Download CHF Treatments Guidelines - Kelly Strine, MS, RN, FNP

Running head: CONGESTIVE HEART FAILURE
Treatment Guidelines for Congestive Heart Failure
Kelly Strine and Jenifer Smith
State University of New York Institute of Technology
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CONGESTIVE HEART FAILURE
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Treatment Guidelines for Congestive Heart Failure
Heart failure is a complex disease process that often involves several body systems and
requires a multidisciplinary approach to care that involves the patient, caregiver, and healthcare
professionals. According Yancy et al. (2013), heart failure is often a result of poorly managed or
uncontrolled cardiac diseases such as hypertension, atrial fibrillation, coronary artery disease,
myocardial infarction, diabetes mellitus, and obesity. Heart failure is the most common Medicare
diagnosis with more money spent on the diagnosis and treatment than any other diagnosis. Heart
failure affects approximately five million.. Heart failure is the main diagnosis of 12 to 15 million
office visits and 80% of hospitalized patients greater than 65 years. The number of deaths from
heart failure has increased despite advances in treatment. In addition to mortality, poorly
managed heart failure can lead to a significant long-term disability from complications such as
myocardial infarction, cerebral vascular attacks, and end-stage renal disease (Yancy, 2013).
The American College of Cardiology Foundation (ACCF) and the American Heart
Association (AHA) has developed guidelines for the detection, management, and treatment of
congestive heart failure based on data from clinical trials. Management of heart failure includes:
correcting the underlying cause for failure, improving cardiac muscle, reducing the workload of
the heart, controlling arrhythmias, reducing physical and emotional stress, and limiting excessive
salt and water (Cerlo, 2001). According to McMurray (2010), the goal of heart failure
management is to decrease symptoms, reduce hospitalizations and prevent premature death.
Treatment of underlying structural heart disease and the management of comorbidities such as
diabetes mellitus, hypertension, and hyperlipidemia is essential to prevent the progression of
heart failure. The disease management of heart failure includes both pharmacological and nonpharmacological guidelines and requires a collaborate effort among health care professionals.
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The treatment of heart failure may be optimized by closely examining the results of
clinical trials and using evidence-based guidelines. The purpose of this article is to describe the
results of a literature review of disease management strategies for heart failure. An electronic
search was conducted in February 2014 using the New England Journal of Medicine, the Agency
for Healthcare Research and Quality’s National Guideline Clearing House, and ProQuest. The
search headings included: congestive heart failure, heart failure, systolic heart failure, diastolic
heart failure, disease management of heart failure, evidence-based guidelines for treatment of
heart failure, epidemiology, diuretics, and nitrates. A total of 22 articles were reviewed for
relevance to the disease management of heart failure.
Pharmacological Treatment Guidelines
Angiotensin Converting Enzyme Inhibitors
Angiotensin-converting enzyme inhibitors (ACE) are the first-line pharmacological treatment
for patients with systolic heart failure and should be started upon diagnosis and continued
indefinitely unless contraindicated by renal function, angioedema, or hyperkalemia (Yancy et al.,
2013) . Two large clinical trials showed that patients with NYHA class II, III, and IV heart
failure treated with enalapril compared to placebo in addition to diuretics had reduced
hospitalization and decreased mortality rates (Fu et al., 2012); (Mujib et al., 2013); (Yancy et al.,
2013). In placebo-controlled trials, enalapril therapy reduced the risk of developing symptomatic
heart failure among NYHA class I patients with left ventricular systolic function. Treatment with
ACE inhibitors is recommended to all patients with left ventricular systolic dysfunction
regardless of NYHA classification (McMurray, 2010). Renal function and electrolytes should be
monitored with each dose adjustment (National Collaborating Centre for Acute and Chronic
Conditions, 2010).
CONGESTIVE HEART FAILURE
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Beta-blockers
Along with ACE inhibitors beta-blockers are first-line therapy in patients with systolic heart
failure regardless of the cause of the condition. Beta-blockers improve systolic dysfunction,
increases the EF 5-10%, and reduces symptoms (Yancy et al., 2013). In three placebo-controlled
trials, beta-blocker therapy with bisoprolol, carvedilol, or metoprolol succinate reduced the rate
of hospitalization and reduced mortality by 34% when used with ACE inhibitors, diuretics, and
digoxin among patients with NYHA class II, III, or IV. The CHARM-Preserved study compared
candesartan with placebo in NYHA class II, III, or IV and an EF greater than 40% had improved
outcomes and decreased mortality with candesartan. Another study, involving patients with
previous myocardial infarction and diastolic heart failure showed that treatment with propranolol
reduced mortality (Aurigemma et al, 2004). El-Refai et al. (2013) found in their retrospective
cohort study that beta-blockers were cardio-protective and decreased all-cause rehospitalization
in heart failure patients with preserved ejection fraction. In addition, beta-blockers are an
important aspect of rate control of tachycardia and atrial fibrillation. Tachycardia increases
oxygen demand and decreases coronary perfusion, which may lead to ischemia without
obstructive coronary artery disease. (Aurigemma et al, 2004).
Diuretics
The use of diuretics provides rapid relief of fluid retention and dyspnea and is the primary
treatment of patients with heart failure (Felker et al., 2011). The requirements of diuretics
increase and decrease based on the patient’s condition (McMurray, 2010). When diuresis is
inadequate the following therapy can be considered: increasing the dose of loop diuretic, addition
of a second diuretic, or a continuous infusion of loop diuretic (Hunt et al, 2005). In a prospective,
double-blind randomized study among patients receiving intravenous loop diuretics, there was no
CONGESTIVE HEART FAILURE
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significant differences in symptoms when diuretic therapy was administered by bolus or
continuous infusion. (Felker et al., 2011). In the same study, there was also found to be no
significant difference between the low dose strategy and the high dose strategy in the efficacy or
safety end points. Patients with high doses were found to have quicker resolution of their
dyspnea with high dose treatments.
