Download 2014 HF Guidelines - Canadian Cardiovascular Society

CCS Heart Failure Guidelines:
Practical Implementation
October 2014
Disclaimer
The Canadian Cardiovascular Society (CCS) welcomes reuse of our
educational slide deck for medical institution internal education or training (i.e.
grand rounds, medical college/classroom education, etc.). However, if the
material is being used in an industry sponsored CME program, permission
must be sought through our publisher Elsevier (www.onlinecjc.com).
If your reuse request qualifies as medical institution internal education, you
may reuse the material under the following conditions:
•
•
•
•
www.ccs.ca
You must cite the Canadian Journal of Cardiology and the Canadian
Cardiovascular Society as references.
You may not use any Canadian Cardiovascular Society logos or
trademarks on any slides or anywhere in your presentation or
publications.
Do not modify the slide content.
If repeating recommendations from the published guideline, do not
modify the recommendation wording.
Heart Failure Guidelines
Overview
•
Who is this document primarily intended to reach? What is the format?
•
How soon should I see a newly referred heart failure patient?
•
How often should my heart failure patient be seen?
•
Who can I discharge from my heart failure clinic?
•
How quickly and in what order should standard heart failure therapy be titrated
for most patients?
•
When should I measure electrolytes, serum Creatinine and BUN?
•
How should I manage hyper or hypokalemia in my patients?
•
I know I should get a baseline measure of left ventricular ejection fraction- but
should I measure it again? If so, when should it be measured?
•
Can heart failure medications ever be stopped? If so, then when?
•
How should I manage an acute episode of gout?
•
In what ways do I care differently for frail elderly patients with heart failure?
•
How do I teach self care to my patients?
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Self-care Tips
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Case Study
• Mr. M.
• 71 year old man with an ischemic cardiomyopathy.
NYHA III, LVEF 30%.
• COPD, diabetes, chronic renal failure, atrial fibrillation
• Takes 12 different types of medications daily (blister pack)
• Lives alone in an apartment- “lady friend nearby”
• 4 admissions for heart failure in the past year
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Nobody Ever Told Me…
Excerpts from patient (Mr. M)’s chart:
July - ER with worsening SOB and orthopnea
August - ER with increasing SOB
September - 1 week follow up appointment post hospital discharge
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Self-care Maintenance
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Self-care Monitoring and Management
Are my
symptoms
different
today?
Was that a
good
decision?
Do I feel
better?
What should
I do to relieve
my
symptoms?
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
I wonder why
my symptoms
changed?
Do I need to
do anything
about my
symptoms?
Self-care Strategies
Patients define self-care not only by the actual performance of tasks but
also by the emotional reactions and strategies necessary for learning
how to adapt to living with HF.
Self-care is a process of learning, and self-care activities are often
intentional, planned, and built on previous experiences.
Individualized approaches that emphasize how to self-care must be
adopted for patients to develop the necessary HF self-care skills.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Harkness et al., 2014 J. Cardiovasc Nurs
“Lay Clinical Trials”: Expert Approach
One patient described her strategy to improve her tolerance to a
medication based on a past experience of symptomatic hypotension that
prevented her from going to work.
She stopped the medication for a few days, reintroduced the medication
at 1/2 the prescribed dose and then slowly titrated the medication
depending on how she felt getting out of bed in the morning.
At the same time, she did not report this to her physician and actually
‘‘lied to him about the dose’’ she was taking, as she was too
embarrassed to disclose her own approach to titrating the medication.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
38(p109)
Glassman KS. Older Persons’ Experience of Managing Medication: The Myth of Compliance [dissertation]
2007 in Harkness et al., J Cardiovasc Nurs 2014
Heart Failure Guidelines
“Lay Clinical Trials”: Good Intentions
• Increasing fluid intake to ‘flush out the system’ to increase diuresis and
improve symptoms
• Choosing Kentucky Fried Chicken rather than Swiss Chalet when
dining out (Swiss Chalet worsens edema)
“I thought I was doing the right thing trying to lose weight, had no idea I
was making my heart problem worse”
Woman trying to lose weight and switched to low fat frozen dinners - but high in sodium
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Gary R. Heart Lung. 2006; Harkness et al., J Cardiovasc Nurs 2014
Past Experience
“I don’t take my Lasix when I am going out somewhere, I can’t always get
to a bathroom quick enough. I had an accident when I was out a few
months ago and I was so embarrassed I could have died.’’
“My weight just kept going up - I knew if I gained weight I would need to
go back to the hospital. So I just stopped checking my weight.”
The “catch 22’. She was afraid to call for help, based on past
experiences, that she would call too soon, and so tended to wait until a
crisis to ask for help.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Clark et al., Int J Nurs Studies 2012; Harkness et al., J Cardiovasc Nurs 2014
Self-care Tips


