copyright © 2013, canadian cardiovascular society 27/08/2015 1 2012 ccs heart failure management...

Copyright © 2013, Canadian Cardiovascular Society23-04-19 1

2012 CCS Heart Failure Management Guidelines Update

McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181

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Canadian Cardiovascular Society Guidelines

2012 UPDATE Heart Failure Management: Focus on Acute and

Chronic Heart Failure




Learning Objectives

At the conclusion of this workshop, participants will be able to:

1.Review changes and updates for optimal management of chronic and acute heart failure; updating 2006 recommendations to 2012 context and environment;

2.Discuss exercise for heart failure patients - where to begin, what to do and where to end; and

3.Identify opportunities and challenges of surgery for patients with an ischemic etiology for heart failure.




Acute Heart Failure




What is heart failure?

• Chronic Heart Failure (CHF):– Heart failure is a complex syndrome in which

abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion.

• Acute Heart Failure Syndrome (AHF):– “gradual or rapid change in heart failure signs

and symptoms resulting in the need for urgent therapy”




Classification of AHF

high BP, +/- preserved LV systolic fxn; increased sympathetic tone with

↑HR, vasoconstriction; may be euvolaemic or only mildly

hypervolemic, and frequently with signs of pulmonary or systemic

congestion

Severe respiratory distress, ↑RR, orthopnea, rales. O2 sats <90% RA prior to O2

Clinical and lab evidence of an ACS; ~15% of patients with an ACS have signs and symptoms of HF. Episodes of AHF are frequently assoc w/ or precipitated by arrhythmia (bradycardia, AF, VT).

Usually sys BP <90 mmHg or drop in MAP >30 mmHg and absent/low urine output. Organ hypoperfusion and pulmonary congestion develop rapidly

low output in absence of pulmonary congestion with increased JVP, w/ or w/out HSM, and low LV filling pressures

usually a hx of prog. worsening of known chronic HF on Rx, and evidence of systemic/pulmonary congestion.

ESC 2008




Has care evolved?

1950 1974 2012

Morphine Morphine Morphine?

Sedation

Oxygen Oxygen?

Dietary sodium restriction Dietary sodium restriction Dietary sodium restriction?

Strict bed rest Early mobilization

Digitalis Inotropes Avoid inotropes

Mercurial diuretics Diuretics ?Diuretics

Venesection Vasodilators ?Vasodilators

Harrison’s Principles of Internal Medicine 1st Edition (1950) Ramirez A et al. N Engl J Med 1974;290(9):499-501




CASE 1

• 74 year old female• 2 months worsening SOB/orthopnea• Presented to ED after Chinese food

• Past Hx unclear, no meds• Physical exam

• HR 98, BP 142/82, RR 28, temp 36.0C• JVP elevated, crackles, pulses 2+,

legs warm and LEE+




CASE 1

• 74 year old female• CXR = pending• Labs = pending




……prepare to provide your answer!prepare to provide your answer!




How confident are you that it is AHF?1. <20%

2. 21-40%

3. 41-60%

4. 61-80%

5. >80%




How confident are you that it is AHF?1. <20%

2. 21-40%

3. 41-60%

4. 61-80%

5. >80%

No right answer




AHF Dx Scoring systems

Baggish AL, et al. Am Heart J 2006; 151: 48-54].

Predictor Points Our CaseElevated NT-proBNP 4 ?Interstitial edema on CXR 2 ?

Orthopnea 2 -Absence of fever 2 2Current loop diuretic use 1 -

Age > 75 years 1 -Rales on lung examination 1 1

Absence of cough 1 1Interpretation 4

e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93




CASE 1

• 74 year old female• CXR = increased pulmonary markings c/w

edema, no evidence of COPD• Labs = troponin I 0.20

– BNP 728 pg/ml– Creatinine 130




AHF Dx Scoring systems

Baggish AL, et al. Am Heart J 2006; 151: 48-54].

Predictor Points Our CaseElevated NT-proBNP 4 4Interstitial edema on CXR 2 2

Orthopnea 2 -Absence of fever 2 2Current loop diuretic use 1 -

Age > 75 years 1 -Rales on lung examination 1 1

Absence of cough 1 1Interpretation 10

e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93




CCS 2012We recommend the use of a validated diagnostic scoring

system for patients in whom the diagnosis of AHF is being considered (Strong Recommendation, Moderate Quality Evidence).

e.g. PRIDE score, Boston criteria

This recommendation places a relatively high value on evaluating the constellation of clinical findings in a patient with suspected AHF and less value on an individual physical examination finding, presenting symptom or investigation.




