Download HFSA 2010 Practice Guideline

HFSA 2010 Comprehensive
Heart Failure Practice Guideline
Key Recommendations
HFSA 2010 Comprehensive Heart Failure Practice Guideline
Strength of Recommendation
“Is recommended”
Part of routine care

“Should be considered”
Exceptions should be
minimized
Majority of patients should
receive intervention

Some discretion allowed
“May be considered”
Individualization of
therapy is indicated
“Is not recommended”
Therapy should not be
used
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Comprehensive Heart Failure Practice Guideline
Strength of Evidence
A
Randomized controlled trials
 May be assigned on results of 1 trial
B
Cohort and case control studies
 Includes sub group analyses, metaanalyses, observational studies,
registries
C
Expert opinion
 Includes observational, epidemiological
findings; in-practice safety reporting
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
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
The Additional Value of Beta
Blockers Post-MI: CAPRICORN
Studied impact of beta blocker (carvedilol) on
post-MI patients with LVEF ≤ 40% already receiving
contemporary treatments, including
revascularization, anticoagulants, ASA, and ACEI:
 All-cause mortality reduced (HR = 0.077; p = 0.03)
 Cardiovascular mortality reduced
(HR = 0.75; p = .024)
 Recurrent non-fatal MIs reduced (HR =.59; p = .014)
Dargie HJ. Lancet 2001;357:1385-90
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 in Heart Failure:
From Asymptomatic LVD to Severe HF
SOLVD Prevention
(Asymptomatic LVD)
CONSENSUS
(Severe Heart Failure)
20%
death or HF hosp.
40%
mortality at 6 mos.
29%
death or new HF
31%
mortality at 1 year
27%
mortality at end of
study
SOLVD Treatment
(Chronic Heart Failure)
16%
mortality