Understand patient and caregiver beliefs about HF and its self-care,
their expectations and aspirations for daily life
Harness cues in patients’ home environments and routines to
increase adherence patterns

Plan ahead using a problem-solving approach that for supporting
self-care when usual activities are altered

Involve caregivers - key source of support
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Strachan et al., J Cardiac Fail, 2014; Clark et al., BMJ, 2014
Self-care Tips

Personalize Signs and Symptoms- How do you know if you are
starting to retain fluid?

Expect a large variety of vague descriptions from patients/family
caregivers.

Highlight signs or symptoms that reflect HF decompensation.

Help clarify signs and symptoms that are probably not related to
HF.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Self-care Tips

Try to determine the trigger with the patient/family.

Through story telling - pick out the details that seem relevant to
heart failure.

Problem solving and experiential learning versus determining blame
to help prevent feelings of guilt.


Watch for “unintentional non-adherence”
e.g. Restaurant food, holidays, over-the-counter-medications.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Nobody Ever Told Me…
“Teach back” technique
I want to make sure I explained this in a way you could understand…
Can you tell me…
So when you go home to your (family)… how are you going to explain…
 Sometimes the information is not clear to the patient, not 'clicking' with
them, ensure they understand what it is you are explaining.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
White et al., J Cardiovasc Nurs. 2013
Difficulty with Self-care
 Some self-care challenges/misunderstandings are the result of minor
cognitive impairment; consider administering a MoCA test
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Summary
• Self-care is a skill and needs practice and learning over time.
• Do not expect HF patients to ‘catch on’ to all the necessary instructions
without repetition and reinforcement.
• Teach back techniques help ensure understanding.
• Involvement of family member/caregiver is often necessary.
• ‘Non-adherence’ may be unintentional and represent difficulty with the
level of complexity associated with self-care.
• Consider formal screening for underlying depression or subtle cognitive
impairment in patient who have ongoing challenges with self-care.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Summary
“People don't care how much you know until they know how
much you care”
Theodore Roosevelt
“They listen… like my input… I feel so
much better. They don’t argue with me…
respect me as a person. That is really,
really important to me… they are
interested in me”
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Currie et al., Eur J Cardiovasc Nurs, 2014
Medications
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Objectives
• To highlight the importance of evidence-based medications (EBM) in
the treatment of HF
• To describe issues relating to the sub-optimal use of medication in the
treatment of heart failure
• To describe tools that are available to help front-line practitioners
manage medications in patients with HF
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
HF Management
Medications
Multidisciplinary
team
Risk factor
modification
Device therapy
Procedures
Self-care
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Incremental benefit in HF treatment
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
J Am Heart Assoc 2012;1:16-26
