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HFSA 2010 Comprehensive Heart Failure Practice Guideline Key Recommendations.

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1 HFSA 2010 Comprehensive Heart Failure Practice Guideline Key Recommendations

2 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 Recommendation “Is recommended” “Should be considered” “May be considered” “Is not recommended” Part of routine care  Exceptions should be minimized Majority of patients should receive intervention  Some discretion allowed Individualization of therapy is indicated Therapy should not be used

3 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 ABCABC Randomized controlled trials  May be assigned on results of 1 trial Cohort and case control studies  Includes sub group analyses, meta- analyses, observational studies, registries Expert opinion  Includes observational, epidemiological findings; in-practice safety reporting

4 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:

5 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 FactorGoal HypertensionGenerally < 130/80 DiabetesSee ADA guidelines 1 HyperlipidemiaSee NCEP guidelines 2 Inactivity20-30 min. aerobic 3-5 x wk. ObesityWeight reduction < 30 BMI AlcoholMen ≤ 2 drinks/day, women ≤ 1 SmokingCessation Dietary SodiumMaximum 2-3 g/day 1 Diabetes Care 2006; 29: S4-S42 2 JAMA 2001; 285: Adapted from:

6 Treating Hypertension to Prevent HF Aggressive blood pressure control: Aggressive BP control in patients with prior MI: Decreases risk of new HF by ~ 80% Decreases risk of new HF by ~ 50% 56% in DM2 Decreases risk of new HF by ~ 50% 56% in DM2 Lancet 1991;338: (STOP-Hypertension JAMA 1997;278:212-6 (SHEP) UKPDS Group. UKPDS 38. BMJ 1998;317:

7 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. HFSA 2010 Practice Guideline ( ) 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

8 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. NEJM 2000;342: (HOPE) Lancet 2003;362:782-8 (EUROPA) Placebo Ramipril Placebo Perindopril 20% rel. risk red. p = % rel. risk red. p <.001 HOPE EUROPA

9 Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF ≤ 40%) SAVE Study  All-cause mortality ↓19%  CV mortality ↓21%  HF development ↓37%  Recurrent MI ↓25% Placebo Captopril Years Mortality Rate 19% rel. risk reduction p = Pfeffer et al. NEJM 1992;327:669-77

10 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:

11 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. 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:

12 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

13 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:

14 ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF SOLVD Prevention (Asymptomatic LVD) 20% death or HF hosp. 29% death or new HF CONSENSUS (Severe Heart Failure) 40% mortality at 6 mos. 31% mortality at 1 year 27% mortality at end of study  No difference in incidence of sudden cardiac death SOLVD Investigators. N Engl J Med 1992;327: SOLVD Investigators. N Engl J Med 1991;325: CONSENSUS Study Trial Group. N Engl J Med 1987;316: (Chronic Heart Failure) SOLVD Treatment 16% mortality

15 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 NameInitial Daily Dose Target DoseMean Dose in Clinical Trials CaptoprilCapoten6.25 mg tid50 mg tid122.7 mg/day EnalaprilVasotec2.5 mg bid10 mg bid16.6 mg/day FosinoprilMonopril5-10 mg qd80 mg qdN/A LisinoprilZestril, Prinivil mg qd20 mg qd4.5 mg/day, 33.2 mg/day* QuinaprilAccupril5 mg bid80 mg qdN/A RamiprilAltace mg qd10 mg qdN/A TrandolaprilMavik1 mg qd4 mg qdN/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.

16 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

17 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

18 Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD Study Drug HF Severity Target Dose (mg) Outcome US Carvedilol 1 carvedilolmild/ moderate BID ↓48% disease progression (p=.007) CIBIS-II 2 bisoprololmoderate/ severe 10 QD↓34% mortality (p <.0001) MERIT-HF 3 metoprolol succinate mild/ moderate 200 QD↓34% mortality (p =.0062) COPERNICUS 4 carvedilolsevere25 BID↓35% mortality (p =.0014) CAPRICORN 5 carvedilolpost-MI LVD 25 BID↓23% mortality (p =.031) 1 Colucci WS et al. Circulation 1196;94: CIBIS II Investigators. Lancet 1999;353: MERIT-HF Study Group. Lancet 1999;353: Packer M et al. N Engl J Med 2001; The CAPRICORN Investigators. Lancet 2001;357:

19 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. 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:

20 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:

21 % of Patients With Event 2468 Carvedilol Placebo HR = 0.67 (CI = ) Weeks After Randomization 30 Krum et al. JAMA 2003;289 COPERNICUS: Death, Hospitalization, or Study Drug Withdrawal in High Risk Patients Krum H et al. JAMA 2003;289:754-6

22 IMPACT-HF Primary End Point: Patients Receiving Beta Blocker at 60 Days Carvedilol Predischarge Initiation (n=185) Physician Discretion Postdischarge Initiation* (n=178) 18%Improvement Gattis WA et al. JACC 2004;43:

23 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. 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

24 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 Mohacsi. Circulation. 2001;104(17):abstr Hjalmarson. JAMA. 2000;283(10):1295.

