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 failure31 Vital Health Statistics ;157:1-70.2 AHA Heart Disease and Stroke Statistics 2010 Update. Circulation. 2010;121:e3 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:
18 Beta Blockers ACC Guidelines Beta-blockers (using 1 of the 3 proven to reducemortality, i.e., bisoprolol, carvedilol, and sustainedrelease metoprolol succinate) are recommended forall stable patients with current or prior symptoms ofHF and reduced LVEF, unless contraindicated.
28 Aldosterone Antagonists ACC guidelinesAddition of an aldosterone antagonist is recommended inselected patients with moderately severe to severesymptoms of HF and reduced LVEF who can becarefully monitored for preserved renal function andnormal potassium concentration. Creatinine should beless than or equal to 2.5 mg/dL in men or less than orequal to 2.0 mg/dL in women and potassium should beless than 5.0 mEq/L. Under circumstances wheremonitoring for hyperkalemia or renal dysfunction is notanticipated to be feasible, the risks may outweigh thebenefits of aldosterone antagonists.Routine combined use of an ACEI, ARB, and aldosteroneantagonist is not recommended for patients with currentor prior symptoms of HF and reduced LVEF.IIIaIIbIIIB
33 40 months average follow- up SCD-HeFT ProtocolInclusion criteriaPlacebo n=847Amiodarone n=845ICD implant n=829SCD-HeFT is a Landmark Study of SCA in HFLarge, randomized, double-blind, placebo controlled2.5 year follow-upProscribed programming approachMinimized pacing therapyThe 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 enrollmentSCD-HeFT is a trial of ICDs and Amio in patients with HFThe ICD in the study is the Medtronic MicroJewel II, 7223 CXThe trial has the Power to detect a 25% change in mortality at 2.5 years of f/u.ACE, diuretics, Dig, BB, Spironolactone, statinsHF of > 3 months duration40 months average follow- upOptimize: B, ACE-I, DiureticsBardy 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 IIaIIbIIIAICD 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.IIIaIIbIIIBAll 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 FailureIIIaIIbIIIAFor 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 TherapyCardiac TransplantationPalliative 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 lineDevice therapy-ICD-Cardiac Resynchronization TherapyEnd Stage Heart Failure-Ventricular Assist Device/Heart Transplant