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Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Management of chest pain and heart failure. Cardiac rehabilitation
and secondary prevention
WT BongDept of Family Medicine, HUKM
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Case scenario 1
• 60 yo gentleman, a known case of DM for the past 2 years complains of chest pain for the past 2-3 months when he walks more than 10 minutes. The chest pain radiates to left arm, lasts 5 min, relieved by rest. Currently during his visit to the primary care clinic, he has no chest pain. He is a smoker for the past 40 years. He is on metformin 500mh bd only. Clinically, BP 120/60mmHg and cardiovascular examination was unremarkable.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Patient comes in with chest pain..
• ?cardiovascular– Cardiac.
• MV prolapse.pericarditis• ischemic
– Non cardiac. Aortic dissection• ?gastrointestinal. GERD• ?Musculoskeletal.fibromyalgia.• ?pulmonary• ?psychogenic
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
We start with stable angina..
• By definition. Clinical syndrome characterised by – discomfort in chest, jaw, shoulder, back or arm– Typically aggravated by exertion or emotional
stress– Reduced by rest or GTN
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Most common cause for stable angina is atherosclerotic coronary artery disease (CAD)
• Other causes could be– Hypertrophic cardiomyopathy– Aortic stenosis– Coronary vasospasm etc
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Atherosclerosis process in coronary
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Stable angina is classified into 4 classes based on Canadian Cardiovascular
Society Classification (CCS 0-IV)CLASS SEVERITY OF EXERTIONL STRESS
INDUCING ANGINALIMITATION OF ORDINARY ACTIVITY
I STRENUOUS, RAPID OR PROLONGED EXERTION AT WORK OR RECREATION
NONE
II WALKING OR CLIMBING STAIRS RAPIDLY, WALKING UPHILL, CLIMBING STAIRS AFTER MEAL
SLIGHT
III WALKING 1-2 BLOCKS ON THE LEVEL AND CLIMBING ONE FLIGHT OF STAIRS AT NORMAL PACE
MARKED
IV INABILITY TO CARRY OUT ANY PHYSICAL ACTIVITY WITHOUR DISCOMFORT OR SYMPTOMS PRESENT AT REST
DISCOMFORT IN ALL ACTIVITY PERFORMED
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Diagnosis of stable angina can be established by
• Clinical assessment– Look for complication of CAD.murmur(MR).septal
defect.sign of cardiomegaly.CHF– Other site of atherosclerosis.carotid
bruit.peripheral vascular disease.aortic aneurysm– Risk factor for atherosclerosis.hpt.metabolic syn– Other cause of angina.HOCM.aortic stenosis
• Lab test• Specific cardiac investigation
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Lab test to establish CVS risk factor– FLP. FBS. homocysteine level– Determine prognosis, creatinine– CXR only if suspect CHF if want to see calcification,
cardiomegaly/atrial enlargement, valvular disease, pulmonary congestion (help establish prognosis)
• Specific cardiac investigation
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Specific cardiac investigation, non invasive– ECG. See previous ischemia, LVH, BBB, arrhythmia
or conduction defect– Stress test. More sensitive and specific than
resting ECG– Echo.when there is abnormal auscultation suggest
valvular, if HCM or prev MI changes on ECG, SSx CHF , to study diastolic function
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Risk-stratify our patient
• For the purpose of prognosis + treatment (revascularize in high risk patient)
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Clinical history – important predictor of adverse outcome in established CAD
DM HPT Metabolic syndrome
Current smoker Increasing age Prior MI
SSx of CHF Recent onset or progressive
angina
Responsiveness of angina to therapy
dyslipidaemia
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Risk stratify .. Higher risk if ECG shows
Evidence of prior MI
LBBB Second of third degree
AV block
LVH AF
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Other aspects to be considered in risk-stratifying
• Stress test• Ventricular function• COROS LVEF 12- year
survival rate (p<0.0001)
< 35 % 21 %
35-49 % 54 %
> 50 % 73 %
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Treatment goal
• Prevent MI & death• Improve SSx of angina & increase QoL
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Non pharmacological approach
Life style• Smoking cessation
– 36 % risk reduction mortality– 32 % risk reduction non fatal
MI– Nicotine replacement is safe
and cost effective even for CAD patient (take into account risk of depression and suicidal thought)
diet• Variety of fruits and
vegetable.legumes.nuts. Soy products.low fat dairy.whole grain
• Replace saturated & trans-fat (red meat.whole milk . Pastries) with polysaturated fat (oily fish,walnut,sesame. Pumpkin seed.vegetable oil)
• Soluble fibre.oat.peas.bean
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Alcohol restriction. Moderate/beneficial. Insufficient evidence
Physical activity. 30min 3-4x/week
Target BP <130/80