CCS 2012

• We recommend that in the clinical scenario when the clinical diagnosis of AHF is of intermediate pre-test probability, NP level be obtained to rule-out (BNP <100 pg/ml; NT-proBNP <300 pg/ml) or rule-in (BNP >500 pg/ml; NT-proBNP >900 pg/ml if age 50-75 years, NT-proBNP >1800 if age >75 years) AHF as the cause for the presenting symptoms suspicious of AHF

(Strong Recommendation, Moderate Quality

Evidence)




CCS 2012: Practical Tips

• A precipitating cause for AHF should be sought.

• An ECG and a chest x-ray should be performed within 2 hours of initial presentation.

• Initial blood tests should include: complete blood count, creatinine, blood urea nitrogen, glucose, sodium, potassium, and troponin.




CCS 2012: Practical Tips

• A transthoracic echocardiogram should be performed within 72 hours of presentation.

• For patients with a prior echocardiogram, another is not required unless there has been a significant change in clinical status requiring investigation, a lack of clinical response to appropriate therapy and/or it is greater than 12 months since the prior echocardiogram.




CASE 2

• 52 year old male with history of HF– Presented to ED after the Edmonton Oilers won the Stanley

Cup

• SOBOE, orthopnea• HR 98, BP 99/52, RR 24, temp 36.0c• JVP difficult to assess (thick neck)• crackles• pulses weak, legs cool and LEE• Trop 0.15




Where on this table does this pt fit?

Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804

Dry and Warm

Dry and Cold

Wet and Warm

Wet and Cold

Increasing Congestion / PCWP

Increasing Perfusion/

Cardiac Output

1 2

3 4





1. Dry and Warm

2. Wet and Warm

3. Dry and Cold

4. Wet and Cold





Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804

Dry and Warm

Dry and Cold

Wet and Warm

Wet and Cold

Increasing Congestion / PCWP

Increasing Perfusion/

Cardiac Output

1 2

3 4




Admit or discharge?




Treatment options?




CCS 2012: Oxygen

We recommend supplemental oxygen be considered for patients who are hypoxemic; titrated to an oxygen saturation >90% (Strong Recommendation, Moderate Quality Evidence).

•

Values and Preferences: This recommendation places relatively higher value on the physiologic studies demonstrating potential harm with the use of excess oxygen in normoxic patients and less value on long-term clinical usage of supplemental oxygen without supportive data.




CCS 2012: CPAP/BIPAP

We recommend CPAP or BIPAP not be used routinely (Strong Recommendation, Moderate Quality Evidence).

Values and Preferences: This recommendation places high weight on RCT data with a demonstrated lack of efficacy and with safety concerns in routine use. Treatment with BIPAP/CPAP may be appropriate for patients with persistent hypoxia and pulmonary edema.




CASE 2

• 52 year old male with history of HF– Presented to ED after the Edmonton Oilers won the Stanley

Cup

• SOBOE, orthopnea• HR 98, BP 99/52, RR 24, temp 36.0c• JVP difficult to assess (thick neck)• crackles• pulses weak, legs cool and LEE• Trop 0.15




How much diuretic will you give and how?1. IV lasix 20 mg bid

2. IV lasix 40 mg bid

3. IV lasix 80 mg bid

4. IV lasix 10 mg/hour infusion

5. Other choice




Acute Heart Failure (1 symptom AND 1 sign)<24 hours after admission

2x2 factorial randomization

Low Dose (1 x oral)Q12 IV bolus

48 hours

1) Change to oral diuretics2) continue current strategy

3) 50% increase in dose

Co-primary endpoints

High Dose (2.5 x oral)

Q12 IV bolus

Low Dose (1x oral)Continuous

infusion

High Dose (2.5 x oral)

Continuous infusion

72 hours

DOSE: Study Design

Clinical endpoints

60 days

e.g.Home dose = 40 mg BIDBolus = 80 (low) 200 (high)

Felker, NEJM 2011




• Efficacy:– Patient Global Assessment by visual analog

scale over 72 hours using area under the curve

• Safety:– Change in creatinine from baseline to 72 hours

DOSE: Co-Primary Endpoints




DOSE: patient global assessment




DOSE: Death, Rehosp, ER visit




• There was no statistically significant difference in global symptom relief or change in renal function at 72 hours for either:

• bolus vs. infusion or low vs. high• No clinical differences…but

– High was associated with favorable trends:– Symptom relief (global assessment and dyspnea)

– Weight loss and net volume loss

– Proportion free from signs of congestion

– Reduction in NT-proBNP

DOSE-AHF Conclusions




CCS 2012: Diuretics

We recommend intravenous diuretics be given as first line therapy for patients with congestion (Strong Recommendation, Moderate Quality Evidence).