Angiotensin Receptor Blockers
The efficacy of Angiotensin-Receptor Blockers (ARBs) is similar to ACE inhibitor in a large
trial in which candesartan was used (Patel et al., 2012). ARBs are more expensive than ACE
inhibitors and are recommended as an acceptable alternative to patients that develop a cough
with ACE inhibitor therapy. ARBs is also recommended in conjunction with ACE inhibitors and
beta-blockers in patients who have persistent symptoms in NYHA class II, III, or IV. In two
placebo-controlled randomized trials, the addition of an ARB reduced hospitalization for heart
failure by 17% for valsartan (Patel et al., 2012); (Mujib et al., 2013) . Candesartan reduced the
risk of cardiovascular mortality by 16% (Patel et al, 2012).
Aldosterone Receptor Antagonists
According to large, placebo-controlled randomized trials the addition of spironolactone in
addition to diuretic, digoxin, and ACE inhibitors reduced hospitalizations and had a 30%
reduction in mortality in NYHA class III and IV (McMurray, 2010). The addition of aldosterone
antagonists should be considered in class III and IV patients who remain symptomatic despite
being treated with an ACE or ARB, diuretics, and a beta-blocker. Patients should be either on an
aldosterone antagonists or an ARB but not both at the same time due to the risk of hyperkalemia
and renal dysfunction. An aldosterone antagonist may be added to an ACE inhibitor (McMurray,
2010).
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Hydralazine and Isosorbide Dinitrate
The Vasodilator Heart Failure Trial (V-HeFT I) demonstrated increased efficacy of combining
nitric oxide isosorbide dinitrate with hydralazine in patients with mild-to-severe heart failure
(McMurray, 2010). A retrospective subgroup analysis from two clinical trials of hydralazine and
isosorbide dinitrate suggested that black patients did not respond as well to ACE inhibitors
(McMurray, 2010). Studies show that African-American individuals have a less active reninangiotensin system and a lower bioavailability of nitric oxide than Caucasians. The AfricanAmerican Heart Failure Trial (A-HeFT) conducted a randomized, placebo-controlled, doubleblind trial with patients from 161 centers in the United States. A total of 1050 black patients with
NYHA class III or IV heart failure with dilated ventricles were randomly assigned to receive a
fixed dose of isosorbide dinitrate plus hydralazine or placebo, in addition to standard treatment
for heart failure. The study terminated early due to increased mortality of the placebo group. The
results of the study concluded that the addition of a fixed dose of isosorbide dinitrate plus
hydralazine to standard heart failure therapy is more effective in black patients (Taylor et al.,
2004).
Digoxin
Digoxin has shown improvement in patient’s symptoms and exercise tolerance in patients
with mild-to-moderate heart failure regardless of underlying rhythm or concomitant therapy.
Digoxin has been shown in 2 separate studies to reduce 30 day all cause readmission when use in
systolic heart failure (Ahmed, Bourge, Fonarow, Patel, Morgan, & Fleg, 2014; Bart, Goldsmith,
Lee, Givertz, O'Connor, & Bull, 2012). Digoxin is considered an adjunct to therapy in patients
with persistent symptoms despite other medical management.
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Inotropic Support
Intravenous nitroglycerin relieves dyspnea in decompensated heart failure especially when
ischemia is involved. Patients with reduced systolic function may have improved quality of life
with inotropic therapy but should only be used for short-term management (Goodlin, 2009).
Intravenous inotropics are indicated when there is evidence of hypoperfusion and obvious
elevated cardiac filling pressures to maintain systemic perfusion and preserve organ function
until a more definitive therapy is found (Hunt et al, 2005).
Warfarin and Aspirin
A double-blind, multi-center trial at 168 centers in 11 countries sponsored by the National
Institute of Health compared warfarin with aspirin therapy in patients with systolic heart failure
in sinus rhythm. The Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF)
study showed no significant differences between the two medications. The reduced risk of
ischemic stroke with warfarin was outweighed by an increased risk of significant hemorrhage.
The results of the study indicate the choice between warfarin and aspirin should be
individualized with benefit outweighing the risk (Homma et al., 2012).
Non-pharmacological Treatment Guidelines
Pharmacological treatment has a significant role in the treatment of heart failure, but it should
be used in conjunction with non-pharmacological lifestyle management such as: dietary therapy,
physical activity, smoking cessation, and moderation in alcohol consumption.
Smoking Cessation
Tobacco use is strongly associated with the development of heart failure. Clinicians should
strongly advise their patients not smoke and provide smoking cessation counseling and
interventions (Yancy et al., 2013). In a retrospective study of the Survival and Ventricular
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Enlargment (SAVE) randomized control study, it was found that those who had a myocardial
infaction complicated by left ventricular dysfunction had a nearly 40% lower hazard of all-cause
mortality and a 30% lower chance of death or recurrent MI or heart failure hospitalization
compared to persistent smokers (Shah et al., 2010).
Dietary Restriction
A combination of healthy dietary patterns with reduced sodium intake and reduced body fat
reduces an individual’s risk of developing hypertension, cardiovascular disease and diabetes. A
diet high in sodium is strongly correlated with the development of hypertension and the
progression of heart failure. Sodium intake initiates an auto-regulatory sequence that increases
intravascular fluid volume affecting cardiac output, peripheral resistance, and elevating blood
pressure (Sacks & Campos, 2010). Restricting sodium and fluid intake improves fatigue and
edema and may reduce the need for diuretics.
