Download 2013 HF Guidelines: Focus on Rehabilitation, Exercise and Surgical

The 2013 Canadian Cardiovascular
Society Heart Failure Management
Guidelines Update: Focus on
Rehabilitation and Exercise and
Surgical Coronary Revascularization
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Heart Failure Guidelines
CCS Heart Failure Guidelines
2013 Update
Primary Panel
Gordon W. Moe, (Chair)
Justin A. Ezekowitz, (Co-Chair)
Eileen O’Meara
Jonathan G. Howlett
Steve Fremes
Abdul Al-Hesayen
George A. Heckman
Anique Ducharme
Adam Grzeslo
Karen Harkness
Serge Lepage
Michael McDonald
Robert McKelvie
Anil Nigam
Miroslaw Rajda
Vivek Rao
Elizabeth Swiggum
Sean Virani
Estrellita Estrella-Holder
Vy Van Le
Shelley Zieroth
Heart Failure Guidelines
CCS Heart Failure Guidelines
2013 Update
Secondary Panel
Simon Kouz
J.Malcolm O. Arnold
Tom Ashton
Michel D’Astous
Paul Dorian
Nadia Giannetti
Haissam Haddad
Debra L. Isaac
Marie-Hélène Leblanc
Peter Liu
Heather J. Ross
Bruce Sussex
Michel White
Heart Failure Guidelines
Surgical Coronary Revascularization
Recommendations - Surgical Coronary
Revascularization in Heart Failure
We recommend that non-invasive imaging for
patients with heart failure be considered in
order to determine the presence or absence of
coronary artery disease.
Strong Recommendation
Moderate Quality
Evidence
Values and Preferences:
This recommendation places value upon identification of coronary artery disease,
which may identify the cause of heart failure, have prognostic implications and
require treatments aimed toward secondary vascular prevention.
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be:
a)Performed in patients with heart failure with
ischemic symptoms and who are likely to be
good candidates for revascularization.
Strong Recommendation
Moderate Quality
Evidence
b)Considered in patients with systolic heart
failure (LVEF < 35%), at risk of coronary artery
disease, irrespective of angina, who may be
good candidates for revascularization.
Strong Recommendation
Low Quality Evidence
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be:
c) Considered in patients with systolic heart
Strong Recommendation
failure and in whom non-invasive coronary
Moderate Quality
perfusion testing yields features consistent with Evidence
high risk.
Values and Preferences:
These recommendations place value on the need of coronary angiography to
identify coronary artery disease amenable to revascularization. Available
evidence suggests that coronary revascularization may provide quality of life and
prognostic benefits to patients with heart failure and non-invasive imaging
delineating high risk. In particular, patients with systolic heart failure due to
ischemic heart disease may derive clinical benefit from coronary
revascularization even in the absence of angina or reversible ischemia.
Heart Failure Guidelines
Practical Tips
Revascularization Procedures
Imaging
1. Several non-invasive methods for detection of coronary artery disease are in
widespread use, including:
• Dobutamine stress echocardiography (DSE)
• perfusion cardiac magnetic resonance (CMR)
• cardiac positron emission testing (PET)
• nuclear stress imaging
Local factors (availability, price, expertise, practice patterns) will determine the
optimal strategy for imaging.
2. Non- invasive imaging modalities may provide critical information such as the
amount and degree of ischemic or hibernating myocardium, and may be used
to determine the likelihood of regional and global improvement in left
ventricular systolic function following revascularization.
Heart Failure Guidelines
Practical Tips (cont’d)
Revascularization Procedures
Imaging
3. Patients with heart failure and reduced LVEF are more likely to experience
significant improvement in LVEF following successful coronary revascularization if
they demonstrate:
a) Reversible ischemia or a large segment of viable myocardium (> 30% of
the left ventricle) by nuclear stress testing/ viability study;
b) Reversible ischemia or >7% hibernating myocardium on PET scanning;
c) Reversible ischemia or > 20% of the left ventricle shown as viable by
DSE;
Failure
Guidelines
d) <50% wall thicknessHeart
scarring
as shown
by late gadolinium
Recommendations - Revascularization
Procedures
Disease Management, Referral and Peri-operative Care
We recommend that the decision to refer
patients with heart failure and ischemic heart
disease for coronary revascularization should
be made on a individual basis and in
consideration of all cardiac and non- cardiac
factors which affect procedural candidacy.