25 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

26 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. Continue titration to target after symptoms return to baseline If up-titration continues to be difficult Prolong titration interval Reduce target dose Consider referral to a HF specialist *Consult language of specific recommendations Adapted from:

27 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 NameInitial Daily Dose Target DoseMean Dose in Clinical Trials BisoprololZebeta1.25 mg qd10 mg qd8.6 mg/day CarvedilolCoreg3.125 mg bid25 mg bid37 mg/day CarvedilolCoreg CR10 mg qd80 mg qd Metoprolol succinate CR/XL Toprol XL mg qd200 mg qd159 mg/day

28 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

29 ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative Val-HeFT Valsartan Placebo p = Months Survival % CV Death or HF Hosp % Placebo Candesartan CHARM-Alternative HR 0.77, p = Months Maggioni AP et al. JACC 2002;40: Granger CB et al. Lancet 2003;362:772-6

30 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 NameInitial Daily Dose Target DoseMean Dose in Clinical Trials CandesartanAtacand4-8 mg qd32 mg qd24 mg/day LosartanCozaar mg qd150 mg qd129 mg/day ValsartanDiovan40 mg bid160 mg bid254 mg/day

31 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. HFSA 2010 Practice Guideline ( ) 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. Adapted from: Strength of Evidence = A

32 Aldosterone Antagonists in HF RALES (Advanced HF) EPHESUS (Post-MI) Spironolactone Placebo Months RR = 0.70 P < Eplerenone Placebo RR = 0.85 P < Pitt B. N Engl J Med 1999;341: Pitt B. N Engl J Med 2003;348: Probability of Survival

33 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. HFSA 2010 Practice Guideline ( ) 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:

34 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

35 A-HeFT Outcomes End point ISDN-HDZN (n=518) Placebo (n=532) p Primary end point composite score All-cause mortality (%) st HF hospitalization (%) Change in quality-of-life score at 6 months** Taylor AL et al. N Engl J Med 2004; 351;

36 A-HeFT All-Cause Mortality Survival % Days Since Baseline Visit 43% Decrease in Mortality Fixed Dose ISDN/HDZN Placebo P = 0.01 Taylor AL et al. N Engl J Med 2004;351:

37 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

38 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:

39 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. Loop Diuretics AgentInitial Daily Dose Max Total Daily Dose Elimination: Renal – Met. Duration of Action Furosemide20-40mg qd or bid 600 mg65%R-35%M4-6 hrs Bumetanide mg qd or bid 10 mg62%R/38%M6-8 hrs Torsemide10-20 mg qd 200 mg20%R-80%M12-16 hrs Ethacrynic acid mg qd or bid 200 mg67%R-33%M6 hrs

40 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. Potassium-Sparing Diuretics AgentInitial Daily Dose Max Total Daily Dose EliminationDuration of Action Spironolactone mg qd 50 mgMetabolic48-72 hrs Eplerenone25-50 mg qd 100 mgRenal, Metabolic Unknown Amiloride5 mg qd 20 mgRenal24 hrs Triamterene50-75 mg bid 200 mgMetabolic7-9 hrs

41 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:

42 MADIT II: Prophylactic ICD in Ischemic LVD (LVEF  30%) Moss AJ, et al. N Engl J Med. 2002;346; (.69)170 (.78)329 (.90)490 Conventional 9110 (.78)274 (.84)503 (.91)742 Defibrillator Number at Risk Probability of Survival Conventional Therapy Defibrillator Year Moss AJ et al. N Engl J Med 2002;346:877-83

43 ICD Therapy in the SCD-HeFT Trial: Mortality by Intention-to-Treat HR97.5% ClP Value Amiodarone vs Placebo ICD vs Placebo Months of Follow-Up Mortality Amiodarone ICD Therapy Placebo 17% 22% Bardy GH et al. N Engl J Med 2005;352:225-37

44 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. 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

45 CRT Improves Quality of Life and NYHA Functional Class *P<.05 (%) Abraham WT et al. Circulation 2003;108:

46 CRT in Patients with Advanced HF and a Prolonged QRS Interval: COMPANION Bristow MR et al. N Engl J Med 2004;350: 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)

47 Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF Medical Therapy CRT Number at risk 05001,0001, % Event-Free Survival Medical Therapy CRT Days 0 HR = 0.64 (95% CI = ) p =.0019 Cleland JG et al. N Engl J Med 2005;352:

48 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. HFSA 2010 Practice Guideline ( ) 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 Adapted from: Strength of Evidence = C

49 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. Figure Diagnostic Algorithm for HF with Preserved LVEF Some patients with RV dysfunction have LV dysfunction due to ventricular interaction. No inducible ischemia, fibrotic, collagen- Vascular, RCM, cardinoid, diabetes, Radiation or chemotherapy induced heart disease, infiltrative disease, co- morbid conditions, reconsider diagnosis of HF

50 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

51 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. HFSA 2010 Practice Guideline ( ) 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.

52 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:

53 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 BUN > 43 mg/dL Systolic blood pressure < 115 mmHg Serum creatinine > 2.75 mg/dL Fonarow GC et al. JAMA 2005;293:572-80

54 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. 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:

55 The Potential Impact of Effective Education on Patient Compliance Nonadherence rate when patients... Recall MD adviceDon’t recall advice Medications8.7%66.7% Diet23.6%55.8% Activity76.4%84.5% Smoking60.0%90.4% Alcohol60.0%81.8% Kravitz et al. Arch Int Med 1993;153:

56 Sample Target Behavior: Be Able to Read and Understand Food Labels Labels from cups of soup

57 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. 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:

58 HF Disease Management and the Risk of Readmission Risk Ratio Summary RR = 0.76 (95% CI ) Summary RR for randomized only = 0.75 (CI = )

59 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. 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

60 Evidence-Based Treatment Across the Continuum of Systolic LVD and HF Control Volume Improve Clinical Outcomes Diuretics Renal Replacement Therapy* Digoxin  -Blocker ACEI or ARB Aldosterone Antagonist or ARB Treat Residual Symptoms CRT  an ICD* HDZN/ISDN* *In selected patients


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