Heart Failure Bill Wolf Edited from Vicki Shanmugam, Bob Rabbani and Navreet Sandhu

Heart FailureHeart Failure

Bill WolfBill WolfEdited from Vicki Shanmugam, Bob Rabbani Edited from Vicki Shanmugam, Bob Rabbani

and Navreet Sandhu and Navreet Sandhu

Definintion:Definintion:

““Defined as a pathophysiological state in Defined as a pathophysiological state in which an abnormality of cardiac function is which an abnormality of cardiac function is the cause of the heart to pump blood at a the cause of the heart to pump blood at a rate that is not able to keep up with the rate that is not able to keep up with the

needs of the body.”needs of the body.”


5 million Americans with heart failure today5 million Americans with heart failure today6-10% of people older than 65 yo have it6-10% of people older than 65 yo have it500,000 are diagnosed with HF each year500,000 are diagnosed with HF each yearReason of at least 20% of all hospitalizations (6.5 million Reason of at least 20% of all hospitalizations (6.5 million hospital days each year)hospital days each year)Over past decade, rate of hospitalization has increased Over past decade, rate of hospitalization has increased by 159% (550,000 to nearly 900,000 per year)by 159% (550,000 to nearly 900,000 per year)Symptomatic heart failure has a worse prognosis than Symptomatic heart failure has a worse prognosis than most cancers, with a one-year mortality of almost 45%most cancers, with a one-year mortality of almost 45%Thus, we have a strong incentive to identify, predict, and Thus, we have a strong incentive to identify, predict, and treat the factors contributing to hospitalizationstreat the factors contributing to hospitalizations


Heart failure is a clinical syndrome arising Heart failure is a clinical syndrome arising from any structural or functional cardiac from any structural or functional cardiac disorder that impairs the ability of the disorder that impairs the ability of the ventricle to fill with or eject blood. ventricle to fill with or eject blood. Because not all patients have volume Because not all patients have volume overload, “heart failure” is generally overload, “heart failure” is generally preferred to “congestive heart failure”preferred to “congestive heart failure”

Two types of heart failureTwo types of heart failure

SystolicSystolic– EF<40%, dilated LV, Congestion and EF<40%, dilated LV, Congestion and

cardiomegaly on CXR, S3cardiomegaly on CXR, S3– Assoc with previous MI, HTN, DM, sleep Assoc with previous MI, HTN, DM, sleep

apneaapnea

DiastolicDiastolic– EF>40%, LV hypertrophy, Congestion without EF>40%, LV hypertrophy, Congestion without

cardiomegaly on CXR, S4. cardiomegaly on CXR, S4. – Assoc with HTN, DM, Obesity, COPD, dialysisAssoc with HTN, DM, Obesity, COPD, dialysis

Diastolic Heart FailureDiastolic Heart Failure

Associated conditions include:Associated conditions include:– Restrictive (infiltrative) cardiomyopathy:Restrictive (infiltrative) cardiomyopathy:

AmyloidosisAmyloidosis

SarcoidosisSarcoidosis

hemochromatosishemochromatosis

– Obstructive and nonobstructive hypertrophic Obstructive and nonobstructive hypertrophic cardiomyopathycardiomyopathy

– Pericardial constrictionPericardial constriction– LVH from HTNLVH from HTN

Jessup, M. et al. N Engl J Med 2003;348:2007-2018

Characteristics of Patients with Diastolic Heart Failure and Patients with Systolic Heart Failure

Diastolic FailureDiastolic Failure

Diagnosis often made by clinician who Diagnosis often made by clinician who recognizes the typical signs and recognizes the typical signs and symptomssymptoms

Relatively little evidence to guide care of Relatively little evidence to guide care of patients with this conditionpatients with this condition

Patients are treated with risk factor Patients are treated with risk factor modification, controlling blood pressure, modification, controlling blood pressure, heart rate, ischemia, and volumeheart rate, ischemia, and volume

Systolic Heart FailureSystolic Heart Failure

Coronary artery disease is the cause in 2/3 of Coronary artery disease is the cause in 2/3 of patientspatients

