CCS HEART FAILURE WORKSHOP THE PRACTICAL MANAGEMENT OF HEART FAILURE – 2012 UPDATE

WELCOME!

Learning Objectives

At the conclusion of this workshop, participants will be able to: 1. Review changes and updates for optimal management of chronic and acute heart failure; updating 2006 recommendations to 2012 context and environment; 2. Discuss exercise for heart failure patients - where to begin, what to do and where to end; and 3. Identify opportunities and challenges of surgery for patients with an ischemic etiology for heart failure.

Heart Failure Guidelines

Acute Heart Failure

What is heart failure?

•

Chronic Heart Failure (CHF):

–

Heart failure is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion.

•

Acute Heart Failure Syndrome (AHF):

– “

gradual or rapid change in heart failure signs and symptoms resulting in the need for urgent therapy

” Heart Failure Guidelines

Classification of AHF

usually a hx of prog. worsening of known chronic HF on Rx, and evidence of systemic/pulmonary congestion. high BP, +/- preserved LV systolic fxn; increased sympathetic tone with ↑HR, vasoconstriction; may be euvolaemic or only mildly hypervolemic, and frequently with signs of pulmonary or systemic congestion Severe respiratory distress, ↑RR, orthopnea, rales. O2 sats <90% RA prior to O2 Clinical and lab evidence of an ACS; ~15% of patients with an ACS have signs and symptoms of HF. Episodes of AHF are frequently assoc w/ or precipitated by arrhythmia (bradycardia, AF, VT).

Usually sys BP <90 mmHg or drop in MAP >30 mmHg and absent/low urine output. Organ hypoperfusion and pulmonary congestion develop rapidly Heart Failure Guidelines low output in absence of pulmonary congestion with increased JVP, w/ or w/out HSM, and low LV filling pressures ESC 2008

Has care evolved?

Morphine Sedation

1950

Morphine

1974

Dietary sodium restriction Strict bed rest Digitalis Mercurial diuretics Venesection Oxygen Dietary sodium restriction Inotropes Diuretics Vasodilators Morphine?

2012

Oxygen?

Dietary sodium restriction?

Early mobilization Avoid inotropes ?Diuretics

?Vasodilators

Harrison ’ s Principles of Internal Medicine 1 st Ramirez A

et al

.

N Engl J Med

Edition (1950) 1974;290(9):499-501 Heart Failure Guidelines

CASE 1

• • •

74 year old female

•

2 months worsening SOB/orthopnea

•

Presented to ED after Chinese food Past Hx unclear, no meds Physical exam

•

HR 98, BP 142/82, RR 28, temp 36.0C

•

JVP elevated, crackles, pulses 2+, legs warm and LEE+

Heart Failure Guidelines

CASE 1

• • •

74 year old female CXR = pending Labs = pending

Heart Failure Guidelines

…

prepare to provide your answer!

Heart Failure Guidelines

How confident are you that it is AHF?

1. <20% 2. 21-40% 3. 41-60% 4. 61-80% 5. >80%

Heart Failure Guidelines

How confident are you that it is AHF?

1. <20% 2. 21-40% 3. 41-60% 4. 61-80% 5. >80%

No right answer Heart Failure Guidelines

AHF Dx Scoring systems

Predictor Elevated NT-proBNP Interstitial edema on CXR Orthopnea Absence of fever Current loop diuretic use Age > 75 years Rales on lung examination Absence of cough Interpretation Points 4 2 2 2 1 1 1 1 Our Case ?

?

2 1 1 4

e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93 Baggish AL, et al. Am Heart J 2006; 151: 48-54].

Heart Failure Guidelines

CASE 1

• • •

74 year old female CXR = increased pulmonary markings c/w edema, no evidence of COPD Labs = troponin I 0.20

– –

BNP 728 pg/ml Creatinine 130

Heart Failure Guidelines

AHF Dx Scoring systems

Predictor Elevated NT-proBNP Interstitial edema on CXR Orthopnea Absence of fever Current loop diuretic use Age > 75 years Rales on lung examination Absence of cough Interpretation Points 4 2 2 2 1 1 1 1 Our Case 4 2 2 1 1 10

e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93 Baggish AL, et al. Am Heart J 2006; 151: 48-54].

