Download – H F R

HEART FAILURE ROTATION – FELLOW CURRICULUM
EDUCATIONAL GOALS
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Gain experience in the clinical management of patients with heart failure.
Gain experience in the acute and chronic management of patients following cardiac transplantation.
Develop an understanding of cardiac transplant immunology and the use of immunosuppressives.
Develop a competence in performing and interpreting right heart catheterizations.
Understand the metabolic abnormalities of exercise physiology in patients with heart failure.
Gain experience in selecting patients for VAD and following patients post-VAD placement.
EXPECTATIONS FOR THE FIRST-YEAR FELLOW: OUTPATIENT HEART FAILURE
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Prior to the start of the rotation, Jill Griswold will ask the fellow which available HF clinics he or she would
like to attend. Once selections are made, the fellow must attend those clinics. If a conflict arises, Jill Griswold
and the clinic attending must be notified as soon as possible.
In clinic, the fellow will be expected to interview, examine, and develop a treatment plan for patients with
advanced HF or pulmonary hypertension. In order to do this effectively, the fellow must have a detailed
understanding of the patient’s prior history and management strategies. The fellow will then present the patient
to the HF attending prior to seeing the patient with the HF attending. The fellow will be expected to write the
note for the clinic visit in MiChart in a timely fashion.
The fellow will spend time in the right heart catheterization lab. There, the fellow will perform right heart
catheterizations under the supervision of a HF attending. He or she will also observe the performance of cardiac
biopsies. Between procedures, the HF attending and fellow will discuss findings from prior catheterizations.
The fellow will be expected to attend Thursday afternoon HF conferences from 2-5 PM.
EXPECTATIONS FOR THE SECOND-YEAR FELLOW: INPATIENT HEART FAILURE
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The fellow should be an active participant on rounds. With attending supervision, the fellow will lead the HF
team that is composed of nurse practitioners, pharmacists, and case managers. The fellow will guide clinical
decision-making, educate team members and patients when necessary, and explain the plan of care to each
patient on the service. The attending and fellow will ultimately choose one of two approaches:
 The fellow sees all the patients on the service with the attending and HF team.
 The fellow sees half of the service patients with nurse practitioners and a pharmacist. The fellow then
rounds separately with the attending on these patients later in the day. The fellow would be expected to
briefly present each patient and provide a treatment plan for the day.
 No matter the approach, the fellow should know the patient’s history, clinical course, and treatment
plan in detail. If this is not the case, active participation will be difficult.
The fellow will see all HF consults and staff them with the HF attending.
In the case that the CCU attending is not a HF specialist, the fellow will round on all patients with advanced HF
in the CCU. The patient would then be discussed and seen with the HF attending later in the day.
Following rounds, the fellow should be available to assist members of the HF team with issues that arise.
At the end of the day, the fellow is expected to “run the list” with the attending and HF team touching on
important clinical issues and decisions that arise during the work day.
Each week, the fellow will work every weekday and at least one weekend day. Weekend coverage should be
discussed with the HF attending at the start of the rotation. The fellow will be excused for continuity clinic.
The fellow will be expected to attend Thursday afternoon HF conferences from 2-5 PM.
IMPORTANT TOPICS
Pathophysiology
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Role of neurohormonal activation in the progression of HF
Relationship of LaPlace’s law to progression of HF Pathophysiology
Understand the Frank-Starling relationship, pressure-volume loops, and the force-tension curve.
Understand how preload, afterload, and contractility impact myocardial performance (SV).
Understand how inotropes, vasopressors, and vasodilators alter myocardial performance (SV).
Classification/Etiologies
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ACC/AHA Stages of HF (Stages A-D)
Classification of HF symptoms based on NYHA Functional Classification (I-IV)
Common causes of cardiomyopathy
Diagnostic Evaluation
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Class I recommendations for the initial workup of HF (history, labs, EKG, imaging, etc.)
Indications and approach to evaluation of CAD and revascularization in patients with HF
Indications for right heart catheterization, coronary angiography, and endomyocardial biopsy
Diagnostic and prognostic utility of serum BNP levels
Indications patient has progressed to Stage D HF despite optimal medical therapy
Treatment
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Evidence-based medical therapies for patients with Stage B HFREF (ACE, BB)
Evidence-based medical therapies for patients with Stage C-D HFREF (ACE, BB, AA, Hydralazine-Nitrate)
Recommended medical therapies for the treatment of HFPEF
Role of inotropic agents in the treatment of HF
Clinical events/findings suggesting advanced, Stage D HF
Device Therapy, MCS, and Transplantation
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Selection criteria for ICD implantation for prevention of SCD
Selection criteria for chronic resynchronization therapy
Indications and contraindications for MCS and cardiac transplantation
Frequently encountered complications from LVADs.
