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Management of chest pain and
heart failure. Cardiac rehabilitation
and secondary prevention
WT Bong
Dept of Family Medicine, HUKM
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Case scenario 1
• 60 yo gentleman, a known case of DM for the past 2 years
complains of chest pain for the past 2-3 months when he
walks more than 10 minutes. The chest pain radiates to left
arm, lasts 5 min, relieved by rest. Currently during his visit to
the primary care clinic, he has no chest pain. He is a smoker
for the past 40 years. He is on metformin 500mh bd only.
Clinically, BP 120/60mmHg and cardiovascular examination
was unremarkable.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Patient comes in with chest pain..
• ?cardiovascular
– Cardiac.
• MV prolapse.pericarditis
• ischemic
– Non cardiac. Aortic dissection
•
•
•
•
?gastrointestinal. GERD
?Musculoskeletal.fibromyalgia.
?pulmonary
?psychogenic
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
We start with stable angina..
• By definition. Clinical syndrome characterised
by
– discomfort in chest, jaw, shoulder, back or arm
– Typically aggravated by exertion or emotional
stress
– Reduced by rest or GTN
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Most common cause for stable angina is
atherosclerotic coronary artery disease (CAD)
• Other causes could be
– Hypertrophic cardiomyopathy
– Aortic stenosis
– Coronary vasospasm etc
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Atherosclerosis process in coronary
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Stable angina is classified into 4 classes
based on Canadian Cardiovascular
Society Classification (CCS 0-IV)
CLASS
SEVERITY OF EXERTIONL STRESS
INDUCING ANGINA
LIMITATION OF ORDINARY
ACTIVITY
I
STRENUOUS, RAPID OR PROLONGED
EXERTION AT WORK OR RECREATION
NONE
II
WALKING OR CLIMBING STAIRS RAPIDLY,
WALKING UPHILL, CLIMBING STAIRS AFTER
MEAL
SLIGHT
III
WALKING 1-2 BLOCKS ON THE LEVEL AND
CLIMBING ONE FLIGHT OF STAIRS AT
NORMAL PACE
MARKED
IV
INABILITY TO CARRY OUT ANY PHYSICAL
ACTIVITY WITHOUR DISCOMFORT OR
SYMPTOMS PRESENT AT REST
DISCOMFORT IN ALL
ACTIVITY PERFORMED
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Diagnosis of stable angina can be
established by
• Clinical assessment
– Look for complication of CAD.murmur(MR).septal
defect.sign of cardiomegaly.CHF
– Other site of atherosclerosis.carotid
bruit.peripheral vascular disease.aortic aneurysm
– Risk factor for atherosclerosis.hpt.metabolic syn
– Other cause of angina.HOCM.aortic stenosis
• Lab test
• Specific cardiac investigation
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Lab test to establish CVS risk factor
– FLP. FBS. homocysteine level
– Determine prognosis, creatinine
– CXR only if suspect CHF if want to see calcification,
cardiomegaly/atrial enlargement, valvular disease,
pulmonary congestion (help establish prognosis)
• Specific cardiac investigation
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Specific cardiac investigation, non invasive
– ECG. See previous ischemia, LVH, BBB, arrhythmia
or conduction defect
– Stress test. More sensitive and specific than
resting ECG
– Echo.when there is abnormal auscultation suggest
valvular, if HCM or prev MI changes on ECG, SSx
CHF , to study diastolic function
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Risk-stratify our patient
• For the purpose of prognosis + treatment
(revascularize in high risk patient)
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Clinical history – important predictor
of adverse outcome in established CAD
DM
HPT
Metabolic
syndrome
Current smoker
Increasing age
Prior MI
SSx of CHF
Recent onset or
progressive
angina
dyslipidaemia
Responsiveness of
angina to
therapy
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Risk stratify .. Higher risk if ECG shows
Evidence of
prior MI
LBBB
LVH
AF
Second of
third degree
AV block
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Other aspects to be considered in riskstratifying
• Stress test
• Ventricular function
• COROS
LVEF
< 35 %
12- year
survival rate
(p<0.0001)
21 %
35-49 %
54 %
> 50 %
73 %
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Treatment goal
• Prevent MI & death
• Improve SSx of angina & increase QoL
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Non pharmacological approach
Life style
• Smoking cessation
– 36 % risk reduction mortality
– 32 % risk reduction non fatal
MI
– Nicotine replacement is safe
and cost effective even for
CAD patient (take into
account risk of depression
and suicidal thought)
diet
• Variety of fruits and
vegetable.legumes.nuts.