Heart Failure Guidelines

CCS 2012

We recommend the use of a validated diagnostic scoring system for patients in whom the diagnosis of AHF is being considered (Strong Recommendation, Moderate Quality Evidence).

e.g. PRIDE score, Boston criteria This recommendation places a relatively high value on evaluating the constellation of clinical findings in a patient with suspected AHF and less value on an individual physical examination finding, presenting symptom or investigation. Heart Failure Guidelines

CCS 2012

• We recommend that in the clinical scenario when the clinical diagnosis of AHF is of

intermediate pre-test probability

, NP level be obtained to

rule-out

(BNP <100 pg/ml; NT-proBNP <300 pg/ml) or

rule-in

(BNP >500 pg/ml; NT-proBNP >900 pg/ml if age 50-75 years, NT-proBNP >1800 if age >75 years) AHF as the cause for the presenting symptoms suspicious of AHF (Strong Recommendation, Moderate Quality Evidence) Heart Failure Guidelines

CCS 2012: Practical Tips

• A precipitating cause for AHF should be sought.

• An ECG and a chest x-ray should be performed within 2 hours of initial presentation.

• Initial blood tests should include: complete blood count, creatinine, blood urea nitrogen, glucose, sodium, potassium, and troponin.

Heart Failure Guidelines

CCS 2012: Practical Tips

• A transthoracic echocardiogram should be performed within 72 hours of presentation. • For patients with a prior echocardiogram, another is not required unless there has been a significant change in clinical status requiring investigation, a lack of clinical response to appropriate therapy and/or it is greater than 12 months since the prior echocardiogram.

Heart Failure Guidelines

CASE 2

• 52 year old male with history of HF – Presented to ED after the Edmonton Oilers won the Stanley Cup • SOBOE, orthopnea • HR 98, BP 99/52, RR 24, temp 36.0c

• JVP difficult to assess (thick neck) • crackles • pulses weak, legs cool and LEE • Trop 0.15

Heart Failure Guidelines

…

prepare to provide your answer!

Heart Failure Guidelines

Where on this table does this pt fit?

1

Dry and Warm

2

Wet and Warm Increasing Perfusion/ Cardiac Output

3

Dry and Cold

4

Wet and Cold Increasing Congestion / PCWP Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804 Heart Failure Guidelines

Where on this table does this pt fit?

1.

2.

3.

4.

Dry and Warm Wet and Warm Dry and Cold Wet and Cold 1 0% 0% 2 0% 3 0% 4

Heart Failure Guidelines

Where on this table does this pt fit?

1

Dry and Warm

2

Wet and Warm Increasing Perfusion/ Cardiac Output

3

Dry and Cold

4

Wet and Cold Increasing Congestion / PCWP Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804 Heart Failure Guidelines

Admit or discharge?

Heart Failure Guidelines

Heart Failure Guidelines

Treatment options?

Heart Failure Guidelines

CCS 2012: Oxygen

• We recommend supplemental oxygen be considered for patients who are hypoxemic; titrated to an oxygen saturation >90% (Strong Recommendation, Moderate Quality Evidence).

Values and Preferences

: This recommendation places relatively higher value on the physiologic studies demonstrating potential harm with the use of excess oxygen in normoxic patients and less value on long term clinical usage of supplemental oxygen without supportive data.

Heart Failure Guidelines

CCS 2012: CPAP/BIPAP

We recommend CPAP or BIPAP not be used

routinely

(Strong Recommendation, Moderate Quality Evidence).

Values and Preferences:

This recommendation places high weight on RCT data with a demonstrated lack of efficacy and with safety concerns in routine use. Treatment with BIPAP/CPAP may be appropriate for patients with persistent hypoxia and pulmonary edema.

Heart Failure Guidelines

CASE 2

• 52 year old male with history of HF – Presented to ED after the Edmonton Oilers won the Stanley Cup • SOBOE, orthopnea • HR 98, BP 99/52, RR 24, temp 36.0c

• JVP difficult to assess (thick neck) • crackles • pulses weak, legs cool and LEE • Trop 0.15

Heart Failure Guidelines

…

prepare to provide your answer!

