ch f management
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DEFINITION of HEART FAILURE
Heart Failure is a pathophysiological state in which anabnormality of cardiac function to pump the blood at arate commensurate with requirements of metabolizing
tissue.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1528
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Epidemiology
Europe The prevalence of symptomatic HF range from 0.4-2%.10 million HF pts in 900 million total population
USAnearly 5 million HF pts.± 500,000 pts are D/ HF for the 1 st time each year.Last 10 years number of hospitalizations has
increased.Nearly 300,000 patients die of HF each year.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001
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Aims of treatment
1. Prevention a) Prevention and/or controlling of diseases leading
to cardiac dysfunction and heart failureb) Prevention of progression to heart failure once
cardiac dysfunction is established2. Morbidity
Maintenance or improvement in quality of life
3. Mortality Increased duration of life
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Management outline
Establish that the patient has HF. Ascertain presenting features: pulmonary oedema, exertionalbreathlessness, fatigue, peripheral oedema
Assess severity of symptoms
Determine aetiology of heart failure
Identify precipitating and exacerbating factors
Identify concomitant diseases
Estimate prognosis
Anticipate complications
Counsel patient and relatives
Choose appropriate management
Monitor progress and manage accordingly
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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New York Heart Association (NYHA)Classification of Heart Failure
Class – INo limitation : ordinary physical exercise doesnot cause undue fatigue, dyspnoea or palpita-tions.
Class – II
Slight limitation of physical activity : comfor-
table at rest but ordinary activity results infatigue, dyspnoea, or palpitation.
Class - IIIMarked limitation of physical activity : comfor-table at rest but less than ordinary activityresults in symptoms.
Class - IVUnable to carry out any physical activity with-out discomfort : symptoms of heart failure arepresent even at rest with increased discomfortwith any physical activity.
Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1531
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ACC/AHA – A New Approach To The Classification of HF
Stage Descriptions Examples
A Patient who is at high risk for developing HF but has nostructural disorder of the heart.
Hypertension; CAD; DM;rheumatic fever; cardiomyopathy.
B Patient with a structural disorder
of the heart but who has never developed symptoms of HF.
LV hypertrophy or fibrosis;
LV dilatation; asymptomatic VHD;MI.
C patient with past or currentsymptoms of HF associated withunderlying structural heartdisease .
Dyspnea or fatigue ec LV systolicdysfunction; asymptomaticpatients with HF.
D Patient with end-stage disease Frequently hospitalized pts ; ptsawaiting heart transplantation etc
ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001
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Algorithm for the Diagnosis of Heart FailureSuspected Heart Failure
Because of symptoms and signs
Assess presence of cardiac diseases by ECG, X-ray orNatriuretic peptide (where available)
Test Abnormal
Imaging by Echocardiography(Nuclear angiography or MRI
Where available)
Test Abnormal
Assess etiology, degree, precipitating Factors and type of cardiac dysfunction
Choose Therapy
NormalHeart Failure
Unlickely
NormalHeart Failure
Unlickely
Additonal diagnosis testswhere appropriate
(e.g. coronary angiography)
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1530
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Stage A Stage B Stage C Stage D
Pts with :• Hypertension• CAD• DM• Cardiotoxins• FHx CM
THERAPY• Treat Hypertension• Stop smoking•
Treat lipid disorders• Encourage regular exercise
• Stop alcohol& drug use
• ACE inhibition
Pts with :• Previous MI• LV systolic
dysfunction• Asymptomatic
Valvular disease
THERAPY• All measures under
stage A•
ACE inhibitor • Beta-blockers
THERAPY• All measures under
stage A•
Drugs for routine use:• diuretic• ACE inhibitor • Beta-blockers• digitalis
THERAPY• All measures under
stage A,B and C• Mechanical assist
device• Heart transplantation• Continuous IV
inotrphic infusions for palliation
Pts who havemarked symptomsat rest despitemaximal medicaltherapy.
Pts with :
• Struct. HD
• Shortness of breath and fatigue,reduce exercisetolerance
Struct.HeartDisease
DevelopSymp.of
HF
Refract.Symp.ofHF at rest
Stages in the evolution of HF and recommended therapy by stage
ACC/AHA Guidelines for theEvaluation and Management of Chronic Heart Failure in the Adult 2001
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Treatment options
Non-pharmacological managementGeneral advice and measuresExercise and exercise training
Pharmacological therapy Angiotensin-converting enzyme (ACE) inhibitorsDiureticsBeta-adrenoceptor antagonists
Aldosterone receptor antagonists Angiotensin receptor antagonistsCardiac glycosidesVasodilator agents (nitrates/hydralazine)Positive inotropic agents
Anticoagulation Antiarrhythmic agentsOxygen
Devices and surgeryRevascularization (catheter interventions and surgery), other forms of surgeryPacemakersImplantable cardioverter defibrillators (ICD)Heart transplantation, ventricular assist devices, artificial heartUltrafiltration, haemodialysis
Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560
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Pharmacological therapy
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Angiotensin-converting enzyme inhibitors
Recommended as first-line therapy.
