death in patients 4ith nonische!ic cardio!#opath# 4ho

ha+e an F less than or e@ual to <0) 4ith 3HA

functional class 11 or 111 s#!pto!s 4hile undergoingchronic opti!al !edical therap#) and 4ho ha+e

reasona(le e9pectation of sur+i+al 4ith a good functional

status for !ore than ; #ear'

*lace!ent of an 1CD is reasona(le in patients 4ith F

of <0 to <5 of an# origin 4ith 3HA functional class 11or 111 s#!pto!s 4ho are taking chronic opti!al !edical

therap# and 4ho ha+e reasona(le e9pectation of sur+i+al

4ith good functional status of !ore than ; #ear'

1CDs cont8d111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



*atients 4ith F less than or e@ual to <5) sinus

rh#th!) and 3HA functional class 111 or a!(ulator#

class 1 s#!pto!s despite reco!!ended) opti!al

!edical therap# and 4ho ha+e cardiac

d#ss#nchron#) 4hich is currentl# defined as a .S

duration greater than ;20 !s) should recei+e

cardiac

res#nchroni7ation therap# unless contraindicated'

Cardiac .es#nchroni7ation

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



a9i!al e9ercise testing 4ith or 4ithout

!easure!ent of respirator# gas e9change is

reco!!ended to facilitate prescription of an

appropriate e9ercise progra! for patientspresenting 4ith HF'

9ercise training is (eneficial as an ad:uncti+e

approach to i!pro+e clinical status in a!(ulator#


reduced F'

9ercise &esting and &raining

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



Unpro+en/3ot .eco!!endedDrugs and 1nter+entions for HF

• 3utritional Supple!ents

• Hor!onal &herapies• 1nter!ittent 1ntra+enous

*ositi+e 1notropic &herap#


Stage C &herap#



ongter! use of an infusion of a positi+e inotropic

drug !a# (e har!ful and is not reco!!ended for


reduced F) e9cept as palliation for patients 4ith

endstage disease 4ho cannot (e sta(ili7ed 4ithstandard !edical treat!ent see reco!!endations

for Stage D'

Use of nutritional supple!ents as treat!ent for HF

is not indicated in patients 4ith current or priors#!pto!s of HF and reduced F'

Unpro+en/3ot .eco!!ended Drugs and 1nter+entions

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



Calciu! channel (locking drugs are not indicated

as

routine treat!ent for HF in patients 4ith current or

prior s#!pto!s of HF and reduced F'

Hor!onal therapies other than to replete

deficiencies are not reco!!ended and !a# (e

har!ful to patients 4ith current or prior s#!pto!s

of HF and reduced F'


aldosterone antagonist is not reco!!ended for

patients4ith current or prior s#!pto!s of HF and

reduced F'

Unpro+en/3ot .eco!!ended Drugs and 1nter+entions

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



.eco!!ended &herapies for .outine Use=

•&reating kno4n risk factor h#pertension 4ith therap#

consistent 4ith conte!porar# guidelines•entricular rate control for all patients•Drugs for all patients

•Diuretics•Drugs for appropriate patients

•AC1•A.Bs•BetaBlockers

•Digitalis•Coronar# re+asculari7ation in selected patients•.estoration/!aintenance of sinus rh#th! in

appropriate patients

Stage C &herap#3or!al F 4ith S#!pto!s

Differential Diagnosis in *atient 4ith HF and



Differential Diagnosis in *atient 4ith HF and

3or!al F 4ith S#!pto!s

• 1ncorrect diagnosis of HF• 1naccurate !easure!ent of

F• *ri!ar# +al+ular disease• .estricti+e infiltrati+e

cardio!#opathies• A!#loidosis) sarcoidosis)he!ochro!atosis

• *ericardial constriction• pisodic or re+ersi(le

s#stolic d#sfunction

• Se+ere h#pertension)!#ocardial ische!ia

• HF associated 4ith high!eta(olic de!and highoutput states

• Ane!ia) th#roto9icosis)arterio+enous fistulae

• Chronic pul!onar#disease 4ith right HF

• *ul!onar# h#pertensionassociated 4ithpul!onar# +asculardisorders

• Atrial !#9o!a• Diastolic d#sfunction of

uncertain origin• -(esit#

Stage C &herap#



*h#sicians should control s#stolic and

diastolic h#pertension in patients 4ith HF and

nor!al F) in accordance 4ith pu(lished

guidelines'