Other causes include:Other causes include:– HTNHTN– Thyroid diseaseThyroid disease– Valvular diseaseValvular disease– AlcoholAlcohol– MyocarditisMyocarditis– No identifiable cause (i.e. idiopathic dilated No identifiable cause (i.e. idiopathic dilated

cardiomyopathy)cardiomyopathy)

CAUSESCAUSES

Heart Failure as Progressive Heart Failure as Progressive DisorderDisorder

Ventricular dysfunction begins with injury Ventricular dysfunction begins with injury or stress to the myocardium, and or stress to the myocardium, and progressesprogresses

The heart chamber generally dilates, The heart chamber generally dilates, hypertrophies, and becomes spherical hypertrophies, and becomes spherical (remodeling)(remodeling)

This increases the hemodynamic stress on This increases the hemodynamic stress on the walls of the heartthe walls of the heart

RemodelingRemodeling

Left ventricular remodeling involves mechanical, Left ventricular remodeling involves mechanical, neurohormonal, and genetic factors that alter the neurohormonal, and genetic factors that alter the ventricular size and functionventricular size and functionPatients with HF have elevated levels of Patients with HF have elevated levels of norepinephrine, angiotensin II, aldosterone, norepinephrine, angiotensin II, aldosterone, endothelin, vasopressin, and cytokinesendothelin, vasopressin, and cytokinesRemodeling occurs in several conditions, Remodeling occurs in several conditions, including myocardial infarction, cardiomyopathy, including myocardial infarction, cardiomyopathy, hypertension, valvular heart diseasehypertension, valvular heart diseaseOne sees hypertrophy, myocyte death, and One sees hypertrophy, myocyte death, and increased interstitial fibrosisincreased interstitial fibrosis

Jessup, M. et al. N Engl J Med 2003;348:2007-2018

Ventricular Remodeling after Infarction (Panel A) and in Diastolic and Systolic Heart Failure (Panel B)

Consequences of RemodelingConsequences of Remodeling

Mitral RegurgitationMitral Regurgitation

Arrhythmias and Bundle Branch BlockArrhythmias and Bundle Branch Block

Mitral RegurgitationMitral Regurgitation

As the left ventricle dilates and the heart As the left ventricle dilates and the heart becomes globular, the papillary muscles becomes globular, the papillary muscles and mitral leaflets change orientation, and mitral leaflets change orientation, leading to distortion of the papillary leading to distortion of the papillary apparatusapparatus

Mitral regurgitation results in volume Mitral regurgitation results in volume overload on an overburdened ventricle, overload on an overburdened ventricle, further causing progression of diseasefurther causing progression of disease

ArrhythmiaArrhythmia

Another consequence of ischemia, inflammation, Another consequence of ischemia, inflammation, fibrosis, and aging is arrhythmiafibrosis, and aging is arrhythmia

SVT, especially a. fib., often marks the onset of SVT, especially a. fib., often marks the onset of systolic or diastolic heart failuresystolic or diastolic heart failure

In patients with HTN or abnormal myocardial In patients with HTN or abnormal myocardial function, elevation in ventricular end-diastolic function, elevation in ventricular end-diastolic volume leads to atrial stretch, which in turn volume leads to atrial stretch, which in turn causes electrical instability causes electrical instability


Abnormal myocardial conduction can also lead Abnormal myocardial conduction can also lead to left bundle branch block, which is a predictor to left bundle branch block, which is a predictor of sudden deathof sudden deathLBBB causes abnormal ventricular activation LBBB causes abnormal ventricular activation and contraction, ventricular dyssynchrony, and contraction, ventricular dyssynchrony, delayed opening and closure of the aortic and delayed opening and closure of the aortic and mitral valves, and abnormal diastolic functionmitral valves, and abnormal diastolic functionLBBB can result in reduced ejection fraction, LBBB can result in reduced ejection fraction, cardiac output, and arterial pressure, and cardiac output, and arterial pressure, and paradoxical septal motion, increased LV volume, paradoxical septal motion, increased LV volume, and mitral regurgitationand mitral regurgitation