Medications in HF: Patients
“Medications don’t work in patients who
don’t take them”
- C. Everett Koop
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Medications in HF: Providers
Medications don’t work in patients:
whose Health Care Professionals don’t
prescribe them
whose HCP don’t prescribe them
optimally
whose HCP don’t prescribe them safely
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Medications in HF
50-90%
HCP
Prescribes
40-60%
Patient
Persistence
40-80%
Effectiveness
of EBM HF
Medications
Patient
Adherence
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
HCP
Optimizes
HCP
Monitors
30-70%
?
Circ 2012; 122:585-96
Circ 2007; 116:737-44
Circ Heart Fail 2013; 6:68-75
Congest Heart Fail 2012; 18:9-17
Arch Intern Med 2012; 172:1263-65
EBM Use: Cardiology Clinics
IMPROVE HF n = 34,810
ACEI/ARB = 80%
β-blocker = 86%
MRA = 34.5%
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Circ 2010;122:585-96
Dose Optimization: IMPROVE HF
Figure 2. Absolute (AI) and relative improvement (RI) in the percentage of treated patients
with dosing recorded who received target doses of angiotensin-converting enzyme (ACE)
inhibitors/angiotensin baseline and 24 months post-intervention for the 24-month follow-up
cohort.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Congest Heart Fail 2012; 18:9-17
EBM: Dose matters
ACEI
ARB
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Arch Intern Med 2012;172: 1263-65
EBM: Optimization
Multidisciplinary heart failure clinics improve
outcome in patients with HF.
What components of these specialized clinics are most
beneficial?
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Circ Heart Fail 2013;6:68-75
Clinic Components
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
EBM: Right patient for the right drug
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Patient selection and follow-up are
important
Hospital admissions:
hyperkalemia
In-hospital deaths
associated
with hyperkalemia
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
3X
3X
N Engl J Med 2004;351:543-51
It’s complicated
Right drug?
Right dose?
Right follow-up?
Right patient?
Right monitoring?
How do you choose?
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Practical tools
App specifically
focused on
medications
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Case: Mrs. Tetley
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. Tetley
• ID: 85 yr female referred from GP for new onset HF
• HPI: 3/12 progressive SOBOE, 2+bilateral pitting edema, nocturnal
cough, 2 pillow orthopnea. GP started furosemide 2 weeks ago;
SOBOE improved and orthopnea resolved.
• PMHx:
–
–
–
–
–
HTN (x 30 years, well controlled)
DM (x 15 years, diet controlled)
Atrial fibrillation (x 5 years)
GERD/PUD (UGIB x 3 years ago)
OA
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. Tetley
Medications
HF
Furosemide 40mg daily (started 2 weeks
ago)
HTN
HCTZ 25mg daily
Potassium chloride 20MEq daily
Amlodipine 5mg daily
ECASA 81mg daily
DM
Diet controlled
Rosuvastatin 10mg daily
Atrial Fibrillation
Metoprolol 25mg BID
Dabigatran 150mg BID
GERD/PUD
Pantoprazole 40mg daily
OA
OTC: Naproxen 220mg daily
Vitamin D 2000IU daily, Calcium 1500mg
daily, multivitamin daily, Vitamin E 800IU
daily, Vitamin C 1000mg daily, Vitamin B
Complex 50mcg daily
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. Tetley
• Investigations:
– Echo: LV dilation, dilated LA, EF = 40%, diastolic dysfunction, aortic
sclerosis
– MIBI: normal perfusion
– ECG: atrial fibrillation, HR = 68bpm
– CXR: mild pulmonary edema