Heart Failure Guidelines

How much diuretic will you give and how?

1. IV lasix 20 mg bid 2. IV lasix 40 mg bid 3. IV lasix 80 mg bid 4. IV lasix 10 mg/hour infusion 5. Other choice

Heart Failure Guidelines

DOSE: Study Design

Acute Heart Failure (1 symptom AND 1 sign) <24 hours after admission 2x2 factorial randomization Low Dose (1 x oral) Q12 IV bolus Low Dose (1x oral) Continuous infusion e.g.

Home dose = 40 mg BID Bolus = 80 (low) 200 (high) High Dose (2.5 x oral) Q12 IV bolus 48 hours 1) Change to oral diuretics 2) continue current strategy 3) 50% increase in dose 72 hours

Co-primary endpoints

60 days Heart Failure Guidelines High Dose (2.5 x oral) Continuous infusion Felker,

NEJM

2011

DOSE: Co-Primary Endpoints

• •

Efficacy:

–

Patient Global Assessment by visual analog scale over 72 hours using area under the curve Safety:

–

Change in creatinine from baseline to 72 hours

Heart Failure Guidelines

DOSE: patient global assessment

Heart Failure Guidelines

DOSE: Death, Rehosp, ER visit

Heart Failure Guidelines

DOSE-AHF Conclusions

• •

There was no statistically significant difference in global symptom relief or change in renal function at 72 hours for either:

•

bolus vs. infusion or low vs. high No clinical differences…but

–

High was associated with favorable trends:

– – – –

Symptom relief (global assessment and dyspnea) Weight loss and net volume loss Proportion free from signs of congestion Reduction in NT-proBNP

Heart Failure Guidelines

CCS 2012: Diuretics

We recommend intravenous diuretics be given as first line therapy for patients with congestion (Strong Recommendation, Moderate Quality Evidence).

We recommend for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (e.g. twice daily) or as a continuous infusion (Strong Recommendation, Moderate Quality Evidence).

Heart Failure Guidelines

Diuretic dosing for ADHF Creatinine clearance* Patient Initial IV dose † Maintenance dose ≥ 60 mL/min/1.73m

2 New-onset HF or no maintenance diuretic therapy Furosemide 20-40 mg 2-3 times daily Lowest diuretic dose that allows for Established HF or chronic oral diuretic therapy Furosemide bolus equivalent to oral dose clinical stability is the ideal dose < 60 mL/min/1.73m

2 New-onset HF or no maintenance diuretic therapy Furosemide 20-80 mg 2-3 times daily Established HF or chronic oral diuretic therapy Furosemide bolus equivalent to oral dose

*Creatinine clearance is calculated from the Cockroft-Gault or Modified Diet in Renal Disease formula. See text for details.

† Intravenous continuous furosemide at doses of 5 to 20mg/h is also an option.

Practical Tips When Response to Diuretic is Suboptimal

• Reevaluate the need for additional diuresis by assessing volume status • Restrict NA+/H2O intake (and exercise caution reducing oral intake below 500 ml per 24 hours).

• Review diuretic dosing. Higher bolus doses will be more effective than more frequent lower doses. Diuretic infusions (eg, furosemide 20-40 mg bolus then 5-20 mg/h) can be a useful strategy when other options are not available.

• Add another type of diuretic with different site of action (thiazides, spironolactone). Thiazide diuretics (eg oral metolazone 2.5-5 mg OB/BID or hydrochlorothiazide 25-50 mg) are often given at least 30 minutes before the loop diuretic to enhance diuresis, although this is not required to have an adequate effect.

• Consider hemodynamic assessment and/or positive inotropic agents if clinical evidence of poor perfusion coexists with diuretic resistance.

• Refer for hemodialysis, ultrafiltration, or other renal replacement strategies if diuresis is impeded by renal insufficiency.

Heart Failure Guidelines

…

prepare to provide your answer!

Heart Failure Guidelines

For a persistently symptomatic patient with HF, what is next option?