DMGenerally target HbA1c < 6.5 %. Individualize as hypoglycemia worsen angina & increase mortality
Keep waist circumference< 85 cm for men< 80 cm for women
Correct anaemiaCorrect hyperthyroid state
LDL < 1.8 ( primary target) HDL > 1.0 male, 1.2 female( secondary target)
TG < 1.7(secondary target)
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
education
Can also take GTN as preventive measure if
patient know he is going to have attack while carrying
out some activity
If SSx persist more than 10min at rest or not
improved after 3 tablet of GTN, advice to go to
hospital
Self management
During acute anginal attack-Restrain activity-GTN S/L or spray-Sit . Hypotension. Headache after GTN
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Antithrombotic
ASA 75-150mg od. Lower MI, cardiac death or strokeTake into account GI side effect
*double antiplatelet not warranted in angina
Antithrombotic
Clopidogrel 75mg -more effective than ASA in peripheral vascular disease
Ticlopidine – proven efficacy in stroke and post-PCI, no evidence in angina
Lipid lowering
Statin reduce mortality & CV event by 20 – 30 %
Can add ezetimide if target not reached with statin
ACEi
For secondary prevention in post MI + reduced EF < 40 %
Recommended for all patients with CAD esp with concomitant LV dysfunction/DM
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ARB
\as secondary prevention in CAD with Hpt/ CHF / post MI + LV dysfunction / DM if not tolerable to ACEi
Beta blocker
First line treatment in angina- 30 % reduction risk of CV death / MI (beta blocker in post MI trials)
-Beta1 blockade by Metoprolol/bisoprolol reduce cardiac event in CHF-Non selective beta blockade by carvedilol reduce death & CV hospitalisation in CHF
Ivabradine
HR reducing, acting on SA nodeSymptomatic treatment in patient with N`SR, esp with contraindication for beta blocker
No significant interaction with other cardiac drugs
Calcium Channel Blocker
-non dihydropyridine – diltiazem/verapamil, as alternative to beta blocker
-dihydropyridine (long acting) –amlodipine - use in patient reduce coronary intervention but no reduction in treatment endpoints (ie death , MI)
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Nitrates
(long acting – isordil,imdur)
Symptomatic improvement of anginaNo prognostic benefit
Trimetazidine
(Vasteral MR)
symptomatic relief of anginaSafe and effective in patient with ED
Dipyridamole
(Persanthine)
not recommended, poor antithrombotic efficacy in angina
Anticoagulant
Not indicated unless has AF
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
revascularization
• PCI or CABG– In high risk group it is firstline treatment
• Significant LMS ( > 50% stenosis)• Significant proximal mutivessel involvement• Multivessel disease with impaired LV function with
proven viable myocardium– Or if failed medical treatment to control angina
SSx– In asymptomatic patient, consider if there is
extensive inducible ischaemia (stress test)
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
What if it is aMI ?
Chest pain
ECG ,cardiac biomarker
STEMI
Concomitant initial management
Sublingual GTN, continuous ECG monitoring, oxygen, ASA, clopidogrel, analgesia
Assessment for reperfusion
< 3hrs 3-12hrs > 12 hrs
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Onset of symptoms < 3 hrs 3-12 hrs > 12 hrs
Preferred options Primary PCI (preferred in high risk patient or contraindicated for thrombolytic) or fibrinolytic
Primary PCI (if door to balloon time < 90min)
Medical therapy +/- anti thrombotics
Second options fibrinolytics Primary PCI ( if clinically indicated)
Concomitant therapy
Anti thromboticsBeta blockers
ACEi / ARBStatins
NitratesCCB
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Secondary prevention
• Basically similar to angina which includeSmoking cessation diet Regular exercise
BP control Glycemic control Antiplatelet agent*consider dual antiplatelet 1mth-1yr depend on stent used
Beta blocker ACEi and ARB Lipid lowering
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Oral Anticoagulant (warfarin)– If AF– LV thrombus for 3-6mths
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Secondary prevention
• Hormone replacement therapy is not beneficial for secondary prevention
• Postmenopausal women who were taking HRT at the time of STEMI should discontinue it
• Vitamin E and antioxidants have no clinical benefit
• Garlic, lecithin, vitamin A and C are not beneficial
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Heart failure
• Is a complex clinical syndrome results from structural or functional impairment of ventricular filling or ejection of blood
• Cardinal manifestation are dyspnea, fatigue, which may limit effort tolerance, and fluid retention, which may lead to pulmonary or splanchnic congestion or peripheral edema.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Definition of Heart FailureClassification Ejection
FractionDescription
I. Heart Failure with Reduced Ejection Fraction (HFrEF)
≤40% Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFrEF and it is only in these patients that efficacious therapies have been demonstrated to date.