Strong Recommendation
Low Quality Evidence
We recommend that efforts be made to optimize
medical status prior to coronary
revascularization, including optimizing
intravascular volume medical therapy.
Strong Recommendation
Low Quality Evidence
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Disease Management, Referral and Peri-operative Care
We recommend that performance of coronary
Strong Recommendation
revascularization procedures in patients with
Low Quality Evidence
chronic heart failure and reduced left ventricular
ejection fraction be undertaken with a medicalsurgical team approach with experience and
expertise in high risk interventions.
Values and Preferences:
This recommendation reflects the preference that high risk revascularization is best
performed in higher volume centers with significant experience, and known,
published outcomes.
Heart Failure Guidelines
Practical Tip
Revascularization Procedures
Disease Management, Referral and Peri-operative Care
1. Assessment for advanced heart failure therapies, by an appropriate team,
should be performed prior to revascularization procedure in any patient with
advanced heart failure
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF
We recommend consideration of coronary
artery bypass surgery for patients with chronic
ischemic cardiomyopathy, left venticular
ejection fraction < 35%, graftable coronary
arteries and who are otherwise suitable
candidates for surgery, irrespective of the
presence of angina and heart failure symptoms
in order to improve quality of life,
cardiovascular death and hospitalization.
Strong Recommendation
Moderate Quality
Evidence
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF
We suggest consideration of percutaneous
coronary intervention for patients with heart
failure and limiting symptoms of cardiac
ischemia, and for whom CABG is not
considered appropriate.
Conditional
Recommendation
Low Quality Evidence
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF
We recommend against routine performance of
surgical ventricular restoration for patients with
heart failure undergoing CABG who have
akinetic or dyskinetic segments.
Strong Recommendation
Moderate Quality
Evidence
Values and Preferences:
These recommendations are based on data from RCTs on CABG and surgical
ventricular restoration on patients with reduced systolic function and CAD. The
recommendation on percutaneous coronary intervention is based on clinical need
rather than RCT trial data.
Heart Failure Guidelines
Practical Tips
Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF
1.In the setting of heart failure, angina and single territory coronary artery disease,
PCI may be the treatment of first choice. However, PCI has not been shown to
improve outcomes for patients with chronic stable heart failure, irrespective of
underlying anatomy.
2.In contrast to the chronic stable patient with heart failure, urgent directed culprit
vessel angioplasty continues to be the revascularization modality of choice for
patients with acute coronary syndrome complicated by heart failure.
3.In highly selected cases, patients with advanced heart failure symptoms in
association with large areas of dyskinetic and non-viable myocardium may
experience clinical improvement with SVR or similar type procedures, when
performed by experienced surgeons.
4.Mitral valve repair, when used concomitantly during CABG, may lead to clinical
improvement in symptoms of heart failure in highly selected cases.
Heart Failure Guidelines
Recommendations - Revascularization
Procedures
Device Considerations in HF Patients Following Cardiac Surgery
We recommend that following successful
cardiac surgery, patients with heart failure
undergo assessment for implantable cardiac
devices within 3-6 months of optimal treatment.
Strong Recommendation
High Quality Evidence
We recommend that patients with implantable
cardiac devices in situ should be evaluated for
programming changes prior to surgery and
again following surgery, in accordance with
existing CCS recommendations.
Strong Recommendation
Low Quality Evidence
We recommend that following successful
cardiac surgery, all patients be referred to a
local cardiac rehabilitation program.
Strong Recommendation
High Quality Evidence
Values and Preferences:
These recommendations reflect our support of and conformity with pre-existing
cardiac device and rehabilitation guidelines statements.
Heart Failure Guidelines
Practical Tips
Revascularization Procedures
Device Considerations in HF Patients Following Cardiac Surgery
1.During surgical revascularization, consideration can be given to implantation of
epicardial left ventricular leads to facilitate biventricular pacing in eligible patients
who may be candidates for cardiac resynchronization therapy, especially if the
coronary sinus anatomy is known to be unfavourable for lead placement.
