1. Heart Failure Ben Starnes MD FACC Interventional Cardiology
Arkansas Cardiology
Baptist Health Heart Institute

2. Financial disclosures
-None

3. Heart Failure
Moving away from the term Congestive Heart Failure

6. Heart Failure imposes a significant burden on the US healthcare system
-Heart failure accounts for over 3.4 million visits to physician offices, hospital outpatient departments, and emergency departments1
-More than 1,000,000 hospitalizations occur with the primary diagnosis of heart failure2
-Over 6.5 million days are spent in US hospitals for heart failure3
1 Vital Health Statistics ;157:1-70.
2 AHA Heart Disease and Stroke Statistics 2010 Update. Circulation. 2010;121:e
3 European Heart Journal Supplements; V.7; Suppl B; 2005; pB8.

7. Heart Failure is a Clinical Diagnosis
Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41:

13. Heart Failure

17. Beta Blockers

18. Beta Blockers ACC Guidelines
Beta-blockers (using 1 of the 3 proven to reduce
mortality, i.e., bisoprolol, carvedilol, and sustained
release metoprolol succinate) are recommended for
all stable patients with current or prior symptoms of
HF and reduced LVEF, unless contraindicated.

19. Heart Failure

20. Ace Inhibitors in severe heart failure

21. Ace Inhibitors in mild to moderate heart failure

22. Ace Inhibitors ACEIs are recommended for all patients with
ACC Guidelines
ACEIs are recommended for all patients with
current or prior symptoms of HF and reduced
LVEF, unless contraindicated.

25. Aldosterone Antagonists

26. Aldosterone Antagonists

27. Aldosterone Antagonists

28. Aldosterone Antagonists
ACC guidelines
Addition of an aldosterone antagonist is recommended in
selected patients with moderately severe to severe
symptoms of HF and reduced LVEF who can be
carefully monitored for preserved renal function and
normal potassium concentration. Creatinine should be
less than or equal to 2.5 mg/dL in men or less than or
equal to 2.0 mg/dL in women and potassium should be
less than 5.0 mEq/L. Under circumstances where
monitoring for hyperkalemia or renal dysfunction is not
anticipated to be feasible, the risks may outweigh the
benefits of aldosterone antagonists.
Routine combined use of an ACEI, ARB, and aldosterone
antagonist is not recommended for patients with current
or prior symptoms of HF and reduced LVEF. I
IIa
IIb
III B

32. SCD-HeFT

33. 40 months average follow- up
SCD-HeFT Protocol
Inclusion criteria
Placebo n=847
Amiodarone n=845
ICD implant n=829
SCD-HeFT is a Landmark Study of SCA in HF
Large, randomized, double-blind, placebo controlled
2.5 year follow-up
Proscribed programming approach
Minimized pacing therapy
The study design is a prospective randomized control trial comparing Amiodarone or ICD to Optimal medical Therapy in patients who present with ischemic or non-ischemic dilated cardiomyopathy in NYHA class II or III who are on an ACE inhibitor and a beta blockers with an EF of less than or equal to 35% at the time of enrollment
SCD-HeFT is a trial of ICDs and Amio in patients with HF
The ICD in the study is the Medtronic MicroJewel II, 7223 CX
The trial has the Power to detect a 25% change in mortality at 2.5 years of f/u.
ACE, diuretics, Dig, BB, Spironolactone, statins
HF of > 3 months duration
40 months average follow- up
Optimize: B, ACE-I, Diuretics
Bardy GH. Chapter Excerpt from Arrhythmia Treatment and Therapy. Woosley RL, Singh SN, editors. Marcel Dekker, 1st edition. 2000;
SCD-HeFT Investigators Meeting, August 2001, data from most recent follow-up

36. Implantable Cardioverter-Defibrillators
IIa
IIb
III A
ICD therapy is indicated in patients with LVEF less than 35% due to prior MI who are at least 40 days post-MI and are in NYHA functional Class II or III.
ICD therapy is indicated in patients with nonischemic DCM who have an LVEF less than or equal to 35% and who are in NYHA functional Class II or III. I
IIa
IIb
III B
All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

45. Cardiac Resynchronization Therapy
Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure I
IIa
IIb
III A
For patients who have left ventricular ejection fraction (LVEF) less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, cardiac resynchronization therapy (CRT) with or without an ICD is indicated for the treatment of New York Heart Association (NYHA) functional Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy.
*All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

46. End Stage Heart Failure
Ventricular assist Device
-Bridge to transplant
-Destination Therapy
Cardiac Transplantation
Palliative Care

47. Diastolic Heart Failure
Heart failure with preserved LV systolic function Generally due to hypertension  left ventricular hypertrophy  impaired LV filling and decreased LV stroke volume

48. Diastolic Heart Failure
Treatment: -Diuretics to relieve congestion -Beta Blockers/Calcium channel blockers to reduce heart rate and improve diastolic filling -Control blood pressure -Maintain sinus rhythm Atrial fibrillation leads to loss of atrial kick (20% of cardiac output)

49. Take Home Points Medical Therapy Device therapy
-Ace inhibitors/beta blockers
-Aldosterone antogonist (LVEF <35)
-Diuretics as needed
-Digoxin last line
Device therapy
-ICD
-Cardiac Resynchronization Therapy
End Stage Heart Failure
-Ventricular Assist Device/Heart Transplant