We recommend for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (e.g. twice daily) or as a continuous infusion (Strong Recommendation, Moderate Quality Evidence).




Diuretic dosing for ADHF

Creatinine

clearance*

Patient InitialIV dose†

MaintenancedoseLowest diuretic dosethat allows for

clinical stability isthe ideal dose

≥ 60 mL/min/1.73m2 New-onset HF or no maintenance diuretic therapy

Established HF or chronic oraldiuretic therapy

New-onset HF or no maintenance diuretic therapy

Established HF or chronic oraldiuretic therapy

Furosemide 20-40 mg2-3 times daily

Furosemide bolus equivalentto oral dose

Furosemide 20-80 mg2-3 times daily

Furosemide bolus equivalentto oral dose

< 60 mL/min/1.73m2

*Creatinine clearance is calculated from the Cockroft-Gault or Modified Diet in Renal Disease formula. See text for details.† Intravenous continuous furosemide at doses of 5 to 20mg/h is also an option.

Practical Tips When Response to Diuretic is Suboptimal• Reevaluate the need for additional diuresis by assessing volume status• Restrict NA+/H2O intake (and exercise caution reducing oral intake below 500 ml per 24 hours).• Review diuretic dosing. Higher bolus doses will be more effective than more frequent lower doses. Diuretic infusions (eg, furosemide 20-40 mg bolus then 5-20 mg/h) can be a useful strategy when other options are not available.• Add another type of diuretic with different site of action (thiazides, spironolactone). Thiazide diuretics (eg oral metolazone 2.5-5 mg OB/BID or hydrochlorothiazide 25-50 mg) are often given at least 30 minutes before the loop diuretic to enhance diuresis, although this is not required to have an adequate effect.• Consider hemodynamic assessment and/or positive inotropic agents if clinical evidence of poor perfusion coexists with diuretic resistance.• Refer for hemodialysis, ultrafiltration, or other renal replacement strategies if diuresis is impeded by renal insufficiency.




For a persistently symptomatic patient with HF, what is next option?1. Higher dose lasix

2. Different diuretic

3. Add vasodilator

4. Add inotropic agent

5. Patience….

6. Other choice




CCS 2012: Vasodilators

• We recommend the following intravenous vasodilators, titrated to systolic blood pressure (SBP) > 100 mmHg, for relief of dyspnea in hemodynamically stable patients (SBP > 100 mmHg):

a) Nitroglycerin (Strong Recommendation, Moderate Quality Evidence);

b) Nesiritide (Weak Recommendation, High Quality Evidence);

c) Nitroprusside (Weak Recommendation, Low Quality Evidence).

AHA 2012: RELAX-AHF, CARRESS




CCS 2012: Inotropes

• We recommend hemodynamically stable patients do not routinely receive inotropes like dobutamine, dopamine or milrinone (Strong Recommendation, High Quality Evidence).

• Values and Preferences These recommendations for inotropes place high value on the potential harm demonstrated when systematically studied in clinical trials and less value on potential short term hemodynamic effects of inotropes.




Do I stop the beta-blockers on admission?

• Cohorts suggest continuing beta-blockers advantageous

• RCT: B-CONVINCED– Keep vs. Stop strategy in known HF pts on beta-blockers– Keep was non-inferior to Stop. – Does not delay clinical improvement– Predicts staying on BB in the longer term

Eur Heart J 2009; 30:2186-92




RESYNCHRONIZATION THERAPY and DEVICES

Anique Ducharme, MD MSc FRCPC




Anique Ducharme, Institut de Cardiologie de Montréal, Université de Montréal

The speaker has received fees/honoraria from the following sources:

Abbott vascular, Medtronic, Merck, Otsuka, Pfizer, Sorin & St-Jude Medical

None of the drugs, devices, or treatment modalities mentionedin this presentation are non approved indications.

