chf_nikam

8/13/2019 chf_nikam

1/94

Congestive Heart Failure CHFSUGAR LAND

HEART CENTER

By

Nik Nikam, M.D.Interventional Cardiologist

Sugar Land Texas

May 2010

8/13/2019 chf_nikam

2/94


HEART CENTER Epidemiology

Approximately 4.9 million people have CHF

More than 550,000 cases detected annually

Account for 5 to 10% of all hospitalizations

250,000 deaths per year related to CHF

Five year mortality as high as 60% in men & 45%

in women

Median survival is 3.5 years for men and 5.4 yearsfor women

8/13/2019 chf_nikam

3/94


HEART CENTER

CHF precipitating factors

Non Compliance with Meds and Diet

Acute MI

Arrhythmia

Pneumonia

Increased Sodium Diet (Holiday Failure)

AnxietyPregnancy

8/13/2019 chf_nikam

4/94


HEART CENTER

Rhythm problems leading to CHF

8/13/2019 chf_nikam

5/94


HEART CENTER

Pathophysiology

Hemodynamic changes

Neurohormonal changes

Cellular changes

8/13/2019 chf_nikam

6/94


HEART CENTER

Neurohormonal changes in CHF

RAS, renin-angiotensin system; SNS, sympathetic nervous system.

Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease)

Morbidity and mortality

Arrhythmias

Pump failure

Peripheral vasoconstriction

Hemodynamic alterations

Heart failure symptoms

Remodeling and progressive

worsening of LV function

Initial fall in LV performance, wall stress

Activation of RAAS and SNS

Fibrosis, apoptosis,

hypertrophy, cellular/

molecular alterations,

myotoxicity

Fatigue

Activity altered

Chest congestion

Edema

Shortness of breath

8/13/2019 chf_nikam

7/94


HEART CENTER

Neurohormonal changes

N/H changes Favorable effect Unfavor. effect

Sympathetic activityHR ,contractility,

vasoconst.V return,

filling

Arteriolar constriction

After loadworkload

O2consumption

Renin-Angiotensin

Aldosterone

Salt & water retentionVR Vasoconstriction

after load

Vasopressin Same effect Same effect

interleukins &TNF May have roles in myocytehypertrophy

Apoptosis

EndothelinVasoconstrictionVR After load

8/13/2019 chf_nikam

8/94


HEART CENTER

Cardiovascular physiology

Frank-Starling Length: Tension Ratio

Ejection Fraction

End diastolic volume/end systolic volumeCardiac Output

Stroke volume x heart rate

Preload

Volume of blood delivered to heart during diastole

Afterload Peripheral vascular resistance

8/13/2019 chf_nikam

9/94


HEART CENTER

Volume overload: Regurgitate valveHigh output status

Pressure overload: Systemic hypertension

Outflow obstructionAS

Loss of muscles: Post MI, Chronic ischemiaConnective tissue diseases

Infection, Poisons(alcohol,cobalt,Doxorubicin)

Restricted Filling: Pericardial diseases,Restrictive cardiomyopathy

Tachyarrhythmia

Causes of CHF

8/13/2019 chf_nikam

10/94


HEART CENTER

Types of CHF

Systolic & Diastolic

High Output Failure

Pregnancy, anemia, thyrotoxicosis, A/V fistula, Beriberi, Pagetsdisease

Low Output Failure

Acute large MI, aortic valve dysfunction---

Chronic

8/13/2019 chf_nikam

11/94


HEART CENTER

Types of CHF

Right v. Left sided heart failure

Right sided heart failure :

Most common cause is left sided failure

Other causes included : Pulmonary embolisms

Other causes of pulmonary HTN

RV infarction

MS

Usually presents with: LL edema, ascities

Hepatic congestion

Cardiac cirrhosis (on the long run)

8/13/2019 chf_nikam

12/94


HEART CENTER

New York Heart Association (NYHA)

Functional Classification

Class % of pts Symptoms

I 35% No symptoms or limitations in ordinary physical

activity

II 35% Mild symptoms and slight limitation during

ordinary activity

III 25% Marked limitation in activity even during minimal

activity. Comfortable only at rest

IV 5% Severe limitation. Experiences symptoms even at

rest

8/13/2019 chf_nikam

13/94


HEART CENTER

Physical Exam

Anxious

Pale

Clammy

Tachypnea

Confusion

EdemaHypertension

Diaphoretic

Rales

Rhonchi

Tachycardia

S3Gallop

JVD

Pink Frothy Sputum

CyanosisDisplaced PMI

8/13/2019 chf_nikam

14/94


HEART CENTER Measurement of Jugular Venous pressure

Jugular Venous Distention

not directly related to LVF.