Should be uptitrated to the dosages shown to beeffective in the large, controlled trials, and nottitrated based on symptomatic improvement.
Moderate renal insufficiency and a relatively low bloodpressure (serum creatinine < 250 µmol.l -1 and systolicBP > 90 mmHg) are not contraindications .
Absolute contraindications : bilateral renal arterystenosis and angioedema.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Diuretics
Essential for symptomatic treatment when
fluid overload is present and manifest. Always be administered in combination
with ACE inhibitors if possible.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Recommended in advanced HF (NYHA III-IV),
in addition to ACE inhibition and diuretics to
improve survival and morbidity
Aldosterone receptor antagonists - spironolactone
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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The RALES mortality trial Low dose spironolactone (12.5 – 50 mg) on topof an ACE inhibitor and a loop diuretic improved survival of patients in advancedheart failure (NYHA class III or IV).
Aldosterone receptor antagonists - spironolactone
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Recommended for the treatment of all ptswith stable , mild, moderate and severe heartfailure on standard treatment, unless there is
a contraindication.
Patients with LV systolic dysfunction, with or without symptomatic HF, following an AMIlong-term betablockade is recommended in addition to ACE inhibitor.
Beta-adrenoceptor antagonists
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Carvedilol(n=696)
Placebo(n=398)
Survival
Days0 50 100 150 200 250 300 350 400
1.0
0.9
0.8
0.7
0.6
0.5
Risk reduction = 65%P<0.001
Packer et al (1996)
Lancet (1999)0 200 400 600 800
1.0
0.8
0.6
0
Bisoprolol
Placebo
Time after inclusion (days)
P<0.0001
Survival
Risk reduction = 34%
The MERIT-HF Study Group (1999)Months of follow-up
Mortality %
0 3 6 9 12 15 18 21
20
15
10
5
0
Placebo
Metoprolol CR/XL
P=0.0062
Risk reduction = 34%
US Carvedilol Study
-Blockers in CHF -All-cause Mortality
CIBIS-II MERIT-HF
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% S u r v
i v a l
0 0
3 6 9 12 15 18 21
Months
100
90
80
60
70
P=0.00013
Carvedilol
Placebo
COPERNICUS
All-cause mortality
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Beta-adrenoceptor antagonists
CIBIS II, MERIT HF, US CARVEDILOL AND COPERNICUS study
Reduction in total mortality, cardiovascular mortality, sudden death and death due toprogression of heart failure in patients in func.class II-IV.
reduces hospitalizations
improves the functional class and leads toless worsening of heart failure.
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ARBs could be considered in patients who do nottolerate ACE inhibitors for symptomatictreatment.
It is unclear whether ARBs are as effective as ACE inhibitors for mortality reduction.
In combination with ACE inhibition, ARBs mayimprove heart failure symptoms and reducehospitalizations for worsening heart failure.
Angiotensin II receptor antagonists
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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VAL-H
Patients were randomized to placebo or valsartan on top of standard therapy.
The results showed no difference in overallmortality , but a reduction in the combined end-
point all-cause mortality or morbidity expressed as hospitalization because of worsening heart failure.
Angiotensin II receptor antagonists
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indicated in atrial fibrillation and any degree of symptomatic heart failure.
A combination of digoxin and beta-blockadeappears superior than either agent alone.
In sinus rhythm, digoxin is recommended toimprove the clinical status of patients withpersisting heart failure despite ACE inhibitor anddiuretic treatment.
Cardiac glycosides
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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DIG trial
Long-term digoxin did not improve survival .
The primary benefit and indication for digoxinin heart failure is to reduce symptoms andimprove clinical status decrease the risk of
hospitalization for heart failure without animpact on survival.
Cardiac glycosides
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No specific role for vasodilators in the treatment of HF
Used as adjunctive therapy for angina or concomitanthypertension.
In case of intolerance to ACE inhibitors ARBs arepreferred to the combination hydralazine – nitrates.
HYDRALAZINE-ISOSORBIDE DINITRATE
Hydralazine (up to 300 mg) in combination with ISDN (up to 160mg) without ACE inhibition may have some beneficial effect on
mortality, but not on hospitalization for HF.Nitrates may be used for the treatment of concomitant angina or relief of acute dyspnoea .
Vasodilator agents in chronic heart failure
Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560
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Commonly used to limit severe episodes of HF or as a bridge to heart transplantation in end-stage HF.
Repeated or prolonged treatment with oralinotropic agents increases mortality.
Currently, insuffcient data are available to
recommend dopaminergic agents for heartfailure treatment.
Positive inotropic therapy
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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POSITIVE INOTROPHIC AGENTSDobutaminMilrinoneLevosimendan
DOPAMINERGIC AGENTSIbopamine is not recommended for the treatment of chronic HF due to systolic LV dysfunction.
Intravenous dopamine is used for the sort-termcorrection of haemodynamic disturbances of severeepisodes of worsening HF.
