Download Heart Failure in the Setting of Ischemic Heart Disease

Dr M. Abubakr Shaikh
The Aga Khan University Hospital,
Karachi
HEART FAILURE GUIDELINES: A
COMPARISON
HEART FAILURE GUIDELINES
Eur Heart J 1995;16:741-51
JACC 2001;38:2101-2113 / Circ
2001;104:2996-3007
Circ 2005;112:1825-1852
J Card Failure 2006;12:e1-e122
HFSA 2006 Comprehensive Heart Failure Practice Guideline
Strength of Recommendation
“Is recommended”
Part of routine care

“Should be considered”
Exceptions should be
minimized
Majority of patients should
receive intervention

Some discretion allowed
“May be considered”
Individualization of
therapy is indicated
“Is not recommended”
Therapy should not be
used
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Comprehensive Heart Failure Practice Guideline
Strength of Evidence
A
Randomized controlled trials
 May be assigned on results of 1 trial
B
Cohort and case control studies
 Includes sub group analyses, metaanalyses, observational studies,
registries
C
Expert opinion
 Includes observational, epidemiological
findings; in-practice safety reporting
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (3.3-3.4)
Prevention—ACEI and Beta Blockers
ACE inhibitors are recommended for prevention of HF in
patients at high risk for this syndrome, including those
with:
 Coronary artery disease
 Peripheral vascular disease
 Stroke
 Diabetes and another major risk factor
Strength of Evidence = A
ACE inhibitors and beta blockers are recommended for all
patients with prior MI.
Strength of Evidence = A
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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
HFSA 2006 Practice Guideline (7.1, 7.4)
Pharmacologic Therapy: ACE Inhibitors
ACE inhibitors are recommended for symptomatic and
asymptomatic patients with an LVEF  40%.
Strength of Evidence = A
ACE inhibitors should be titrated to doses used in clinical
trials (as tolerated during uptitration of other medications,
such as beta blockers).
Strength of Evidence = C
ACE inhibitors are recommended as routine therapy for
asymptomatic patients with an LVEF  40%.
 Post MI
Strength of Evidence = B
 Non Post-MI
Strength of Evidence = C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
ACE Inhibitors in Heart Failure:
From Asymptomatic LVD to Severe HF
SOLVD Prevention
(Asymptomatic LVD)
CONSENSUS
(Severe Heart Failure)
20%
death or HF hosp.
40%
mortality at 6 mos.
29%
death or new HF
31%
mortality at 1 year
27%
mortality at end of
study
SOLVD Treatment
(Chronic Heart Failure)
16%
mortality