2.Patients with heart failure and who have successful surgical coronary
revascularization can be referred to a cardiac rehabilitation program.
Heart Failure Guidelines
Approach to Assessment for Coronary Artery
Disease in Patients with Heart Failure
Angina or angina
equivalent symptoms?
Is the patient a suitable
risk for surgical
revascularization?
Coronary angiography*
Is the patient a suitable
risk for surgical
revascularization?
Non-invasive rest and
stress imaging
according to local
preferences#
Either a) non-invasive
rest and stress imaging
according to local
preferences or b)
directly to coronary
angiography
Is patient potential
candidate for PCI?
Non-invasive rest and
stress imaging
according to local
preferences#
Heart Failure Guidelines
Medical therapy^
Decision Regarding Coronary Revascularization in
Heart Failure
Angina or
ischemic
equivalent?
Acceptable risk
for surgical
revascularization?
Acceptable risk for
surgical
revascularization?
Surgical
revascularization most
appropriate given
coronary anatomy?*
Surgical
Revascularization
PCI focus on
culprit artery using
non-invasive
approach or I.C.
Flowire
Anatomy
acceptable for
PCI?
PCI, +/- directed
by non-invasive
imaging or I.C.
Flowire
Evidence of
extensive
ischemia on noninvasive imaging
AND/OR another
cardiac surgery
i.e. AVR
indicated?
Is LVEF < 35%??
Medical therapy
Anatomy appropriate for
surgical
revascularization OR
another cardiac surgery
indicated i.e. AVR?
Surgical
Revascularization
+/- other indicated
procedure
Medical therapy#
Medical therapy#
Heart Failure Guidelines
Is surgical
revascularization
most appropriate
given coronary
anatomy?*
Surgical
revascularization
Medical therapy
Medical therapy#
Exercise Training and Heart Failure
Recommendations - Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure
We recommend that all patients with stable New
York Heart Association class I-III symptoms be
considered for enrolment in a supervised
tailored exercise training program, in order to
improve exercise tolerance and quality of life .
Strong Recommendation
Moderate Quality
Evidence
Values and Preferences:
This recommendation places a high value on improvements in non-morbid
outcomes and recognizes that not all patients will be able to participate in a
structured exercise training program due to patient preferences or availability of
resources.
Heart Failure Guidelines
Recommendations - Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure
We recommend that an assessment of clinical
status by a clinician experienced in the
management of heart failure patients be
completed prior to considering an exercise
training program.
Strong Recommendation
Low Quality Evidence
Values and Preferences:
This recommendation places a high value on clinician’s assessment of both the clinical
stability of a patient and their appropriateness to start exercise, recognizing that most
patients will be eligible to participate.
Heart Failure Guidelines
Practical Tip
Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure
Adherence to an Exercise Program
1.Frequent reinforcement, including letters, phone calls and home visits, may
enhance adherence to exercise.
2.Identifying and addressing patient-specific barriers may aid in the uptake of
exercise for patients.
3.Once a home-based program is initiated, more frequent follow-up visits and
occasional supervised “refresher” sessions to answer questions, review concerns
or modify the training program may give patients the guidance needed to ensure
that home-based cardiac rehabilitation is successful.
Heart Failure Guidelines
Recommendations Rehabilitation and Exercise in HF
Cardiac Rehabilitation Programs for Patients with Recently Decompensated or
Advanced Heart Failure
We recommend that gradual mobilization and/or Strong Recommendation
small muscle group strength/flexibility
Low Quality Evidence
exercises be considered as soon as possible
either alone or in combination for patients with
New York Heart Association class IV symptoms
or recently decompensated heart failure. This
should be considered only in consultation with
an experienced heart failure team.
Values and Preferences:
This recommendation places high value on initiating mobilization and therapy early (even
if only limited exercises are prescribed) in order to prevent further decline of muscle
function, improve function during day to day activities and provide a baseline from which
to add further exercise modalities.