Rate of sudden cardiac death in patients Rate of sudden cardiac death in patients with heart failure is 6-9 times that in the with heart failure is 6-9 times that in the general populationgeneral population

HistoryHistory

Typically will present with symptoms of:Typically will present with symptoms of:– Dyspnea on exertionDyspnea on exertion– OrthopneaOrthopnea– PNDPND– Ankle swellingAnkle swelling– Weight gainWeight gain– Sometimes abdominal distensionSometimes abdominal distension– Tiredness and weaknessTiredness and weakness

Special Questions to askSpecial Questions to ask

Chest pain or exertional angina – strongly suggests IHD as Chest pain or exertional angina – strongly suggests IHD as causecauseRecent flu like illness – consider viral myocarditisRecent flu like illness – consider viral myocarditisHistory of longstanding alcohol or HTN – consider alcoholic or History of longstanding alcohol or HTN – consider alcoholic or hypertensive cardiomyopathyhypertensive cardiomyopathyHistory of proteinuria or chronic inflammatory condition, History of proteinuria or chronic inflammatory condition, consider amyloidconsider amyloidRecent blood transfusion or Sx consider volume overloadRecent blood transfusion or Sx consider volume overloadFHx, along with diabetic “bronzed” pt – consider hereditary FHx, along with diabetic “bronzed” pt – consider hereditary hemochromatosis. hemochromatosis. Things that worsen underlying heart failure:Things that worsen underlying heart failure:

NSAIDSNSAIDSAntiarrhythmics – disopyramide and flecanideAntiarrhythmics – disopyramide and flecanideCa channel blockers – esp. VerapamilCa channel blockers – esp. VerapamilB BlockersB Blockers

Physical exam – look specifically for evidence Physical exam – look specifically for evidence of how bad their HF is and clues to the of how bad their HF is and clues to the

underlying causeunderlying cause

Sympathetic overdrive (to compensate for low CO) – Sympathetic overdrive (to compensate for low CO) – evidenced by sinus tachycardia, diaphoresis, and evidenced by sinus tachycardia, diaphoresis, and peripheral vasoconstrictionperipheral vasoconstrictionPulsus alternans – alternating strong and weak Pulsus alternans – alternating strong and weak peripheral pulses, exact pathophysiology not known. peripheral pulses, exact pathophysiology not known. Manifestations of volume overloadManifestations of volume overload– JVPJVP– Pleural effusions, alveolar edema – cracklesPleural effusions, alveolar edema – crackles– Peripheral edemaPeripheral edema– Ascites, hepatomegaly, splenomegalyAscites, hepatomegaly, splenomegaly– Ventricular enlargement – displaced PMIVentricular enlargement – displaced PMI– S3 or S4S3 or S4– Pulmonary hypertension – complaints of chest pain, palpable Pulmonary hypertension – complaints of chest pain, palpable

pulmonic tap, pulmonary insufficiency. pulmonic tap, pulmonary insufficiency.

LabsLabs

CBC – R/o anemia as ppt. CBC – R/o anemia as ppt.

Chem 7 – assess BUN/Creat/KChem 7 – assess BUN/Creat/K

LFT – may rise with hepatic congestionLFT – may rise with hepatic congestion

Fasting glucose – screen for DMFasting glucose – screen for DM

TFT – r/o thyrotoxicosis or hypothyroidismTFT – r/o thyrotoxicosis or hypothyroidism

Fe/TIBC – if hemochromatosis is a riskFe/TIBC – if hemochromatosis is a risk

BNP -- >100 is 90% sensitive for HF, equally as BNP -- >100 is 90% sensitive for HF, equally as predictive as finding cardiomegaly on CXR, or predictive as finding cardiomegaly on CXR, or rales on clinical exam. Cost only $20rales on clinical exam. Cost only $20