No difference in incidence of
sudden cardiac death
SOLVD Investigators. N Engl J Med 1992;327:685-91.
SOLVD Investigators. N Engl J Med 1991;325:293-302.
CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35.
HFSA 2006 Practice Guideline (7.2)
Pharmacologic Therapy: Substitutes for ACEI
It is recommended that other therapy be substituted for
ACE inhibitors in the following circumstances:
 In patients who cannot tolerate ACE inhibitors due to cough,
ARBs are recommended.
Strength of Evidence = A
 The combination of hydralazine and an oral nitrate
may be considered in such patients not tolerating ARBs.
Strength of Evidence = C
 Patients intolerant to ACE inhibitors due to hyperkalemia or
renal insufficiency are likely to experience the same side
effects with ARBs. In these cases, the combination of
hydralazine and an oral nitrate should be considered.
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.3, 7.4)
Pharmacologic Therapy: Beta Blockers
Beta blockers shown to be effective in clinical trials
are recommended for symptomatic and
asymptomatic patients with an LVEF  40%.
Strength of Evidence = A
Beta blockers are recommended as routine therapy
for asymptomatic patients with an LVEF  40%.
 Post MI
Strength of Evidence = B
 Non Post-MI
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
The Additional Value of Beta
Blockers Post-MI: CAPRICORN
Studied impact of beta blocker (carvedilol) on
post-MI patients with LVEF  40% already receiving
contemporary treatments, including
revascularization, anticoagulants, ASA, and ACEI:
 All-cause mortality reduced (HR = 0.077; p = 0.03)
 Cardiovascular mortality reduced
(HR = 0.75; p = .024)
 Recurrent non-fatal MIs reduced (HR =.59; p = .014)
Dargie HJ. Lancet 2001;357:1385-90.
Effect of Beta Blockade on Outcome
in Patients With HF and Post-MI LVD
HF
Severity
Target
Dose (mg)
Outcome
Study
Drug
US Carvedilol1
carvedilol
mild/
moderate
6.2525 BID
↓48% disease progression
(p= .007)
CIBIS-II2
bisoprolol
moderate/
severe
10 QD
↓34% mortality (p <.0001)
MERIT-HF3
metoprolol
succinate
mild/
moderate
200 QD
↓34% mortality (p = .0062)
COPERNICUS4
carvedilol
severe
25 BID
↓35% mortality (p = .0014)
CAPRICORN5
carvedilol
post-MI
LVD
25 BID
↓23% mortality (p =.031)
4. Packer M et al. N Engl J Med 2001;3441651-8.
1. Colucci WS et al. Circulation 1196;94:2800-6.
5. The CAPRICORN Investigators. Lancet 2001;357:1385-90.
2. CIBIS II Investigators. Lancet 1999;353:9-13.
3. MERIT-HF Study Group. Lancet 1999;353:2001-7.
HFSA 2006 Practice Guideline (7.5, 7.8)
Pharmacologic Therapy: Beta Blockers
RECENT DECOMPENSATION OR EXACERBATION
Beta blocker therapy is recommended for patients with a recent
decompensation of HF after optimization of volume status and
successful discontinuation of IV diuretics and vasoactive agents.
Whenever possible, beta blocker therapy should be initiated in
the hospital at a low dose prior to discharge of stable patients.
Strength of Evidence = B
Continuation of beta blocker therapy is recommended in most
patients experiencing a symptomatic exacerbation of HF during
chronic maintenance treatment.
Strength of Evidence = C

If necessary, consider temporary dose reduction

Avoid abrupt discontinuation

Reinstate or gradually increase before discharge
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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.
HFSA 2006 Practice Guideline (7.6)
Pharmacologic Therapy: Beta Blockers
CONCOMITANT DISEASE
Beta blocker therapy is recommended in the great majority of
patients with LV systolic dysfunction—even if there is
concomitant diabetes, chronic obstructive lung disease or
peripheral vascular disease.
 Use with caution in patients with:
 Diabetes with recurrent hypoglycemia
 Asthma or resting limb ischemia.

Use with considerable caution in patients with marked
bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).

Not recommended in patients with asthma with active
bronchospasm.
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (11.8, 15.2)
Pharmacologic Therapy: Beta Blockers
PRESERVED LVEF
Beta blocker treatment is recommended in patients with HF and
preserved LVEF who have:

Prior MI
Strength of Evidence = A

Hypertension
Strength of Evidence = B

Atrial fib. requiring control of ventricular rate
Strength of Evidence = B
THE ELDERLY
Beta-blocker and ACE inhibitor therapy is recommended as standard
therapy in all elderly patients with HF due to LV systolic dysfunction.
Strength of Evidence = B
In the absence of contraindications, these therapies are also
recommended in the very elderly (age > 80 years). Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline
Pharmacologic Therapy: Beta Blocker Overview*
General
considerations
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
If symptoms worsen
or other side effects
appear
Adjust dose of diuretic or concomitant vasoactive med.
If up-titration
continues to be
difficult
Prolong titration interval
Continue titration to target after symptoms return to
baseline
Reduce target dose
Consider referral to a HF specialist
* Consult language of specific recommendations
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.10)
Pharmacologic Therapy:
Angiotensin Receptor Blockers
ARBs are recommended for routine
administration to symptomatic and
asymptomatic patients with an
LVEF  40% who are intolerant to
ACE inhibitors for reasons other than
hyperkalemia or renal insufficiency.
Strength of Evidence = A
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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.
HFSA 2006 Practice Guideline (7.14-7.15)
Pharmacologic Therapy:
Aldosterone Antagonists
An aldosterone antagonist is recommended for
patients on standard therapy, including diuretics,
who have:

NYHA class IV HF (or class III, previously class IV)
due to LV systolic dysfunction (LVEF  35%)
One should be considered in patients post-MI
with clinical HF or diabetes and an LVEF < 40%
who are on standard therapy, including an ACE
inhibitor or an ARB.
Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Aldosterone Antagonists in HF
Probability of Survival
RALES (Advanced HF)
EPHESUS (Post-MI)
1.00
1.00
0.90
0.90
0.80
Spironolactone
0.70
0.80
Placebo
0.70
0.60
0.50
Epleronone
Placebo
0.60
0.50
RR = 0.70
P < 0.001
0.40
RR = 0.85
P < 0.008
0.40
0 3 6 9 12 15 18 21 24 27 30 33 36
0 3 6 9 12 15 18 21 24 27 30 33 36
Months
Months
Pitt B. N Engl J Med 1999;341:709-17.
Pitt B. N Engl J Med 2003;348:1309-21.
HFSA 2006 Practice Guideline (7.16-7.18)
Aldosterone Antagonists and Renal Function
Aldosterone antagonists are not recommended when:
 Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
 Serum potassium> 5.0 mmol/L
 Therapy includes other potassium-sparing diuretics
Strength of Evidence = A
It is recommended that potassium be measured at
baseline, then 1 week, 1 month, and every 3 months
Strength of Evidence = A
Supplemental potassium is not recommended unless
potassium is < 4.0 mmol/L
Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.23)
Pharmacologic Therapy: Diuretics
Diuretic therapy is recommended to restore and
maintain normal volume status in patients with
clinical evidence of fluid overload, generally
manifested by:
 Congestive symptoms
 Signs of elevated filling pressures
Strength of Evidence = A
Loop diuretics rather than thiazide-type diuretics
are typically necessary to restore normal volume
status in patients with HF.
Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.23)
Potassium-Sparing Diuretics
Agent
Initial Daily
Dose
Max Total
Daily Dose
Elimination
Duration
of Action
Spironolactone
12.5-25 mg
qd
50 mg
Metabolic
48-72 hrs
Eplerenone
25-50 mg
qd
100 mg
Renal,
Metabolic
Unknown
Amiloride
5 mg qd
20 mg
Renal
24 hrs
Triamterene
50-75 mg
bid
200 mg
Metabolic
7-9 hrs
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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 in
those with NYHA II-III HF (LVEF  30%)