Obesity contributes to the pathogenesis of hypertension and The American Heart Association
(AHA) guidelines have a target BMI of less than 25 to reduce the risk of heart disease. However,
heart failure patients that have a BMI between 30-35 kg/m2 have reduced hospitalizations and
mortality rates (Yancy, 2013). The AHA recommend a diet similar to the Dietary Approaches to
Stop Hypertension (DASH) or 1.5 gm of sodium, limiting alcohol beverages to two daily for
men and one for women, and a Mediterranean-style diet (Sacks et al, 2010). Patients should be
given written instructions on how to adopt healthy diet such as the DASH diet, or a
Mediterranean-style diet.
Strict fluid restrictions does not appear to benefit patients unless they are diuretic
resistant or have hyponatremia. Fluid restrictions of two liters a day is adequate for hospitalized
patients. Fluid restrictions along with sodium restrictions enhances volume management and may
CONGESTIVE HEART FAILURE
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reduce the dose of diuretic needed. Patients in hot climates with low-humidity are at high risk of
heat stroke if on fluid restrictions (Yancy et al., 2013).
Physical Activity
Controlled clinical trials show that supervised exercise training programs lessen symptoms,
increases exercise tolerance, improves the quality of life, and reduces hospitalizations and
mortality. In these studies, physical conditioning is achieved through formal exercise training
programs which require patients to gradually increase their activity. The goal is to achieve a
workloads of 40% - 70% of maximal effort for 20 to 45 minutes three to five times a week for
eight to 12 weeks (Hunt et al, 2005). The ACC/AHA guidelines recommend exercise training for
all stable outpatients with chronic heart failure who are able to participate. Exercise programs are
intended to be individualized based on disease progression, medical management, and
hemodynamic monitoring. The safety of an exercise program is monitored by heart rate,
electrocardiogram, blood pressure, and patient’s rate of perceived exertion (Certo, 2001).
Internal Cardiac Defibrillator
According the Framingham studies 60% of the deaths that occur among patients with mild
systolic heart failure are related to a ventricular arrhythmia. An implantable cardioverterdefibrillator (ICD) reduces the risk of death with no adverse effects on the quality of life. An
ICD is indicated for secondary prevention in any patient that survives an unprovoked episode of
ventricular fibrillation or sustained ventricular tachycardia. The Multicenter Automatic
Defibrillator Implantation Trial II (MADIT-II) showed a relative 3% decrease in mortality in
patients after myocardial infarction and EF less than or equal to 30% receiving a ICD implant, in
addition to the standard of the care (Yancy, 2013). ICD implantation is indicated for primary
prevention in NYHA class II or III who have an ejection fraction of 35% or less despite optimal
CONGESTIVE HEART FAILURE
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medical management. ICD devices should be reserved for patients that and are expected to live
for at least one year and have a reasonable quality of life (McMurray, 2010).
Cardiac Resynchronization Therapy
Cardiac resynchronization therapy (CRT) reduces the morbidity and mortality in patients
with chronic systolic heart failure and a wide QRS complex (Ruschitzka et al., 2013). CRT with
atrial-synchronized biventricular pacing immediately improves stroke volume and reduces mitral
regurgitation improving cardiac output. CRT is recommended for NYHA class III or IV with an
ejection fraction of 35% or less, sinus rhythm, and a QRS of 120 milliseconds or more. Patients
with NYHA class I or II with ejection fraction of 30% or less, a wide QRS interval greater than
130 milliseconds benefit from CRT, in addition to implantable cardioverter defibrillator.
Biventricular Pacing
The Biventricular versus Right Ventricular Pacing in Heart Failure Patients with
Atrioventricular Block (BLOCK HF) conducted a multicenter, randomized double-blinded trial
involving 691 patients with indication for ventricular pacing for atrioventricular block, EF less
than or equal to 50%, and mild-to-moderate heart failure. The results of the BLOCK HF trial
reveal that biventricular pacing is superior to conventional right ventricular pacing in patients
with atrioventricular block and left ventricular systolic dysfunction with NYHA class I, II, or III
heart failure (Curtis, Worley, Adamson, Chung, Niazi, Sherfesee, Shinn, & Sutton, 2013).
Rhythm Control versus Rate Control
Atrial fibrillation with excessive ventricular rate results in the loss of atrial contraction and
irregular filling times. Atrial fibrillation with rapid ventricular rate negatively impacts patients
with heart failure and increases the risk of mortality. A multicenter, randomized trial compared
the benefits of restoring sinus rhythm to rate control of atrial fibrillation in patients with heart
CONGESTIVE HEART FAILURE
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failure. A total of 1376 patients enrolled and progress followed for 37 months. The results
denote that rhythm control did not reduce morbidity compared to the rate-control strategy.
Medical management of patients with heart failure and atrial fibrillation should include ratecontrol. Patients with heart failure are at increased risk for adverse events from antiarrhythmic
drugs and need to be examined frequently for side effects (Roy et al, 2008).
Coronary-Artery Bypass Surgery
According to the Surgical Treatment for Ischemic Heart Failure (STICH) trial, coronaryartery bypass grafting (CABG) is the treatment of choice for patients with heart failure and
coronary artery disease. The STICH trial was a randomized multi-center, non-blinded study
conducted between 2002 and 2007 at 127 clinical sites in 26 countries. Eligible patients had
coronary artery disease and an EF of 35% or less. The trial compared medical therapy alone with
medical therapy in addition to CABG. The mortality rate from cardiovascular causes was lower
among the group assigned to CABG compared to those assigned to receive medical therapy
alone (Velezquez et al, 2011).