Positive inotropic therapy
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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No indication for the use of antiarrhythmic agents in HF
Indications for antiarrhythmic drug therapy include AF(rarely flutter), non-sustained or sustained VT.
CLASS I ANTIARRHYTHMICS
should be avoidedCLASS II ANTIARRHYTHMICS Beta-blockers reduce sudden death in heart failureCLASS III ANTIARRHYTHMICS
Amiodarone is the only antiarrhythmic drug withoutclinically relevant negative inotropic effects.
Antiarrhythmics
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Recommendation
1. All pts with HF and AF should be treated withwarfarin unless contraindicated.
2. Patients with LVEF 35% or less.
Anticoagulation
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
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Antiplatelet Drugs
Recommendation
There is insufficient evidence concerning thepotential negative therapeutic interaction between ASA and ACE inhibitors.
Antiplatelet agent for pts with HF who haveunderlying CAD.
HFSA Guidelines for Management of Patients With Heart Failure Caused by LeftVentricular Systolic Dysfunction - Pharmacological Approaches 2000
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Chronic heart failure — choice of pharmacological therapy
LV systolic dysfunction ACE inhibitor Diuretic Beta-blockerAldosteroneAntagonist
Asymptomatic LVdysfunction Indicated Not indicated Post MI Not indicated
Symptomatic HF (NYHA II) Indicated Indicated ifFluid retention
Indicated Not indicated
Worsening HF (NYHA III-IV) IndicatedIndicated
comb. diureticIndicated
Indicated
End-stage HF (NYHA IV) Indicated Indicatedcomb. diuretic
Indicated Indicated
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
A
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Chronic heart failure — choice of pharmacological therapy
LV systolic dysfunction
Angiotensin
II receptorantagonists
Cardiac glycosides
Vasodilator(hydralazine/
isosorbidedinitrate)
Potassium -sparingdiuretic
Asymptomatic LVdysfunction Not indicated With AF Not indicated Not indicated
Symptomatic HF (NYHA II)
If ACE inhibitorsare not toleratedand not on beta-
blockade
(a) when AF(b) when improved
from more severeHF in sinusrhythm
If ACE inhibitorsand angiotensin
II antagonistsare nottolerated
If persisting
hypokalaemia
Worsening HF (NYHA III-IV)
If ACE inhibitorsare not toleratedand not on beta-
blockade
indicated
If ACE inhibitorsand angiotensin
II antagonistsare not
tolerated
If persistinghypokalaemia
End-stage HF (NYHA IV)If ACE inhibitorsare not toleratedand not on beta-
blockade
indicated
If ACE inhibitorsand angiotensin
II antagonistsare not
tolerated
If persistinghypokalaemia
Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560
B
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Pts with heart failure of ischaemic origin revascularization symtomatic improvement.
A strong negative correlation of operative mortality and LVEF,
a low LVEF (<25%) was associated with increasedoperative mortality . Advance HF symptoms (NYHA IV)resulted in a greater mortality rate.
Off pump coronary revascularization may lower the surgical
risk for HF.
Heart Transplantation is an accepted mode of treatment for end-stage HF.
RevascularizationSurgical
Non Surgical
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560
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Care and Follow-up
Recommended components of programs
use a team approachvigilant follow-up, first follow-up within 10 days of dischargedischarge planningincreased access to health careoptimizing medical therapy with guidelinesintense education and counselling inpatient andoutpatient
strategies address barriers to complianceearly attention to signs and symptomsflexible diuretic regimen
Guidelines for the diagnosis and treatment of chronic heart failureEuropean Heart Journal (2001) 22, 1527-1560
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Resume
Pharmacological Treatment :
I. Asymptomatic Systolic LV dysfunction :• ACE Inhibitor • -Blocker (in CAD)
II. Symptomatic Systolic LV dysfunctionA. No fluid retention
ACE Inhibitor -Blocker
If ischaemia (+) nitrate / revascularizationB. Fluid retention
Diuretic ACE Inhibitor (ARBs if not tolerated)
-Blocker ± Digitalis
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Resume
III. Worsening HFStandard treatment : ACE Inhibitor, -Blocker Diuretic : doses + loop diureticLow dose spironolactoneDigitalisConsider :
» Revascularization» Valve surgery» Heart transplant
IV. End-stage HFIntermittent inotrophic supportCirculatory support (IABP, Ventr.Assist Devices)Haemofiltration on dialysis
briddging to heart transplantation
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Conclusion
Management of HF must be starting fromthe earlier stage (AHA/ACC stage A).Treatment at each stage can reduce
morbidity and mortality.
Before initiating therapy :
Established the correct diagnose.Consider management outline.
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ConclusionNon pharmacolgical intervention are helpfull in :
improving quality of lifereducing readmissionlowering cost.
Organize multi-disciplinary care :HF clinic, HF nurse specialist, pts telemonitoring.Health care system.
To optimize HF management Treatment should be according to the Guidelines,intensive education, and behavioral change efforts.