Soy products.low fat
dairy.whole grain
• Replace saturated & transfat (red meat.whole milk .
Pastries) with polysaturated
fat (oily fish,walnut,sesame.
Pumpkin seed.vegetable oil)
• Soluble fibre.oat.peas.bean
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Alcohol restriction.
Moderate/beneficial.
Insufficient evidence
Physical activity.
30min
3-4x/week
Target BP <130/80
DM
Generally target HbA1c <
6.5 %. Individualize as
Keep waist circumference
< 85 cm for men
< 80 cm for women
Correct anaemia
Correct hyperthyroid state
HDL > 1.0 male, 1.2 female
( secondary target)
TG < 1.7
(secondary target)
hypoglycemia worsen angina &
increase mortality
LDL < 1.8 ( primary target)
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
education
Self management
During acute anginal
attack
-Restrain activity
-GTN S/L or spray
-Sit . Hypotension.
Headache after GTN
Can also take GTN as
preventive measure if
patient know he is going to
have attack while carrying
out some activity
If SSx persist more than
10min at rest or not
improved after 3 tablet of
GTN, advice to go to
hospital
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Antithrombotic
Antithrombotic
ASA 75-150mg od. Lower MI, cardiac death
Clopidogrel 75mg
-more effective than ASA in peripheral
vascular disease
or stroke
Take into account GI side effect
*double antiplatelet not warranted in
angina
Ticlopidine – proven efficacy in stroke
and post-PCI, no evidence in angina
Lipid lowering
ACEi
Statin reduce mortality & CV event by
20 – 30 %
For secondary prevention in post MI +
reduced EF < 40 %
Can add ezetimide if target not
reached with statin
Recommended for all patients with
CAD esp with concomitant LV
dysfunction/DM
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ARB
Beta blocker
\as secondary prevention in CAD with Hpt/
CHF / post MI + LV dysfunction / DM if not
tolerable to ACEi
First line treatment in angina
- 30 % reduction risk of CV death / MI (beta
blocker in post MI trials)
-Beta1 blockade by Metoprolol/bisoprolol reduce cardiac
event in CHF
-Non selective beta blockade by carvedilol reduce death
& CV hospitalisation in CHF
Ivabradine
Calcium Channel Blocker
HR reducing, acting on SA node
-non dihydropyridine – diltiazem/verapamil,
Symptomatic treatment in patient with N`SR, as alternative to beta blocker
esp with contraindication for beta blocker
-dihydropyridine (long acting) –amlodipine No significant interaction with other cardiac use in patient reduce coronary intervention
but no reduction in treatment endpoints (ie death , MI)
drugs
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Nitrates
Trimetazidine
(long acting – isordil,imdur)
(Vasteral MR)
Symptomatic improvement of angina
No prognostic benefit
symptomatic relief of angina
Safe and effective in patient with ED
Dipyridamole
Anticoagulant
Not indicated unless has AF
(Persanthine)
not recommended, poor antithrombotic
efficacy in angina
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
revascularization
• PCI or CABG
– In high risk group it is firstline treatment
• Significant LMS ( > 50% stenosis)
• Significant proximal mutivessel involvement
• Multivessel disease with impaired LV function with
proven viable myocardium
– Or if failed medical treatment to control angina
SSx
– In asymptomatic patient, consider if there is
extensive inducible ischaemia (stress test)
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
What if it is aMI ?