– Labs: Scr = 100umol/L; K = 4.8 mmol/L; Na = 135mmol/L
• Weight = 40kg
• BP = 114/68 mmHg sitting; 110/60 standing
• CVS Exam = JVP 5cm ASA; Bilateral crackles; II/IV MSM; 2+bilateral
pitting edema to mid-shin
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. Tetley
• Plan:
• Plan:
– Furosemide:
• A) increase
• B) decrease
• C) maintain
– Metoprolol:
•
•
•
•
– ACEI:
• A) yes
• B) no
– Other meds:
A) increase
B) decrease
C) maintain
D) discontinue
 Overall thoughts: Complex
case with the opportunity to
simplify her regimen outside of
her HF medications
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
•
•
•
•
•
•
•
A) stop amlodipine
B) stop HCTZ
C) stop potassium
D) stop ASA
E) stop vitamins
F) stop naproxen
G) all the above
S
I
M
P
L
I
F
Y
Mrs. Tetley
• Would your plan change with:
– Baseline Scr = 40umol/L = CrCl 68ml/min
– Current Scr = 100umol/L = CrCl 27ml/min
a)
b)
Yes
No
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. Tetley
• Would your plan change with:
– Baseline K = 3.2mmol/L
– Current K = 4.8mmol/L
a)
b)
Yes
No
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
 The app will
warn you if the
drug you selected
has a potential
contraindication to
therapy
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. Tetley
• Mrs. Tetley is followed up via telephone 1 week later
– Furosemide and metoprolol were maintained and ramipril 1.25mg BID was
started; other medications were streamlined
– She reports feeling better, but still has some SOBOE and mild peripheral
edema
– Blood work done the day prior reveals:
• SCr = 101 umol/L (was 100 umol/L)
• K = 5.5 mmol/L (was 4.8 umol/L)
• Plan:
– A) Hold ACEI, repeat BW in 3-5 days
– B) Hold ACEI and give sodium polysterene (Kayexalate®), repeat BW in 2
days
– C) Assess dietary intake, ensure K+ supplement was discontinued, repeat
BW in 5-7days
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Key Points
• Evidence-based medications (EBM) are a major cornerstone in HF
treatment
• Poor CV outcomes in HF are correlated to
– Underutilization of EBM
– Poor optimization of EBM
– Patient non-adherence and non-persistence to EBM
• Under-intensification of EBM is common and results in poorer
outcomes
• Clinical tools exist to help improve the application of EBM in HF to
front-line practitioners. For example the app can form the underpinning
of a collaborative practice arrangement between
nurses/physicians/pharmacists.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Timing of Visits and Whether
to Stop Medications
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
36 Year Old Female
• Diagnosed with pre-ecclampsia at 24 weeks
• Progressive edema
• Dyspnea noted, thought to be ‘normal’ and told to ‘suck it up’
• Went into labour at 34 weeks
– Pulmonary edema day 2 post natal
– Nearly intubated
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. Doe
• ECHO: LV 57 mm (EDD), EF 18%, moderate MR
• She was treated with vasodilators and diuretics
• Improved
• ACE and BB started
– Tolerated, titrated
• Clinical improvement over 12-14 weeks
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Peripartum Cardiomyopathy
Incidence
• Varies widely geographically, ranging
– United States : 1/2289-1/4000 live births,
– to 1/300 live births in Haiti99.
 We are seeing a lot more cases like Mrs. Doe, than true incidences of
peripartum cardiomyopathy due to: more non-Caucasians, more obesity, and
increased hypertension in pregnancy
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
How soon should I see HF patients?
Triage category
Emergent
Access target
< 24 hours
Clinical scenarios

