Key Recommendations Guidelines

8/14/2019 Key Recommendations Guidelines

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2006 HFSA Comprehensive

Heart Failure Practice Guideline

Key Recommendations

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive

Heart Failure Guideline. J Card Fail 2006;12:e1-e122.


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HFSA 2006 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 beminimized

Majority of patients shouldreceive intervention

Some discretion allowed

Individualization of

therapy is indicated

Therapy should not beused




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HFSA 2006 Comprehensive Heart Failure Practice Guideline

Strength of Evidence

A

B

C

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, epidemiologicalfindings; in-practice safety reporting




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HFSA 2006 Practice Guideline (3.1)

Heart Failure Prevention

Strength of Evidence = A

A careful and thorough clinical

assessment, with appropriate

investigation for known or potential riskfactors, is recommended in an effort to

prevent development of LV remodeling,

cardiac dysfunction, and HF.

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive



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Treating Hypertension to Prevent HF

Aggressive blood

pressure control:

Aggressive BP control

in patients with prior MI:

Decreasesrisk of

new HF

by ~ 80%

Decreasesrisk of

new HF

by ~ 50%

56% in DM2

Decreasesrisk of

new HF

by ~ 50%

56% in DM2

Lancet 1991;338:1281:1281-5 (STOP-Hypertension).

JAMA 1997;278:212-6 (SHEP).

UKPDS Group. UKPDS 38. BMJ 1998;317:703-713.


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HFSA 2006 Practice Guideline (3.3-3.4)

PreventionACEI and Beta Blockers

ACE inhibitors are recommended for prevention of HF inpatients at high risk for this syndrome, including thosewith:

Coronary artery disease Peripheral vascular disease

Stroke

Diabetes and another major risk factorStrength of Evidence = A

ACE inhibitors and beta blockers are recommended for allpatients with prior MI.



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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.

Placebo

Ramipril

Placebo

Perindopril

20% rel. risk red. p = .0003

22% rel. risk red. p < .001

HOPE

EUROPA

NEJM 2000;342:145-53 (HOPE).

Lancet 2003;362:782-8 (EUROPA).

0

24

68

10

1214

16

0 1 2 3 4

Years

% MI,

Stroke,

CV Death

0

3

6

9

12

15

0 1 2 3 4 5

Years

% MI,

CV Death,

Cardiac Arrest


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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% relative risk reduction

p = 0.019

Pfeffer et al. NEJM 1992;327:669-77.

0

0.1

0.2

0.3

0 0.5 1 1.5 2 2.5 3 3.5 4


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The Additional Value of Beta

Blockers Post-MI: CAPRICORN

Studied impact of beta blocker (carvedilol) on

post-MI patients with LVEF 40% already receivingcontemporary 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;357:1385-90.


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HFSA 2006 Practice Guideline (4.8, 4.10)

Heart Failure Patient EvaluationRecommended evaluation for patients with a diagnosis of HF:

Assess clinical severity and functional limitation by history, physicalexamination, 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




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EvaluationFollow 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 sodiumrestriction

Patient understanding of and compliance with medical regimen

History of arrhythmia, syncope, pre-syncope or palpitation

Compliance and response to therapeutic interventions

Exacerbating factors for HF, including worsening ischemicheart disease, hypertension, and new or worsening valvulardisease Strength of Evidence = B




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Pharmacologic Therapy: ACE Inhibitors

ACE inhibitors are recommended for symptomatic andasymptomatic patients with an LVEF 40%.


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 forasymptomatic patients with an LVEF 40%. Post MI Strength of Evidence = B

Non Post-MI Strength of Evidence = C




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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;327:685-91.

SOLVD Investigators. N Engl J Med 1991;325:293-302.

CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35.

(Chronic Heart Failure)

SOLVD Treatment

16% mortality


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Pharmacologic Therapy: Substitutes for ACEI

It is recommended that other therapy be substituted forACE 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 nitratemay be considered in such patients not tolerating ARBs.

Strength of Evidence = C

Patients intolerant to ACE inhibitors due to hyperkalemia or

renal insufficiency are likely to experience the same sideeffects with ARBs. In these cases, the combination ofhydralazine and an oral nitrate should be considered.





