Download Peripheral Vascular Disease

Heart Failure
Ben Starnes MD FACC
Interventional Cardiology
Arkansas Cardiology
Baptist Health Heart Institute
Financial disclosures
-None
Heart Failure
Moving away from the term Congestive
Heart Failure
Heart Failure imposes a significant
burden on the US healthcare system
-Heart failure accounts for over 3.4 million visits to
physician offices, hospital outpatient departments, and
emergency departments1
-More than 1,000,000 hospitalizations occur with the
primary diagnosis of heart failure2
-Over 6.5 million days are spent in US hospitals for heart
failure3
1 Vital Health Statistics 13. 2004;157:1-70.
2 AHA Heart Disease and Stroke Statistics 2010 Update. Circulation. 2010;121:e46-215.
3 European Heart Journal Supplements; V.7; Suppl B; 2005; pB8.
Heart Failure is a Clinical
Diagnosis
Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that
predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41:1797-1804.
Heart Failure
Beta Blockers
Beta Blockers
ACC Guidelines
I IIa IIb III
Beta-blockers (using 1 of the 3 proven to reduce
mortality, i.e., bisoprolol, carvedilol, and sustained
release metoprolol succinate) are recommended for
all stable patients with current or prior symptoms of
HF and reduced LVEF, unless contraindicated.
Heart Failure
Ace Inhibitors in severe heart failure
Ace Inhibitors in mild to moderate heart
failure
Ace Inhibitors
ACC Guidelines
I IIa IIb III
ACEIs are recommended for all patients with
current or prior symptoms of HF and reduced
LVEF, unless contraindicated.
Aldosterone Antagonists
Aldosterone Antagonists
Aldosterone Antagonists
Aldosterone Antagonists
ACC guidelines
I IIa IIb III
I IIa IIb III
Addition of an aldosterone antagonist is recommended in
selected patients with moderately severe to severe
symptoms of HF and reduced LVEF who can be
carefully monitored for preserved renal function and
normal potassium concentration. Creatinine should be
less than or equal to 2.5 mg/dL in men or less than or
equal to 2.0 mg/dL in women and potassium should be
less than 5.0 mEq/L. Under circumstances where
monitoring for hyperkalemia or renal dysfunction is not
anticipated to be feasible, the risks may outweigh the
benefits of aldosterone antagonists.
Routine combined use of an ACEI, ARB, and aldosterone
antagonist is not recommended for patients with current
or prior symptoms of HF and reduced LVEF.
SCD-HeFT
SCD-HeFT Protocol
Inclusion criteria
Placebo n=847
Amiodarone n=845
ICD implant n=829
40 months average follow- up
• Optimize: B, ACE-I, Diuretics
Bardy GH. Chapter Excerpt from Arrhythmia Treatment and Therapy. Woosley RL, Singh SN, editors. Marcel Dekker, 1st edition. 2000;323-42.
SCD-HeFT Investigators Meeting, August 2001, data from most recent follow-up
Implantable Cardioverter-Defibrillators
I IIa IIb
IIbIII
III
I IIa IIb III
ICD therapy is indicated in patients with LVEF less than
35% due to prior MI who are at least 40 days post-MI and
are in NYHA functional Class II or III.
ICD therapy is indicated in patients with nonischemic
DCM who have an LVEF less than or equal to 35% and
who are in NYHA functional Class II or III.
All primary SCD prevention ICD recommendations apply only to patients
who are receiving optimal medical therapy and have reasonable
expectation of survival with good functional capacity for more than 1 year.
Cardiac Resynchronization Therapy* in
Patients With Severe Systolic Heart Failure
I IIa IIb
IIbIII
III
For patients who have left ventricular ejection fraction
(LVEF) less than or equal to 35%, a QRS duration greater
than or equal to 0.12 seconds, and sinus rhythm, cardiac
resynchronization therapy (CRT) with or without an ICD is
indicated for the treatment of New York Heart Association
(NYHA) functional Class III or ambulatory Class IV heart
failure symptoms on optimal recommended medical
therapy.
*All primary SCD prevention ICD recommendations apply only to patients
who are receiving optimal medical therapy and have reasonable
expectation of survival with good functional capacity for more than 1 year.
End Stage Heart Failure
Ventricular assist Device
-Bridge to transplant
-Destination Therapy
Cardiac Transplantation
Palliative Care
Diastolic Heart Failure
Heart failure with preserved LV systolic
function
Generally due to hypertension  left
ventricular hypertrophy  impaired LV
filling and decreased LV stroke volume
Diastolic Heart Failure
Treatment:
-Diuretics to relieve congestion
-Beta Blockers/Calcium channel blockers
to reduce heart rate and improve diastolic
filling
-Control blood pressure
-Maintain sinus rhythm
Atrial fibrillation leads to loss of atrial
kick (20% of cardiac output)
Take Home Points
Medical Therapy
-Ace inhibitors/beta blockers
-Aldosterone antogonist (LVEF <35)
-Diuretics as needed
-Digoxin last line
Device therapy
-ICD
-Cardiac Resynchronization Therapy
End Stage Heart Failure
-Ventricular Assist Device/Heart Transplant