No difference in incidence
of sudden cardiac death
SOLVD Investigators. N Engl J Med 1992;327:685-91
SOLVD Investigators. N Engl J Med 1991;325:293-302
CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35
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 (7.8)
Pharmacologic Therapy: Beta Blockers
RECENT DECOMPENSATION
Beta blocker therapy is recommended for
patients with a recent decompensation of HF
after optimization of volume status and
successful discontinuation of IV diuretics and
vasoactive agents.
Whenever possible, beta blocker therapy
should be initiated in the hospital at a low dose
prior to discharge of stable patients.
Strength of Evidence = B
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.11)
Pharmacologic Therapy: Beta Blockers
SYMPTOMATIC EXACERBATION
Continuation of beta blocker therapy is recommended in
most patients experiencing a symptomatic exacerbation of
HF during chronic maintenance treatment, unless they
develop cardiogenic shock, refractory volume overload, or
symptomatic bradycardia.
Strength of Evidence = C
 Temporary dose reduction may be considered
 Avoid abrupt discontinuation
 Reinstate or gradually increase prior to discharge
 Titrate dose to previously tolerated dose as soon as
possible
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
COPERNICUS: Death, Hospitalization, or
Study Drug Withdrawal in High Risk Patients
% of Patients With Event
30
HR = 0.67 (CI = 0.47-0.96)
20
Placebo
10
Carvedilol
0
0
2
4
6
Weeks After Randomization
8
Krum H et al. JAMA 2003;289:754-6
Krum et al. JAMA 2003;289
IMPACT-HF Primary End Point:
Patients Receiving Beta Blocker at 60 Days
Improvement
Patients
100%
18%
91%
73%
75%
P <.0001
50%
25%
0%
Carvedilol
Predischarge Initiation
(n=185)
Physician Discretion
Postdischarge Initiation*
(n=178)
Gattis WA et al. JACC 2004;43:1534-41
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.
Diabetes and the Use of Beta Blockers for HF: Relative
Risk for Mortality and Hospitalization for Heart Failure
COPERNICUS (carvedilol)1
With diabetes
Without diabetes
MERIT-HF (ER metoprolol succinate)2
With diabetes
Without diabetes
0
0.5
1.0
1.5
2.0
Mohacsi. Circulation. 2001;104(17):abstr 3551.
Hjalmarson. JAMA. 2000;283(10):1295.
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.
HFSA 2010 Practice Guideline
Pharmacologic Therapy: Beta Blocker Overview*
General
considerations
Initiate at low doses
Up-titrate gradually, generally no sooner than at 2 week
intervals
Use target doses shown to be effective in clinical trials
Aim to achieve target dose in 8-12 weeks
Maintain at maximum tolerated dose
If symptoms worsen
or other side effects
appear
Adjust dose of diuretic or concomitant vasoactive med.
If up-titration
continues to be
difficult
Prolong titration interval
Continue titration to target after symptoms return to
baseline
Reduce target dose
Consider referral to a HF specialist
*Consult language of specific recommendations
Adapted from:
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 for reasons other than
hyperkalemia or renal insufficiency.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ARBS in Patients Not Taking ACE Inhibitors:
Val-HeFT & CHARM-Alternative
Val-HeFT
CHARM-Alternative
50
CV Death or HF Hosp %
Survival %
100
Valsartan
90
80
Placebo
70
Placebo
40
30
Candesartan
20
10
60
p = 0.017
HR 0.77, p = 0.0004
50
0
0
3
6
9
12
15
18
21
24
27
0
9
Months
18
27
Months
Maggioni AP et al. JACC 2002;40:1422-4
Granger CB et al. Lancet 2003;362:772-6
36
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.
Aldosterone Antagonists in HF
EPHESUS (Post-MI)
Probability of Survival
RALES (Advanced HF)
1.00
1.00
0.90
0.90
0.80
Spironolactone
0.70
Eplerenone
0.80
Placebo
0.70
0.60
0.60
Placebo
0.50
0.50
RR = 0.70
P < 0.001
0.40
RR = 0.85
P < 0.008
0.40
0
3
6
9
12 15 18 21 24 27 30 33 36
0
3
6
9
12 15 18 21 24 27 30 33 36
Months
Pitt B. N Engl J Med 1999;341:709-17
Pitt B. N Engl J Med 2003;348:1309-21
HFSA 2010 Practice Guideline (7.16-7.18)
Aldosterone Antagonists and Renal Function
Aldosterone antagonists are not recommended when:
 Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
 Serum potassium> 5.0 mmol/L
 Therapy includes other potassium-sparing diuretics
Strength of Evidence = A
It is recommended that potassium be measured at
baseline, then 1 week, 1 month, and every 3 months
Strength of Evidence = A
Supplemental potassium is not recommended unless
potassium is < 4.0 mmol/L
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 (7.19)
Pharmacologic Therapy:
Hydralazine and Oral Nitrates
A combination of hydralazine and
isosorbide dinitrate is recommended as
part of standard therapy, in addition to
beta-blockers and ACE-inhibitors, for
African Americans with HF and reduced
LVEF:
 NYHA III or IV HF
Strength of Evidence = A
 NYHA II HF
Strength of Evidence = B
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
A-HeFT Outcomes
End point
Primary end point
composite score
ISDN-HDZN Placebo
(n=518)
(n=532)
p
-0.1
-0.5
0.01
6.2
10.2
0.02
1st HF hospitalization (%)
16.4
24.4
0.001
Change in quality-of-life
score at 6 months**
-5.5
-2.7
0.02
All-cause mortality (%)
Taylor AL et al. N Engl J Med 2004; 351;2049-57
A-HeFT All-Cause Mortality
43% Decrease in Mortality
100
Survival %
Fixed Dose ISDN/HDZN
95
90
Placebo
P = 0.01
85
0
100
200
Days Since Baseline Visit
300
400
500
600
Taylor AL et al. N Engl J Med 2004;351:2049-57
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
 Oral torsemide may be considered in patients exhibiting poor
absorption of oral medication or erratic diuretic effect.
Strength of Evidence = C
 IV administration of diuretics may be necessary.
Strength of Evidence = A
 Diuretic refractoriness may represent patient nonadherence,
a direct effect of diuretic use on the kidney, 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
In patients who are undergoing implantation of a biventricular
pacing device, use of a device that provides defibrillation
should be considered.
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.
MADIT II: Prophylactic ICD in
Ischemic LVD (LVEF 30%)
Probability of Survival
1.0
.9
.8
Defibrillator
.7
Conventional
Therapy
.6
0
0
Number at Risk
Defibrillator
Conventional
1
2
3
4
110 (.78)
65 (.69)
9
3
Year
742
490
503 (.91)
329 (.90)
274 (.84)
170 (.78)
Moss AJ et al. N Engl J Med 2002;346:877-83
Moss AJ, et al. N Engl J Med. 2002;346;877-883.
ICD Therapy in the SCD-HeFT Trial:
Mortality by Intention-to-Treat
HR
97.5% Cl
P Value
Amiodarone vs Placebo
1.06
.86-1.30
.53
ICD vs Placebo
.77
.62-.96
.007
.4
Mortality
.3
22%
.2
17%
.1
Amiodarone
ICD Therapy
Placebo
0
0
6
12
18
24
30
36
Months of Follow-Up
42
48
54
60
Bardy GH et al. N Engl J Med 2005;352:225-37
HFSA 2010 Practice Guideline (9.7)
Device Therapy:
Biventricular Pacing
Biventricular pacing therapy is recommended for
patients with all of the following:
 Sinus rhythm
 A widened QRS interval (≥120 ms)
 Severe LV systolic dysfunction (LVEF < 35%)
 Persistent, moderate-to-severe HF (NYHA III)
despite optimal medical therapy.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
CRT Improves Quality of Life and
NYHA Functional Class
Average Change in Score
(MLWHF)
NYHA: Proportion Improving
by 1 or More Class
0
80
-5
*
*
*
60
(%)
-10
40
-15
20
EI
CD
D
AK
C
Control
*
0
MI
RA
CL
MU
ST
IC
SR
E
MI
RA
CL
*
*
CO
NT
*
-20
CRT
MIRACLE
*P<.05
CONTAK
CD
Control
MIRACLE
ICD
CRT
Abraham WT et al. Circulation 2003;108:2596-603
CRT in Patients with Advanced HF and a
Prolonged QRS Interval: COMPANION
Primary End Point: All-Cause Mortality
Death or Hospitalization Due to HF
Risk of all-cause mortality reduced by 19%
in group with CRT and ICD (p =.014)
Risk of death or hospitalization from HF
reduced by 34% in ICD group and by 40% in
ICD-CRT group (p < .001)
Bristow MR et al. N Engl J Med 2004;350:2140-50
Effect of CRT Without an ICD on
All-Cause Mortality: CARE-HF
% Event-Free Survival
100
75
CRT
50
Medical
Therapy
25
HR = 0.64 (95% CI = .48-.85)
p = .0019
0
Number at risk
CRT
Medical Therapy
0
409
404
500
376
365
351
321
Days
213
192
1,000
89
71
1,500
8
5
Cleland JG et al. N Engl J Med 2005;352:1539-49
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.
HFSA 2010 Practice Guideline (12.3, Table 12.3)
Acute Decompensated Heart Failure (ADHF)—
Treatment Goals for Hospitalized Patients
• Improve symptoms, especially congestion and low-output symptoms
• Optimize volume status
• Identify etiology
• Identify precipitating factors
• Optimize chronic oral therapy; minimize side effects
• Identify who might benefit from revascularization
• Education patients concerning medication and HF self-assessment
• Consider enrollment in a disease management program
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 (12.5-12.20)
Overview of Treatment Options for Patients with
Acute Decompensated HF
 Fluid and sodium restriction
 Diuretics, especially loop diuretics
 Ultrafiltration/renal replacement therapy
(in selected patients only)
 Parenteral vasodilators *
(nitroglycerin, nitroprusside, nesiritide)
 Inotropes * (milrinone or dobutamine)
*See recommendations for stipulations and restrictions.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (12.25, Table 12.7)
Discharge Criteria for Hospitalized ADHF Patients
Recommended prior to discharge for all patients with HF:

Exacerbating factors addressed

Near optimum fluid status and pharmacologic therapy achieved

Transition from IV to oral diuretic completed

Patient education completed with clear discharge instructions

Follow-up clinic visit scheduled, usually 7-10 days
Should be considered prior to discharge for patients with
advanced HF or a history of recurrent admissions:

Oral regimen stable for 24 hours

No IV inotrope or vasodilator for 24 hours

Ambulation before discharge to assess functional capacity

Plans for post-discharge management

Referral for disease management, if available
Strength of Evidence =C
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Predictors of Mortality Based on
Analysis of ADHERE Database
Classification and Regression Tree (CART) analysis of
ADHERE data shows:
Three variables are the strongest predictors of mortality in
hospitalized ADHF patients:
BUN > 43 mg/dL
Systolic blood pressure < 115 mmHg
Serum creatinine > 2.75 mg/dL
Fonarow GC et al. JAMA 2005;293:572-80
HFSA 2010 Practice Guideline (8.1)
Heart Failure Patient Education
 It is recommended that patients with HF and
their family members or caregivers receive
individualized education and counseling that
emphasizes self-care.
 This education and counseling should be
delivered by providers using a team approach.
 Teaching should include skill building and
target behaviors.
Strength of Evidence = B
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
The Potential Impact of Effective
Education on Patient Compliance
Nonadherence rate when patients . . .
Recall MD advice
Don’t recall advice
Medications
8.7%
66.7%
Diet
23.6%
55.8%
Activity
76.4%
84.5%
Smoking
60.0%
90.4%
Alcohol
60.0%
81.8%
Kravitz et al. Arch Int Med 1993;153:1869-78
Sample Target Behavior: Be Able to
Read and Understand Food Labels
Labels from cups of soup
HFSA 2010 Practice Guideline (8.7)
Heart Failure Disease Management
Patients recently hospitalized for HF
and other patients at high risk
should be considered for referral
to a comprehensive HF disease
management program that delivers
individualized care.
Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HF Disease Management and the
Risk of Readmission
1.1
Risk
Ratio
Ekman
1
0.9
0.8
Jaarsma
0.7 Cline
Lasater
Stewart
Rich
Rauh
Venner
0.6
Naylor
Fonarow
0.5
Summary RR = 0.76 (95% CI .68-.87)
Summary RR for randomized only = 0.75 (CI = .60-.95)
HFSA 2010 Practice Guideline (8.13)
End-of-Life Care in Heart Failure
End-of-life care should be considered in patients
who have advanced, persistent HF with symptoms
at rest despite repeated attempts to optimize
pharmacologic, device, and other therapies, as
evidenced by one or more of the following:
 HF hospitalization
Strength of Evidence = C
 Chronic poor quality of life with inability to
accomplish activities of daily living
Strength of Evidence = C
 Need for continuous IV inotropic therapy support
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Evidence-Based Treatment Across the
Continuum of Systolic LVD and HF
Control Volume
Diuretics
Renal Replacement
Therapy*
Improve Clinical Outcomes
Aldosterone
ACEI
-Blocker Antagonist
or ARB
or ARB
CRT 
an ICD*
HDZN/ISDN*
*In selected patients
Treat Residual Symptoms
Digoxin