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Pharmacologic Therapy: Beta Blockers

Beta blockers shown to be effective in clinical trialsare recommended for symptomatic andasymptomatic patients with an LVEF 40%.


Beta blockers are recommended as routine therapyfor asymptomatic patients with an LVEF 40%. Post MI Strength of Evidence = B

Non Post-MI Strength of Evidence = C




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Effect of Beta Blockade on Outcome

in Patients With HF and Post-MI LVD

23% mortality (p =.031)25 BIDpost-MILVD

carvedilolCAPRICORN5

35% mortality (p = .0014)25 BIDseverecarvedilolCOPERNICUS4

34% mortality (p = .0062)200 QDmild/

moderate

metoprolol

succinate

MERIT-HF3

34% mortality (p


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RECENT DECOMPENSATION OR EXACERBATION

Beta blocker therapy is recommended for patients with a recentdecompensation of HF after optimization of volume status andsuccessful discontinuation of IV diuretics and vasoactive agents.

Whenever possible, beta blocker therapy should be initiated inthe hospital at a low dose prior to discharge of stable patients.

Strength of Evidence = B

Continuation of beta blocker therapy is recommended in mostpatients experiencing a symptomatic exacerbation of HF during

chronic maintenance treatment. Strength of Evidence = C If necessary, consider temporary dose reduction

Avoid abrupt discontinuation

Reinstate or gradually increase before discharge




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0000

2020

1010

%ofPatients

WithEvent

%ofPatients

WithEvent

22 44 66 88

Carvedilol

Placebo

HR = 0.67 (CI = 0.47HR = 0.67 (CI = 0.47--0.96)0.96)

Weeks After RandomizationWeeks After Randomization

3030

COPERNICUS: Death, Hospitalization, or

Study Drug Withdrawal in High Risk Patients

Krum H et al. JAMA 2003;289:754-6.


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IMPACT-HF Primary End Point:Patients Receiving Beta Blocker at 60 Days

Carvedilol

Predischarge Initiation

(n=185)

Physician Discretion

Postdischarge Initiation*

(n=178)

18%18%ImprovementImprovement

Gattis WA et al. JACC 2004;43:1534-41.

91%

73%

0

25

50

75

100

Patients(%

)P < .0001


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CONCOMITANT DISEASE

Beta blocker therapy is recommended in the great majority ofpatients with LV systolic dysfunctioneven if there isconcomitant 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 markedbradycardia (


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Diabetes and the Use of Beta Blockers for HF: Relative

Risk for Mortality and Hospitalization for Heart Failure

0 0.5 1.0 1.5 2.0

COPERNICUS (carvedilol)1

With diabetes

Without diabetes

MERIT-HF (ER metoprolol succinate)2

With diabetes

Without diabetes

1. Mohacsi. Circulation. 2001;104(17):abstr 3551.

2. Hjalmarson. JAMA. 2000;283(10):1295.


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PRESERVED LVEF

Beta blocker treatment is recommended in patients with HF andpreserved 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 standardtherapy in all elderly patients with HF due to LV systolic dysfunction.


In the absence of contraindications, these therapies are alsorecommended in the very elderly (age > 80 years). Strength of Evidence = C




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HFSA 2006 Practice Guideline

Pharmacologic Therapy: Beta Blocker Overview*

Prolong titration interval

Reduce target dose

Consider referral to a HF specialist

If up-titrationcontinues to be

difficult

Adjust dose of diuretic or concomitant vasoactive med.

Continue titration to target after symptoms return to

baseline

If symptoms worsen

or other side effects

appear

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

Generalconsiderations

* Consult language of specific recommendations




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Pharmacologic Therapy:

Angiotensin Receptor Blockers

ARBs are recommended for routine

administration to symptomatic and

asymptomatic patients with an

LVEF 40% who are intolerant toACE inhibitors for reasons other than

hyperkalemia or renal insufficiency.Strength of Evidence = A




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ARBS in Patients Not Taking ACE Inhibitors:

Val-HeFT & CHARM-Alternative

Val-HeFT

Valsartan

Placebo

p = 0.017

Months

Survival%

CVDeathorHF

Hosp%

Placebo

Candesartan

CHARM-Alternative

HR 0.77, p = 0.0004

Months

Maggioni AP et al. JACC 2002;40:1422-4.

