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Acute vs. Chronic
Heart Failure
Pharmacological
Objectives and Treatment
Karen Crespo ARNP
Integris HF/Advanced Cardiac Care
Heart Failure
Definition of Heart Failure:
Heart failure is a syndrome of ventricular dysfunction.
Left ventricular failure causes shortness of breath
and fatigue, and right ventricular failure causes
peripheral and abdominal fluid accumulation; both
ventricles are usually involved to some extent.
Diagnosis is clinical, supported by chest x-ray and
echocardiography. Initial Treatment may include
diuretics, ACE-I, BBs, and correction of the
underlying disorder.
The Merck Manual 18th Edition. May 2005.
Primary Causes of Heart Failure (US)
Systolic
Coronary Artery Disease
Myocardial infarction
Hypertension
Valvular disease
Congenital heart disease
Viral infection
Toxins (EtOH, chemoRx)
Diastolic
Hypertension
Diabetes mellitus
Restrictive
cardiomyopathy
(amyloidosis)
Aging
Obesity
Heart Failure: Significant Clinical and
Economic Burden
• Persons with HF in the US
5.8
million
• Overall prevalence
2.3%
• Incidence
670,000 new
cases each year
• Mortality
864,480 deaths in
2008.
Reference:
American Heart Association. Heart Disease and Stroke Statistics – 2005 Update.
Heart Failure: Epidemic & Expensive
1.106 million hospital discharges for HF in 2006, up from
877,000 in 1996.
Outpatient visits for HF: 3.434 million
Direct cost for care of patients with HF estimated to be
$39.2 billion.
– Likely underestimated because estimates based on data
for HF as primary diagnosis or cause of death.
• 1992 – 2002
• Deaths increased 35.3%
• As a population ages, the number of patients with HF is
expected to double in 30 years
American Heart Association. Heart Disease and Stroke Statistics – 2010 Update.
Hospitalization Due to Heart Failure
Continues to Rise
• Progression of disease inevitable
• Incidence of HF rising
• Population of US is aging
• Survival is improving with AMI* and
revascularization
• HF not treated appropriately during
hospitalization
• Patients do not adhere to diet and drugs
* AMI=acute myocardial infarction
A Growing Medical Challenge
Compliance
• 50% have three or more comorbidities
• Average of six medications
• 78% had at least two admissions per
year
• Only 10% completed their annual
prescription regimen
• One-third never refilled any heart
failure prescription
English M, Mastream M. Congestive heart failure: public and private burden. Crit Care Nurs Q. 1995;18:1-6.
Complications of Heart Failure
•The most serious and life-threatening complications of
heart failure are:
•Arrhythmias (irregular beating of the heart)
•Acute pulmonary edema (fluid in the lungs)
•Weight Issues (cardiac cachexia)
•Impaired Kidney Function
•Congestion/edema
•Left Bundle Branch Block
•Depression
•Death
ACC Heart Failure
Stages and
Classification
Refractory
End-Stage HF:
Marked symptoms
at rest despite maximal
medical therapy
D
C
B
A
Symptomatic HF: Known
structural
heart disease, shortness of breath and
fatigue, reduced exercise tolerance
Asymptomatic LVD: Previous MI, LV systolic
dysfunction, asymptomatic valvular disease
High Risk: Hypertension, coronary artery disease,
diabetes, family history of cardiomyopathy
Reference:
Adapted from Jessup M et al. NEJM. 2003;348:2007-18.
NYHA –Classification of Heart Failure
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Class
Class
Class
Class
1
2
3
4
Our Approach to Heart Failure
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Cause
Determine if cause can be corrected
Lifestyle modifications
Medications
Progression of Disease-consider
advanced treatment options
Treatable Risk Factors for HF
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Hypertension
Hyperlipidemia
Diabetes
Physical Inactivity
Obesity
Excessive alcohol intake
Smoking
Dietary Sodium intake
Recommended Medications for Heart
Failure
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Diuretics
Beta Blockers
Ace inhibitors or ARB
Aldosterone inhibitors
Hydralazine and Nitrates
Digoxin
Anissa Bouzamondo*, Jean-Sébastien Hulot, Paola Sanchez , Philippe Lechat
(June 11, 2002). Beta-blocker benefit according to severity of heart failure,
volume 5(issue 3). Retrieved from http://eurjhf.oxfordjournals.org/content/5/3/281.full
Why all the Confusion with Heart
Failure?
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May be classified as one disease process,
really 2 stages of the same disease
process (acute and chronic)
• Acute – the exacerbation
• Chronic – preventing the exacerbation
The large direct costs with chronic heart
failure are largely attributable to
hospitalization
Heart Disease and Stroke Statistics 2007 Update: A Report from the AHA Statistics Committee and Stroke Statistics Subcommittee. Circulation
2007;115(5):e69-e171.
2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e.
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.
Heart Failure - Distinctions
Acute Heart Failure
• “The exacerbation”
• Goal of therapy is symptomatic and
hemodynamic improvement
• Few studies
• Studies in small populations of patients
(hundreds)
• Often requires hospitalization
• Often requires IV therapy
• First Guidelines in 2006 (HFSA)
2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e.
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.
Heart Failure - Distinctions
Chronic Heart Failure
• Treat to prevent the exacerbation
• Goal of therapy is to reduce morbidity and
mortality
• Many studies
• Studies in large populations of patients
(thousands)
• Often managed in the outpatient setting
• Often managed with oral medications and/or
devices
Treatment Objectives
Acute Heart Failure1
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Improve symptoms
Optimize volume status
Identify etiology
Identify precipitating factors
Optimize chronic oral therapy
Minimize side effects
Identify patients who might
benefit from revascularization
Educate (medications/self
assessment of HF)
Chronic Heart Failure2
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 Survival
 Mortality
 Exercise capacity
 Quality of life
 Neuro-hormonal
changes
 Progression of CHF
 Symptoms
1
2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e.
2
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:1825-1852.
Pharmacological & Treatment Objectives in
Acute Heart Failure
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Oxygen
Diuretic
Vasodilators
Ace Inhibitors/ARB
Aldosterone blocking agent
Digoxin
Anticoagulation
Pharmacological & Treatment Objectives in
Chronic Heart Failure
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ACE inhibitors/ARB
Beta Blockers
Digitalis
Aldosterone antagonist
Diuretics
Appropriate treatment of co-morbidities
Summary
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Heart Failure is a continuum that has 2 distinct phases,
Acute and Chronic.
The goal for Acute Heart Failure is symptomatic and
hemodynamic improvement, whereas the goal for
managing Chronic Heart Failure is to reduce morbidity and
mortality.
Acute Heart Failure is often managed in the hospital
setting and often requires IV therapy. Patients with
Chronic Heart Failure may often be managed in an
outpatient setting with oral medications and/or devices.
Lack of research in Heart Failure therapy leads to
discrepancy in treatment
2006 HFSA Comprehensive Heart Failure Practice Guideline. JCF 2006;6:1e-199e.
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 2005;112:18251852.
What Happens if All Else Fails ?
• Mechanical circulatory Support
• Heart Transplantation
• Hospice