II. Heart Failure with Preserved Ejection Fraction (HFpEF)
≥50% Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified.
a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFpEF.
b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Stages, Phenotypes and Treatment of HF ACC AHA 2013
STAGE AAt high risk for HF but without structural heart
disease or symptoms of HF
STAGE BStructural heart disease
but without signs or symptoms of HF
THERAPYGoals· Control symptoms· Improve HRQOL· Prevent hospitalization· Prevent mortality
Strategies· Identification of comorbidities
Treatment· Diuresis to relieve symptoms
of congestion· Follow guideline driven
indications for comorbidities, e.g., HTN, AF, CAD, DM
· Revascularization or valvular surgery as appropriate
STAGE CStructural heart disease
with prior or current symptoms of HF
THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality
Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists
Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin
In selected patients· CRT· ICD· Revascularization or valvular
surgery as appropriate
STAGE DRefractory HF
THERAPYGoals· Prevent HF symptoms· Prevent further cardiac
remodeling
Drugs· ACEI or ARB as
appropriate · Beta blockers as
appropriate
In selected patients· ICD· Revascularization or
valvular surgery as appropriate
e.g., Patients with:· Known structural heart disease and· HF signs and symptoms
HFpEF HFrEF
THERAPYGoals· Heart healthy lifestyle· Prevent vascular,
coronary disease· Prevent LV structural
abnormalities
Drugs· ACEI or ARB in
appropriate patients for vascular disease or DM
· Statins as appropriate
THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital
readmissions· Establish patient’s end-
of-life goals
Options· Advanced care
measures· Heart transplant· Chronic inotropes· Temporary or permanent
MCS· Experimental surgery or
drugs· Palliative care and
hospice· ICD deactivation
Refractory symptoms of HF at rest, despite GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:· Marked HF symptoms at
rest · Recurrent hospitalizations
despite GDMT
e.g., Patients with:· Previous MI· LV remodeling including
LVH and low EF· Asymptomatic valvular
disease
e.g., Patients with:· HTN· Atherosclerotic disease· DM· Obesity· Metabolic syndrome orPatients· Using cardiotoxins· With family history of
cardiomyopathy
Development of symptoms of HF
Structural heart disease
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Classification of Heart FailureACCF/AHA Stages of HF NYHA Functional Classification
A At high risk for HF but without structural heart disease or symptoms of HF.
None
B Structural heart disease but without signs or symptoms of HF.
I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
C Structural heart disease with prior or current symptoms of HF.
I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.
II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.
III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.
IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.
