“NOT another CHF overview” A few pearls extracted from the guidelines and applied to clinical care Richard Garmany MD

Disclosures None Unless otherwise noted, all slides reference the 2009 Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults, Circulation. 2009;119: 1977-2016

Objectives 1. Understand the role of guidelines based care in the management of a complex condition such as heart failure 2. Appreciate the role of at least one diagnostic study, medication, and intervention in the management of the heart failure patient 3. Think about the critical importance of a multidisciplinary approach in improving outcomes in patients with heart failure

Non-objectives Detailed epidemiology, pathogenesis, natural history, diagnosis, or management outside of guideline based care Coverage of all Guideline based care Detailed Performance Measures Appropriate use criteria I do not have a simple strategy to manage this condition, prevent readmissions for heart failure patients, or dramatically reduce cost of care

Definition Clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or eject blood Primary manifestations are dyspnea/fatigue and fluid retention, both can impair functional capacity

The syndrome May result from abnormalities of the pericardium, myocardium, endocardium, and vasculature Most heart failure results from dysfunction of the left ventricular myocardium this includes those with both normal and abnormal LV size and systolic function

The syndrome May result from abnormalities of the pericardium, myocardium, endocardium, and vasculature Most heart failure results from dysfunction of the left ventricular myocardium this includes those with both normal and abnormal LV size and systolic function Cardiomyopathy ≠ Heart Failure

The syndrome No single diagnostic test! Diagnosis largely based on history and physical exam

Stages in the Development of Heart Failure

Stages in the Development of Heart Failure

New York Heart Association Functional Classification Class I: No symptoms with ordinary activity Class II: Slight limitation of physical activity Class III: Marked limitation of physical activity Class IV: Symptoms at rest or with minimal exertion After completing a thorough history and physical exam, physicians will commonly use the New York Heart Association (NYHA) functional classification to help describe the degree of physical disability a patient has. The NYHA class is also commonly used to determine entry criteria for patients participating in clinical research trials.

Common Causes Coronary Artery Disease Hypertension Dilated cardiomyopathy Valvular heart disease Arrhythmias

Diagnostic evaluation of patient should be focused on:

Diagnostic evaluation of patient should be focused on: Coronary Artery Disease Hypertension Dilated cardiomyopathy Valvular heart disease Arrhythmias

Practice Guidelines ACC/AHA 2009 update of 2005 guidelines Other societies overlap Consensus of expert opinion Graded into level of evidence A-C Various Populations and Settings Initial evaluation Follow Up assessment Patients with reduced left ventricular systolic function End Stage Heart failure Hospitalized patients

Practice Guidelines Patients/Situations NOT SPECIFICALLY covered Heart failure with normal left ventricular systolic function The very elderly as a group Multiple comorbidities

Guide to the guidelines Class I : Should be performed Class IIa : It is reasonable to perform procedure or administer treatment Class IIb : Procedure or treatment may be considered Class III : Should NOT be performed, not helpful and may be harmful

Initial and Serial Assessment of Patients Presenting with Heart Failure Class I Guidelines History and Physical Disorders that may contribute Drugs and alcohol Functional status Weight, volume status, blood pressure General labs: CBC, CMP, Lipids, TSH EKG and CXR All level of evidence C

Initial and Serial Assessment of Patients Presenting with Heart Failure Class I Guidelines Echocardiogram Coronary angiogram in all patients with angina or evidence of significant ischemia unless they are not candidates for revascularization of any kind Echo is level C, Angio is Level of evidence B

Initial and Serial Assessment of Patients Presenting with Heart Failure Paraphrased Class IIa Guidelines Angiography is reasonable if there is any real suspicion for coronary disease Screening for “zebras” (HIV, hemochromatosis, etc) Measurement of BNP in the urgent care or ER setting when the diagnosis is uncertain

Serial Clinical Assessment Class I Guidelines Each clinical visit: Assessment of ability to perform activities of daily living Assessment of volume status and weight History for Tobacco, ETOH, Drugs, Na intake

Serial Clinical Assessment Class IIa Guidelines Repeat Echo Change in clinical status Clinical event or recovery from event Treatment given that might have significant effect on cardiac function

Guidelines for Patients with Reduced Left Ventricular Systolic Function

Class I Guidelines for Patients with Reduced Left Ventricular Systolic Function Diuretics and Salt restriction for volume overload Level of evidence C

Class I Guidelines for Patients with Reduced Left Ventricular Systolic Function Avoid NSAIDS and Non-Vasoselective calcium channel blockers (Verapamil, Diltiazem, Nifedipine) ACE Inhibitors, ARB if intolerant Beta Blockers Carvedilol Metoprolol Succinate Bisoprolol Level of Evidence A for ACE and Beta blockers, B for avoiding other drugs