Prophylactic ICD placement may be considered in those
with NYHA II-III HF (LVEF 31-35%)
Strength of Evidence = A
Concomitant placement should be considered in NYHA IIIIV patients undergoing implantation of a biventricular
pacing device.
Strength of Evidence = B
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
MADIT II: Prophylactic ICD in
Ischemic LVD (LVEF 30%)
Probability of Survival
1.0
.9
Defibrillator
.8
.7
Conventional
Therapy
.6
0
0
Number at Risk
Defibrillator
Conventional
1
2
3
4
110 (.78)
65 (.69)
9
3
Year
742
490
503 (.91)
329 (.90)
274 (.84)
170 (.78)
Moss AJ et al. N Engl J Med 2002;346:877-83.
ICD Therapy in the SCD-HeFT Trial:
Mortality by Intention-to-Treat
.4
HR
97.5% Cl
P Value
Amiodarone vs Placebo
1.06
.86-1.30
.53
ICD vs Placebo
.77
.62-.96
.007
Mortality
.3
22%
.2
17%
Amiodarone
.1
ICD Therapy
Placebo
0
0
6
12
18
24
30
36
42
48
54
60
Months of Follow-Up
Bardy GH et al. N Engl J Med 2005;352:225-37.
HFSA 2006 Practice Guideline (9.7)
Device Therapy:
Biventricular Pacing
Biventricular pacing therapy should be considered
for patients with 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
optimal medical therapy.
Strength of Evidence = A
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
CRT Improves Quality of Life and
NYHA Functional Class
Average Change in Score
(MLWHF)
NYHA: Proportion Improving
by 1 or More Class
0
80
-5
*
*
*
60
-10
(%) 40
-15
*
Control
CRT
RA
CL
EI
CD
*
MI
NT
AK
CO
ST
IC
SR
*
CD
*
MU
MI
RA
C
LE
-20
20
0
MIRACLE CONTAK MIRACLE
CD
ICD
* P < .05
Abraham WT et al. Circulation 2003;108:2596-2603.
Effect of CRT Without an ICD on
All-Cause Mortality: CARE-HF
% Event-Free Survival
100
75
CRT
50
Medical
Therapy
25
HR = 0.64 (95% CI = .48-.85)
p = .0019
0
Number at risk
CRT
Medical Therapy
0
409
404
500
376
365
351
321
Days
213
192
1,000
89
71
1,500
8
5
Cleland JG et al. N Engl J Med 2005;352:1539-49.
HFSA 2006 Practice Guideline (7.19)
Pharmacologic Therapy:
Hydralazine and Oral Nitrates
A combination of hydralazine and
isosorbide dinitrate is recommended as
part of standard therapy, in addition to
beta-blockers and ACE-inhibitors, for
African Americans with LV systolic
dysfunction:
 NYHA III or IV HF
Strength of Evidence = A
 NYHA II HF
Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
CONCLUSIONS
• HF guidelines have evolved to promote
aggressive medical therapy
• Controversy exists regarding indications of
device therapy despite clear scientific
evidence, due to other factors
• For better efficacy, ECG criteria should be
substituted by echo and EP criteria for
device therapy
HFSA 2006 Practice Guideline (3.2)
HF Risk Factor Treatment Goals
Risk Factor
Goal
Hypertension
Generally < 130/80
Diabetes
See ADA guidelines1
Hyperlipidemia
See NCEP guidelines2
Inactivity
20-30 min. aerobic 3-5 x wk.
Obesity
Weight reduction < 30 BMI
Alcohol
Men  2 drinks/day, women  1
Smoking
Cessation
Dietary Sodium
Maximum 2-3 g/day
1. Diabetes Care 2006; 29: S4-S42.
2. JAMA 2001; 285:2486-97.
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Treatment of Post-MI Patients with
Asymptomatic LV Dysfunction (LVEF  40%)
SAVE Study
0.3
Placebo
 All-cause mortality ↓19%
 CV mortality ↓21%
 HF development ↓37%
 Recurrent MI ↓25%
0.2
Mortality
Rate
Captopril
0.1
19% relative risk reduction
p = 0.019
0
0 0.5 1 1.5 2 2.5 3 3.5 4
Years
Pfeffer et al. NEJM 1992;327:669-77.
HFSA 2006 Practice Guideline (7.24)
Pharmacologic Therapy: Diuretics
 Restoration of normal volume status may require multiple
adjustments.
 Once a diuretic effect is achieved with short-acting loop
diuretics, increase frequency to 2-3 times a day if necessary,
rather than increasing a single dose.
Strength of Evidence = B
 Oral torsemide may be considered in patients exhibiting poor
absorption of oral medication or erratic diuretic effect.
Strength of Evidence = C
 IV administration of diuretics may be necessary.
Strength of Evidence = A
 Diuretic refractoriness may represent patient noncompliance,
a direct effect of diuretic use on the kidney, or progression of
underlying dysfunction.