Granger CB et al. Lancet 2003;362:772-6.

50

60

70

80

90

100

0 3 6 9 12 15 18 21 24 27

0

10

20

30

40

50

0 9 18 27 36 42


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Pharmacologic Therapy:

Aldosterone AntagonistsAn aldosterone antagonist is recommended for

patients on standard therapy, including diuretics,

who have:

NYHA class IV HF (or class III, previously class IV)

due to LV systolic dysfunction (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 an ARB. Strength of Evidence = A




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Aldosterone Antagonists in HF

RALES (Advanced HF) EPHESUS (Post-MI)

Spironolactone

Placebo

Months

RR = 0.70P < 0.001

Epleronone

Placebo

RR = 0.85P < 0.008

Pitt B. N Engl J Med 1999;341:709-17.

Pitt B. N Engl J Med 2003;348:1309-21.

ProbabilityofS

urvival

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 3 6 9 12 15 18 21 24 27 30 33 36

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 3 6 9 12 15 18 21 24 27 30 33 36

Months


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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


It is recommended that potassium be measured atbaseline, then 1 week, 1 month, and every 3 months


Supplemental potassium is not recommended unlesspotassium is < 4.0 mmol/L Strength of Evidence = A



HFSA 2006 P ti G id li (7 19)


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Pharmacologic Therapy:Hydralazine and Oral Nitrates

A combination of hydralazine andisosorbide dinitrate is recommended as

part of standard therapy, in addition tobeta-blockers and ACE-inhibitors, forAfrican Americans with LV systolicdysfunction:

NYHA III or IV HF Strength of Evidence = A

NYHA II HF Strength of Evidence = B




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A-HeFT Outcomes

0.02-2.7-5.5Change in quality-of-lifescore at 6 months**

0.00124.416.41st HF hospitalization (%)

0.0210.26.2All-cause mortality (%)

0.01-0.5-0.1Primary end point

composite score

pPlacebo

(n=532)

ISDN-HDZN

(n=518)

End point

Taylor AL et al. N Engl J Med 2004; 351;2049-2057.


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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;351:2049-57.

85

90

95

100

0 100 200 300 400 500 600


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Pharmacologic Therapy: Diuretics

Diuretic therapy is recommended to restore andmaintain normal volume status in patients withclinical evidence of fluid overload, generallymanifested by:

Congestive symptoms

Signs of elevated filling pressuresStrength of Evidence = A

Loop diuretics rather than thiazide-type diureticsare typically necessary to restore normal volumestatus in patients with HF.





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Loop Diuretics

6 hrs67%R-33%M200 mg25-50 mg qd

or bid

Ethacrynic

acid

12-16 hrs20%R-80%M200 mg10-20 mg qdTorsemide

6-8 hrs62%R/38%M10 mg0.5-1.0 mg

qd or bid

Bumetanide

4-6 hrs65%R-35%M600 mg20-40mg qd

or bid

Furosemide

Duration of

Action

Elimination:

Renal Met.

Max Total

Daily Dose

Initial Daily

Dose

Agent




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Potassium-Sparing Diuretics

7-9 hrsMetabolic200 mg50-75 mgbid

Triamterene

24 hrsRenal20 mg5 mg qdAmiloride

UnknownRenal,Metabolic

100 mg25-50 mgqd

Eplerenone

48-72 hrsMetabolic50 mg12.5-25 mg

qd

Spironolactone

Duration

of Action

EliminationMax Total

Daily Dose

Initial Daily

Dose

Agent




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Pharmacologic Therapy: Diuretics

Restoration of normal volume status may require multipleadjustments.

Once a diuretic effect is achieved with short-acting loopdiuretics, 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 poorabsorption of oral medication or erratic diuretic effect.


IV administration of diuretics may be necessary.


Diuretic refractoriness may represent patient noncompliance,a direct effect of diuretic use on the kidney, or progression ofunderlying dysfunction.