Comes from backpressure buildingfrom right heart into

venous circulation

8/13/2019 chf_nikam

15/94


HEART CENTER

Framingham Criteria for CHF

Major Criteria:

PND

JVD Rales

Cardiomegaly

Acute Pulmonary Edema

S3 Gallop Positive hepatic Jugular reflex

venous pressure >16 cm H2O

8/13/2019 chf_nikam

16/94


HEART CENTER

Lab Tests

Anemia

Hyperthyroid

Chronic renal insuffiency

Electrolyte abnormality-Na, K, Mag, Calcium

Pre-renal azotemia

Hemochromatosis

BNP

TSH

HgA1c

8/13/2019 chf_nikam

17/94


HEART CENTER

EKG

Old MI or recent MI

Arrhythmia

Some forms of Cardiomyopathy are tachycardiarelated

LBBBmay help in management

Heart Block

8/13/2019 chf_nikam

18/94


HEART CENTER

Chest X-ray

Look for Heart size

Pulmonary vascular markings

COPD, pneumonia, Pneumothorax, widened mediastinum

Pleural effusions

8/13/2019 chf_nikam

19/94


HEART CENTER

Echocardiogram

Function of both ventricles

Wall motion abnormality that may signify CAD

Valvular abnormality

Intra-cardiac shunts

Pericardial effusion

Restrictive pericarditis

Pulmonary hypertension

8/13/2019 chf_nikam

20/94


HEART CENTER

Cardiac Catheterization

Coronary artery disease

Dilated ventricle

Hyperdynamic small ventricle

Wall motion abnormality that may signify CAD

Valvular abnormalityIntra-cardiac shunts

Pulmonary hypertension

8/13/2019 chf_nikam

21/94


HEART CENTER

Differential Diagnosis of CHF

Pericardial diseases

Liver diseasesNephrotic syndrome

Protein losing enteropathy

8/13/2019 chf_nikam

22/94


HEART CENTER


COPD CHF Pneumonia

Cough Frequent Occasional Frequent

Wheeze Frequent Occasional Frequent

Sputum Thick Thin/white Thick/yellow/brown

Hemoptysis Occasionally Pink frothy occasionally

PND Sometimes after

a few hours

Often within 1

hour

Rare

Smoking Common Less common Less common

Pedal edema Occasional Common with

chronic

none

8/13/2019 chf_nikam

23/94


HEART CENTER


COPD CHF Pneumonia

Onset Often URI with

cough

Orthopnea at

night

Gradual with

fever, cough

Chest Pain pleuritic Substernal,crushing Pleuritic, oftenlocalized

Clubbing Often Rare Rare

Cyanosis Often and severe Initially mild but

progresses

May be present

Diaphoresis May be present Mild to heavy Dry to moist

Pursed Lips Often Rare Rare unless

COPD

8/13/2019 chf_nikam

24/94


HEART CENTER

HFSA 2006 Comprehensive Heart Failure Practice Guideline

Strength of Evidence

A

B

C

Randomized controlled trials

May be assigned on results of 1 trial

Cohort and case control studies

Includes sub group analyses, meta-analyses, observational studies,registries

Expert opinion

Includes observational, epidemiologicalfindings; in-practice safety reporting

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive

Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

8/13/2019 chf_nikam

25/94


HEART CENTER

Goals for CHF management in a hospital

1. Relieve symptoms rapidly

2. Reverse hemodynamic abnormalities

3. Prevent end-organ dysfunction

4. Initiate patient education and survival-enhancingmedications before discharge

5. Optimize survival-enhancing oral medications (ACEinhibitor, beta blocker, aldosterone receptor antagonist)

6. Optimize patient education and HF disease management

8/13/2019 chf_nikam

26/94


HEART CENTER

CHF treatment-Acute

NTG- SL and IV infusion

Morphine sulfate: 2-6 mg IV

Lasix 40-80 mg IV

O2High flow O2

CPAP

Foley catheter

8/13/2019 chf_nikam

27/94


HEART CENTER

CHF Management

Beta Blocker

Diuretics for fluid retention

Aldosterone antagonists in

select patient

Digoxin to reduce

hospitalizations

Hydralazine/nitrate or ARB if

BP allows + sxs

Bi-Vv pacing if sxs CRT

ACE-I (or ARB if ACE intolerant)