Acute severe myocarditis

Cardiogenic shock

Transplant and device evaluation of unstable
patients
Urgent
Semi urgent
Scheduled
< 2 weeks
< 4 weeks
<6weeks

New-onset acute pulmonary edema

Progressive HF / decompensated HF

New diagnosis of HF, unstable, decompensated

New progression to NYHA IV, AHA/ACC stage D

Post myocardial infarction HF

Post hospitalization or ER visit for HF

HF with severe valvular heart disease

New diagnosis of HF, stable, compensated

NYHA III, AHA/ACC stage C

Chronic HF disease management, NYHA II

NYHA I, AHA/ACC stage B
<12 weeks
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
How often should my HF patient be seen?
Risk group
Low risk
Features defining risk of group
NYHA Class I or II; No hospitalizations in past year;
No recent changes in medications; On all optimal
medical HF therapies
Intermediate No clear features of high or low risk.
High risk
NYHA IIIb or IV symptoms, frequent symptomatic
hypotension, more than 1 HF admission (or need for
outpatient intravenous therapy) in past year,
recent HF hospitalization esp. in past month, rising
creatinine, especially eGFR < 30 ml/min, Nonadherence to therapy for any reason; During titration of
HF medications (ACEi/BB/ARB/MRA); New onset
heart failure; Complication of HF therapy; Need to
downtitrate or discontinue beta-blockers or ACE/ARB ;
Concomitant and active illness (i.e. high grade angina,
severe COPD, frailty); frequent ICD firings (1 month)
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Suggested frequency of follow-up*
At least yearly
(90% suggested within 12 months,
50% within 6 months)
In certain cases, may consider
discharge of patient from clinic to
specialist office (in addition to primary
care).
1-6 months
Minimum 1-2 visit per month
In some cases, there may be weekly
assessments or even more frequentespecially if patient willing to undergo
multiple visits to potentially avoid a
hospitalization.
When should I get another EF Measurement?
Clinical Scenario
Timing of measurement
New Onset Heart Failure Immediately or within 2
weeks for baseline
assessment
Following titration of
3 months after completion
triple therapy for HFrEF, of titration
or consideration of
ICD/CRT implantation
Stable Heart Failure
Approximately every 2-3
years, especially if EF is
above 40%
Following significant
clinical event (i.e.
hospitalization for HF)
ECHO or MUGA or CMR
(preferably the same
modality and lab as initial
test)
ECHO or MUGA or CMRI
Comments
70% request ECHO and
30% MUGA, report
should include numeric
EF or small range of EF
as well as diastolic
function evaluation
LVEF following optimal
medical therapy may
obviate device therapy.
Rationale is to screen for
those who may cross
from HFrEF to HFpEF
and vice versa, which
may change therapeutic
goals
Within 30 days, during
ECHO or MUGA or CMRI, Frequently helpful
hospitalization if possible. cardiac catheterization in information such as EF,
context of ACS
degree of valvular
dysfunction and RVSP.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Modality of
Measurement
ECHO (preferred when
available); or MUGA or
CMRI
Heart Failure Guidelines
 Ejection fractions do not
remain the same foreverthey will change over time,
thus should be checked
periodically (or at least
thought about) as there is no
predefined schedule for EF
measurement
Circ Heart Fail. 2012;5:720-726
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. Doe Follow Up
• Now asymptomatic
• Diuretic stopped due to hypovolemia
• Repeat ECHO EF 54%
– LV EDD 48 mm
– No MR
– Normal RVSP est but only trivial TR
 Because she is asymptomatic, she starts ‘playing’ with her drugs, and
questions whether she could go off them completely.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Now she wants to stop her HF meds
• Yes or no?
• If so, which ones?
 If EF goes above 40, good prognosis. Thus, for certain conditions you
may be able to stop/discontinue medications if EF returns to normal, or
above 40% (refer to following 2 slides).
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Maternal Complications Associated
With Subsequent Pregnancy*
50%
44%
%
40
31%
30%
25%
21%
21%
19%
%
20
14%
10%
0%
%
0
*including aborted
pregnancies
A
B
HF
Symptoms
A
B
>20%
Decreased
LVEF
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
A
B >20%
Decreased LVEF at
F/U
A
B
Maternal
Mortality
Contractile Reserve in Patients With
Peripartum Cardiomyopathy and Recovered
Left Ventricular Function
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Lampert et al. AM J Ob Gyn 1997; 176:189
Who can I discharge from my HF clinic?
• Stable NYHA I or II for 6-12 months
• On optimal devices and pharmacological therapies
• Stable adherence to optimal HF therapy
• No hospitalizations for > 1 year
• LVEF > 35% (consistently shown if more than one recent EF