Chest pain
ECG ,cardiac biomarker
STEMI
Concomitant initial
management
Sublingual GTN, continuous ECG
monitoring, oxygen, ASA, clopidogrel,
analgesia
Assessment for reperfusion
< 3hrs
3-12hrs
> 12 hrs
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Onset of symptoms < 3 hrs
3-12 hrs
> 12 hrs
Preferred options
Primary PCI
(if door to balloon time <
Medical therapy +/anti thrombotics
Primary PCI
(preferred in high risk
patient or
contraindicated for
thrombolytic) or
90min)
fibrinolytic
Second options
fibrinolytics
Primary PCI
( if clinically indicated)
Concomitant
therapy
Anti thrombotics
Beta blockers
ACEi / ARB
Statins
Nitrates
CCB
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Secondary prevention
• Basically similar to angina which include
Smoking cessation
diet
Regular exercise
BP control
Glycemic control
Antiplatelet agent
*consider dual antiplatelet
1mth-1yr depend on stent
used
Beta blocker
ACEi and ARB
Lipid lowering
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Oral Anticoagulant (warfarin)
– If AF
– LV thrombus for 3-6mths
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Secondary prevention
• Hormone replacement therapy is not
beneficial for secondary prevention
• Postmenopausal women who were taking HRT
at the time of STEMI should discontinue it
• Vitamin E and antioxidants have no clinical
benefit
• Garlic, lecithin, vitamin A and C are not
beneficial
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Heart failure
• Is a complex clinical syndrome results from
structural or functional impairment of
ventricular filling or ejection of blood
• Cardinal manifestation are dyspnea, fatigue,
which may limit effort tolerance, and fluid
retention, which may lead to pulmonary or
splanchnic congestion or peripheral edema.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Definition of Heart Failure
Classification
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
Ejection
Fraction
≤40%
Description
Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
≥50%
Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline
41% to 49%
These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved
>40%
It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Stages, Phenotypes and Treatment of HF
ACC AHA 2013
At Risk for Heart Failure
Heart Failure
STAGE A
STAGE B
STAGE C
At high risk for HF but
without structural heart
disease or symptoms of HF
Structural heart disease
but without signs or
symptoms of HF
Structural heart disease
with prior or current
symptoms of HF
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Structural heart
disease
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
Development of
symptoms of HF
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
remodeling
Drugs
· ACEI or ARB as
appropriate
· Beta blockers as
appropriate
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
STAGE D
Refractory HF
Refractory
symptoms of HF
at rest, despite
GDMT
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
HFrEF
THERAPY
Goals
· Control symptoms
· Patient education
· Prevent hospitalization
· Prevent mortality
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
Drugs for routine use
· Diuretics for fluid retention
· ACEI or ARB
· Beta blockers
· Aldosterone antagonists
Drugs for use in selected patients
· Hydralazine/isosorbide dinitrate
· ACEI and ARB
· Digoxin
In selected patients
· CRT
· ICD
· Revascularization or valvular
surgery as appropriate
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Reduce hospital
readmissions
· Establish patient’s endof-life goals
Options
· Advanced care
measures
· Heart transplant
· Chronic inotropes
· Temporary or permanent
MCS
· Experimental surgery or
drugs
· Palliative care and
hospice
· ICD deactivation
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Classification of Heart Failure
A
B
C
ACCF/AHA Stages of HF
At high risk for HF but without structural
heart disease or symptoms of HF.
Structural heart disease but without signs
or symptoms of HF.
Structural heart disease with prior or
current symptoms of HF.
NYHA Functional Classification
None
I
I
II
III
IV
D
Refractory HF requiring specialized
interventions.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Physical examination
•
•
•
•
•
•
•
•
BMI and evidence of weight loss
Bp, supine and upright( orthostatic changes – volume depletion)
Pulse – strength and regularity
JVP
Extra heart sound, murmur, apex beat displacement, RV heave
Pulmonary status
Hepatomegaly
Peripheral edema
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Lab investigation
•
•
•
•
•
•
•
Class I
1.Initial laboratory evaluation of patients presenting with HF should include complete
blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea
nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, and thyroidstimulating hormone. (Level of Evidence: C)
2.Serial monitoring, when indicated, should include serum electrolytes and renal function.
(Level of Evidence: C)
3.A 12-lead ECG should be performed initially on all patients presenting with HF. (Level of
Evidence: C)
Class Iia
1.Screening for hemochromatosis or HIV is reasonable in selected patients who present
with HF (Level of Evidence: C)
2.Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are
reasonable in patients presenting with HF in whom there is a clinical suspicion of these
diseases. (Level of Evidence: C)
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Recommendations for Biomarkers in HF
Biomarker, Application
Setting
COR
LOE
Diagnosis or exclusion of HF
Ambulatory,
Acute
I
A
Prognosis of HF
Ambulatory,
Acute
I
A
Ambulatory
IIa
B
Acute
IIb
C
Acute,
Ambulatory
I
A
IIb
B
IIb
A
Natriuretic peptides
Achieve GDMT
Guidance of acutely decompensated
HF therapy
Biomarkers of myocardial injury
Additive risk stratification
Biomarkers of myocardial fibrosis
Ambulatory
Additive risk stratification
Acute
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Recommendations for Noninvasive Imaging
Recommendation
Patients with suspected, acute, or new-onset HF should undergo a chest xray
A 2-dimensional echocardiogram with Doppler should be performed for
initial evaluation of HF
Repeat measurement of EF is useful in patients with HF who have had a
significant change in clinical status or received treatment that might affect
cardiac function, or for consideration of device therapy
Noninvasive imaging to detect myocardial ischemia and viability is
reasonable in HF and CAD
Viability assessment is reasonable before revascularization in HF patients
with CAD
Radionuclide ventriculography or MRI can be useful to assess LVEF and
volume
MRI is reasonable when assessing myocardial infiltration or scar
Routine repeat measurement of LV function assessment should not be
performed
COR
LOE
I
C
I
C
I
C
IIa
C
IIa
B
IIa
C
IIa
B
III: No
Benefit
B
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Comprehensive
Heart Failure Practice Guideline
Key Recommendations
HFSA 2010 Practice Guideline (3.1)
Heart Failure Prevention
A careful and thorough clinical
assessment, with appropriate
investigation for known or potential risk
factors, is recommended in an effort to
prevent development of LV remodeling,
cardiac dysfunction, and HF.
Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 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
1Diabetes
2JAMA
Adapted from:
Care 2006; 29: S4-S42
2001; 285:2486-97
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Treating Hypertension to Prevent HF
Aggressive blood
pressure control:
Decreases
risk of
new HF
by ~ 50%
56% in DM2
Lancet 1991;338:1281-5 (STOP-Hypertension
JAMA 1997;278:212-6 (SHEP)
UKPDS Group. UKPDS 38. BMJ 1998;317:703-713
Aggressive BP control
in patients with prior MI:
Decreases
risk of
new HF
by ~ 80%
HFSA 2010 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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
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
Ramipril
22% rel. risk red. p < .001
0
1
2
3
4
Years
15
EUROPA
12
NEJM 2000;342:145-53 (HOPE)
Lancet 2003;362:782-8 (EUROPA)
Placebo
HOPE
Placebo
% MI,
CV Death, 9
Cardiac 6
Arrest
Perindopril
3
20% rel. risk red. p = .0003
0
0
1
2
3
Years
4
5
Treatment of Post-MI Patients with
Asymptomatic LV Dysfunction (LVEF ≤ 40%)
SAVE Study
0.3
Mortality
Rate
 All-cause mortality ↓19%
Placebo
0.2
Captopril
 CV mortality ↓21%
0.1
 HF development ↓37%
 Recurrent MI ↓25%
19% rel. 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 2010 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:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (4.19)
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 and medical regimen
 History of arrhythmia, syncope, pre-syncope, palpitation, or ICD
discharge
 Adherence 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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.1, 7.7)
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:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ACE Inhibitors Used in Clinical Trials
Generic
Name
Trade Name
Initial
Daily Dose
Target Dose
Mean Dose in
Clinical Trials
Captopril
Capoten
6.25 mg tid
50 mg tid
122.7 mg/day
Enalapril
Vasotec
2.5 mg bid
10 mg bid
16.6 mg/day
Fosinopril
Monopril
5-10 mg qd
80 mg qd
N/A
Lisinopril
Zestril,
Prinivil
2.5-5 mg qd
20 mg qd
4.5 mg/day,
33.2 mg/day*
Quinapril
Accupril
5 mg bid
80 mg qd
N/A
Ramipril
Altace
1.25-2.5 mg qd
10 mg qd
N/A
Trandolapril
Mavik
1 mg qd
4 mg qd
N/A
*No mortality difference between high and low dose groups, but 12% lower risk of
death or hospitalization in high dose group vs. low dose group.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 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 from 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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.6, 7.7)
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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
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)
1Colucci
WS et al. Circulation 1196;94:2800-6. 2CIBIS II Investigators. Lancet 1999;353:9-13.
3MERIT-HF Study Group. Lancet 1999;353:2001-7. 4Packer M et al. N Engl J Med 2001;344
1651-8. 5The CAPRICORN Investigators. Lancet 2001;357:1385-90.
HFSA 2010 Practice Guideline (7.9)
Pharmacologic Therapy: Beta Blockers
CONCOMITANT DISEASE
Beta blocker therapy is recommended in the great majority of
patients with HF and reduced LVEF—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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Beta Blockers
Used in Clinical Trials
Generic
Name
Trade Name
Initial
Daily Dose
Target Dose
Mean Dose in
Clinical Trials
Bisoprolol
Zebeta
1.25 mg qd
10 mg qd
8.6 mg/day
Carvedilol
Coreg
3.125 mg bid
25 mg bid
37 mg/day
Carvedilol
Coreg CR
10 mg qd
80 mg qd
Metoprolol
succinate
CR/XL
Toprol XL
12.5-25 mg qd
200 mg qd
159 mg/day
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.3)
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
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Angiotensin Receptor Blockers
Used in Clinical Trials
Generic
Name
Trade Name
Initial
Daily Dose
Target Dose
Mean Dose in
Clinical Trials
Candesartan
Atacand
4-8 mg qd
32 mg qd
24 mg/day
Losartan
Cozaar
12.5-25 mg qd
150 mg qd
129 mg/day
Valsartan
Diovan
40 mg bid
160 mg bid
254 mg/day
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 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) HF from
reduced 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 ARB) and a beta blocker.
Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 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
 Diuretic refractoriness may represent patient nonadherence
or progression of underlying dysfunction.
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
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
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (9.1, 9.4)
Device Therapy:
Prophylactic ICD Placement
Prophylactic ICD placement should be considered in patients
with an LVEF ≤35% and mild to moderate HF symptoms:

Ischemic etiology
Strength of Evidence = A

Non-ischemic etiology
Strength of Evidence = B
Decisions should be made in light of functional status and
prognosis based on severity of underlying HF and comorbid
conditions, ideally after 3-6 mos. of optimal medical therapy.
Strength of Evidence = C
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 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)

Cardiac catheterization
Strength of Evidence = C
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Figure 11.3. Diagnostic Algorithm
for HF with Preserved LVEF
HF with
Preserved LVEF
Dilated LV
Valvular disease
AR, MR
Non-dilated LV
No valvular dis.
High output HF
Increased
thickness
Normal or
increased QRS
Hypertrophic dis.
No aortic
valve disease
No hypertensive
history of PE
HCM, Fabry dis.
Normal
Thickness
Low QRS voltage
Infiltrative
myopathy
Aortic valve dis.
Aortic stenosis
Hypertensive
history of PE
Hypertensive-HCM
Some patients with RV
dysfunction have LV
dysfunction due to
ventricular interaction.
Right vent.
dysfunction
No mitral
obstruction
Pulmonary
hypertension
Pericardial dis.
Tamponade
Constriction
Isolated predominant RVMI
No pericardial
disease
Inducible ischemia
Intermittent/active
ischemia
Mitral obstruction
MS, atrial myxoma
No inducible ischemia, fibrotic, collagenVascular, RCM, cardinoid, diabetes,
Radiation or chemotherapy induced
heart disease, infiltrative disease, comorbid conditions, reconsider diagnosis
of HF
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Case scenario 2
• A 55 yo man presents with gradually increasing shortness of breath and
leg swelling that occurred while on a business trip. He has congestive
heart failure, which has caused fatigue and shortness of breath if he walks
a block or climbs a flight of stairs. BP is 140/ 90; there is no jugular venous
distension or gallop, and only minimal pedal edema. AN echo shows left
ventricular EF 45 %. Current medication include aspirin and simvastatin.
The patient desires to keep medications to a minimum. What additional
treatments are indicated at this time?
• A. Spironolactone
• B. ACE inhibitor and beta blocker
• C. Digoxin
• D. Frusemide
• E. An implantable defibrillator
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Answer is B
• ACE inhibitor is recommended in both symptomatic n
asymptomatic heart failure
• Beta blocker stabilize left ventricular remodeling
• Spironolactone recommended for NYHA III-IV with EF <35%
despite on loop diuretic + ACEi + b blocker
• Frusemide can improve SSx but patient wants to keep
medication to minimal
• Defibrillator not indicated yet
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Cardiac rehabilitation
• Coordinated interventions designed to
optimize a cardiac patient’s physical,
psychological, and social functioning, in
addition to stabilizing or slowing the progress
of underlying atherosclerotic process, thereby
reducing morbidity and mortality.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Cardiac rehabilitation
• Include
– baseline patient assesssment,
– nutritional counselling,
– aggressive risk factor management ie
• lipid, hpt, weight, diabetes and smoking,
– psychosocial and vocational counseling , and
– physical activity counseling and exercise training, in
addition to
– appropriate use of cardioprotective drugs that have
evidence-based efficacy for secondary prevention
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Who should be included in cardiac
rehab ?
•
•
•
•
•
Patient with previous MI
Who had undergone CABG
Those with PCI done
Heart transplant candidate or recipient
Who has stable chronic heart failure,
peripheral arterial disease
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Exercise training
intervention
Return to work
Cardioprotective mechanism (improve endothelial function)
Risk factor
modification &
intervention
Psychosocial
intervention (address depression,
anxiety, social isolation. Consider SSRI, cognitive
behavioral therapy.
Aggresive reduction of risk factors via nutritional
counselling, weight management, adherence to drug
therapy
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Thank you for your kind
attention
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.