1. Higher dose lasix 2. Different diuretic 3. Add vasodilator 4. Add inotropic agent 5.

Patience….

6. Other choice

Heart Failure Guidelines

CCS 2012: Vasodilators

• We recommend the following intravenous vasodilators, titrated to systolic blood pressure (SBP) > 100 mmHg, for relief of dyspnea in hemodynamically stable patients (SBP > 100 mmHg): a) Nitroglycerin (Strong Recommendation, Moderate Quality Evidence); b) Nesiritide (Weak Recommendation, High Quality Evidence); c) Nitroprusside (Weak Recommendation, Low Quality Evidence).

AHA 2012: RELAX-AHF, CARRESS Heart Failure Guidelines

CCS 2012: Inotropes

• We recommend hemodynamically stable patients do not routinely receive inotropes like dobutamine, dopamine or milrinone (Strong Recommendation, High Quality Evidence).

•

Values and Preferences

These recommendations for inotropes place high value on the potential harm demonstrated when systematically studied in clinical trials and less value on potential short term hemodynamic effects of inotropes.

Heart Failure Guidelines

Do I stop the beta-blockers on admission?

• Cohorts suggest continuing beta-blockers advantageous • RCT: B-CONVINCED – Keep vs. Stop strategy in known HF pts on beta-blockers – Keep was non-inferior to Stop.

– Does not delay clinical improvement – Predicts staying on BB in the longer term Heart Failure Guidelines Eur Heart J 2009; 30:2186-92

RESYNCHRONIZATION THERAPY and DEVICES

Anique Ducharme, MD MSc FRCPC

Conflict Disclosures

The speaker has received fees/honoraria from the following sources: Abbott vascular, Medtronic, Merck, Otsuka, Pfizer, Sorin & St-Jude Medical None of the drugs, devices, or treatment modalities mentioned in this presentation are non approved indications.

Anique Ducharme, Institut de Cardiologie de Montréal, Université de Montréal

A Case of Mild Heart Failure

• 61 years old female, previous MI, • stable NYHA II, LVEF 25% • On optimal dose of lisinopril, eplerone and bisoprolol, occasional diuretics • Has not been assessed for device Rx • BP 99/67 mmHg, HR 76 bpm • K, 4.7 mEq/L; NT-proBNP 4500 pg/mL • EKG: old anterior MI, LBBB QRS 155 ms.

Heart Failure Guidelines

…

prepare to provide your answer!

Heart Failure Guidelines

You started treating this patient with mild symptoms of HF and low ejection fraction with epleronone as recommended. Dosage was increased up to 50 mg without side effects. What do you do next?

1. Angiotensin receptor blocker 2. ICD 3. CRT 4. CRT + ICD (CRT-D)

Heart Failure Guidelines

CRT in Patients with Mild HF Symptoms: MADIT-CRT

1820 pts, mostly NYHA II, CRT+ICD vs ICD alone Low risk population, annual mortality ~3% 40% reduction in HF events in CRT-ICD group Moss et al, NEJM 2009 Heart Failure Guidelines

RAFT: Death or HF hospitalization

Outcome ICD (N=904) ICD-CRT (N=894) Primary outcome Death or hospitalization for HF Secondary outcomes Death from any cause 363 (40.3%) 236 (26.1%) 297 (33.2%) 186 (20.8%) Hazard ratio (95% CI)

P value

0.75 (0.64 0.87) <0.001

Hospitalization for HF 236 (26.1%) 174 (19.5%) 0.75 (0.62 0.91) 0.68 (0.56 0.83) 0.003

<0.001

1800 pts, 80% NYHA II CRT-D vs ICD Median follow-up 40 months Tang AS, et al. N Engl J Med 2010 Heart Failure Guidelines

CRT: Mortality reduction

Al-Majed et al, Annals of Internal Medicine 2011

Heart Failure Guidelines

CRT: HF Hosp reduction

Al-Majed et al, Annals of Internal Medicine 2011

Heart Failure Guidelines

Medical Therapy in Perspective

RAFT 1800 pts, 80% NYHA II CRT-D vs ICD; median f/u 40 months EMPHASIS HF 2700+ patients, NYHA II Eplerenone vs Placebo; median f/u 21mo