measurement)
• Reversible causes of HF
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Case
• 74 yo male with 10 year hx DCM (normal coronaries), followed in HF
clinic
• ICD inserted 6 years ago
• Has done very well since you have seen him
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Case
• Perindopril 8 mg OD
• Digoxin 0.125 mg OD
• Carvedilol 25 mg BID
• Spironolactone 25 mg OD
• Lasix 40 mg OD- patient has not been taking it
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Case
• BP 120/70, HR 60 reg
• JVP ASA, - AJR
• HS: S1, S2, no murmurs, no rub
• 1+ pretibial edema bilaterally
• No palpable organomegaly
• Chest: clear
• NT-proBNP 810, reasonably well controlled
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Case
• Hb 128, WBC 6.5 (n diff)
• Na 139, K 4.7, creat 100
• LVEF 54% and LVID 55 mm
– Had been 23% and 64 mm 3 years ago
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Would you stop his medications?
• Yes
• No
• It depends
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Would you replace his ICD?
•
•
•
•
Yes
No
Leave it to EP
Depends
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Can HF Meds be stopped?
Clinical
Presentation
Conditions to justify withdrawal
of TT after 6-12 months of
therapy
Tachycardia
1) Normal EF
related
2) NYHA FC I
cardiomyopathy 3) Underlying tachycardia
controlled
Alcoholic
1) Normal EF
Cardiomyopathy: 2) NYHA FC I
3) Abstinence ETOH
Chemotherapy
related CM
1)
2)
3)
Normal EF
NYHA FC I
No further drug exposure
Peripartum
Cardiomyopathy
1)
2)
Normal EF
NYHA FC I
Valve
replacement
surgery
1)
2)
3)
Normalization of EF
NYHA FC I
Normally functioning valve
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Comments
Usually due to atrial fibrillation/flutter with increase
HR, may rarely occur due to PVCs. May need BB for
rate control
Nutritional deficiency may coexist.
May need control of obesity and obstructive sleep
apnea
Certain types of chemo (trastuzamab - high rate of
improvement one it is stopped) are more likely to
reverse than others (anthracyclines for which therapy
should be continued).
Long-term surveillance strongly recommended
Repeat pregnancy may be possible for some(REF
2009); (silversides). Consultation at high-risk
maternal centre should be undertaken.
Less consensus on regurgitant lesions with ongoing
dilation of LV
What is the evidence for drug
withdrawal in HF?
• Almost nil for ACE (however symptoms may return in majority of cases)
• Few studies of BB (show development of symptoms, and recurrence of
phenotypic HF syndrome)
– Several case series of up to 60 patients
– No controls
– No ‘denominator’
• Largest Trial Waagstein 24pts withdrawal
– 66% deteriorated, 4 died
• Morimoto- Japan- 13 patients
– 7 deteriorated, 4 died
• Swedberg, initial paper in 15 DCM
– 40% worsened
• When deterioration occurred, it did so within a few months
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Consort Diagram
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Withdrawal of agents
• ACE inhibitors
– Clinical worsening in 70%
– Minor change in EF
– Exception seems to be in renal dysfunction
• Beta Blockers
– In both NICM and ICM
– Odds ratio of return of HF 26 in one study if BB stopped
– About 70% chance of lower EF, often with symptoms
• MRA:
– No real data
• Diuretics
– Increased likelihood of return of symptoms
• PPCM
– Low incidence of HF if EF returned to normal
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
39 year old male
• Seen last year with A Flutter and LVEF 22%
– Was drinking heavily at time and was hypertensive
• Cardioverted and in NSR since then
• Now LVEF on ACE and BB and OAC is 60%
• Asymptomatic
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Do you stop his medications?
• Yes
• No
• Depends
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Tachycardia-Induced Cardiomyopathy
• Caused by persistent supraventricular or ventricular arrhythmias,
especially atrial fibrillation, atrial flutter, atrial tachycardia, junctional
tachycardia, ventricular tachycardia
• May occur at any age
• Should be suspected when LV dysfunction (with or without typical HF
signs/symptoms) occurs with a persistent, inappropriate tachycardia or
tachyarrhythmia, without another identified cause
• Important to exclude inadequately treated HF and other conditions that
may produce a persistent tachycardia
Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008;24(1):21-40.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Follow up
• Patient still drinking 2 drinks per day (what he admits to)
• Patient has gained 30 lbs (salesman, travel) and BP is elevated
150/94
• Patients has developed diabetes during the past year
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Alcohol-Induced Cardiomyopathy
