Heart Failure Management Applying the ACC/AHA Chronic Heart Failure Guidelines David Bragin Sánchez MD FACC Cardiomyopathy and Cardiac Transplant Specialist Intercontinental Hotel March

The Core

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Patients With Current or Prior Symptoms of Heart Failure (HF) Left ventricle (LV) dysfunction Class I Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HF and reduced left ventricle ejection fraction (LVEF) should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs). (Level of Evidence: B) Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: B)

Stage C Class I Daily weight Influenza and pneumococcal vaccination Monitor potassium (4-5 mmol per L) and magnesium Emphasis on compliance with diet and medications Patient education and close supervision

Stage C Class III Use of nutritional supplements as treatment for HF is not indicated in patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C) Hormonal therapies other than to replete deficiencies are not recommended and may be harmful to patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C)

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Beta Blockers Class I Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. (Level of Evidence: A)

Stage C Beta blockers Alleviate symptoms, improve clinical status, reduce risk of death and of hospitalization. Diuretics are needed to maintain sodium balance and prevent fluid retention that can accompany initiation of beta-blocker Should be given only if no or only minimal evidence of fluid retention Should not be totally withdrawn in acute decompensation Should be started before hospital discharge in all HF patients

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Class I Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. (Level of Evidence: A) Class III Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C)

Stage C Not only interferes with RAS but potentates action of kinins and kinin-mediated prostaglandin Alleviate symptoms, improve clinical status, reduce risk of death and of hospitalization Contraindicated if angioedema or pregnant Fluid retention can blunt effects and fluid depletion can potentate adverse effects (Hypotension, hyperkalemia, renal failure) Cough. All other causes must be excluded

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Class I Angiotensin II receptor blockers approved for the treatment of HF are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACEI-intolerant. (Level of Evidence: A) Class IIA Angiotensin II receptor blockers are reasonable to use as alternatives to ACEIs as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications. (Level of Evidence: A) Class IIB The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy. (Level of Evidence: B)

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Class I Aldosterone antagonist is reasonable in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be less than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should be less than 5.0 mEq/L. (Level of Evidence: B)

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Class I Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention. (Level of Evidence: C)

Stage C Inhibit reabsorption of sodium or chloride at specific sites in the renal tubule. Loop diuretics excrete up to 20-25% Na, enhance free water clearance and remain effective unless severe renal impairment. No long term studies effects on morbidity and mortality are not known Produce symptomatic relief more rapidly than any other drug. Risk of use is electrolyte depletion, hypotension and azotemia.

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Class IIa Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF. (Level of Evidence: B) Dose should be of mg QD, without loading and lower if patient is over age 70, has renal impairment or low lean body mass Serum levels are followed for purpose of toxicity and not to guide therapy

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Class IIa The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACEI and beta- blocker for symptomatic HF and who have persistent symptoms. (Level of Evidence: A)

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Class I Implantable cardioverter-defibrillator therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death. LVEF less than or equal to 30% NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy Reasonable expectation of survival with a good functional status for more than 1 year

Stage C Ischemic heart disease who are at least 40 days post-MI (Level of Evidence: A) Nonischemic cardiomyopathy (Level of Evidence: B)

Stage C Class I CRT Patients with LVEF less than or equal to 35% Sinus rhythm NYHA functional class III or ambulatory class IV symptoms despite optimal medical therapy QRS duration greater than 0.12 ms (Level of Evidence: A)

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage C Class III Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of HF and reduced LVEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment. (Level of Evidence: C)

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage D End stage heart disease Cardiac transplantation is currently the only established surgical approach to the treatment of refractory HF, but it is available to fewer than 2500 patients in the United States each year Alternate surgical and mechanical approaches for the treatment of end-stage HF are under development

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage D Class III Routine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF. (Level of Evidence: B) However, continuous intravenous support can provide palliation of symptoms as part of an overall plan to allow the patient to die with comfort at home

Stage D Referral of patients with refractory end-stage HF to an HF program with expertise in the management of refractory HF is useful. (Level of Evidence: A) Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory end-stage HF persist despite application of all recommended therapies. (Level of Evidence: C) Patients with refractory end-stage HF and implantable defibrillators should receive information about the option to inactivate defibrillation. (Level of Evidence: C)

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Stage D Class I Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF. (Level of Evidence: B) Class IIa Consideration of an LV assist device as permanent or “destination” therapy is reasonable in highly selected patients with refractory end-stage HF and an estimated 1- year mortality over 50% with medical therapy. (Level of Evidence: B)

Stage D Absolute indications for cardiac transplant For hemodynamic compromise due to HF Refractory cardiogenic shock Documented dependence on IV inotropic support to maintain adequate organ perfusion Peak VO2 less than 10 mL per kg per min with achievement of anaerobic metabolism Severe symptoms of ischemia that consistently limit routine activity and are not amenable to coronary artery bypass surgery or percutaneous coronary intervention Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalities

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

Special populations High-risk ethnic minority groups (e.g., blacks, hispanics) Groups underrepresented in clinical trials (women and elderly) Should have clinical screening and therapy in a manner identical to that applied to the broader population. (Level of Evidence: B)

 Stage C  Basic management  Beta blockers  ACE inhibitors  ARB  Aldosterone blocker  Diuretics  Digoxin  Hydralazine/Nitrate  Devices  Inotropic agents  Stage D  Refractory HF  Transplantation  Subgroups  HF with normal LVEF

HF with preserved EF Control systolic and diastolic BP (Class I Level of evidence A) Control ventricular rate in atrial fibrillation (Class I Level of evidence C) Diuretics to control pulmonary congestion and peripheral edema (Class I Level of evidence C) Coronary revascularization patients with CAD in whom ischemia is judged to have effect on diastolic dysfunction (Class IIa Level of evidence C)