Class I Guidelines for Patients with Reduced Left Ventricular Systolic Function (Continued) Should Receive Implanted Defibrillators Survivors of cardiac arrest or symptomatic sustained VT EF 35% or less, on good chronic medical therapy, NYHA class II or III symptoms and expected survival of greater than one year Should receive Biventricular pacing with or without a defibrillator EF 35% or less, class III or IV symptoms, on optimal medical therapy, with a QRS duration greater than 120 msec Level of evidence is A for all the above SCD-Heft: 22% all cause mortality in the ICD group at 45 months, 29% in both the Amio and medical therapy group Hazard ratio .77, 7% absolute risk reduction, 25% relative risk reduction Compare to a 2% absolute reduction in mortality for primary PCI over thrombolytics

Class I Guidelines for Patients with Reduced Left Ventricular Systolic Function (Continued) Aldosterone antagonists Selected patients with moderate to severe symptoms In patients who can be closely monitored only for renal function and K levels Cr 2.5 or less for Men Cr 2.0 or less for women Potassium < 5 Level of evidence is A for all the above

Class IIa Guidelines for Patients with Reduced Left Ventricular Systolic Function Afib: rate or rhythm control is ok Exercise stress testing to facilitate exercise prescription (not for detection of ischemia) ARB as first line treatment Digoxin to decrease hospitalizations Combination hydralazine/nitrates for patients on beta blockers and ACE with ongoing sx Level of evidence is A for all the above

Class III Guidelines for Patients with Reduced Left Ventricular Systolic Function Combination of ACE, ARB, and Aldosterone antagonist Calcium channel blockers Long term infusions Nutritional supplements Hormonal therapies, other than to replete deficiencies Level of evidence is A for all the above

End Stage Heart Failure Class I Control of fluid retention Referral to transplant/LVAD/ Heart failure center Discussion of end of life issues Option to inactivate defibrillators

Guidelines for Hospitalized Patients Ominous event 50% risk of readmission at 6 months 25-35% risk of death at 6 months

Guidelines for Hospitalized Patients Precipitating factors Noncompliance (Meds, Na, Diet) Untreated hypertension Atrial fibrillation Acute myocardial ischemia Recent addition of negative inotropic agents (nifedipine, verapamil, diltiazem, beta blockers) NSAID use Infections ETOH or drug use Endocrine abnormalities (Hyper or Hypothyroidism, DM) Pulmonary emboli

Guidelines for Hospitalized Patients Class I Evaluate perfusion, volume status, factors that may cause the exacerbation, chronicity, association with preserved ejection fraction Identification of ischemia with EKG and Enzymes BNP for distinguishing other causes of dyspnea Use of Intravenous loop diuretics at baseline oral dose or higher Daily electrolytes during IV diuresis For low EF continue ACE, BB unless hemodynamically unstable If not on ACE or BB, start in hospital if indicated Discharge “systems of care”

How does this apply to a patient? Consult from Teaching Service: 59 year old woman with known CAD, obesity, DM, COPD, very low baseline activity Jehovah's Witness 2 weeks after anginal sx with increased dyspnea Elevated enzymes, Echo with EF 30%

Meds at time of consult 1. Aspirin 81 mg daily. 2. Lipitor 40 mg daily. 3. Lovenox 40 mg subcu daily. 4. Lasix 40 mg twice daily. 5. Insulin. 6. Prinivil 40 mg daily. 7. Metformin 1000 mg twice daily. 8. Lopressor 25 mg twice daily.

Evaluation Moderate volume overload Normal blood pressure Free of active anginal sx Poor CABG candidate

Assessment/Treatment Systolic HF Recent MI To cath lab: 1. Three-vessel coronary disease with acute appearing stenosis of the right coronary artery and minimal right collateralization. 2. Stable yet high-grade appearing disease in both her large OM and diagonal with complete occlusion of her LAD. Declined CABG, angioplasty to RCA with plan for outpatient assessment of viability Follow up arranged 1 week with new PCP, 4 weeks with cardiology, immediately with Cardiac Rehab

Course Admitted with a TIA 4 weeks later EF 40-45% Admitted 7 weeks later with angina, cough declined surgical evaluation, concerned about blood Switched to ARB Antianginal meds intensified Never saw new PCP or cardiologist, prefers f/u through her chronic mid level provider

Who is responsible for Readmissions? Hospital Cardiologist The primary hospital service The outpatient midlevel provider The patient More than one of the above!

Conclusion CHF: ACE Aldactone B-Blocker Dig Diuretic Phil Mohler, Prudent Prescriber April 2013

Conclusion CHF: In all heart failure think: Volume Status Hypertension ACE Aldactone B-Blocker Dig Diuretic Volume Status Hypertension Diabetes Coronary Artery Disease Ejection Fraction

Conclusion CHF: In all heart failure think: Volume Status Hypertension Diabetes Coronary Artery Disease Ejection Fraction ACE Aldactone B-Blocker Dig Diuretic In heart failure with reduced systolic function think: Carvedilol Ace Inhibitors ICD