CXRCXR

CardiomegalyCardiomegaly

Prominent upper lobe vesselsProminent upper lobe vessels

Kerley B linesKerley B lines

Pleural effusionsPleural effusions

Bats wing pulmonary edemaBats wing pulmonary edema

EKG and EchoEKG and Echo

EKGEKGLook for arrhythmias e.g. A fib, V TachLook for arrhythmias e.g. A fib, V TachConduction abnormalities – esp. seen in pts with Conduction abnormalities – esp. seen in pts with dilated cardiomyopathydilated cardiomyopathy

EchoEchoEF – helps distinguish systolic and diastolic HFEF – helps distinguish systolic and diastolic HFRegional wall motion abnormalities suggesting Regional wall motion abnormalities suggesting ischemiaischemiaValvular diseaseValvular diseasePulmonary artery pressures. Pulmonary artery pressures.

Framingham CriteriaFramingham Criteria

2 major2 major

1major and1major and

2 minor2 minor

NYHA (functional classes)NYHA (functional classes)

ClassClass FunctionFunction 1 yr mortality1 yr mortality

II Asymptomatic with ordinary activityAsymptomatic with ordinary activity 5%5%

IIII Slight limitation of normal functionSlight limitation of normal function 15%15%

IIIIII Marked limitation of physical activitiesMarked limitation of physical activities 30%30%

IVIV Dyspneic at restDyspneic at rest 60%60%

ACC/AHA Stages of heart failureACC/AHA Stages of heart failure

StageStage

AA High risk for heart failure without structural disease, currently High risk for heart failure without structural disease, currently asymptomaticasymptomatic

BB Heart disease with asymptomatic LV dysfunctionHeart disease with asymptomatic LV dysfunction

CC Prior or current symptoms of Heart failurePrior or current symptoms of Heart failure

DD Advanced heart disease and severely symptomatic or Advanced heart disease and severely symptomatic or refractory heart failurerefractory heart failure

““Staging” introduced to get people to realize that there is Staging” introduced to get people to realize that there is an element of preventability in HF and that pts need an element of preventability in HF and that pts need screening while asymptomatic in order to prevent screening while asymptomatic in order to prevent progression (just like cancer screening)progression (just like cancer screening)

Stages of Heart FailureStages of Heart Failure

Examples of patients in each stage:Examples of patients in each stage:– Stage A: patients with HTN, CAD, DM, history of Stage A: patients with HTN, CAD, DM, history of

cardiotoxic drug therapy or alcohol abuse, h/o cardiotoxic drug therapy or alcohol abuse, h/o rheumatic fever, FHx of cardiomyopathyrheumatic fever, FHx of cardiomyopathy

– Stage B: LVH or fibrosis, LV dilatation or Stage B: LVH or fibrosis, LV dilatation or hypocontractility, asymptomatic valvular heart hypocontractility, asymptomatic valvular heart disease, previous MIdisease, previous MI

– Stage C: dyspnea or fatigue due to LV systolic Stage C: dyspnea or fatigue due to LV systolic dysfunction, asymptomatic pts undergoing tx for prior dysfunction, asymptomatic pts undergoing tx for prior sx of HFsx of HF

– Stage D: pts frequently hospitalized for HF and can Stage D: pts frequently hospitalized for HF and can not be safely d/c ed from hospital, pts in hospital not be safely d/c ed from hospital, pts in hospital awaiting transplant, pts at home receiving IV awaiting transplant, pts at home receiving IV inotropes or LVAD, pts in hospiceinotropes or LVAD, pts in hospice

How do you manage this How do you manage this patient?patient?

ASAASA

B-BlockerB-Blocker

ACEACE

SpirnolactoneSpirnolactone

LasixLasix

NitratesNitrates

HydralazineHydralazine


Large trials have looked at the effects of Large trials have looked at the effects of ACE inhibitors, angiotensin receptor ACE inhibitors, angiotensin receptor antagonists, beta-blockers, antagonists, beta-blockers, spironolactone, biventricular pacing, spironolactone, biventricular pacing, CABG, and the use of multidisciplinary CABG, and the use of multidisciplinary teams. All have been shown to reduce teams. All have been shown to reduce rates of hospitalization and improve rates of hospitalization and improve functional status.functional status.