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (4.18)
Evaluation—Follow Up Assessments
Recommended Components of Follow-Up Visits
 Signs and symptoms evaluated during initial visit
 Functional capacity and activity level
 Changes in body weight
 Patient understanding of and compliance with dietary sodium
restriction
 Patient understanding of and compliance with medical regimen
 History of arrhythmia, syncope, pre-syncope or palpitation
 Compliance and response to therapeutic interventions
 Exacerbating factors for HF, including worsening ischemic
heart disease, hypertension, and new or worsening valvular
disease
Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (11.1-11.2)
HF with Preserved LVEF—Diagnosis
Careful attention to differential diagnosis is recommended
in patients with HF and preserved LVEF.
Treatments may differ based on cardiac disorder.
Evaluation for ischemic disease and inducible myocardial
ischemia should be included.
Recommended diagnostic tools:
 Echocardiography
 Electrocardiography
 Stress imaging (via exercise or pharmacologic means, using
myocardial perfusion or echocardiographic imaging)
Strength of Evidence = C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
CRT in Patients with Advanced HF and a
Prolonged QRS Interval: COMPANION
Primary End Point: All-Cause Mortality
Death or Hospitalization Due to HF
Risk of all-cause mortality reduced by 19%
in group with CRT and ICD (p =.014)
Risk of death or hospitalization from HF
reduced by 34% in ICD group and by 40% in
ICD-CRT group (p < .001)
Bristow MR et al. N Engl J Med 2004;350:2140-50.
Figure 11.1. Diagnostic Categories
of Heart Failure with Preserved LVEF
Heart Failure with Preserved LVEF
Dilated LV
Valvular disease
AR; MR
NonNon-dilated LV
No valvular
disease
High output HF
Normal or Increased
QRS voltage
Hypertrophic disease
No Aortic valve
disease
No Hypertensive Hx or
PE
Hypertrophic
cardiomyopathy
Increased thickness
Low QRS voltage
Infiltrative myopathy
Aortic valve disease
Aortic stenosis
Normal thickness
Mitral obstruction
MS; Atrial myxoma
No mitral
obstruction
Pericardial disease
Tamponade /Constriction
Hypertensive Hx or PE
Inducible ischemia
Intermittent/active
ischemia
HypertensiveHypertensive-hypertrophic
cardiomyopathy
LVEF=left ventricular ejection fraction; HF=heart failure;
QRS=electrocardiographic ventricular depolarization; AR= aortic
regurgitation; MR=mitral regurgitation; MS=mitral stenosis; RVMI=right
ventricular myocardial infarction; Hx=history; PE= physical examination.
Right Ventricular Dysfunction*
Pulmonary
Hypertension
Isolated or
predominant RVMI
No pericardial
disease
No inducible ischemia
Fibrotic; collagencollagen-vascular;
Restrictive CM; carcinoid;
Reconsider diagnosis of HF
* Some patients with right ventricular
dysfunction have LV dysfunction due to
ventricular interaction.
Figure courtesy of Marvin Konstam MD and Marvin Kronenberg MD.
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (12.3, Table 12.3)
Acute Decompensated Heart Failure (ADHF)—
Treatment Goals for Hospitalized Patients
• Improve symptoms, especially congestion and low-output symptoms
• Optimize volume status
• Identify etiology
• Identify precipitating factors
• Optimize chronic oral therapy; minimize side effects
• Identify who might benefit from revascularization
• Educate patients concerning medication and HF self-assessment
• Consider enrollment in a disease management program
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (12.5-12.18)
Overview of Treatment Options for Patients with
Acute Decompensated HF
 Fluid and sodium restriction
 Diuretics, especially loop diuretics
 Ultrafiltration/renal replacement therapy
(in selected patients only)
 Parenteral vasodilators *
(nitroglycerin, nitroprusside, nesiritide)
 Inotropes * (milrinone or dobutamine)
*See recommendations for stipulations and restrictions.
HFSA 2006 Practice Guideline (12.23, Table 12.7)
Discharge Criteria for Hospitalized ADHF Patients
Recommended prior to discharge for all patients with HF:

Exacerbating factors addressed

Near optimum fluid status achieved

Transition from IV to oral diuretic completed

Near optimum pharmacologic therapy achieved

Follow-up clinic visit scheduled, usually 7-10 days
Should be considered prior to discharge for patients with
advanced HF or a history of recurrent admissions:

Oral regimen stable for 24 hours

No IV inotrope or vasodilator for 24 hours

Ambulation before discharge to assess functional capacity

Plans for post-discharge management

Referral to a disease management program
Strength of Evidence =C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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 in
hospitalized ADHF patients:
BUN
BUN>>43
43mg/dL
mg/dL
Systolic
Systolicblood
bloodpressure
pressure<<115
115mmHg
mmHg
Serum
Serumcreatinine
creatinine>>2.75
2.75mg/dL
mg/dL
Fonarow GC et al. JAMA 2005;293:572-80.
HFSA 2006 Practice Guideline (8.1)
Heart Failure Patient Education
 It is recommended that patients with HF and
their family members or caregivers receive
individualized education and counseling that
emphasizes self-care.
 This education and counseling should be
delivered by providers using a team approach.
 Teaching should include skill building and
target behaviors.
Strength of Evidence = B
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
The Potential Impact of Effective
Education on Patient Compliance
Noncompliance rate when patients . . .
Recall MD advice
Don’t recall advice
Medications
8.7%
66.7%
Diet
23.6%
55.8%
Activity
76.4%
84.5%
Smoking
60.0%
90.4%
Alcohol
60.0%
81.8%
Kravitz et al. Arch Int Med 1993;153:1869-78.
Sample Target Behavior: Be Able to
Read and Understand Food Labels
Labels from cups of soup
HFSA 2006 Practice Guideline (8.7)
Heart Failure Disease Management
Patients recently hospitalized for HF
and other patients at high risk
should be considered for referral
to a comprehensive HF disease
management program that delivers
individualized care.
Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HF Disease Management and the
Risk of Readmission
1.1
Risk
Ratio
Ekman
1
0.9
0.8
Jaarsma
0.7
Cline
Lasater
Stewart
Rich
Rauh
Venner
0.6
Naylor
0.5
Fonarow
Summary RR = 0.76 (95% CI .68-.87)
Summary RR for randomized only = 0.75 (CI = .60-.95)
HFSA 2006 Practice Guideline (8.13)
End-of-Life Care in Heart Failure
End-of-life care should be considered in patients who have
advanced, persistent HF with symptoms at rest despite
repeated attempts to optimize pharmacologic and
nonpharmacologic therapy, as evidenced by
one or more of the following:
 Frequent hospitalizations (3 or more per year)
 Chronic poor quality of life with inability to accomplish
activities of daily living
 Need for intermittent or continuous intravenous support
 Consideration of assist devices as destination therapy
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Evidence-Based Treatment Across the
Continuum of Systolic LVD and HF
Control Volume
Diuretics
Renal Replacement
Therapy*
Improve Clinical Outcomes
Aldosterone
ACEI
-Blocker Antagonist
or ARB
or ARB
CRT 
an ICD*
HDZN/ISDN*
*In selected patients
Treat Residual Symptoms
Digoxin
HFSA 2006 Practice Guideline (4.8, 4.10)
Heart Failure Patient Evaluation
Recommended evaluation for patients with a diagnosis of HF:

Assess clinical severity and functional limitation by history, physical
examination, and determination of functional class*

Assess cardiac structure and function

Determine the etiology of HF

Evaluate for coronary disease and myocardial ischemia

Evaluate the risk of life threatening arrhythmia

Identify any exacerbating factors for HF

Identify co-morbidities which influence therapy

Identify barriers to adherence and compliance
Strength of Evidence = C
* Metrics to consider include the 6-minute walk test and NYHA functional class
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
A-HeFT Outcomes
End point
Primary end point
composite score
ISDN-HDZN Placebo
(n=518)
(n=532)
p
-0.1
-0.5
0.01
6.2
10.2
0.02
1st HF hospitalization (%)
16.4
24.4
0.001
Change in quality-of-life
score at 6 months**
-5.5
-2.7
0.02
All-cause mortality (%)
Taylor AL et al. N Engl J Med 2004; 351;2049-2057.
A-HeFT All-Cause Mortality
43% Decrease in Mortality
100
Survival %
Fixed Dose ISDN/HDZN
95
90
Placebo
P = 0.01
85
0
100
200
300
400
500
600
Days Since Baseline Visit
Taylor AL et al. N Engl J Med 2004;351:2049-57.
Diabetes and the Use of Beta Blockers for HF: Relative
Risk for Mortality and Hospitalization for Heart Failure
COPERNICUS (carvedilol)1
With diabetes
Without diabetes
MERIT-HF (ER metoprolol succinate)2
With diabetes
Without diabetes
0
0.5
1.0
1.5
2.0
1. Mohacsi. Circulation. 2001;104(17):abstr 3551.
2. Hjalmarson. JAMA. 2000;283(10):1295.
HFSA 2006 Practice Guideline (7.23)
Loop Diuretics
Agent
Initial Daily
Dose
Max Total
Daily Dose
Elimination: Duration of
Renal – Met. Action
Furosemide
20-40mg qd
or bid
600 mg
65%R-35%M 4-6 hrs
Bumetanide
0.5-1.0 mg
qd or bid
10 mg
62%R/38%M 6-8 hrs
Torsemide
10-20 mg qd
200 mg
20%R-80%M 12-16 hrs
Ethacrynic
acid
25-50 mg qd
or bid
200 mg
67%R-33%M 6 hrs
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.