Conflict Disclosures




• 61 years old female, previous MI,

• stable NYHA II, LVEF 25%• On optimal dose of

lisinopril, eplerone and bisoprolol, occasional diuretics

• Has not been assessed for device Rx

• BP 99/67 mmHg, HR 76 bpm

• K, 4.7 mEq/L; NT-proBNP 4500 pg/mL

• EKG: old anterior MI, LBBB QRS 155 ms.




You started treating this patient with mild symptoms of HF and low ejection fraction with epleronone as recommended. Dosage was increased up to 50 mg without side effects. What do you do next?

1.Angiotensin receptor blocker

2.ICD

3.CRT

4.CRT + ICD (CRT-D)




CRT in Patients with Mild HF Symptoms:MADIT-CRT

Moss et al, NEJM 2009

1820 pts, mostly NYHA II, CRT+ICD vs ICD aloneLow risk population, annual mortality ~3%40% reduction in HF events in CRT-ICD group




RAFT: Death or HF hospitalization

Outcome ICD (N=904) ICD-CRT (N=894)

Hazard ratio (95% CI)

P value

Primary outcome

Death or hospitalization for HF

363 (40.3%) 297 (33.2%) 0.75 (0.64-0.87)

<0.001

Secondary outcomes

Death from any cause 236 (26.1%) 186 (20.8%) 0.75 (0.62-0.91)

0.003

Hospitalization for HF 236 (26.1%) 174 (19.5%) 0.68 (0.56-0.83)

<0.001

Tang AS, et al. N Engl J Med 2010

1800 pts, 80% NYHA IICRT-D vs ICDMedian follow-up 40 months




CRT: Mortality reduction

Al-Majed et al, Annals of Internal Medicine 2011




CRT: HF Hosp reduction

Al-Majed et al, Annals of Internal Medicine 2011




Medical Therapy in Perspective

Zannad et al, N Engl J Med, 2010Tang et al, N Engl J Med 2010

RAFT 1800 pts, 80% NYHA IICRT-D vs ICD; median f/u 40 months

25% reduction in mortality

EMPHASIS HF2700+ patients, NYHA IIEplerenone vs Placebo; median f/u 21mo

25% reduction in mortality




Recommendation 2011 (Update)

• We recommend the use of CRT in combination with an ICD for HF patients on optimal medical therapy with NYHA II HF symptoms, LVEF < 30%, and QRS duration > 150 ms.

(Strong Recommendation, High Quality Evidence)




Practical tips

• QRS> 150 ms based on a subgroup analysis of MADIT-CRT and RAFT studies– Most LBBB are >150 msec

• The selection of patients should be individualized and based on risk features




CRT for Everyone?…Maybe not

• Not everyone will benefit

“Non-response” is ~30% depending on the definition of:

• Death• Hospitalization• Failure to improve 1 NYHA functional class• Failure to improve peak VO2 or 6 min walk distance• Absence of reverse remodelling (LVESV or EF) • Absence of improvement in dyssynchrony




Consider Risks vs Benefits: Real WorldReal World

Krahn et al, Ont ICD Database Circulation 2011 Poole et al, REPLACE Registry Circulation 2010

N = 1081 ICD replacements N = 713 Upgrade Procedures




• Much uncertainty persists:

– Narrow QRS with mechanical dyssynchrony

– LV dysfunction and chronic RV pacing

– Atrial fibrillation and LBBB

– Right bundle branch block

– Asymptomatic patients

– Class IV/Stage D patients

Real World Patient Population

Importance of Patient Selection




Recommendation• Routine CRT implantation is not currently recommended for

patients with heart failure and narrow QRS (<120 ms)

• Patients enrolled in CRT studies who show benefit have a QRS duration >150ms, on average. The benefit in patients with QRS 120ms to 150ms is less clear

• Echocardiography derived parameters of dyssynchrony cannot be recommended on a routine basis since clinical utility has not been established

Practical tips




Practical tip

• The use of CRT may prevent worsening in patients with LV systolic dysfunction who require permanent pacing and who are expected to have a high burden of ventricular pacing




The ACEI-ARB-MRA Dilemma

Jonathan Howlett MD

Disclosures at www.hfcc.ca




……prepare to provide your answers!prepare to provide your answers!