HFSA 2006 Practice Guideline (9 1 9 4)


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Device Therapy:

Prophylactic ICD PlacementIn patients on optimal medical therapy (ideally 3-6 months)with or without concomitant coronary artery disease(including a prior MI > 1 month ago):

Prophylactic ICD placement should be considered inthose with NYHA II-III HF (LVEF 30%) Prophylactic ICD placement may be considered in those

with NYHA II-III HF (LVEF 31-35%)


Concomitant placement should be considered in NYHA III-IV patients undergoing implantation of a biventricularpacing device. Strength of Evidence = B



MADIT II: Prophylactic ICD in


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MADIT II: Prophylactic ICD in

Ischemic LVD (LVEF 30%)

365 (.69)170 (.78)329 (.90)490Conventional

9110 (.78)274 (.84)503 (.91)742Defibrillator

Number at Risk

0 1 2 3

.7

.8

.9

1.0

Probability

ofSurvival

Conventional

Therapy

Defibrillator

Year

.6

04

Moss AJ et al. N Engl J Med 2002;346:877-83.

ICD Th i th SCD H FT T i l


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ICD Therapy in the SCD-HeFT Trial:

Mortality by Intention-to-Treat

.007.62-.96.77ICD vs Placebo

.53.86-1.301.06Amiodarone vs Placebo

PValue97.5% ClHR

Months of Follow-Up

Mortalit

y

0 6 12 18 24 30 36 42 48 54 600

.1

.2

.3

.4

Amiodarone

ICD TherapyPlacebo

17%

22%

Bardy GH et al. N Engl J Med 2005;352:225-37.

HFSA 2006 Practice Guideline (9 7)


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Device Therapy:

Biventricular Pacing

Biventricular pacing therapy should be consideredfor patients with all of the following:

Sinus rhythm

A widened QRS interval (120 ms) Severe LV systolic dysfunction (LVEF 35% with LV

dilation > 5.5 cm)

Persistent, moderate-to-severe HF (NYHA III) despiteoptimal medical therapy.




CRT I Q lit f Lif d


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CRT Improves Quality of Life and

NYHA Functional Class

(%)

Abraham WT et al. Circulation 2003;108:2596-2603.

Average Change in Score(MLWHF)

-20

-15

-10

-5

0

MIRACLE

MUS

TIC

SR

CONT

AK

CD

MIRAC

LE

ICD

* P< .05Control CRT

* **

*

NYHA: Proportion Improvingby 1 or More Class

0

20

40

60

80

MIRACLE CONTAK

CD

MIRACLE

ICD

**

*


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CRT in Patients with Advanced HF and a

Prolonged QRS Interval: COMPANION

Bristow MR et al. N Engl J Med 2004;350:2140-50.

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)


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Effect of CRT Without an ICD on

All-Cause Mortality: CARE-HF

571192321365404Medical Therapy

889213351376409CRT

Number at risk0 500 1,000 1,500

25

50

75

100

%Event-FreeSurvival

Medical

Therapy

CRT

Days

0

HR = 0.64 (95% CI = .48-.85)

p = .0019

Cleland JG et al. N Engl J Med 2005;352:1539-49.


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HF with Preserved LVEFDiagnosis

Careful attention to differential diagnosis is recommendedin patients with HF and preserved LVEF.

Treatments may differ based on cardiac disorder.

Evaluation for ischemic disease and inducible myocardialischemia should be included.

Recommended diagnostic tools:

Echocardiography

Electrocardiography

Stress imaging (via exercise or pharmacologic means, usingmyocardial perfusion or echocardiographic imaging)





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Figure 11.1. Diagnostic Categories

of Heart Failure with Preserved LVEF

Figure courtesy of Marvin Konstam MD and Marvin Kronenberg MD.