25% reduction in mortality 25% reduction in mortality

Tang et al, N Engl J Med 2010 Heart Failure Guidelines Zannad et al, N Engl J Med, 2010

Recommendation 2011 (Update)

• We recommend the use of CRT in combination with an ICD for HF patients on optimal medical therapy with NYHA II HF symptoms, LVEF < 30%, and QRS duration > 150 ms. (

Strong Recommendation, High Quality Evidence

) Heart Failure Guidelines

Practical tips

• QRS> 150 ms based on a subgroup analysis of MADIT-CRT and RAFT studies – Most LBBB are >150 msec • The selection of patients should be individualized and based on risk features Heart Failure Guidelines

CRT for Everyone?…Maybe not

•

Not everyone will benefit

“

Non-response

”

is ~30% depending on the definition of:

• • • • • •

Death Hospitalization Failure to improve 1 NYHA functional class Failure to improve peak VO2 or 6 min walk distance Absence of reverse remodelling (LVESV or EF) Absence of improvement in dyssynchrony

Heart Failure Guidelines

Consider Risks vs Benefits: Real World

N = 1081 ICD replacements N = 713 Upgrade Procedures Krahn et al, Ont ICD Database Circulation 2011 Poole et al, REPLACE Registry Circulation 2010 Heart Failure Guidelines

Importance of Patient Selection

•

Much uncertainty persists:

–

Narrow QRS with mechanical dyssynchrony

–

LV dysfunction and chronic RV pacing

–

Atrial fibrillation and LBBB

–

Right bundle branch block

–

Asymptomatic patients

–

Class IV/Stage D patients

Heart Failure Guidelines

Recommendation

• Routine CRT implantation is not currently recommended for patients with heart failure and narrow QRS (<120 ms)

Practical tips

• Patients enrolled in CRT studies who show benefit have a QRS duration >150ms, on average. The benefit in patients with QRS 120ms to 150ms is less clear • Echocardiography derived parameters of dyssynchrony cannot be recommended on a routine basis since clinical utility has not been established Heart Failure Guidelines

Practical tip

• The use of CRT may prevent worsening in patients with LV systolic dysfunction who require permanent pacing and who are expected to have a high burden of ventricular pacing Heart Failure Guidelines

The ACEI-ARB-MRA Dilemma

Jonathan Howlett MD Disclosures at www.hfcc.ca

…

prepare to provide your answers!

Heart Failure Guidelines

Case 1.

34 year old female with NYHA FC II HF with LVEF 29% BP 130/70, HR 63, Na 139, Creat 100, K+ 4.0

On BB, ACE, diuretic target doses.

Which drug should you start next?

A. ARB B. Aldo Inhibitor C. Neither D. Does not matter, going for device anyway Heart Failure Guidelines

Case 2.

64 year old female with NYHA FC I HF with LVEF 29% BP 160/70, HR 63, Na 139, Creat 100, K+ 4.2

On BB, ACE, CCB, diuretic target doses.

Which drug should you start next?

A. ARB B. Aldo Inhibitor C. Neither D. Both Heart Failure Guidelines

Case 3.

84 year old female with NYHA FC IIIb HF with LVEF 29% BP 100/70, HR 70, Na 139, Creat 160, K+ 4.7

On BB, ACE, Digoxin, diuretic optimal doses.

Which drug should you start next?

A. ARB B. Aldo Inhibitor C. Neither- I will use nitrates preferentially D. Both Heart Failure Guidelines

When to Use ARBs as Add-on Therapy?

•

In patients with persistent HF symptoms, and who are at increased risk of HF hospitalization, despite optimal treatment with ACE inhibitors and beta blockers (Class I, Level A) CHARM

– Proportion of patients with CV death or hospital admission for CHF

Val-HeFT

– Probability of freedom from combined endpoint (All-cause mortality, cardiac arrest with resuscitation, hospitalization for worsening HF, or therapy with intravenous inotropes or vasodilators) Pfeffer MA et al.