Ventricular Assist
Ventricular assist devices (VAD) have evolved over the past 50 years and are still an
acceptable solution for patients with advanced heart failure refractory to medical management.
VAD may be used short-term for the management of acute decompensated unstable heart failure
that has not responded to inotropic medications. VAD provide an opportunity to discuss further
disease management such as cardiac surgery, permanent VAD, or palliative care. VAD are most
commonly used as a bridge to cardiac transplant. VAD devices are also used in patients that do
not meet transplantation requirements.
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Ultrafiltation
Ultrafiltration can be used as an alternative strategy to diuretic therapy is patients with acute
decompensated heart failure and impaired renal function. Venous ultrafiltration is an alternative
method that has advantages over diuretic therapy because the rate and volume of fluid removed
can be controlled. A randomized trial of hospitalized patients with acute decompensated heart
failure, worsening renal function, and persistent congestion compared ultrafiltration with a tiered
pharmacological-therapy algorithm. The Cardiorenal Rescue Study in Acute Decompensated
Heart Failure (CARRESS-HF) randomly assigned patients to ultrafiltration (94 patients) with
pharmacologic therapy (94 patients). The study determined that the patients in the ultrafiltration
group had a higher rate of adverse events and the pharmacologic-therapy algorithm had a similar
amount of fluid loss with preserved renal function after 96 hours (Bart et al., 2012).
Heart Transplant
Heart transplantation is a last resort for patients that have exhausted medical management.
Cardiac transplant is the gold standard for refractory end-stage heart failure. Consider referral to
a specialist for evaluation of cardiac transplant for patients with severe, refractory symptoms or
cardiogenic shock. Advances in immunosuppressant therapy increased the five year survival rate
to 71.7%. (Yancy et al., 2013).
Pediatric Heart Failure
Heart failure is considerably different in the pediatric population. The main causes of
cardiac failure in children are congenital cardiac malformations and complex congenital heart
(Hsu & Pearson, 2009). Cardiomyopathies are the most common cause of heart failure in
children with structurally normal hearts (Hsu & Pearson, 2009). Congenital heart disease caused
by structural malformations are more common with adult heart failure and include issues with
CONGESTIVE HEART FAILURE
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volume overload, pressure overload, or a combination of both when complex malformations are
involved (Hsu & Pearson, 2009) . Non-structural causes such as primary cardiomyopathy are
loss common than structural disease but is places the child at greater risk of heart failure (Hsu &
Pearson, 2009).
When classifying heart failure, the NYHA Heart Failure Classification is no longer
applicable in the pediatric populations. The Ross Heart Failure Classification was developed to
assess infants with heart failure (Hsu & Pearson, 2009). Scores for the Ross Classification are
based on feeding difficulties, growth and development, and exercise intolerance (Hsu & Pearson,
2009). For children and adolescents, the New York University Pediatric Heart Failure Index was
developed (Hsu & Pearson, 2009). These scores were weighted on physiological indicators and
medical therapy (Hsu & Pearson, 2009). The symptoms of heart failure in the pediatric
populations include growth failure, respiratory distress, and exercise intolerance.
When treating heart failure in children, the underlying cause and the child’s age are what
determine treatment. As with adult patients treatment goals include correction of the underlying
problem, minimize morbidity and mortality, and improving functional status and quality of life
(Hsu & Pearson, 2009). Due to the limited amount of research that has been established in the
way of pediatric heart failure due to the protected population, the single practice guideline that is
available, which was established by the International Society for Heart and Lung
Transplantation, does not have any level A evidence and only 7 level B studies (Hsu & Pearson,
2009) . Most of the guidelines are based upon expert opinion. Treating the underlying cause of
the heart failure when structure defects are presents seem to be the consensus of the expert
opinion. When treatment must be medically managed or co-managed, it is recommended based
on expert opinion that diuretics, digitalis, and ACE inhibitors are used and beta-blockers are
CONGESTIVE HEART FAILURE
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avoided (Hsu & Pearson, 2009). With volume overloaded heart failure, furosemide is the drug of
choice in the pediatric population (Hsu & Pearson, 2009). Thiazide diuretics have not been
tested as monotherapy in the pediatric population (Hsu & Pearson, 2009). Due to the low rate of
sudden death in children awaiting heart transplantation, implantable cardiac defibrillator with left
ventricular dysfunction is not indicated (Hsu & Pearson, 2009). There is little evidence or long
term trials with biventricular pacing in children with heart failure although some evidence shows
biventricular pacing improves functional status (Hsu & Pearson, 2009) . Ventricular Assist
Devices (VAD) has shown as a successful bridge in up to 80% of children awaiting
transplantation (Hsu & Pearson, 2009). Heart transplantation remains the gold standard of
treatment for end-stage heart failure in children (Hsu & Pearson, 2009). Nutritional support may
be just as important in pediatric heart failure patients. Sodium restrictions are not recommended
in infants and young children as sodium in often not in surplus in formulas and sodium is needed
as an important growth factor (Hsu & Pearson, 2009). Children can also benefit from regular
physical activity, just as adults with heart failure who undergo exercise training (Hsu & Pearson,
2009).
Heart failure is a complex disease that involves multisystem modalities. It is not only
important for management to occur by the cardiology through thorough medication management,
but a multidisciplinary approach is necessary. The American Heart Association along with the
American College of Cardiologist has established guidelines for the management of heart failure
including pharmacologic as well as non-pharmacologic means. While prevention of heart failure
is the best way to manage heart failure, early detection of heart disease can help prevent
worsening of the disease process and further management of heart failure.