TreatmentsTreatments

Stage A Heart FailureStage A Heart Failure

Treat risk factors!Treat risk factors!Treatment of hypertension decreases incidence of left Treatment of hypertension decreases incidence of left ventricular hypertrophy and cardiovascular mortality and ventricular hypertrophy and cardiovascular mortality and reduces incidence of heart failure by 30-50%reduces incidence of heart failure by 30-50%Use of ACE inhibitors in asymptomatic high-risk patients Use of ACE inhibitors in asymptomatic high-risk patients with DM or vascular disease reduces rate of death, MI, with DM or vascular disease reduces rate of death, MI, and strokeand strokeUse of ARBs (losartan) has delayed the first Use of ARBs (losartan) has delayed the first hospitalization for heart failure in patients with DM and hospitalization for heart failure in patients with DM and nephropathynephropathyGoal of treatment is to prevent remodeling!Goal of treatment is to prevent remodeling!

Stages B, C, and D Heart FailureStages B, C, and D Heart Failure

Goals of those with low ejection fraction are to Goals of those with low ejection fraction are to slow progression of disease and alleviate slow progression of disease and alleviate symptomssymptoms

Lifestyle modification remains a mainstay, for Lifestyle modification remains a mainstay, for example:example:– Moderate sodium restrictionModerate sodium restriction– Weight monitoringWeight monitoring– Medication regimen complianceMedication regimen compliance– Moderation of alcoholModeration of alcohol– Exercise program for selected patientsExercise program for selected patients


ACE inhibitors limit the physiologic consequences of ACE inhibitors limit the physiologic consequences of angiotensin II levels, and decrease degradation of angiotensin II levels, and decrease degradation of bradykinin (which promotes vasodilation and natriuresis bradykinin (which promotes vasodilation and natriuresis in the kidney)in the kidney)ACE inhibitors after an MI improve survival, rates of ACE inhibitors after an MI improve survival, rates of hospitalization, symptoms, cardiac output and promote hospitalization, symptoms, cardiac output and promote reverse remodelingreverse remodelingOptimal target dose of ACE inhibitors is not clear, with Optimal target dose of ACE inhibitors is not clear, with trials showing low and high doses as having similar trials showing low and high doses as having similar effects on mortalityeffects on mortalityNot certain whether any difference among the many Not certain whether any difference among the many different ACE inhibitors out there todaydifferent ACE inhibitors out there today


Beta-blockers counteract the effects of the Beta-blockers counteract the effects of the sympathetic nervous system during heart failuresympathetic nervous system during heart failureBeta-blockers improve survival, morbidity, Beta-blockers improve survival, morbidity, ejection fraction, remodeling, quality of life, rates ejection fraction, remodeling, quality of life, rates of hospitalization, and incidence of sudden of hospitalization, and incidence of sudden deathdeathShould be used in select patients who are not Should be used in select patients who are not decompensateddecompensatedIn those with asthma, DM with frequent In those with asthma, DM with frequent hypoglycemia, and bradycardia +/- heart blocks hypoglycemia, and bradycardia +/- heart blocks should use cautionshould use caution


With beta-blockers one sees improvement With beta-blockers one sees improvement in systolic function even after 3 mos, with in systolic function even after 3 mos, with reversal of remodeling after 4 mosreversal of remodeling after 4 mos

Carvedilol (nonspecific beta-blocker with Carvedilol (nonspecific beta-blocker with alpha effects) and metoprolol (beta-1 alpha effects) and metoprolol (beta-1 selective with no alpha effects) are selective with no alpha effects) are approved for the treatment of heart failure, approved for the treatment of heart failure, but the most prescribed med is atenololbut the most prescribed med is atenolol


ARBs should be used for those who can ARBs should be used for those who can not tolerate ACE inhibitors, with trials not tolerate ACE inhibitors, with trials showing that ARBs have similar efficacy in showing that ARBs have similar efficacy in heart failure to ACE inhibitorsheart failure to ACE inhibitors