Lancet

2003;363:759-66. Cohn JN et al.

N Engl J Med

2001;345:1667-75.

Arnold JMO et al.

Can J Cardiol

2006;22(1):23-45.

Heart Failure Guidelines

CHARM-Added Permanent study drug discontinuations

Percent of patients 25

24.2

Placebo Candesartan

What are the effects of Spiro?

20

18.3

15 10 5 0 AE/ lab. abnorm.

p=0.0003

3.1

4.5

4.1

7.8

Hypo tension Increased creatinine Heart Failure

p=0.0001

3.4

0.7

Increased potassium

p<0.0001

2006 Recommendation

•

Patients with LVEF



30% and severe symptoms despite optimized other therapies (Class I, Level B)

•

Or with AHF with an LVEF less than 30% following acute myocardial infarction (Class IIa, level B)

Heart Failure Guidelines 69

EMPHASIS: Baseline Characteristics

Characteristic

Mean age — yr Female sex — % Ischemic heart disease – % Blood pressure – mm Hg Atrial fibrillation or flutter – % Diabetes mellitus — no. (%) Serum Creatinine – mg/dl Estimated GFR ml/min/1.73 m 2 < 60 ml/min/1.73 m 2 – no. (%) Serum Potassium – mmol/liter

Zannad, NEJM 2011; 364:11-21 Eplerenone (N=1364)

68.7 (7.7) 22.7% 70 124 ± 17/75 ± 10 30 34 1.14 (0.30) 71.2 (21.9) 32 4.3 (0.4) Heart Failure Guidelines

Placebo (N=1373)

68.6 (7.6) 21.9% 68 124 ± 17/75 ± 10 32 29 1.16 (0.31) 70.4 (21.7) 35 4.3 (0.4)

EMPHASIS: Primary Endpoint

50 HR [95% CI] = 0.63 [0.54, 0.74] P < 0.0001

40 30 20 Placebo 356 (25.9) Eplerenone 249 (18.3) 10 0 0 1 2 3 Years from Randomization No. at Risk Placebo 1373 848 512 199 Eplerenone 1364 925 562 232 40 HR [95% CI] = 0.58 [0.47, 0.70] P < 0.0001

30 20 10 Placebo 253 (18.4) Eplerenone 164 (12.0) 0 0 1 2 3 Years from Randomization No. at Risk Placebo 1373 848 512 199 Eplerenone 1364 925 562 232 213 (15.5) 171 (12.5)

*Unadjusted HR, 0.78; 0.64, 0.95; p=0.01

Heart Failure Guidelines 71

Patient Follow-up and Dosing

Discontinuations in surviving patients (%) Discontinuations for AE – n (%) Mean dose at month 5 (mg/day) * p = 0.09

Eplerenone

16.3% 188 (13.8%) 39.1 ± 13.8

Placebo

16.6% 222 (16.2%)* 40.8 ± 12.9

Heart Failure Guidelines

Recommendation 2011

• •

We recommend that an aldosterone receptor blocking agent such as eplerenone be considered for patients with mild to moderate (NYHA II) HF, aged > 55 years with LV systolic dysfunction (LVEF < 30%, or if LVEF is 30% and 35% with QRS duration >130 ms), and recent hospitalization for CVD or elevated BNP/NT-pro BNP levels, who are on standard HF therapy (Strong Recommendation, High-Quality Evidence)

Heart Failure Guidelines

Combination RAAS Blockade- Options Add an ARB      • Mean BP reduction 5-7 / 3-5 mmHg • Mean Δ in creatinine < 30 umol/L • Mean Δ in potasssium 0.3 Mmol/L • Reduction in CHF/CV Death in Mild/mod HF • Evidence with triple therapy Combination RAAS Blockade Add Spironolactone Mean BP reduction Mean Δ in creatinine Mean Δ in potasssium Trials stopped early in ‘ enhanced moderate HF ’ No evidence in triple therapy -1 to +5/ _1+3 mmHg < 50 umol/L 0.5- 0.9 Mmol/L Heart Failure Guidelines

But we vote with our feet!