• Alcohol consumption is a major risk factor for dilated cardiomyopathy
Recommendation
• Permanent abstention from alcohol must be recommended and
reinforced (refer to a counselling program if necessary) in patients
diagnosed with an alcohol-related cardiomyopathy
(Class I, Level C)
Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008;24(1):21-40.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mrs. PP
• 60 year old female presented 1 year ago with breat cancer, HER +
• Underwent FAC and Trastuzamab therapy for 6 months
• 9 month EF showed EF 60 to 44%
• Trastuzamab stopped
• Progressive heart failure 3 months later
• Placed on Ace and BB and diuretic and Trastuzamab stopped
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Questions (Y or N)
• Would you stop trastuzamab for good?
• When would you re-check LVEF?
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Further Follow-up
• 3 months later LVEF is 55% on therapy
• Do you stop therapy?
– Why or why not?
• How long would you follow if EF stayed normal?
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Chemotherapy-Induced Cardiomyopathy
• Most common and severe with anthracyclines and herceptin
Recommendations
• Patients receiving known cardiotoxic agents for cancer should be
carefully monitored during and after therapy. If LV function
deteriorates, they should be aggressively treated with beta-blockers
and other standard therapies for HF
(Class IIa, Level B)
• In patients with a history of chemotherapy-induced cardiomyopathy or
HF, other cancer treatment options should be considered
(Class IIa, Level B)
Arnold JMO, Howlett JG, Ducharme A et al. Can J Cardiol 2008;24(1):21-40.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Additional Case
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Case study: Mr. CC
• 62 year old man- presents to ER: 4 week history of increasing SOB, 3
pillow orthopnea, PND.
• PMHx- viral cardiomyopathy (8 years ago).
• EF 35%, NYHA class I symptoms (until recently)
• Hypertension, family history CAD, non-smoker, rare ETOH, no
diabetes, lipids normal.
• Normal coronaries – coronary angiogram 8 years ago
• Medications: Ramipril 12.5 mg daily, metoprolol 25 mg BID (not taking
these for a few months- they make him “itchy and give him a cough”)
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mr. CC: findings
• Weight: 103.7 Kg
• bp 159/96 mm Hg
• ECG: Sinus rhythm- 80 bpm (narrow QRS)
• Lab: Creatinine 110umol/L, urea 9.2mmol/L, K+4.3 mmol/L, Na+140mmol/L
• CXR: mild pulmonary edema
• Echo: global hypokinesis, EF 15%, no significant valvular
abnormalities, RVSP 54 mm Hg. Dilated LA, RA, LV.
1.
2.
3.
4.
How would you optimize the pharmacological management for this patient?
Does he need to be followed in a heart function clinic?
How do you work through adherence issues?
Does he need an ICD?
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Mr. CC: 2 years later
Progress over next 2 years:
Followed in HFC- optimization
No hospitalizations
NYHA Class I within 6 months
Medications
Atacand 32 mg OD
Coreg 37.5 mg BID
Lasix 40 mg prn- rarely
• Optimized medications
• Working through challenges with adherence
* trust, negotiation
• Sleep clinic assessment
• Developed atrial fibrillation
• No ICD
Norvasc 2.5 mg OD
Pradaxa 110 mg BID
uses
Weight: 100 Kg. BP 124/82 mm Hg, ECG- Afib 72bpm .
Echo: global HK- EF 35-40%. No valvular abnormalities, RVSP <35mmHg
RNA- EF 34%
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Case Summary
•
78 year old lady with a history of mildly obstructive cardiomyopathy for the past 30 years
•
Very stable on diltiazem 180 mg daily
•
Lives with husband and used to walk everyday
•
No history of CAD
•
Over the past 2 years, developed shortness of breath on exertion and palpitations, also
presents occasional dizziness
•
Referred for evaluation at CHF clinic
•
PEx: JVP 15, irregular HR 80/ min, loud systolic murmur of aortic stenosis, no S3, mild
hepatomegaly and no pedal edema.
•
ECG Afib and LVH
•
Echo small LV with asymmetric hypertrophy and normal LVEF
•
Severe calcified aortic stenosis Grad 80/45 with very small LVOT, very calcified mitral
annulus with 20/10 gradients and severe LA dilatation
•
No significant MR
•
Moderate TR with PA pressure 50 mmHg +JVP
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
What is your plan?
A. Anticoagulation and cardioversion
B. Diuretics
C. Change cardizem for B blocker
D. Cardiac cath with intended surgery
E. Keep in CHF clinic
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines
Looking for best practices in heart
failure diagnosis and management?
To access this tool, and to view all of our guideline
resources, please visit www.ccs.ca.
Moe GW, Ezekowitz JA et al., Can J Cardiol
www.ccs.ca
Heart Failure Guidelines