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Appendix A
Author
Intervention
Method
Sample
Main Findings
Ahmed, A.,
Balanced
9649 medical
In Medicare
Bourge, R. C.,
Matched Cohort
records of 8555
beneficiaries
Fonarow, G. C.,
Study
unique fee-for-
with systolic
Patel, K.,
service Medicare
heart failure, a
Morgan, C. J.,
beneficiaries
discharge
Fleg, J. L., …
discharged with a prescription of
Allman, R. M.
primary
digoxin was
(2014).
discharge
associated with
diagnosis of
lower 30-day all-
heart failure from cause hospital
106 Alabama
readmission,
hospitals
which was
between 1998
maintained at 12
and 2001
months, and was
not at the
expense of
higher mortality.
Aurigemma, G.
Initial
Randomized,
The sample size
Over a median
P., & Gaasch, W. management of
controlled trials
included 3023
follow up period
H. (2004).
acute heart
involving
patients with
of 36 months,
failure includes
patients with
New York Heart
patients that
CONGESTIVE HEART FAILURE
20
reducing
diastolic
Association
received the
pulmonary and
dysfunction
functional class
candesartan had
venous
II-IV heart
significantly
congestion with
failure and LVEF fewer
diuretics,
greater than 40%
supplemental
were randomly
oxygen,
assigned to
morphine, and
receive
nitroglycerin.
candesartan
Long term
(n=1514, target
management
does 32 mg
includes rate
daily) or placebo
control with beta-
(n=1509).
blockers or rate
lowering
calcium-channel
blockers for
tachycardia and
atrial fibrillation
to reduce
myocardial
oxygen demand.
Revascularization
hospitalizations.
CONGESTIVE HEART FAILURE
if myocardial
ischemia is
contributing to
diastolic
dysfunction.
Control
hypertension by
utilizing the Joint
National
Committee on
Prevention,
Detection,
Evaluation, and
Treatment of
High Blood
Pressure.
Medications to
improve heart
failure such as
ACE inhibitors,
angiotensinreceptor blockers
(ARB), or
21
CONGESTIVE HEART FAILURE
22
Spironolactone.
The CHARM
study specifically
studied the use of
candesartan as
the ARB of
choice for the
treatment of heart
failure.
Bart, B. A.,
Goldsmith, S. R.,
Lee, K. L.,
Givertz, M. M.,
O'Connor, C. M.,
Bull, D. A.,…
Braunwalk, E.
(2012).
This study
discusses using
ultrafiltration as
an alternative
strategy to
diuretics for
patients with
decompensated
heart failure in
patients with
cardio renal
syndrome. The
study is referred
to as the
Cardiorenal
Rescue Study in
Acute
Decompensated
Heart Failure
(CARRESS-HF)
and was funded
by NHLBI.
Ultrafiltration
A randomized
A total of 188
The patients in
trial was used for
patients with
the ultrafiltration
this study,
acute
group had a
patients were
decompensated
higher rate of
assigned
heart failure and
adverse events.
ultrafiltration or
worsening renal
The patients
diuretic therapy.
function were
receiving
involved in this
diuretics. The
study. The
study was
patients were
aborted in
followed for 60
February 2012
days. Patients
due to excess
was performed at
were enrolled
adverse events
a fluid removal
between June 22,
with
CONGESTIVE HEART FAILURE
23
rate of 200 ml per
2008 and January ultrafiltration.
hour.
27, 2012 in the
Major adverse
United States and events such as:
Canada.
worsening
kidney function,
bleeding, and
intravenous
catheter-related
conditions. The
60 day mortality
rate of the
ultrafiltration
group was 17%
compared to 13%
in the
pharmacologic
group.
Bourge, R. C.,
Patients were
Double-blind,
6800 ambulatory
Digoxin reduces
Fleg, J. L.,
randomly
placebo-
patients with
30-day all-cause
Fonarow, G. C.,
assisgned to
controlled
chronic heart
hospital
Cleland, J.,
Digoxin or
randomized
failure (ejection
admission in
McMurray, J. V.,
Placebo group.
clinical trial of
fraction ≤45%)
ambulatory older
VanVelduisen,
digoxin in
patients with
CONGESTIVE HEART FAILURE
24
D. J.,… Ahmed,
patients with
chronic systolic
A. (2013)
chronic heart
heart failure.
failure and
reduced ejection
fraction.
Certo, C. (2001,
June)
Chaudhry, S. I.,
Patients received
The study design
The study
Telemonitoring
Mattera, J. A.,
educational
was a
included 1653
did not improve
Spertus, J. A.,
materials
multicenter,
patients who had
the outcomes for
Herrin, J., Lin,
developed by the
randomized,
recently been
patients recently
A., Phillips, C.
Heart Failure
controlled trial.
hospitalized for
hospitalized for
O.,… Krumholz,
Society of
heart failure to
heart failure.
H. M. (2010).
America. Patients
undergo either
Readmission for
were provided
telemonitoring
any reason
with a scale to
(n=826) or usual
occurred in
perform weights
care (n=827).
49.3% of patients
if needed.
The median age
in the
Patients were
of the patients
telemonitoring
provided with
was 61 years;
group and 47.4%
detailed
42% female, and
of patients in the
instructions and
39% African
usual care group.
demonstration of
American
Death occurred
CONGESTIVE HEART FAILURE
25
how to use the
11/1% of the
telemonitoring
telemonitoring
system. The
group and 11.4%
telemonitoring
in the usual care
was performed
group. No
using a
adverse events
commercial
were reported.
system, TelAssurance which
was selected on
the basis of
technical quality.