Heart Failure Guidelines

Fonarow, Circulation 2011.; p 1601-10 Heart Failure Guidelines

CHF Clinics Increased use of EBM versus Community- the First 1933 Patients EB Therapy First visit from Community (n= 1155) Previously seen in clinic (n= 778) P value

Age (SD) 62 (16) 63 (14) ns LVEF (SD) ACE inhibitor (%) ACE inhibitor (% at target) Diuretic (%) 30 (14) 79 25 31 (14) 81 60 49 66 Beta Blocker (%) 49 Aldo Antagonist (%) 15 J Card Fail, Volume 7, Issue 3 Suppl 2, p.90 (2001) 58 30 Heart Failure Guidelines ns ns 0.01

0.01

0.01

0.01

Impact of HF Clinic Care on LVEF in Canadians with HF

• • •

21 Clinics with data from 1999-2010 599 patients with LVEF data at 0, 1,2 years 74% male, 63% ischemic etiology Measurement Baseline Assessment (SD) Year 1 follow up (SD) Year 2 follow up (SD) P value baseline to 2 years (SD)

LVEF Improve by > 20% Improve by >10% ACE use ACE or ARB Beta blocker use Aldo Antagonist Eur Heart J 2011;32 (suppl 1) 32 (14) baseline ACE inhibitor (%) 54% 70% 63% 38 (15) 30 (14) 79 69% 93% 85% 38 (14) 31 (14) 81 69% 95% 85% 21% 35% Heart Failure Guidelines 45% p< 0.001

p< 0.001

p< 0.001

p< 0.001

p< 0.001

p< 0.001

P< 0.001

Management of Patients with HF and Acute Intercurrent Medical Illness

•

HF patients with an acute dehydrating illness of any kind should undergo prompt evaluation (electrolytes, BUN, Crcl).

•

If diarrhea or vomiting occurs, the aldosterone blocker should be stopped until resolution.

•

Caution is also necessary when there are other potential causes of dehydration, including increase in diuretic dose.

Canadian Cardiovascular Society Consensus Conference recommendations update 2007 American College of Cardiology Foundation/American Heart Association practice guidelines 2009 Heart Failure Guidelines 79

Suggested addition…….

•

Most of the time, the Aldosterone Antagonist is the way to go

•

Monitoring is the most important aspect of Rx

•

Triple therapy is discouraged outside special circumstances

•

Role for ARBs if:

–

Very high BP

–

Difficulty with K+ high

–

Cannot tolerate AA due to side effects

–

Osteoarthritis?

Heart Failure Guidelines

Should all patients with HF exercise and how?

Eileen O ’Meara, M.D.

…

prepare to provide your answer!

Heart Failure Guidelines

EXERCISE TRAINING IN CHRONIC HEART FAILURE QUESTION 1. TRUE OR FALSE?

All patients with stable New York Heart Association (NYHA) class I-III should be considered for enrolment in a tailored exercise training program, in order

to improve exercise tolerance and quality of life

. A. True B. False Heart Failure Guidelines

The benefits of rehabilitation in HF

It is now well recognized that exercise-based cardiac rehabilitation programs for patients with HF improve exercise capacity, skeletal and respiratory muscle function, quality of life, autonomic function, biomarkers, and reduce depressive symptoms as well as cardiovascular risk factors .

Piepoli MF et al. Eur J Heart Fail 2011; 13(4): 347 –357.

Vanhees L et al. Eur J Cardiovasc Prev Rehabil 2011.

Based on the results of prior studies of exercise training, the Canadian Cardiovascular Society has adopted recommendations that physical activity be considered for stable patients with systolic dysfunction.

Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 2006;22(1):23 –45. Heart Failure Guidelines

The HF-ACTION trial



The HF-ACTION trial demonstrated no significant reduction in the combined endpoint of all-cause mortality or hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.84

–1.02; P=0.13).



After adjusting for 4 covariables associated with an increase in the primary endpoint and for HF etiology, exercise training was found to reduce the incidence of all-cause mortality or all-cause hospitalization by 11% (HR, 0.89; 95% CI, 0.81

–0.99; P = 0.03).



exercise training conferred modest but statistically significant improvements in self-reported health status.