Regular exercise program

Sodium restriction

ICD

8/13/2019 chf_nikam

28/94


HEART CENTER

Treatment of CHF

Correction of reversible causes

Medications

Diuretics, ACE inhibitors, beta blokers etc. Ischemia

Arrhythmia: A fib, flutter, PJRT

Valvular heart disease

Thyrotoxicosis and other high output status Shunts

SUGAR LAND

8/13/2019 chf_nikam

29/94


HEART CENTER

CHF treatment-Acute

Pharmacological

Morphine sulfate

NitratesDiuretics

ACE inhibitors

Beta blockers

Aspirin therapy

statinsVasodilators

Neurohormonal antagonists

Anticoagulant therapy

Antiarrhymics

SUGAR LAND

8/13/2019 chf_nikam

30/94


HEART CENTER

Diet and Activity

Salt restriction (2 grams per day)

Fluid restriction (Less than 1-2 liters per day)

Daily weight (tailor therapy)

Gradual exercise programs

Blood sugar monitoring

SUGAR LAND

8/13/2019 chf_nikam

31/94


HEART CENTER

Adams KF, Lindenfeld J, et al. HFSA 2006 ComprehensiveHeart Failure Guideline. J Card Fail 2006;12:e1-e122.

Sodium Equivalents

2400 mg6100 mg1 tsp

1800 mg4650 mg tsp

1200 mg3100 mg tsp

600 mg1550 mg tsp

SodiumSodium ChlorideSalt

SUGAR LAND

8/13/2019 chf_nikam

32/94


HEART CENTER

Diuretics

The most effective symptomatic relief

Mild symptoms

HCTZ Chlorthalidone

Metolazone

Block Na reabsorbtion in loop of henle and distal

convoluted tubules

Thiazides are ineffective with GFR < 30 --/min

SUGAR LAND

8/13/2019 chf_nikam

33/94


HEART CENTER



Thiazide Diuretics

36 hrsMetabolic5 mg2.5 mg qdIdapamide

12-24 hrs80% Renal,10% into Bile,

10% Unknown

20 mg2.5 mg qdMetolazone

6-12 hrsRenal200 mg25 mg qd

or bid

Hydrochloro-

thiazide

24-72 hrs65% Renal,

10% into Bile,

25% Unknown

100 mg12.5-25 mg

qd

Chlorthalidone

6-12 hrsRenal1000 mg250-500 mg

qd or bid

Chlorothiazide

Duration

of Action

EliminationMax Total

Daily Dose

Initial Daily

Dose

Agent

SUGAR LAND

8/13/2019 chf_nikam

34/94


HEART CENTER

Diuretics

Loop diuretics for more severe heart failure

Lasix (20320 mg QD), Furosemide

Bumex (Bumetanide 1-8mg)

Torsemide (20-200mg)

Mechanism of action: Inhibit chloride reabsortion in ascendinglimb of loop of Henle results in natriuresis, kaliuresis andmetabolic alkalosis

Adverse reaction:pre-renal azotemia

Hypokalemia

Skin rash

Ototoxicity

SUGAR LAND

8/13/2019 chf_nikam

35/94


HEART CENTER


Loop Diuretics

6 hrs67%R/33%M200 mg25-50 mg qd

or bid

Ethacrynic

acid

12-16 hrs20%R/80%M200 mg10-20 mg qdTorsemide

6-8 hrs62%R/38%M10 mg0.5-1.0 mg

qd or bid

Bumetanide

4-6 hrs65%R/35%M600 mg20-40mg qdor bid

Furosemide

Duration of

Action

Elimination:

Renal Met.