Stage C and D Heart FailureStage C and D Heart Failure

Spironolactone, which blocks deleterious Spironolactone, which blocks deleterious effects of increased aldosterone (salt effects of increased aldosterone (salt retention, hypertrophy, etc), has been retention, hypertrophy, etc), has been shown to be helpful in patients with NYHA shown to be helpful in patients with NYHA class III or IV symptomsclass III or IV symptoms


Diuretics are used to control congestionDiuretics are used to control congestion

Thiazide or loop diuretics often prescribed, Thiazide or loop diuretics often prescribed, and combination therapy may be helpful in and combination therapy may be helpful in advanced casesadvanced cases

Digoxin has no improvement in mortality, Digoxin has no improvement in mortality, but reduces rates of hospitalization and but reduces rates of hospitalization and worsening heart failureworsening heart failure


Biventricular pacemakers (where one lead is in the right Biventricular pacemakers (where one lead is in the right ventricle and the other is passed through the right ventricle and the other is passed through the right atrium, through the coronary sinus, and into a cardiac atrium, through the coronary sinus, and into a cardiac vein on the lateral wall of the left ventricle) improves vein on the lateral wall of the left ventricle) improves ventricular synchronyventricular synchronyThe pacemaker can be used to treat patients with heart The pacemaker can be used to treat patients with heart failure and a wide QRSfailure and a wide QRSEffects include reverse remodeling (leading to decreased Effects include reverse remodeling (leading to decreased heart size, improved EF, and decreased mitral heart size, improved EF, and decreased mitral regurgitation)regurgitation)Exercise tolerance improves, as does quality of life, and Exercise tolerance improves, as does quality of life, and rate of hospitalizationrate of hospitalizationHas not been shown to enhance survivalHas not been shown to enhance survival


Revascularization (either PCI or CABG):Revascularization (either PCI or CABG):– Improves symptomsImproves symptoms– Improves cardiac performanceImproves cardiac performance– Reduces risk of sudden deathReduces risk of sudden death

Mechanical devices (e.g. LVADs) are Mechanical devices (e.g. LVADs) are continuing to evolve for patients awaiting continuing to evolve for patients awaiting heart transplantation or as destination heart transplantation or as destination therapytherapy

AHA/ACC RecommendationsAHA/ACC Recommendations

The following classification system has been The following classification system has been used by the AHA/ACC:used by the AHA/ACC:– Class I: conditions for which there is evidence and/or Class I: conditions for which there is evidence and/or

general agreement that a given procedure/therapy is general agreement that a given procedure/therapy is useful and effectiveuseful and effective

– Class II: conditions for which there is conflicting Class II: conditions for which there is conflicting evidence and/or a divergence of opinion about the evidence and/or a divergence of opinion about the usefulness/efficacy of performing the usefulness/efficacy of performing the procedure/therapyprocedure/therapy

– Class III: conditions for which there is evidence and/or Class III: conditions for which there is evidence and/or general agreement that a procedure/therapy is not general agreement that a procedure/therapy is not useful/effective and in some cases may be harmfuluseful/effective and in some cases may be harmful

Specifically… ACE InhibitorsSpecifically… ACE Inhibitors

Class I AHA/ACC recommendations:Class I AHA/ACC recommendations:– Stage A patients with a history of Stage A patients with a history of

atherosclerotic vascular disease, DM, or HTN atherosclerotic vascular disease, DM, or HTN and associated CV risk factorsand associated CV risk factors

– Stage B patients with recent or remote history Stage B patients with recent or remote history of MI regardless of EFof MI regardless of EF

– Stage B patients with reduced EF, whether or Stage B patients with reduced EF, whether or not they have experienced an MInot they have experienced an MI

– In all Stage C and D patients unless In all Stage C and D patients unless contraindicatedcontraindicated