The
telemonitoring
group was
instructed to
make daily calls
and answer a
series of
questions about
their general
health and heart
failure
CONGESTIVE HEART FAILURE
26
symptoms.
Curtis, A. B.,
The study
Worley, S. J.,
Randomization
Of the 918
The study
compared
patients enrolled
concluded
Adamson, P. B.,
biventricular
698 were
biventricular
Chung, E. S.,
pacing to
randomly chosen
pacing was
Niazi, I.,
conventional
n=349 were
superior to
Sherfesee, L.,…
right ventricular
assigned
conventional
Suttong, M.
pacing in patients
biventricular
right ventricular
(2013).
with
pacing and
pacing in patients
atrioventricular
n=342 were
with AV block
(AV) block and
assigned right
and left
left ventricular
ventricular
ventricular
systolic
pacing. Patients
systolic
dysfunction. The
with indications
dysfunction with
study is called
for pacing with
NYHA class I,
the BLOCK HF
AV block;
II, or III heart
trial and funded
NYHA class I,
failure. Patients
by Medtronic.
II, or III failure;
receiving
and left
biventricular
ventricular
pacing had lower
ejection fraction
incidence of
of 50% or less.
heart failure,
death from any
CONGESTIVE HEART FAILURE
27
cause, and
progression of
heart failure as
measured by left
ventricular endsystolic volume
index.
El-Refai, M.,
This was a
1,835 patients
BB exposure
Peterson, E. L.,
retrospective study met the inclusion was associated
Wells, K., Swadia,
of insured patients
criteria and made with a similar
T., Sabbah, H. N.,
who were
up the study
protective effect
Spertus, J. A.,…
hospitalized for
cohort.
regarding time
Lanfear, D. E.
HF from January
to death or
(2013).
2000 to June
hospitalization
2008.
in HF patients
regardless of
whether EF was
preserved or
reduced.
Felker, G. M., Lee,
This study
The DOSE study
A total of 308
Patients
K. L., Bull, D. A.,
compared the
was a prospective,
patients were
assigned to the
Redfield, D. A.,
administration
randomized,
enrolled between
high-dose
CONGESTIVE HEART FAILURE
28
Stevenson, L. W.,
of furosemide
double-blind,
March 2008 and
furosemide
Goldsmith, S. R.,
intravenously
controlled trial
November 2009.
therapy were
… O'Connor, C.
by means of
conducted by the
The mean age of
more likely to
M. (2011).
either a bolus
Heart Failure
the patients was
change to oral
every 12 hours
Clinical Research
66 years, 27%
diuretics within
or continuous
Network and was
women, and 25% 48 hours. High-
infusion and at
funded by the
African
dose furosemide
either low dose National Heart,
American. The
resulted in
(equivalent to
Lung, and Blood
mean ejection
greater net fluid
the patient’s
Institute. The trial
fraction was
loss, weight loss,
previous oral
used a 2-by-2
35%, 74% were
and decrease in
dose) or high
factorial design
hospitalized
symptoms.
dose (2.5 times and randomly
within the
Patients in the
the oral dose)
previous 12
low-dose group
in patients with 1:1:1:1 ratio.
months for heart
were more likely
acute
failure with
to require 50%
decompensated
moderate renal
increase in the
heart failure.
dysfunction
dose within 48
(mean serum
hours (24%
creatinine level
compared to
1.5 mg/dl.
9%). There were
assigned, in a
no differences
between the
CONGESTIVE HEART FAILURE
29
bolus group and
the continuous
infusion group.
There were more
cases of
ventricular
tachycardia in
the bolus group
and more cases
of renal failure
in the
continuous
infusion
group.The
median length of
hospitalization
was 5 days and
did not change
across the
Fu, M., Zhou, J.,
Meta Analysis of
A total of 2554
The present
Sun, A., Zhang, S.,
7 prospective
patients (mean
study
Zhang, C.,
studies
age: 75.1 years,
demonstrated
female: 58%)
that ACE
Yunzeng, A.,…
CONGESTIVE HEART FAILURE
Ge, J. (2012).
30
were recruited
inhibitors as
with an average
monotherapy or
follow up of 20.9 first-line therapy
months.
resulted in a
significant
reduction in allcause mortality
in HFPEF. In
addition, ACE
inhibitors
reduced heart
failure related
rehospitalization
in a HEPEF
subgroup aged >
75 or treatment
over a period of
21 months.
Galin, I., & Baran,
D.A. (2003,
September).
Goodlin, S.J.
(2009).
CONGESTIVE HEART FAILURE
31
Gjesdal, K., Feyzi,
Patients were
The results
randomized to
7329 patients
with
AF at moderate-
J., & Olsson, S. B.
(2008).
preventive
to-high risk
digitalis, like
suggest that
ireatment of
other
thromboembolism,
Inotropic drugs,
either with
may increase
warfarin or the
mortality. This
oral direct
may be
thrombin inhibitor
Concealed in
ximelagatran. The
heart failure, but
survival of users
be revealed in
and non-users of
Patients with
digitalis was
AF, who need
investigated.
the rate-reducing
effect of
digitalis, but do
not benefit much
from an
increased
inotropy.
Homma, S.,
The WARCEF
The study was
The study
The study
Thompson, J. L.,
trial was
conducted using a
followed 2305
concluded there
CONGESTIVE HEART FAILURE
32
Pullicino, P. M.,
completed to
cooperative,
patients for up to
was no
Freudenberger, R.
compare the
double-blind,
six years.
significant
S., Teerlink, J. R.,
efficacy of
multicenter trial at
Eligible patients
overall
Ammon, S. E.,
warfarin (with
168 centers in 11
were at least 18
difference in the
…Buchsbaum, R.
a target ratio of countries
years old with
primary
(2012).
