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Heart Failure: ACC Guidelines for Dx and Management Steven W. Harris MHS PAC Epidemiology Approximately 5 million patients in this country have HF Over 550,000 patients are diagnosed with HF for the first time each year Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year In 2001, nearly 53,000 patients died of HF as a primary cause Epidemiology The incidence of HF approaches 10 per 1000 population after age 65 HF is the most common Medicare diagnosis-related group More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare ACC Guidelines Focus on : Prevention of HF Diagnosis and management of chronic HF in the adult. Definition HF is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Because not all patients have volume overload at the time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive heart failure.” • Use terms: Compensated Heart Failure: euvolemic Decompensated Heart Failure: fluid overload Etiology For a substantial proportion of patients, causes are: Coronary artery disease Hypertension Dilated cardiomyopathy Signs and Symptoms ? ? ? ? ? ? ? Symptoms Decreased • • • • • • • Perfusion: Weakness Fatigue Confusion Restlessness Anxiety Palpitations Cold Extremities Symptoms Increased • • • • • • • LV preload: DOE PND Cough: often positional Wheeze Orthopnea Abdominal Distension edema Signs Increased Preload/Decreased perfusion Pedal edema Hepatic congestion JVD Rales Wheezing S3 Tachycardia Cyanosis Cold extremities New York Heart Association Classes NYHA I: no symptoms w/ physical activity, but known disease NYHA II: slight limitations, symptoms w/ normal activities, but able to walk 3 blocks NYHA III: symptoms w. minimal activity and marked limitation of activity NYHA IV: symptoms at rest and any activity Stages of Heart Failure Designed to emphasize preventability of HF through treatment therapies. Designed to recognize the progressive nature of LV dysfunction. Stages of HF COMPLEMENT, DO NOT REPLACE NYHA CLASSES NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease) Stages - progress in one direction due to cardiac remodeling Stages of HF At Risk for Heart Failure: STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction Heart Failure: STAGE C Past or current symptoms of HF STAGE D End-stage HF Management of Patients with Known Atherosclerotic Disease But No HF Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest. 16 14 12 % MI, 10 Stroke, 8 CV Death 6 4 2 0 15 Placebo HOPE Ramipril 22% rel. risk red. p < .001 0 1 2 Years EUROPA 3 4 Placebo 12 % MI, CV Death, Cardiac Arrest NEJM 2000;342:145-53 (HOPE). Lancet 2003;362:782-8 (EUROPA). 9 6 Perindopril 3 20% rel. risk red. p = .0003 0 0 1 2 3 Years 4 5 ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative Val-HeFT Valsartan Survival % 90 80 Placebo 70 60 CHARM-Alternative 50 CV Death or HF Hosp % 100 Placebo 40 30 Candesartan 20 10 p = 0.017 50 HR 0.77, p = 0.0004 0 0 3 6 9 12 15 18 21 24 27 Months 0 9 18 27 36 42 Months Maggioni AP et al. JACC 2002;40:1422-4. Granger CB et al. Lancet 2003;362:772-6. COPERNICUS: Death, Hospitalization, or Study Drug Withdrawal in High Risk Patients % of Patients With Event 30 HR = 0.67 (CI = 0.47-0.96) 20 Placebo 10 Carvedilol 0 0 2 4 6 Weeks After Randomization 8 Krum H et al. JAMA 2003;289:754-6. Stage A: at risk for HF Therapy Treat Hypertension Encourage Smoking cessation Treat lipid disorders Encourage regular exercise Discourage ETOH, drugs Control Metabolic Syndrome ACE or ARB in appropriate patents for vasc dz or diabetes Stage B: Structural disease/No Sx Therapy: All measures under Stage A ACE or ARB in appropriate patients Beta-blockers in appropriate patients ICDs in appropriate patients Stage C: Structural Disease with current or prior sx Therapy: All measures under Stages A and B Routine Use • ACE, Beta-blocker • Diuretics for fluid retention Selected Patients • • • • Aldosterone antagonist ARB Digitalis Hydralazine/nitrates Devices: BI-V, ICD Stage D: refractory HF Therapy All measures from stages A, B, C Decision: • • • • • • Appropriate level of care Compassionate end-of-life care Transplant Chronic Inotropes: neo, epi, dopamine. Permanent Mechanical Support: LVAD Experimental surgery /drugs. Devices An implantable cardioverter-defibrillator (ICD) for secondary prevention to prolong survival in patients with a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. Devices An ICD for primary prevention to reduce total mortality by preventing sudden cardiac death (SCD) in patients with ischemic heart disease who meet the following criteria: at least 40 days post-myocardial infarction, an LVEF 30 percent, New York Heart Association functional class II or III symptoms despite optimal chronic medical therapy, and a reasonable expectation of survival with a good functional status for more than one year. Devices An ICD for primary prevention to reduce total mortality by preventing SCD in patients with nonischemic cardiomyopathy who meet the following criteria: an LVEF less than 30 percent, New York Heart Association functional class II or III symptoms despite optimal chronic medical therapy, and a reasonable expectation of survival with a good functional status for more than one year. Devices Cardiac resynchronization therapy, unless contraindicated, in patients who meet the following criteria: cardiac dyssynchrony as defined by a QRS duration >120 msec, LVEF 35 percent, sinus rhythm, and New York Heart Association functional class III or ambulatory class IV symptoms despite optimal chronic medical therapy. Patient Surveilance MAWDS Medicine Activity Weight Diet Symptoms CASE 1 56 y/o female DM BP 146/84 LDL 150 Non-smoker Exercises daily Case 2 63 y/o male AWMI 1 year ago EF 28% Diabetic BP 128/72 Smoker DOE with strenuous activity Case 3 44 y/o male DM CHD, prior Inferior MI EF 46% BP 132/78 Walks daily. Unable to walk up inclines. C/o LE edema and weight gain of 10 lbs Case 4 60 y/o female H/o BRCA treated with adriamycin BP 110/68 on ACE, Coreg EF 30% Non-diabetic Symptoms with minimal activity LBBB