Be familiar with immunosuppression and antibiotic prophylaxis used for cardiac transplantation
Hypertrophic Cardiomyopathy
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Inheritance pattern and the underlying pathology of hypertrophic cardiomyopathy
Understand how changes in preload, afterload, and contractility affect LVOT obstruction in HCM
Indications for medical and surgical therapy of HCM
Recommended medical and surgical therapies for HCM
Risk factors used to determine need for ICD placement in HCM patients
Pulmonary Hypertension
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Diagnostic criteria and WHO classification of pulmonary hypertension
Cellular targets for the commonly used pharmacologic therapies
Indications and evidence for Prostacyclins, ERAs, PDE-5 Inhibitors, and calcium channel blockers
General approach to selecting pharmacologic therapy for pulmonary arterial hypertension
Treatment goals for pharmacologic therapy of pulmonary hypertension
BOOK CHAPTERS
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Braunwald’s Heart Disease Chapters 24-32 (located on shared drive)
2012 ACC BOARD REVIEW LECTURES
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Heart Failure 1: Pathophysiology (Drazner)
Heart Failure 2: Cardiomyopathies (Russell)
Heart Failure 3: Treatment (Fang)
Pulmonary Hypertension (Mathier)
Heart Failure 4: Cases (Drazner, Russell, Fang, Mathier)
EP 8: ICD and CRT Therapies (Hundley & Verdino)
MAYO BOARD REVIEW LECTURES
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Systolic Heart Failure: Pathophysiology, Etiology, Initial Evaluation
Medical Treatment of Systolic Heart Failure
Cardiac Device and Transplant Therapy
Diastolic Heart Failure
The Cardiomyopathies
Ventricular Function
GUIDELINES
2013 ACCF/AHA Guideline for the Management of Heart Failure
2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy
REVIEW ARTICLES & OTHER STUDIES
HFREF and HFPEF
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McMurray (2010). Systolic heart failure. NEJM.
Maisel et al. (2008). Using natriuretic peptide levels in clinical practice. Eur J Heart Failure.
Cohn (1996). The management of chronic heart failure. NEJM.
Butler et al. (2014). Developing therapies for heart failure with preserved ejection fraction. JACC HF.
Wan et al. (2014). Pre-clinical diastolic dysfunction. JACC.
Heart Failure Pharmacotherapy
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Overgaard & Dzavik (2008). Inotropes and Vasopressors. Circulation.
Francis et al. (2014). Inotropes. JACC.
Ambrosy et al. (2014). The use of digoxin in patients with worsening heart failure. JACC.
Mechanical Circulatory Support and Transplantation
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Aaronson et al. (1997). Development and prospective validation of a clinical index to predict survival
in ambulatory patients referred for cardiac transplant evaluation. Circulation.
Stewart & Givertz (2012). Mechanical circulatory support for advanced HF. Circulation.
Lund, Matthews, and Aaronson (2010). Patient selection for left ventricular assist devices. EJHF.
Miller & Guglin (2013). Patient selection for ventricular assist devices. JACC.
Burke & Givertz (2014). Assessment and management of HF after LVAD implantation. Circulation.
Wilson et al. (2009). Ventricular assist devices: the challenges of outpatient management. JACC.
Pulmonary Hypertension
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McLaughlin & McGoon (2006). Pulmonary arterial hypertension. Circulation.
Galie et al. (2013). Updated treatment algorithm of pulmonary arterial hypertension. JACC.
Hoepper et al. (2013). Definitions and diagnosis of pulmonary hypertension. JACC.
McLaughlin et al. (2013). Treatment goals of pulmonary hypertension. JACC.
Hypertrophic Cardiomyopathy
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Maron et al (2014). Hypertrophic Cardiomyopathy. JACC.
RANDOMIZED CONTROLLED TRIALS
Beta Blockers
Carvedilol
Metoprolol Succinate
Bisoprolol
ACE Inhibitors
Captopril
Lisinopril
Enalapril
Ramipril
Angiotensin Receptor Blockers
Valsartan
Candesartan
Losartan
Aldosterone Antagonists
Spironolactone
Eplerenone
CAPRICORN: Post-MI patients with EF ≤ 40%
COPERNICUS: Severe HF and EF < 25%
COMET: Carvedilol vs. Metoprolol Tartrate
US Carvedilol Trial: Mild-Severe HF and EF ≤ 35%
MERIT-HF: Class II-IV HFREF patients
CIBIS-II: Class III-IV HFREF patients
SAVE: Post-MI patients with EF ≤ 40% w/o HF
ATLAS: Class II-IV HF patients with EF ≤ 30%
SOLVD: Patients with HFREF with EF ≤ 35%.
CONSENSUS: Class IV HF patients
AIRE: Clinical HF in patients admitted for MI
HOPE: Patients at ↑ risk for CV events with NL EF
PEACE: Stable CAD patients with normal EF
VALIANT: ARB alternative to ACE in HFREF
Val-HeFT: NYHA II-IV with EF < 40% and LVE
CHARM-Alternative: ARB alternative to ACE
HEAAL: Class II-IV HFREF with EF ≤ 40%
Elite II: Losartan vs. Captopril in HF with EF ≤ 40%
RALES: NYHA Class III-IV HF and EF ≤ 35%.
EPHESUS: Post-MI (3-14d), EF ≤ 40%, HF or DM
EMPHASIS-HF: NYHA Class II HF w/ EF ≤ 30%
Hydralazine & Isosorbide Dinitrate
Taylor 2009: African-Americans w/ III-IV HFREF
V-HEFT I: Men with HF and EF ≤ 45% or LVE
V-HEFT II: Hydralazine/Isosorbide Dinitrate vs. Enalapril
Digoxin
DIG Trial: Patients with HF and EF ≤ 45%.
Diuretics
DOSE: Evaluates diuretic dosing for ADHF
Polyunsaturated Fatty Acids
GISSI-HF: Class II-IV HFREF and HFPEF patients
Pulmonary Artery Catheterization
ESCAPE: Role of PA catheter in ADHF treatment
Exercise Training
HF-ACTION: Stable outpatients with HFREF
Revascularization
STICH: CABG vs. OMT in HFREF (EF ≤ 35%)
Chronic Resynchronization Therapy
CARE-HF: CRT in pts with ↓EF + dyssynchrony
MADIT-CRT: Class I-II, EF ≤ 30%, QRS > 130
Left Ventricular Assist Device
REMATCH: Role for Destination LVAD
INTERMACS: Risk stratification scheme.
Slaughter 2009: Continuous vs. Pulsatile LVAD