Case 1.34 year old female with NYHA FC II HF with LVEF 29%BP 130/70, HR 63, Na 139, Creat 100, K+ 4.0On BB, ACE, diuretic target doses.

Which drug should you start next?

A.ARBB.Aldo InhibitorC.NeitherD.Does not matter, going for device anyway




Case 2.64 year old female with NYHA FC I HF with LVEF 29%BP 160/70, HR 63, Na 139, Creat 100, K+ 4.2On BB, ACE, CCB, diuretic target doses.


A.ARBB.Aldo InhibitorC.NeitherD.Both




Case 3.84 year old female with NYHA FC IIIb HF with LVEF 29%BP 100/70, HR 70, Na 139, Creat 160, K+ 4.7On BB, ACE, Digoxin, diuretic optimal doses.


A.ARBB.Aldo InhibitorC.Neither- I will use nitrates preferentiallyD.Both




When to Use ARBs as Add-on Therapy?

Pfeffer MA et al. Lancet 2003;363:759-66. Cohn JN et al. N Engl J Med 2001;345:1667-75.

• In patients with persistent HF symptoms, and who are at increased risk of HF hospitalization, despite optimal treatment with ACE inhibitors and beta-blockers (Class I, Level A)

CHARM – Proportion of patients with CV death or hospital admission for CHF

Val-HeFT – Probability of freedom from combined endpoint (All-cause mortality, cardiac arrest with resuscitation, hospitalization for

worsening HF, or therapy with intravenous inotropes or vasodilators)

Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.




CHARM-Added Permanent study drug discontinuations

Placebo

Candesartan

0

5

10

15

20

25

Percent of patients

p=0.0003 p=0.079 p=0.0001 p<0.0001

Hypo-tension

Increased creatinine

Increasedpotassium

AE/lab. abnorm.

18.3

3.1 4.1

0.7

24.2

4.5

7.8

3.4

What are the effects of Spiro?




2006 Recommendation

• Patients with LVEF 30% and severe symptoms despite optimized other therapies(Class I, Level B)

• Or with AHF with an LVEF less than 30% following acute myocardial infarction(Class IIa, level B)

69




EMPHASIS: Baseline CharacteristicsCharacteristic Eplerenone (N=1364) Placebo (N=1373)

Mean age — yr 68.7 (7.7) 68.6 (7.6)

Female sex — % 22.7% 21.9%

Ischemic heart disease – % 70 68

Blood pressure – mm Hg 124 ±17/75 ± 10 124±17/75±10

Atrial fibrillation or flutter – % 30 32

Diabetes mellitus— no. (%) 34 29

Serum Creatinine – mg/dl 1.14 (0.30) 1.16 (0.31)

Estimated GFR ml/min/1.73 m2 71.2 (21.9) 70.4 (21.7)

< 60 ml/min/1.73 m2 – no. (%) 32 35

Serum Potassium – mmol/liter 4.3 (0.4) 4.3 (0.4)

Zannad, NEJM 2011; 364:11-21




EMPHASIS: Primary Endpoint

0

10

20

30

40

50

0 1 2 3

Prim

ary

Endp

oint

: Cu

mul

ative

K-M

Rat

e (%

)

Years from Randomization

Eplerenone

HR [95% CI] = 0.63 [0.54, 0.74] P < 0.0001

Placebo

No. at RiskPlacebo 1373 848 512 199 Eplerenone 1364 925 562 232

356 (25.9)

249 (18.3)

0

10

20

30

40

0 1 2 3

Hea

rt F

ailu

re H

ospi

taliz

ation

: Cu

mul

ative

K-M

Rat

e (%

)

Years from Randomization

Eplerenone

HR [95% CI] = 0.58 [0.47, 0.70] P < 0.0001

Placebo

No. at RiskPlacebo 1373 848 512 199 Eplerenone 1364 925 562 232

253 (18.4)

164 (12.0)

71

213 (15.5)

171 (12.5)

*Unadjusted HR, 0.78; 0.64, 0.95; p=0.01




Patient Follow-up and Dosing

Eplerenone Placebo

Discontinuations in surviving patients (%) 16.3% 16.6%

Discontinuations for AE – n (%) 188 (13.8%) 222 (16.2%)*

Mean dose at month 5 (mg/day) 39.1 ±13.8 40.8 ±12.9

* p = 0.09




Recommendation 2011

• We recommend that an aldosterone receptor blocking agent such as eplerenone be considered for patients with mild to moderate (NYHA II) HF, aged > 55 years with LV systolic dysfunction (LVEF < 30%, or if LVEF is 30% and 35% with QRS duration >130 ms), and recent hospitalization for CVD or elevated BNP/NT-pro-BNP levels, who are on standard HF therapy