&reating kno4n risk factors H#pertension

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



*h#sicians should control +entricular rate in

patients 4ith HF and nor!al F and atrial

fi(rillation'

entricular .ate Control111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



*h#sicians should use diuretics to control

pul!onar# congestion and peripheral ede!a in

patients 4ith HF and nor!al F'

Diuretics

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



Coronar# re+asculari7ation is reasona(le in

patients 4ith HF and nor!al F and

coronar# arter# disease in 4ho! s#!pto!aticor de!onstra(le !#ocardial ische!ia is

:udged to (e ha+ing an ad+erse effect on

cardiac function'

Coronar# .e+asculari7ation

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



.estoration and !aintenance of sinus rh#th!

in patients 4ith atrial fi(rillation and HF and

nor!al F !ight (e useful to i!pro+es#!pto!s'

.estoration/aintenanceof Sinus .h#th!

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



&he use of (etaadrenergic (locking agents) AC1s)

A.Bs) or calciu! antagonists in patients 4ith HF

and nor!al F and controlled h#pertension !ight(e effecti+e to !ini!i7e s#!pto!s of HF'

Angiotensin n7#!e Con+erting1nhi(itors AC1s

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#





and nor!al F and controlled h#pertension !ight

(e effecti+e to !ini!i7e s#!pto!s of HF'

Angiotensin .eceptor Blockers A.Bs

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#





and nor!al F and controlled h#pertension !ight

(e effecti+e to !ini!i7e s#!pto!s of HF'

BetaBlockers

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111


Stage C &herap#



&he usefulness of digitalis to !ini!i7e

s#!pto!s of HF in patients 4ith HF and nor!al

F is not 4ell esta(lished'

Digitalis

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111




Stage D

*atients 4ith .efractor# ndStage HF

Stage D &herap#



Stage e ap#

.eco!!ended &herapies 1nclude=

•Control of fluid retention•.eferral to a HF progra! for appropriate pts•Discussion of options for endoflife care•1nfor!ing re= option to inacti+ate defi(rillator •De+ice use in appropriate patients•Surgical therap#

•Cardiac transplantation•itral +al+e repair or replace!ent•-ther

•Drug &herap# •*ositi+e inotrope infusion as palliation

in appropriate patients

Stage D &herap#



g p#

eticulous identification and control of fluid

retention is reco!!ended in patients 4ith

refractor# endstage HF'

Control of Fluid

.etention

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

Stage D &herap#



g p#

.eferral of patients 4ith refractor# endstage

HF to an HF progra! 4ith e9pertise in the

!anage!ent of refractor# HF is useful'

.eferral to an HF *rogra!

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

Stage D &herap#



g p#

-ptions for endoflife care should (e

discussed 4ith the patient and fa!il# 4hen

se+ere s#!pto!s in patients 4ith refractor#endstage HF persist despite application of all

reco!!ended therapies'

Discussion of -ptions forndofife Care

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

Stage D &herap#



g p#

*atients 4ith refractor# endstage HF and

i!planta(le defi(rillators should recei+e

infor!ation a(out the option to inacti+atedefi(rillation'

1nfor! on option to

inacti+ate defi(rillation

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

Stage D &herap#



g p#

.eferral for cardiac transplantation in

potentiall# eligi(le patients is reco!!ended for

patients 4ith refractor# endstage HF'

&he effecti+eness of !itral +al+e repair or

replace!ent is not esta(lished for se+ere

secondar# !itral regurgitation in refractor#

endstage HF'

Surgical &herap#

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

Stage D &herap#



111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

g p#

Consideration of an assist de+ice as

per!anentor >destination? therap# is

reasona(le in highl# selected patients 4ith

refractor# endstage HF and an esti!ated

;#ear !ortalit# o+er 50 4ith !edical therap#'

*ul!onar# arter# catheter place!ent !a# (e

reasona(le to guide therap# in patients 4ith

refractor# endstage HF and persistentl# se+eres#!pto!s'

De+ice Use

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

Stage D &herap#



g p#

Continuous intra+enous infusion of a positi+e

inotropic agent !a# (e considered for

palliation of s#!pto!s in patients 4ith

refractor# endstage HF'

.outine inter!ittent infusions of positi+e

inotropic agents are not reco!!ended for


edical &herap#

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

Stage D &herap#



g #

*artial left +entriculecto!# is not

reco!!ended inpatients 4ith nonische!ic

cardio!#opath# and refractor# endstage HF'

.outine inter!ittent infusions of positi+e

inotropic agents are not reco!!ended for



111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 111111111111 11a11a11a 11(11(11( 11111111111a11a11a 11(11(11( 111111111

Documents

CHF Guideline 2006