D Refractory HF requiring specialized interventions.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Physical examination• BMI and evidence of weight loss• Bp, supine and upright( orthostatic changes – volume depletion)• Pulse – strength and regularity• JVP• Extra heart sound, murmur, apex beat displacement, RV heave• Pulmonary status• Hepatomegaly• Peripheral edema
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Lab investigation• Class I• 1.Initial laboratory evaluation of patients presenting with HF should include complete
blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, and thyroid-stimulating hormone. (Level of Evidence: C)
• 2.Serial monitoring, when indicated, should include serum electrolytes and renal function. (Level of Evidence: C)
• 3.A 12-lead ECG should be performed initially on all patients presenting with HF. (Level of Evidence: C)
• Class Iia• 1.Screening for hemochromatosis or HIV is reasonable in selected patients who present
with HF (Level of Evidence: C)• 2.Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are
reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. (Level of Evidence: C)
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Recommendations for Biomarkers in HFBiomarker, Application Setting COR LOE
Natriuretic peptides
Diagnosis or exclusion of HFAmbulatory,
AcuteI A
Prognosis of HFAmbulatory,
AcuteI A
Achieve GDMT Ambulatory IIa BGuidance of acutely decompensated HF therapy
Acute IIb C
Biomarkers of myocardial injury
Additive risk stratificationAcute,
Ambulatory I A
Biomarkers of myocardial fibrosis
Additive risk stratification
Ambulatory
IIb B
AcuteIIb A
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Recommendations for Noninvasive Imaging
Recommendation COR LOE
Patients with suspected, acute, or new-onset HF should undergo a chest x-ray
I C
A 2-dimensional echocardiogram with Doppler should be performed for initial evaluation of HF
I C
Repeat measurement of EF is useful in patients with HF who have had a significant change in clinical status or received treatment that might affect cardiac function, or for consideration of device therapy
I C
Noninvasive imaging to detect myocardial ischemia and viability is reasonable in HF and CAD
IIa C
Viability assessment is reasonable before revascularization in HF patients with CAD
IIa B
Radionuclide ventriculography or MRI can be useful to assess LVEF and volume
IIa C
MRI is reasonable when assessing myocardial infiltration or scar IIa B
Routine repeat measurement of LV function assessment should not be performed
III: No Benefit
B
HFSA 2010 Comprehensive Heart Failure Practice Guideline
Key Recommendations
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:
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 GoalsRisk Factor Goal
Hypertension Generally < 130/80
Diabetes See ADA guidelines1
Hyperlipidemia See NCEP guidelines2
Inactivity 20-30 min. aerobic 3-5 x wk.
Obesity Weight reduction < 30 BMI
Alcohol Men ≤ 2 drinks/day, women ≤ 1
Smoking Cessation
Dietary Sodium Maximum 2-3 g/day 1Diabetes Care 2006; 29: S4-S42
2JAMA 2001; 285:2486-97
Adapted from:
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;338:1281-5 (STOP-HypertensionJAMA 1997;278:212-6 (SHEP)UKPDS Group. UKPDS 38. BMJ 1998;317:703-713
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (3.3-3.4)
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
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;342:145-53 (HOPE)Lancet 2003;362:782-8
(EUROPA)
02468
10121416
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
Placebo
Ramipril
Placebo
Perindopril
20% rel. risk red. p = .0003
22% rel. risk red. p < .001
HOPE
EUROPA
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% 0
0.1
0.2
0.3
0 0.5 1 1.5 2 2.5 3 3.5 4
Placebo
Captopril
Years
MortalityRate
19% rel. risk reduction
p = 0.019
Pfeffer et al. NEJM 1992;327:669-77
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 EvaluationRecommended 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:
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 AssessmentsRecommended 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
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:
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 Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Captopril Capoten 6.25 mg tid 50 mg tid 122.7 mg/day
Enalapril Vasotec 2.5 mg bid 10 mg bid 16.6 mg/day
Fosinopril Monopril 5-10 mg qd 80 mg qd N/A
Lisinopril Zestril, Prinivil
2.5-5 mg qd 20 mg qd 4.5 mg/day, 33.2 mg/day*
Quinapril Accupril 5 mg bid 80 mg qd N/A
Ramipril Altace 1.25-2.5 mg qd 10 mg qd N/A
Trandolapril Mavik 1 mg qd 4 mg qd N/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.
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
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
Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD
Study Drug
HF Severity
Target Dose (mg)
Outcome
US Carvedilol1 carvedilol mild/ moderate
6.25- 25 BID
↓48% disease progression (p= .007)
CIBIS-II2 bisoprolol moderate/ severe
10 QD ↓34% mortality (p <.0001)
MERIT-HF3 metoprolol succinate
mild/ moderate
200 QD ↓34% mortality (p = .0062)
COPERNICUS4 carvedilol severe 25 BID ↓35% mortality (p = .0014)
CAPRICORN5 carvedilol post-MI LVD
25 BID ↓23% mortality (p =.031)
1Colucci WS et al. Circulation 1196;94:2800-6. 2CIBIS II Investigators. Lancet 1999;353:9-13.3MERIT-HF Study Group. Lancet 1999;353:2001-7. 4Packer M et al. N Engl J Med 2001;3441651-8. 5The CAPRICORN Investigators. Lancet 2001;357:1385-90.