Max Total

Daily Dose

Initial Daily

Dose

Agent

SUGAR LAND

8/13/2019 chf_nikam

36/94


HEART CENTER

Diuretics

Side Effects Pre-renal azotemia

Skin rashes

Neutropenia

Thrombocytopenia

Hyperglycemia

Uric Acid

Hepatic dysfunction

Loss of K and Mag

SUGAR LAND

8/13/2019 chf_nikam

37/94


HEART CENTER

Diuretics

K sparing diuretics

Triamterene

Amilorideacts on distal tubules to K secretion

Spironolactone(Aldosterone inhibitor)

Recent evidence suggests that it may improve survival in CHFpatients due to the effect on renin-angiotensin-aldosterone system withsubsequent effect on myocardial remodeling and fibrosis

SUGAR LAND

8/13/2019 chf_nikam

38/94


HEART CENTER



Potassium-Sparing Diuretics

7-9 hrsMetabolic200 mg50-75 mg

bid

Triamterene

24 hrsRenal20 mg5 mg qdAmilioride

Renal,

Metabolic

100 mg25-50 mg

qd

Eplerenone

48-72 hrsMetabolic50 mg12.5-25 mg

qd

Spironolactone

Duration

of Action

EliminationMax Total

Daily Dose

Initial Daily

Dose

Agent

SUGAR LAND

8/13/2019 chf_nikam

39/94


HEART CENTER

LV size and thickness in CHF

SUGAR LAND

8/13/2019 chf_nikam

40/94


HEART CENTER

Increases pressure withinairway.

Airways at risk for collapsefrom excess fluid are keptopen.

Gas exchange minimizesthe Increased work ofbreathing.

CPAP Mechanism

SUGAR LAND

8/13/2019 chf_nikam

41/94


HEART CENTER

CPAP

Non-invasive

Easily discontinued Easily adjusted

Does not require

sedation

Comfortable

Intubation

InvasivePotential for infectionTraumatic

CPAP Mechanism

SUGAR LAND

8/13/2019 chf_nikam

42/94

Congestive Heart Failure CHFSUG

HEART CENTER

Renin, angiotensin, aldasterone blockers

Renin-angiotensin-aldosterone systemis activation early

in the course of heart failure and plays an important

rolein the progression of the syndrome:

Angiotensin converting enzyme inhibitors

(ACE inhibitors)

Angiotensin receptors blockers (ARBS)

Spironolactone

SUGAR LAND

8/13/2019 chf_nikam

43/94

Congestive Heart Failure CHFHEART CENTER

Renin Angiotensin Blockers

Common ACE inhibitors

CaptoprilLisinopril

Vasotec

Monopril

Accupril

SUGAR LAND

8/13/2019 chf_nikam

44/94


Renin-angiotensin blockers

They block the R-A-A system by inhibiting theconversion of angiotensin I to angiotensin II:

Vasodilation

Na retention

DecreasedBradykinin degradation its level PG secretion & nitric oxide

Ace Inhibitors improve survival in CHF patients Delay onset & progression of HF in pts with

asymptomatic LV dysfunction

cardiac remodeling

C CSUGAR LAND

8/13/2019 chf_nikam

45/94


Renin-angiotensin blockers

Side Effects of ACE inhibitors

AngioedemaHypotension

Renal insuffiency

Rash

cough

C i H F il CHFSUGAR LAND

8/13/2019 chf_nikam

46/94


Sleep related problems in CHF

Affects 40-50% of pts with systolic HF

Central sleep apnea Cheyne Stokes respiration

Does not correlate with ejection fractionOvernight oximetry- easy diagnostic test

Treatment with supplemental oxygen

May also need mild sleeping pills, acetazolamide

May need Full sleep study -BiPap

Nocturnal 02 lowers BNP and catecholamine levels


8/13/2019 chf_nikam

47/94


Beta Blockers

Has been traditionally contraindicated in pts withCHF

Now they are the main stay in treatment on CHF &may be the only medication that shows substantialimprovement in LV function

In addition to improved LV function multiple

studies show improved survival

The only contraindication is severedecompensated CHF


8/13/2019 chf_nikam

48/94


Beta Blocker therapy outcomes

*Adjusted for baseline age, sex, race, HF etiology, LVEF, systolic blood pressure, smoking, signs of

congestion, laboratory values, discharge medications, in-hospital invasive procedures, and history of

diabetes and cardiovascular, neurological, pulmonary, and renal diseases

End point LV systolic

dysfunction, n=3001

Preserved LV systolic

function, n=4153

Mortality 0.77 (0.680.87) 0.94 (0.841.07)

Readmission 0.89 (0.800.99) 0.98 (0.901.06)

Mortality or

readmission

0.87 (0.790.96) 0.98 (0.911.06)

Hernandez AF et al.J Am Coll Cardiol 2009; 53:184-192.