• (Strong Recommendation, High-Quality Evidence)




Combination RAAS Blockade- OptionsAdd an ARB

• Mean BP reduction 5-7 / 3-5 mmHg• Mean Δ in creatinine < 30 umol/L• Mean Δ in potasssium 0.3 Mmol/L• Reduction in CHF/CV Death in Mild/mod HF• Evidence with triple therapy

Combination RAAS BlockadeAdd Spironolactone

Mean BP reduction -1 to +5/ _1+3 mmHg Mean Δ in creatinine < 50 umol/L Mean Δ in potasssium 0.5- 0.9 Mmol/L Trials stopped early in ‘enhanced moderate HF’ No evidence in triple therapy




But we vote with our feet!




Fonarow, Circulation 2011.; p 1601-10




CHF Clinics Increased use of EBM versus Community- the First 1933 Patients

EB TherapyFirst visit from

Community(n= 1155)

Previously seen in clinic

(n= 778)P value

Age (SD) 62 (16) 63 (14) ns

LVEF (SD) 30 (14) 31 (14) ns

ACE inhibitor (%) 79 81 ns

ACE inhibitor(% at target)

25 60 0.01

Diuretic (%) 49 66 0.01

Beta Blocker (%) 49 58 0.01

Aldo Antagonist (%)

15 30 0.01

J Card Fail, Volume 7, Issue 3 Suppl 2, p.90 (2001)




Eur Heart J 2011;32 (suppl 1)

Measurement Baseline Assessment (SD)

Year 1 follow up (SD)

Year 2 follow up (SD)

P value baseline to 2 years (SD)

LVEF 32 (14) 38 (15) 38 (14) p< 0.001

Improve by > 20% baseline 30 (14) 31 (14) p< 0.001

Improve by >10% ACE inhibitor (%) 79 81 p< 0.001

ACE use 54% 69% 69% p< 0.001

ACE or ARB 70% 93% 95% p< 0.001

Beta blocker use 63% 85% 85% p< 0.001

Aldo Antagonist 21% 35% 45% P< 0.001

Impact of HF Clinic Care on LVEF in Canadians with HF• 21 Clinics with data from 1999-2010

• 599 patients with LVEF data at 0, 1,2 years

• 74% male, 63% ischemic etiology




Management of Patients with HF and Acute Intercurrent Medical Illness

• HF patients with an acute dehydrating illness of any kind should undergo prompt evaluation (electrolytes, BUN, Crcl).

• If diarrhea or vomiting occurs, the aldosterone blocker should be stopped until resolution.

• Caution is also necessary when there are other potential causes of dehydration, including increase in diuretic dose.

Canadian Cardiovascular Society Consensus Conference recommendations update 2007American College of Cardiology Foundation/American Heart Association practice

guidelines 2009

79




Suggested addition…….• Most of the time, the Aldosterone Antagonist is the way to

go

• Monitoring is the most important aspect of Rx

• Triple therapy is discouraged outside special circumstances

• Role for ARBs if:

– Very high BP

– Difficulty with K+ high

– Cannot tolerate AA due to side effects

– Osteoarthritis?




Should all patients with HFexercise and how?

Eileen O’Meara, M.D.




EXERCISE TRAINING IN CHRONIC HEART FAILURE

QUESTION 1. TRUE OR FALSE?

All patients with stable New York Heart Association (NYHA) class I-III should be considered for enrolment in a tailored exercise training program, in order to improve exercise tolerance and quality of life.

A.TrueB.False




The benefits of rehabilitation in HF

It is now well recognized that exercise-based cardiac rehabilitation programs for patients with HF improve exercise capacity, skeletal and respiratory muscle function, quality of life, autonomic function, biomarkers, and reduce depressive symptoms as well as cardiovascular risk factors. Piepoli MF et al. Eur J Heart Fail 2011; 13(4): 347–357.

Vanhees L et al. Eur J Cardiovasc Prev Rehabil 2011.