2.0 to 3.5) and
sponsored by the
normal sinus
outcome
aspirin (at a
National Institute
rhythm, no
between the
dose of 325
of Health.
contraindications
treatment with
mg) in patients
to warfarin
warfarin and the
with heart
therapy, and an
treatment with
failure and
LVEF of 35% or
aspirin. There
sinus rhythm.
less. Patients
was a reduced
with a clear
risk of ischemic
indication for
stroke in the
warfarin or
warfarin group
aspirin were
but this was
excluded. The
offset by an
mean LVEF was
increased risk of
24.7+/- 7.5%
major
with no
intracerebral
significant
hemorrhage. The
difference
study concluded
between the
that the choice
CONGESTIVE HEART FAILURE
33
warfarin and the
between
aspirin groups.
warfarin and
aspirin should be
individualized.
Lindenfield, J.,
c
Albert, N.M.,
Boehmer, J.P.,
Collins, S.P.,
Ezekowitz, J.A.,
Givertz, M.M., …
Klapholz, M.
(2010, June).
McMurray, J.
This article
The
Tests and Possible
V. (2010).
discusses
information is
Findings with
evidence-based
based on
Recommendations:
pharmacologic
randomized,
Electrocardiography
treatment of heart controlled
: Control atrial
failure using
trials involving
fibrillation or flutter
ACEI, beta-
patients with
and consider
blockers, ARBs,
chronic heart
anticoagulation,
aldosterone
failure or with
consider cardiac
CONGESTIVE HEART FAILURE
34
blockers, and
heart failure,
resynchronization.
hydralazine. The
left ventricular
Administer beta-
article discusses
systolic
blockers with
possible findings
dysfunction or
caution for sinus
in patients with
both.
bradycardia.
left ventricular
Chest radiography:
systolic
Administer adequate
dysfunction and
diuretics for
recommended
pulmonary
treatment
congestion, edema,
including
or pleural effusion.
lifestyle and
Hematologic tests:
exercise,
perform a diagnostic
implantable
workup and treat
devices, cardiac-
iron deficiency.
resynchronizatio
Increased creatinine:
n therapy,
administer RAAS
coronary
blocker with
revascularization,
caution.
and cardiac
Hypokalemia: add
transplantation.
or increase the dose
of RAAS blocker,
consider potassium
CONGESTIVE HEART FAILURE
35
replacement.
Hyperkalemia: stop
potassium
replacements,
reduce dose or
withdraw RAAS
blocker.
Hypnonatremia:
reduce or
discontinue use of
thiazide diuretic;
reduce water intake;
consider treatment
with tolvaptan if
severe.
Hyperuricemia:
consider reducing
diuretic dose as
much as possible,
administer
prophylaxis for
gout.
ACEI Dosing
CONGESTIVE HEART FAILURE
36
Captopril starting
dose 6.25mg 3 doses
daily with target
dose of
150mg/daily.
Enalapril starting
dose 2.5mg twice
daily with target
dose 20-40mg daily.
Lisinopril starting
dose 2.5-5mg daily
with target dose of
20-35mg daily.
Ramipril starting
dose 2.5mg 1-2
doses with target
dose 10mg/daily.
Beta-blocker dosing
Bisoprolol 1.25mg
daily with
10mg/daily target.
Carvedilol 3.125mg
twice a day with
CONGESTIVE HEART FAILURE
37
target dose 50100mg/daily.
Metoprolol XL
12.5mg-25mgdaily
with target dose
200mg daily.
Angiotensionreceptor blockers
dosing
Candesartan 4 mg
daily with target
dose 32 mg daily,
Valsartan 40mg
twice a day with
target dose
320mg/daily.
Losartan 50mg daily
with target dose 150
mg/daily.
Aldosterone
blockers:
Should be initiated
to patients who
CONGESTIVE HEART FAILURE
38
remain NYHA class
III or IV despite
treatment with
diuretic, and ACEI
or ARB, and a betablocker.
Eplerenone 25 mg
daily with target
dose 50mg/daily.
Spironolactone 25
mg daily with target
dose 25-50mg/daily.
Hydralazineisosorbide dinitrate
Hydralazine 37.5mg
three times a day
with target dose
being 225mg/daily.
Isosorbide dinitrate
20mg three times a
day with target dose
120mg/daily.
CONGESTIVE HEART FAILURE
39
Lifestyle
modification
tailored structured
aerobic exercise
improved functional
capacity and quality
of life.
Implantable
Cardioverter
Defibrillators
reduces risk of
sudden death in
patients with left
ventricular systolic
dysfunction.
Indicated for
patients who survive
unprovoked
ventricular
fibrillation or
sustained
CONGESTIVE HEART FAILURE
40
tachycardia and for
primary prevention
in patients with
NYHA functional
class II or III who
have an ejection
fraction persistently
35% or less despite
optimal medical
management and
expected to survive
greater than one
year.
Cardiac
transplantation is
last resort for
refractory heart
failure.
Mujib, M.,
A retrospective
4189 Patients
Those discharge
Patel, K.,
study of the
were chosen
with the initiation of
Fonarow, G. C.,
Organized
from the 10,570
an ACE inhibitor
Kitzman, D.
Program to
patients aged >65 upon discharge from
W., Zhang, Y.,
Initiate
years with heart
the hospital with a
CONGESTIVE HEART FAILURE
41
Aban, I.