Adjusted* hazard ratios (95% CI) for one-year outcomes, beta

blocker therapy vs no beta blocker therapy, by LV functional status

C ti H t F il CHFSUGAR LAND

8/13/2019 chf_nikam

49/94


Inotropic agents-Digoxin

The role of digitalis has declined somewhat because

of safety concern

Recent studies have shown that digitals does notaffect mortality in CHF patients but causes

significant

Reduction in hospitalization

Reduction in symptoms of HF

Rate control in At fib.


8/13/2019 chf_nikam

50/94


Inotropic agent-Digoxin action

+ve inotropic effect by intracellular Ca &

enhancing actin-myosin cross bride formation

(binds to the Na-K ATPase inhibits Na pump intracellular Na Na-Ca exchange

Vagotonic effect

Arrhythmogenic effect


8/13/2019 chf_nikam

51/94


Inotropic agent-Digitalis toxicity

Cardiac manifestations

Sinus bradycardia and arrest A/V block (usually 2nddegree)

Atrial tachycardia with A/V Block

Development of junctional rhythm in patients with a

fib

PVCs, VT/ V fib (bi-directional VT)

Congesti e Heart Fail re CHFSUGAR LAND

8/13/2019 chf_nikam

52/94


Inotropic agent-Digitalis toxicity

Narrow therapeutic to toxic ratio

Non cardiac manifestations

Anorexia,

Nausea, vomiting,

Headache,

Xanthopsia sotoma,

Disorientation

Treatment: Digibind (Fab antibody)


8/13/2019 chf_nikam

53/94


Antiarrhythmics

Most common cause of SCD in these patients is

ventricular tachyarrhythmia

Patients with h/o sustained VT or SCD ICD implant

Patients with CHF with an ejection fraction of less than

30% may receive ICD implant

Amiodarone for patients with frequent VPCs and at fib

Dranedone for patients with recurrent paroxysmal at fib.


8/13/2019 chf_nikam

54/94


VasodilatorsHydralazine and Nitrates

Reduction of afterloadby arteriolar vasodilatation

(hydralazin)reduce LVEDP, O2 consumption,improvemyocardial perfusion, stroke volume and COP

Reduction of preload Byvenous dilation

( Nitrate) the venous return the load on bothventricles.

Usually the maximum benefit is achieved by usingagents with both action.


8/13/2019 chf_nikam

55/94


Anticoagulation

Atrial fibrillation

H/o embolic episodes

Left ventricular apical thrombus

Low LV ejection fraction


8/13/2019 chf_nikam

56/94


Inotropic Agents

These are the drugs that improve myocardial

contractility ( adrenergic agonists, dopaminergic agents,

phosphodiesterase inhibitors),

Dopamine

Dobutamine

Milrinone,

Aamrinone

Several studies showed mortality with oral inotropic agents

So the only use for them now is in acute sittings such as cardiogenic

shock


8/13/2019 chf_nikam

57/94


ICD placement

HFSA 2006 Practice Guideline (9.1, 9.4)

Device Therapy:Prophylactic ICD Placement

In patients on optimal medical therapy (ideally 3-6 months)

with or without concomitant coronary artery disease(including a prior MI > 1 month ago):

Prophylactic ICD placement should be considered inthose with NYHA II-III HF (LVEF 30%)

Prophylactic ICD placement may be considered in thosewith NYHA II-III HF (LVEF 31-35%)

Strength of Evidence = A

Concomitant placement should be considered in NYHA III-IV patients undergoing implantation of a biventricularpacing device. Strength of Evidence = B

Adapted from: Adams KF, Lindenfe ld J, et al. HFSA 2006 ComprehensiveHeart Failure Guideline. J Card Fail 2006;12:e1-e122.


8/13/2019 chf_nikam

58/94


New Treatment Choices

Implantable ventricular assist devices

Biventricular pacing(only in patient with

LBBB & CHF)

Artificial Heart


8/13/2019 chf_nikam

59/94


Achieving Cardiac ResynchronizationMechanical Goal: Atrial-synchronized bi-ventricular pacing

Standard pacing lead in RA

Standard pacing or defibrillation lead in RV

Specially designed left heart lead placed in a left ventricular cardiacvein via the coronary sinus

Right Atrial

Lead

Right Ventricular

Lead

Left Ventricular

Lead


8/13/2019 chf_nikam

60/94


CHFLong term prognosis

1Framingham Heart Study (1948-1988) in Atlas of Heart Diseases.

2American Heart Association.Heart Disease and Stroke Statistics2005 Update.