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
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
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 Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Bisoprolol Zebeta 1.25 mg qd 10 mg qd 8.6 mg/day
Carvedilol Coreg 3.125 mg bid 25 mg bid 37 mg/day
Carvedilol Coreg CR 10 mg qd 80 mg qd
Metoprolol succinate CR/XL
Toprol XL 12.5-25 mg qd 200 mg qd 159 mg/day
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
Strength of Evidence = A
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 Name Initial Daily Dose
Target Dose Mean Dose in Clinical Trials
Candesartan Atacand 4-8 mg qd 32 mg qd 24 mg/day
Losartan Cozaar 12.5-25 mg qd 150 mg qd 129 mg/day
Valsartan Diovan 40 mg bid 160 mg bid 254 mg/day
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.14-7.15)
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
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
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
Diuretic refractoriness may represent patient nonadherence or progression of underlying dysfunction.
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Loop Diuretics
Agent Initial Daily Dose
Max Total Daily Dose
Elimination: Renal – Met.
Duration of Action
Furosemide 20-40mg qd or bid
600 mg 65%R-35%M 4-6 hrs
Bumetanide 0.5-1.0 mg qd or bid
10 mg 62%R/38%M 6-8 hrs
Torsemide 10-20 mg qd 200 mg 20%R-80%M 12-16 hrs
Ethacrynic acid
25-50 mg qd or bid
200 mg 67%R-33%M 6 hrs
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Potassium-Sparing Diuretics
Agent Initial Daily Dose
Max Total Daily Dose
Elimination Duration of Action
Spironolactone 12.5-25 mg qd
50 mg Metabolic 48-72 hrs
Eplerenone 25-50 mg qd
100 mg Renal, Metabolic
Unknown
Amiloride 5 mg qd 20 mg Renal 24 hrs
Triamterene 50-75 mg bid
200 mg Metabolic 7-9 hrs
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
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:
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (11.1-11.2)
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
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Figure 11.3. Diagnostic Algorithmfor HF with Preserved LVEF
HF with Preserved LVEF
Dilated LV Non-dilated LV
Valvular diseaseAR, MR
No valvular dis.High output HF
Increasedthickness
NormalThickness
Right vent.dysfunction
Pulmonaryhypertension
Isolated pre-dominant RVMI
No mitralobstruction
Mitral obstructionMS, atrial myxoma
Pericardial dis.Tamponade Constriction
No pericardial disease
Inducible ischemiaIntermittent/active
ischemia
Normal or increased QRS
Hypertrophic dis.
Low QRS voltageInfiltrative myopathy
No aortic valve disease
Aortic valve dis.Aortic stenosis
No hypertensive history of PE
HCM, Fabry dis.
Hypertensive history of PE
Hypertensive-HCM
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 diagnosisof HF
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Case scenario 2• A 55 yo man presents with gradually increasing shortness of breath and
leg swelling that occurred while on a business trip. He has congestive heart failure, which has caused fatigue and shortness of breath if he walks a block or climbs a flight of stairs. BP is 140/ 90; there is no jugular venous distension or gallop, and only minimal pedal edema. AN echo shows left ventricular EF 45 %. Current medication include aspirin and simvastatin. The patient desires to keep medications to a minimum. What additional treatments are indicated at this time?
• A. Spironolactone• B. ACE inhibitor and beta blocker• C. Digoxin• D. Frusemide• E. An implantable defibrillator
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
• Answer is B• ACE inhibitor is recommended in both symptomatic n
asymptomatic heart failure• Beta blocker stabilize left ventricular remodeling• Spironolactone recommended for NYHA III-IV with EF <35%
despite on loop diuretic + ACEi + b blocker• Frusemide can improve SSx but patient wants to keep
medication to minimal• Defibrillator not indicated yet
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Cardiac rehabilitation
• Coordinated interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing or slowing the progress of underlying atherosclerotic process, thereby reducing morbidity and mortality.
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Cardiac rehabilitation
• Include – baseline patient assesssment, – nutritional counselling, – aggressive risk factor management ie
• lipid, hpt, weight, diabetes and smoking, – psychosocial and vocational counseling , and – physical activity counseling and exercise training, in
addition to – appropriate use of cardioprotective drugs that have
evidence-based efficacy for secondary prevention
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Who should be included in cardiac rehab ?
• Patient with previous MI• Who had undergone CABG• Those with PCI done• Heart transplant candidate or recipient• Who has stable chronic heart failure,
peripheral arterial disease
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Psychosocial intervention (address depression,
anxiety, social isolation. Consider SSRI, cognitive behavioral therapy.
Risk factor modification & interventionAggresive reduction of risk factors via nutritional counselling, weight management, adherence to drug therapy
Exercise training interventionReturn to workCardioprotective mechanism (improve endothelial function)
Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Thank you for your kind attention