O

’

Connor CM et al. JAMA 2009; 301: 1439 –1450.

Flynn KE et al. JAMA 2009; 301: 1451 –1459.

Heart Failure Guidelines

The case of Madame T…

• • • • • • •

2007: 42 y.o. patient presents with EF 38% and sustained VT. No significant CAD on angio.

Diagnosis: Familial cardiomyopathy 2007 - A defibrillator is implanted i.e. secondary prevention and medical therapy is optimized 2008: EF increased to 45% 2010: EF is 50% on echocardiogram 2010 – Amiodarone is stopped since patient fears the side effects and EF is now « normalized » She undergoes a treadmill test prior to exercise training in November 2010…

Heart Failure Guidelines

Sinus tachycardia then multiple PVCs then VT Heart Failure Guidelines

…

prepare to provide your answer!

Heart Failure Guidelines

Question 2. Select the best answer?

A. She had ischemia and this should have been investigated by another test B. The adrenaline surge during the test lead to ventricular tachycardia and the defibrillator shocks were appropriate C. The treadmill test should have been stopped before her heart rate reached the programmed VT zone so she would not receive shocks D. She should not be allowed to reach this level of exercise even if she did not have a defibrillator anyway E. She should have been on amiodarone or a higher dose of beta-blockers

Heart Failure Guidelines

PATIENT EVALUATION PRIOR TO AN EXERCISE PROGRAM

The following should be obtained prior to a tailored exercise training program:



An assessment of clinical status by a clinician experienced in the management of heart failure patients should be completed



Establish if the patient has an ICD and if yes, verify if previous shocks have been delivered and note the programmed VT zone



Exercise test (evaluate ischemia, arrhythmias, rate responses of patients with pacemakers, and determine training heart rate ranges)



Non-cardiac causes of dyspnea or musculoskeletal disorders may limit exercise tolerance and should be evaluated

Heart Failure Guidelines

Madame T: Actions and Reactions She complained to the hospital authorities and had to receive the help of a psychologist to cope with the fear of defibrillator shocks.

The technician was unaware of how to prepare a patient with a defibrillator for a treadmill test and the attending physician should have supervised more closely in preparation for the test.

A written protocol was made to ensure that this would not happen again. The patient was satisfied with the procedure.

She began training again about 1 year later and still sees her cardiologist in that same hospital.

Current EF is 45% (July 2012 echocardiogram)

Heart Failure Guidelines

Treadmill test protocol for patients with defibrillators



The indication for the treadmill test should be clearly described and the patient must be flagged as having a defibrillator



Defibrillator programmation will be verified immediately prior to the treadmill test



Maximal HR will be the programmed HR for VT therapy minus 20 beats per minute . The test should be stopped immediately as that HR is reached.



All pharmacological treatments should be continued (especially beta-blockers and antiarrhythmics)



No adjustment to the defibrillator programmation should be made in view of the treadmill test

Heart Failure Guidelines

Exercise Training in Stable HF is SAFE

A stepwise approach to exercise training in stable HF is suggested, including:  Cardiopulmonary/exercise testing is used for safety assessment and exercise prescription.  Initial supervision ensures safety of the prescribed program and may help patients understand their limits. For patients who prefer home-based exercise, after a minimum of 6-8 supervised sessions, exercise training may continue with a home-based program. Heart Failure Guidelines

Aerobic Exercise Training Prescription

Moderate-intensity continuous aerobic exercise training at rate of perceived exertion (RPE) 3-5 (Figure), 65-85% maximum heart rate, and 50-75% peak V02 is recommended in HF patients Exercise program schedule in stable patients should begin with aerobic exercise training, 10-15 minutes in duration, 2-3 days per week frequency, before gradually increasing training to a target of 30 minutes, 5 days per week. Walking, treadmill, and stationary cycling can be chosen as primary training modes. Moderate-intensity aerobic interval training may be incorporated into the ET program in selected, stable HF patients. Heart Failure Guidelines

Heart Failure Guidelines

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Heart Failure Guidelines

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Heart Failure Guidelines