100

90

80

70

60

5040

30

20

10

0

ProbabilityofSurvival(%) Men (N=237)

Time After CHF Diagnosis (Years)0 2 4 6 8 10

80% of men and 70% of

women who have CHF will

die within 8 years.2

Women (N=230)


8/13/2019 chf_nikam

61/94


Cardiac transplant

It has become more widely used since the advances

in immunosuppressive treatment

Survival rate

1 year 80% - 90% 5 years 70%


8/13/2019 chf_nikam

62/94


Prognosis

Annual mortality rate depends on patients

symptoms and LV function

5% in patients with mild symptoms and mild inLV function

30% to 50% in patient with advances LV

dysfunction and severe symptoms

40%50% of death is due to SCD


8/13/2019 chf_nikam

63/94


Modes of death in CHF based on NYHA class

1 MERIT-HF Study Group.LANCET. 1999;353:2001-2007.

12%

24%64%

CHF

Other

SuddenDeath(N = 103)

NYHA II

26%

15%

59%

CHF

Other

SuddenDeath(N = 103)

NYHA III

56%

11%

33%

CHF

Other

SuddenDeath(N = 27)

NYHA IV


8/13/2019 chf_nikam

64/94


Predictors of Mortality Based on

Analysis of ADHERE Database

Classification and Regression Tree (CART) analysis of

ADHERE data shows:

Three variables are the strongest predictors of mortality inhospitalized ADHF patients:

BUN > 43 mg/dL

Systolic blood pressure < 115 mmHg

Serum creatinine > 2.75 mg/dL

BUN > 43 mg/dL

Systolic blood pressure < 115 mmHg

Serum creatinine > 2.75 mg/dL

Fonarow GC et al. JAMA 2005;293:572-80.


8/13/2019 chf_nikam

65/94


CHF Prognosis based on BUN


8/13/2019 chf_nikam

66/94


CHF Prognosis based on Serum sodium


8/13/2019 chf_nikam

67/94


Diastolic CHF

Impaired LV relaxation

Increase passive LV stiffness

Endocardial and pericardial disordersw

Microvascular flow

Myocardial turgor

Neurohormonal regulation


8/13/2019 chf_nikam

68/94


Diagnosis of diastolic CHF

Increased ventricular filling pressure with

normal systolic function

Incresed ventricular pressure with preserved

systolic function and normal ventricular

volumes

Increased left atrial and pulmonary capillary

wedge pressure

Clinical symptoms and signs.


8/13/2019 chf_nikam

69/94


Treatment of diastolic CHF

Diureticsprovide the most symptoms relief if

fluid retentionn is a future

ACE inhibitors and Blockers complement

diuretics well

Central sympatholytics hypertensive episodes

Nitratespreventing ischemia

Trimetazidineas a metabolic support


8/13/2019 chf_nikam

70/94


Treatment of diastolic CHF

Benefits of Calcium Channel Blockers

Slowing of heart rate

Reduction of MVO2

Control of BP

Regression of LVH

Dilation of coronary microcirculationAmelioration of intracellular calcium overload


8/13/2019 chf_nikam

71/94




HFSA 2006 Practice GuidelineNonpharmacologicFluid Intake

Recommendation 6.3

Restriction of daily fluid intake to < 2 liters:

Is recommended in patients with severehyponatremia (serum sodium < 130 mEq/L)

Should be considered for all patientsdemonstrating fluid retention that is difficult to

control despite high doses of diuretic andsodium restriction.Strength o f Evidence = C


8/13/2019 chf_nikam

72/94




HFSA 2006 Practice GuidelineNonpharmacologicVitamins

Recommendation 6.5

Patients with HF, especially those on diuretic

therapy and restricted diets,should be considered for daily multivitamin-mineral supplementation to ensure adequateintake of the recommended daily value ofessential nutrients.

Evaluation for specific vitamin or nutrient deficiencies israrely necessary.