Heart Failure with Preserved LVEF

Dilated LVDilated LV NonNon--dilated LVdilated LV

Valvular diseaseValvular diseaseAR; MRAR; MR

No valvularNo valvulardiseasedisease

High output HFHigh output HF

Increased thicknessIncreased thickness Normal thicknessNormal thickness Right Ventricular Dysfunction*Right Ventricular Dysfunction*

Mitral obstructionMitral obstructionMS; Atrial myxomaMS; Atrial myxoma

Normal or IncreasedNormal or IncreasedQRS voltageQRS voltage

Hypertrophic diseaseHypertrophic disease

No mitralNo mitralobstructionobstruction

PulmonaryPulmonaryHypertensionHypertension

HypertensiveHypertensive HxHx or PEor PE

HypertensiveHypertensive--hypertrophichypertrophiccardiomyopathycardiomyopathy

Isolated orIsolated orpredominant RVMIpredominant RVMI

Low QRS voltageLow QRS voltageInfiltrative myopathyInfiltrative myopathy

No Aortic valveNo Aortic valvediseasedisease

Inducible ischemiaInducible ischemiaIntermittent/activeIntermittent/active

ischemiaischemia

No inducible ischemiaNo inducible ischemiaFibrotic; collagenFibrotic; collagen--vascular;vascular;Restrictive CM; carcinoid;Restrictive CM; carcinoid;

Reconsider diagnosis of HFReconsider diagnosis of HF

No pericardialNo pericardialdiseasedisease

Pericardial diseasePericardial diseaseTamponade /ConstrictionTamponade /Constriction

Aortic valve diseaseAortic valve diseaseAortic stenosisAortic stenosis

No HypertensiveNo Hypertensive HxHx ororPEPE

HypertrophicHypertrophiccardiomyopathycardiomyopathy

LVEF=left ventricular ejection fraction; HF=heart failure;QRS=electrocardiographic ventricular depolarization; AR= aorticregurgitation; MR=mitral regurgitation; MS=mitral stenosis; RVMI=rightventricular myocardial infarction; Hx=history; PE= physical examination.

* Some patients with right ventriculardysfunction have LV dysfunction due toventricular interaction.



HFSA 2006 P ti G id li (12 3 T bl 12 3)


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HFSA 2006 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

Educate patients concerning medication and HF self-assessment

Consider enrollment in a disease management program





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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.

HFSA 2006 Practice Guideline (12 23 Table 12 7)


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HFSA 2006 Practice Guideline (12.23, 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 achieved

Transition from IV to oral diuretic completed

Near optimum pharmacologic therapy achieved

Follow-up clinic visit scheduled, usually 7-10 days

Should be considered prior to discharge for patients withadvanced 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 to a disease management programStrength of Evidence =C




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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.


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Heart Failure Patient Education

It is recommended that patients with HF andtheir family members or caregivers receiveindividualized 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 andtarget behaviors.





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The Potential Impact of Effective

Education on Patient Compliance

81.8%60.0%Alcohol

90.4%60.0%Smoking

84.5%76.4%Activity

55.8%23.6%Diet

66.7%8.7%Medications

Dont recall adviceRecall MD advice

Noncompliance rate when patients . . .

Kravitz et al. Arch Int Med 1993;153:1869-78.


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Sample Target Behavior: Be Able to

Read and Understand Food Labels

Labels from cups of soup

HFSA 2006 P ti G id li (8 7)


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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.




HF Di M d h


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HF Disease Management and the

Risk of Readmission

Cline

J aarsma

Rich

Naylor

Stewart

Rauh

Lasater

Ekman

Venner

Fonarow0.5

0.6

0.7

0.8

0.9

1

1.1

Risk

Ratio

Summary RR = 0.76 (95% CI .68-.87)

Summary RR for randomized only = 0.75 (CI = .60-.95)


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End-of-Life Care in Heart Failure

End-of-life care should be considered in patients who haveadvanced, persistent HF with symptoms at rest despiterepeated attempts to optimize pharmacologic andnonpharmacologic therapy, as evidenced byone or more of the following:

Frequent hospitalizations (3 or more per year)

Chronic poor quality of life with inability to accomplishactivities of daily living

Need for intermittent or continuous intravenous support

Consideration of assist devices as destination therapy




Evidence-Based Treatment Across the


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Evidence-Based Treatment Across the

Continuum of Systolic LVD and HF

Control Volume Improve Clinical Outcomes

DiureticsRenal Replacement

Therapy*

Digoxin

-BlockerACEIor ARB

Aldosterone

Antagonist

or ARB

Treat Residual Symptoms

CRT an ICD*

HDZN/ISDN*

*In selected patients

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