ACE inhibitorsACE inhibitors

DrugDrug Target DoseTarget Dose

CaptoprilCaptopril 50 mg TID (SAVE trial)50 mg TID (SAVE trial)

EnalaprilEnalapril 10 mg BID (Delahaye et al. 2000)10 mg BID (Delahaye et al. 2000)

FosinoprilFosinopril 40 mg QD (drug info)40 mg QD (drug info)

LisinoprilLisinopril 40 mg QD (Packer et al. 1999 in 40 mg QD (Packer et al. 1999 in ATLAS trial)ATLAS trial)

QuinaprilQuinapril 40 mg QD (drug info)40 mg QD (drug info)

RamiprilRamipril 10 mg QD (HOPE trial 2000)10 mg QD (HOPE trial 2000)

Specifically… Beta-BlockersSpecifically… Beta-Blockers

Class I AHA/ACC recommendations:Class I AHA/ACC recommendations:– Stage B patients with recent MI regardless of Stage B patients with recent MI regardless of

EFEF– Stage B patients with reduced EF, whether or Stage B patients with reduced EF, whether or

not they have experienced an MInot they have experienced an MI– Stable Stage C and D patients. They should Stable Stage C and D patients. They should

have no or minimal evidence of fluid retention have no or minimal evidence of fluid retention and have not recently required positive and have not recently required positive inotropic agentinotropic agent

Beta-BlockersBeta-Blockers

DrugDrug Target DoseTarget Dose

BisoprololBisoprolol 10 mg QD (CIBIS – II trial)10 mg QD (CIBIS – II trial)

CarvedilolCarvedilol 25 mg BID (US Carvedilol HF 25 mg BID (US Carvedilol HF study)study)

Metoprolol Metoprolol tartatetartate

150 mg QD (50 TID or 75 BID) 150 mg QD (50 TID or 75 BID) (Cleland 2003)(Cleland 2003)

Metoprolol Metoprolol succinate (XL)succinate (XL)

200 mg QD (MERIT-HF study)200 mg QD (MERIT-HF study)

AtenololAtenolol 100 mg QD (Ansari et al. 2003)100 mg QD (Ansari et al. 2003)

Relative contraindications for B-Relative contraindications for B-blocker useblocker use

HR<60HR<60

Systolic<100Systolic<100

Signs of peripheral hypoperfusionSigns of peripheral hypoperfusion

PR interval>0.24PR interval>0.24

Second or third degree heart blockSecond or third degree heart block

Severe COPDSevere COPD

Asthma historyAsthma history

PVDPVD

Specifically… SpironolactoneSpecifically… Spironolactone

Low doses of spironolactone given with an Low doses of spironolactone given with an ACE inhibitor in patients with class IV ACE inhibitor in patients with class IV symptoms reduced the risk of death and symptoms reduced the risk of death and hospitalizationhospitalization

Class IIa recommendations:Class IIa recommendations:– Spironolactone in Stage C patients with recent Spironolactone in Stage C patients with recent

or current Class IV symptoms, preserved or current Class IV symptoms, preserved renal function and a normal potassium renal function and a normal potassium concentrationconcentration

Specifically… ARBsSpecifically… ARBs

They should be considered instead of ACE They should be considered instead of ACE inhibitors due to intolerance.inhibitors due to intolerance.

Class IIa recommendations:Class IIa recommendations:– In Stage C patients who are being treated with In Stage C patients who are being treated with

digitalis, diuretics, and a beta-blocker who digitalis, diuretics, and a beta-blocker who cannot be given an ACE inhibitor because of cannot be given an ACE inhibitor because of cough or angioedemacough or angioedema

Specifically… diureticsSpecifically… diuretics

Class I indications:Class I indications:– In Stage C and D patients who have evidence In Stage C and D patients who have evidence

of fluid retentionof fluid retention– In diastolic failure to control pulmonary In diastolic failure to control pulmonary

congestion and peripheral edemacongestion and peripheral edema

Documents

Heart Failure Bill Wolf Edited from Vicki Shanmugam, Bob Rabbani and Navreet Sandhu