Strength of Evidence = C


8/13/2019 chf_nikam

73/94




HFSA 2006 Practice GuidelineBeta BlockersSummary of Recommendations

Maintain therapy if possible

Reduce dosage if necessary

Avoid abrupt discontinuation

If discontinued or reduced, reinstate gradually before discharge

If an acute exacerbation ofchronic HF occurs

Prolong titration interval

Reduce target dose

Consider referral to a HF specialist

Considerations if up-titrationcontinues to be difficult

Adjust dose of diuretic and/or other concomitant vasoactive

medication

Continue titration to target dose once symptoms return to baseline

Considerations if symptoms

worsen or other side effects

appear

Initiate at low doses

Up-titrate gradually, generally no sooner than at 2 week intervals

Use target doses shown to be effective in clinical trials

Aim to achieve target dose in 8-12 weeks

Maintain at maximum tolerated dose

General


8/13/2019 chf_nikam

74/94




HFSA 2006 Practice GuidelineICD Placement

Recommendation 9.5

ICD placement is not recommended in

chronic, severe refractory HF when thereis no reasonable expectation forimprovement.


Pacing


8/13/2019 chf_nikam

75/94



HFSA 2006 Practice GuidelineBiventricular Pacing

Recommendation 9.7

Biventricular pacing therapy should be considered for patientswith all of the following:

Sinus rhythm

A widened QRS interval (120 ms) Severe LV systolic dysfunction (LVEF < 35% with LV dilation >

5.5 cm)

Persistent, moderate to severe HF (NYHA III) despite optimalmedical therapy.

Strength of Evidence = A

Pacing


8/13/2019 chf_nikam

76/94




HFSA 2006 Practice GuidelineBiventricular Pacing

Recommendation 9.9

Biventricular pacing therapy

is not recommended in patients who are

asymptomatic or have mild HF

symptoms.


Pacing


8/13/2019 chf_nikam

77/94



Heart Failure Guideline. J Card Fail 2006 12:e1-e122.

HFSA 2006 Practice GuidelineHF in African Americans

Recommendation 15.9

A combination of hydralazine and

isosorbide dinitrate is recommended aspart of standard therapy in addition to beta-blockers and ACE-inhibitors for AfricanAmericans with LV systolic dysfunctionand:

NYHA III-IV HF Strength of Evidence = A

NYHA II HF Strength of Evidence = B

Vasodilator

s


8/13/2019 chf_nikam

78/94


CHF treatment-Nursing Initiates

1. Recommend smoking cessation counseling

2. Initiate LV function determination

3. Patient education

4. Instructional video, printed materials

5. Vaccination initiatives


8/13/2019 chf_nikam

79/94


Aldosterone Antagonists in HFRALES (Advanced HF) EPHESUS (Post-MI)

Spironolactone

Placebo

Months

RR = 0.70P < 0.001

Epleronone

Placebo

RR = 0.85P < 0.008

Pitt B. N Engl J Med 1999;341:709-17.

Pitt B. N Engl J Med 2003;348:1309-21.

ProbabilityofSurvival

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 3 6 9 12 15 18 21 24 27 30 33 36

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 3 6 9 12 15 18 21 24 27 30 33 36

Months


8/13/2019 chf_nikam

80/94


MADIT II: Prophylactic ICD in

Ischemic LVD (LVEF 30%)

365 (.69)170 (.78)329 (.90)490Conventional

9110 (.78)274 (.84)503 (.91)742Defibrillator

Number at Risk

0 1 2 3

.7

.8

.9

1.0

ProbabilityofSurvival

Conventional

Therapy

Defibrillator

Year

.6

0 4

Moss AJ et al. N Engl J Med 2002;346:877-83.

Pacing


8/13/2019 chf_nikam

81/94


Effect of CRT Without an ICD on

All-Cause Mortality: CARE-HF

571192321365404Medical Therapy

889213351376409CRT

Number at risk

0 500 1,000 1,500

25

50

75

100

%Event-Free

Survival

MedicalTherapy

CRT

Days

0

HR = 0.64 (95% CI = .48-.85)

p = .0019

Cleland JG et al. N Engl J Med 2005;352:1539-49.

Pacing


8/13/2019 chf_nikam

82/94


CRT Improves Quality of Life and

NYHA Functional Class

(%)

Abraham WT et al. Circulation 2003;108:2596-2603.

Average Change in Score

(MLWHF)

-20

-15

-10

-5

0

MIR

ACLE

MUS

TIC

SR

CONT

AK

CD

MIRACLE

ICD

* P < .05Control CRT

* **

*

NYHA: Proportion Improving

by 1 or More Class

0

20

40

60

80

MIRACLE CONTAK

CD

MIRACLE

ICD

**

*

Pacing


8/13/2019 chf_nikam

83/94

Co ges e ea a u e CHEART CENTER

ICD Therapy in the SCD-HeFT Trial:

Mortality by Intention-to-Treat

.007.62-.96.77ICD vs Placebo

.53.86-1.301.06Amiodarone vs Placebo

P Value97.5% ClHR

Months of Follow-Up

Mortality

0 6 12 18 24 30 36 42 48 54 600

.1

.2

.3

.4

Amiodarone

ICD TherapyPlacebo

17%

22%

Bardy GH et al. N Engl J Med 2005;352:225-37.