Based on the results of prior studies of exercise training, the Canadian Cardiovascular Society has adopted recommendations that physical activity be considered for stable patients with systolic dysfunction. Canadian Cardiovascular Society consensus conference

recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 2006;22(1):23–45.




The HF-ACTION trial

O’Connor CM et al. JAMA 2009; 301: 1439–1450.Flynn KE et al. JAMA 2009; 301: 1451–1459.

The HF-ACTION trial demonstrated no significant reduction in the combined endpoint of all-cause mortality or hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.84–1.02; P=0.13).

After adjusting for 4 covariables associated with an increase in the primary endpoint and for HF etiology, exercise training was found to reduce the incidence of all-cause mortality or all-cause hospitalization by 11% (HR, 0.89; 95% CI, 0.81–0.99; P = 0.03).

exercise training conferred modest but statistically significant improvements in self-reported health status.




• 2007: 42 y.o. patient presents with EF 38% and sustained VT. No significant CAD on angio.

• Diagnosis: Familial cardiomyopathy• 2007 - A defibrillator is implanted i.e. secondary

prevention and medical therapy is optimized• 2008: EF increased to 45%• 2010: EF is 50% on echocardiogram• 2010 – Amiodarone is stopped since patient fears the

side effects and EF is now « normalized »• She undergoes a treadmill test prior to exercise

training in November 2010…

The case of Madame T…




Sinus tachycardia

then multiple PVCs then VT




Question 2. Select the best answer?A. She had ischemia and this should have been

investigated by another test

B. The adrenaline surge during the test lead to ventricular tachycardia and the defibrillator shocks were appropriate

C. The treadmill test should have been stopped before her heart rate reached the programmed VT zone so she would not receive shocks

D. She should not be allowed to reach this level of exercise even if she did not have a defibrillator anyway

E. She should have been on amiodarone or a higher dose of beta-blockers




PATIENT EVALUATION PRIOR TO AN EXERCISE PROGRAM

The following should be obtained prior to a tailored exercise training program:

An assessment of clinical status by a clinician experienced in the management of heart failure patients should be completed

Establish if the patient has an ICD and if yes, verify if previous shocks have been delivered and note the programmed VT zone

Exercise test (evaluate ischemia, arrhythmias, rate responses of patients with pacemakers, and determine training heart rate ranges)

Non-cardiac causes of dyspnea or musculoskeletal disorders may limit exercise tolerance and should be evaluated




She complained to the hospital authorities and had to receive the help of a psychologist to cope with the fear of defibrillator shocks.

The technician was unaware of how to prepare a patient with a defibrillator for a treadmill test and the attending physician should have supervised more closely in preparation for the test.

A written protocol was made to ensure that this would not happen again. The patient was satisfied with the procedure.

She began training again about 1 year later and still sees her cardiologist in that same hospital.

Current EF is 45% (July 2012 echocardiogram)

Madame T: Actions and Reactions




Treadmill test protocol for patients with defibrillators

The indication for the treadmill test should be clearly described and the patient must be flagged as having a defibrillator

Defibrillator programmation will be verified immediately prior to the treadmill test

Maximal HR will be the programmed HR for VT therapy minus 20 beats per minute. The test should be stopped immediately as that HR is reached.

All pharmacological treatments should be continued (especially beta-blockers and antiarrhythmics)

No adjustment to the defibrillator programmation should be made in view of the treadmill test




Exercise Training in Stable HF is SAFE

A stepwise approach to exercise training in stable HF is suggested, including:

Cardiopulmonary/exercise testing is used for safety assessment and exercise prescription.

Initial supervision ensures safety of the prescribed program and may help patients understand their limits. For patients who prefer home-based exercise, after a minimum of 6-8 supervised sessions, exercise training may continue with a home-based program.




Aerobic Exercise Training Prescription

Moderate-intensity continuous aerobic exercise training at rate of perceived exertion (RPE) 3-5 (Figure), 65-85% maximum heart rate, and 50-75% peak V02 is recommended in HF patients

Exercise program schedule in stable patients should begin with aerobic exercise training, 10-15 minutes in duration, 2-3 days per week frequency, before gradually increasing training to a target of 30 minutes, 5 days per week.

Walking, treadmill, and stationary cycling can be chosen as primary training modes. Moderate-intensity aerobic interval training may be incorporated into the ET program in selected, stable HF patients.




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