Heart Failure Guidelines
Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation Programs for Patients with Recently Decompensated or
Advanced Heart Failure
1. Selected patients may benefit from limited exercise therapy, such as lowerextremity or inspiratory muscle strengthening, directed towards alleviating
symptom of muscle fatigue.
Heart Failure Guidelines
Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation in Heart Failure with Preserved Ejection Fraction
1. Until data specific for patients with heart failure and preserved ejection fraction
are available, exercise programs using a similar approach to patients with
impaired systolic function may be considered in patients with heart failure and
preserved ejection fraction.
Heart Failure Guidelines
Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation in Patients with Cardiac Resynchronization Therapy and
Implantable Cardioverter Defibrillators
1. Exercise training is safe and not associated with an increased risk of ICD
therapy. The maximal target HR should be at least 20 beats below the ICD
intervention heart rate to avoid inappropriate ICD shocks.
Heart Failure Guidelines
Practical Tip
Rehabilitation and Exercise in HF
Exercise in Frail Senior with Heart Failure
1. Frail seniors with heart failure should be offered multi-component (endurance
and resistance, balance) tailored exercise programs appropriate for their
comorbidities.
Heart Failure Guidelines
Recommendations - Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in Heart Failure
We recommend moderate-intensity continuous Strong Recommendation
aerobic exercise training (e.g. brisk walking,
Moderate Quality
jogging, and cycling) at rate of Modified Borg
Evidence
Rating Perceived Exertion (RPE) scale 3-5, 6585% maximum heart rate, or 50-75% of peak VO2
in patients with heart failure.
Values and Preferences:
This recommendation places a high value on using commonly available measurements to
assist in developing the exercise prescription. The priority is safety, hence, if a patient has a
history of ICD discharges, exercise should be avoided if a short loss of consciousness is
dangerous, i.e. swimming and activities associated with an increased risk of falling.
Heart Failure Guidelines
Practical Tip
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF
Strength Training
1. For strength training, the use of light (5-10 lbs) free weights for 10-20 repetitions 2 to
3 times per week may improve muscle tone and strength.
Heart Failure Guidelines
Practical Tip
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF
Interval Training
1. Interval training sessions should use 15-30s exercise intervals (RPE 3-5) with rest
intervals of equal duration and may last 15-30 seconds.
Heart Failure Guidelines
Practical Tips
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF
Aerobic Exercise Training Intensity
1. The Modified Borg RPE scale and % HRmax are easier to use in practice than
equations based on heart rate reserve (HRR) or measurement of peak VO2.
Heart Failure Guidelines
Rate of Perceived Exertion (RPE)*
Sing – Talk –Gasp Test
Maximal
Gasp: breathing heavily
Talk: enough breath to carry a conversation
Sing: Enough breath to sing
10
9
8
7
6
very, very hard
5
4
3
hard
somewhat hard
moderate
2
1
0.5
0
very hard
easy
very easy
very, very easy
nothing at all
*Modified Scale adapted by Borg
Heart Failure Guidelines
Table: Exercise Modalities According to Clinical Scenario
Discharged with
Heart Failure
Flexibility Exercises
Aerobic Exercises
• Suggested modality
NYHA I-III
Recommended
•Selected population only
•Supervision by an expert
team needed (see text)
Recommended
•
•
•
•
Walk
Treadmill
Ergocycle
Swimming
• Intensity
Continuous training:
Moderate intensity:
• RPE scale 3-5,or
• 65-855 HRmax, or
• 50-75% peak VO2
Moderate intensity aerobic interval may be incorporated in
selected patients
• Intervals of 15-30 seconds with a RPE scale of 3-5
• Rest intervals of 15-30 seconds
• Frequency
• Starting with 2-3 days/week
• Goal: 5 days/week
• Selected population only
• Supervision by an expert
team needed (see text)
• Starting with 10-15 minutes
• Goal: 30 minutes
Isometric/Resistance
Exercises
• Intensity
• Frequency
• 10-20 repetitions of 5-10 pounds free weights
• 2-3 days/week
NYHA IV
Recommended
•Selected population only
•Supervision by an expert
team needed (see text)
•Selected population only
•Supervision by an expert
team needed (see text)