Pacing


8/13/2019 chf_nikam

84/94

gHEART CENTER

A-HeFT All-Cause Mortality

Survival%

Days Since Baseline Visit

43% Decrease in Mortality

Fixed Dose ISDN/HDZN

Placebo

P = 0.01

Taylor AL et al. N Engl J Med 2004;351:2049-57.

85

90

95

100

0 100 200 300 400 500 600

ISDN/HDZ


8/13/2019 chf_nikam

85/94

gHEART CENTER

ARBS in Patients Not Taking ACE Inhibitors:

Val-HeFT & CHARM-AlternativeVal-HeFT

Valsartan

Placebo

p = 0.017

Months

Survival%

CVDeathorHFHo

sp%

Placebo

Candesartan

CHARM-Alternative

HR 0.77, p = 0.0004

Months

Maggioni AP et al. JACC 2002;40:1422-4.Granger CB et al. Lancet 2003;362:772-6.

50

60

70

80

90

100

0 3 6 9 12 15 18 21 24 27

0

10

20

30

40

50

0 9 18 27 36 42

ARBS


8/13/2019 chf_nikam

86/94

gHEART CENTER

Effect of Beta Blockade on Outcome

in Patients With HF and Post-MI LVD

23% mortality (p =.031)25 BIDpost-MILVD

carvedilolCAPRICORN5

35% mortality (p = .0014)25 BIDseverecarvedilolCOPERNICUS4

34% mortality (p = .0062)200 QDmild/moderate

metoprolol

succinate

MERIT-HF3

34% mortality (p

8/13/2019 chf_nikam

87/94

gHEART CENTER

Treatment of Post-MI Patients with

Asymptomatic LV Dysfunction (LVEF 40%)

SAVE Study

All-cause mortality 19%

CV mortality 21%

HF development 37%

Recurrent MI 25%

Placebo

Captopril

Years

Mortality

Rate

19% relative risk reduction

p = 0.019

Pfeffer et al. NEJM 1992;327:669-77.

0

0.1

0.2

0.3

0 0.5 1 1.5 2 2.5 3 3.5 4

ARBS


8/13/2019 chf_nikam

88/94

gHEART CENTER


8/13/2019 chf_nikam

89/94

HEART CENTER

CHF prognosis based on rhythm

SOLVD Investigators:J Am Coll Cardiol. 1998;32:695-703.

From: Shivkumar, Weiss, Fonarow, and Narula; eds.Braunwalds Atlas of EP in HF.

Arrhythmias


8/13/2019 chf_nikam

90/94

HEART CENTER

CHF Management-long term


8/13/2019 chf_nikam

91/94

HEART CENTER



HFSA 2006 Practice GuidelineHypertensionPreserved EF

Recommendation 14.1

In patients with symptomatic or symptomatic LV hypertrophy

or LV dysfunct ion without LV dilation (Preserved EF):

It is recommended that blood pressure be

aggressively treated to lower systolic and

usually diastolic levels. Target resting

levels should be

8/13/2019 chf_nikam

92/94

HEART CENTER

CHF treatment-7 Core measures

1. Do you have a left ventricular function measurement?

2. If LVEF

8/13/2019 chf_nikam

93/94

HEART CENTER

Sleep related problems in CHFHFSA 2006 Practice Guideline (8.13)

End-of-Life Care in Heart Failure

End-of-life care should be considered in patients who haveadvanced, persistent HF with symptoms at rest despiterepeated attempts to optimize pharmacologic and

nonpharmacologic therapy, as evidenced byone or more of the following:

Frequent hospitalizations (3 or more per year)

Chronic poor quality of life with inability to accomplishactivities of daily living

Need for intermittent or continuous intravenous support Consideration of assist devices as destination therapy

Strength of Evid ence = C




8/13/2019 chf_nikam

94/94

HEART CENTER

By

Nik Nikam, M.D.Interventional Cardiologist

The End

Documents

chf_nikam