Livesaving
failure and
diagnoses of heart
B.,….Ahmed,
Treatment in
preserved
failure with a
A. (2013).
Hospitalized
ejection fraction
preserved ejection
Patients with
in the Organized
fraction showed a
Heart Failure
Program to
modest
(2003-2004)
Initiate
improvement in the
Lifesaving
end point of total
Treatment in
mortality or heart
Hospitalized
failure hospitalizion.
Patients with
Heart Failure
linked to
Medicare
Patel, K.,
A retrospective
3806 Patients
ARB’s were not
Fonarow, G. C.,
study of the
were chosen
associated with
Kitzman, D.
Organized
from the 10,570
improved clinical
W., Aban, I. B.,
Program to
patients aged >65 outcomes.
Love, T. W.,
Initiate
years with heart
Allman, R. M.,
Livesaving
failure and
… Ahmed, A.
Treatment in
preserved
(2012).
Hospitalized
ejection fraction
Patients with
in the Organized
Heart Failure
Program to
CONGESTIVE HEART FAILURE
42
(2003-2004)
Initiate
Lifesaving
Treatment in
Hospitalized
Patients with
Heart Failure
linked to
Medicare
Ruschitzka, F.,
This study was
The study was
The study
The study concluded
Abraham, W.
conducted to
conducted
involved 115
that
T., Singh, J. P.,
determine if
using a
centers in
resynchronization in
Bax, J. J.,
cardiac-
randomized
patients with
patients with in this
Borer, J. S.,
resynchronizatio
trial.
NYHA class III
category had
Brugada, J.,…
n therapy (CRT)
or IV heart
increased mortality
Holzmeister, J.
improved
failure, a LVEF
and the study was
(2013).
morbidity and
of 35% or less, a
stopped. There were
mortality in
QRS duration of
45 deaths in the
chronic systolic
less than 130
CRT group and 26
heart failure with
msec, and
in the control group.
a wide QRS
evidence of left
complex.
ventricular
dyssynchrony on
echocardiogram.
CONGESTIVE HEART FAILURE
43
At study end 809
patients had
undergone
resynchronizatio
n and the study
was aborted due
to futility and
increased
mortality.
Taylor, A. L.,
Ziesche, S.,
Yancy, C.,
Carson, P.,
D'Agostino, R.,
Ferdinand, &
Kohn, J. N.
(2004).
Velazquez, E.J., This study was
The study
A total number
There was no
Lee, K.L., Deja,
conducted to
utilized a
of 2136 patients
significant
M.A., Jain, A.,
determine the
randomized
were involved in
difference with
Sopka, G.,
role of coronary-
trial. Patients
the study
respect to the
Marchenko, A.,
artery bypass
were
between July
primary end point of
…Ali, I.S.,
grafting (CABG)
randomized to
2002 and May
death. Patients
CONGESTIVE HEART FAILURE
(2011, April).
44
to treat patients
either receive
2007 in 99
assigned to CABG
with coronary
medical
centers in 22
and medical
artery disease
management
countries. The
treatment had lower
and heart failure.
alone or
patients had a
rates of death from
The study is
medical
LVEF less than
cardiovascular
referred to as the
management
35% and
causes and of death
Surgical
plus CABG.
coronary artery
from any cause or
Treatment for
disease
hospitalization for
Ischemic Heart
amendable by
cardiovascular
Failure (STICH)
CABG. The
causes.
and was funded
median age of
by the NHLBI in
the patients was
conjunction with
59.
Abbott
Laboratories.
Yancy, C. W.,
Jessup, M.,
Bozkurt, B.,
Butler, J.,
Casey, D. E.,
Drazner, M. H.,
…Wilkoff, B.
L. (2013).
The American
Heart
Association
(AHA) and
American
College of
Cardiology
(ACC) 20013
guidelines make
the following
recommendations
for the
management of
chronic heart
failure in the
adult:
The
The AHA/ACC
AHA/ACC
guidelines were
guidelines
developed based
were
on data from
developed
clinical trials
through
about the
collaboration
usefulness and
with the
efficacy in
N/A
CONGESTIVE HEART FAILURE
1. Control
Hypertensionboth systolic and
diastolic
hypertension,
treat lipid
disorders, and
manage diabetes
according to
guidelines.
2. Patients should
be counseled on
lifestyle
modifications.
3. Ventricular
rate should be
controlled or
sinus rhythm
should be
restored.
4. Thyroid
disorders should
be treated
according to
guidelines.
5. ACEI and
beta-blocker
6. Patients with
known
atherosclerotic
disease should be
managed to
prevent
secondary
complications.
7. An ARB
should be used if
intolerant to
ACEI.
8. Coronary
revascularization
or valve
replacement
repair if needed.
9. AICD in
patients with
45
American
different
College of
populations.
Physicians and
the
International
Society for
Heart and
Lung
Transplantatio
n and endorsed
by the Heart
Rhythm
Society.
CONGESTIVE HEART FAILURE
ischemic
cardiomyopathy
40 days post-MI
if LVEF is 30%
or less, are
NYHA class I on
chronic optimal
medical therapy
and expected to
survive for at
least one year.
10. Digoxin
should not be
used in patients
with low LVEF,
sinus rhythm and
no history of
heart failure
symptoms.
11. Calcium
channel blockers
with negative
inotropic effects
may be harmful.
12. Diuretics and
fluid restrictions
13. NSAIDS and
other drugs
known to
adversely affect
heart failure and
reduce LVEF
should be
discontinued.
14. Immunization
to prevent
pneumonia and
influenza.
15. Aldosterone
Antagonists
16. Exercise
Training
17. Intermittent
intravenous
46
CONGESTIVE HEART FAILURE
positive inotropic
47