Heart Failure: ACC Guidelines for Dx and Management Steven W. Harris MHS PAC

Epidemiology Approximately 5 million patients in this country have HF Over 550,000 patients are diagnosed with HF for the first time each year Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year In 2001, nearly 53,000 patients died of HF as a primary cause

Epidemiology The incidence of HF approaches 10 per 1000 population after age 65 HF is the most common Medicare diagnosis-related group More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare

ACC Guidelines Focus on : Prevention of HF Diagnosis and management of chronic HF in the adult.

Definition HF is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.

Because not all patients have volume overload at the time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive heart failure.” Use terms: Compensated Heart Failure: euvolemic Decompensated Heart Failure: fluid overload

Etiology For a substantial proportion of patients, causes are: Coronary artery disease Hypertension Dilated cardiomyopathy

Signs and Symptoms  ? ? ? ? ? ? ?

Symptoms  Decreased Perfusion: WeaknessWeakness FatigueFatigue ConfusionConfusion RestlessnessRestlessness AnxietyAnxiety PalpitationsPalpitations Cold ExtremitiesCold Extremities

Symptoms  Increased LV preload: DOEDOE PNDPND Cough: often positionalCough: often positional WheezeWheeze OrthopneaOrthopnea Abdominal DistensionAbdominal Distension edemaedema

Signs  Increased Preload/Decreased perfusion Pedal edema Hepatic congestion JVD Rales Wheezing S3 Tachycardia Cyanosis Cold extremities

New York Heart Association Classes NYHA I: no symptoms w/ physical activity, but known disease NYHA II: slight limitations, symptoms w/ normal activities, but able to walk 3 blocks NYHA III: symptoms w. minimal activity and marked limitation of activity NYHA IV: symptoms at rest and any activity

Stages of Heart Failure Designed to emphasize preventability of HF through treatment therapies. Designed to recognize the progressive nature of LV dysfunction.

Stages of HF   COMPLEMENT, DO NOT REPLACE NYHA CLASSES   NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)   Stages - progress in one direction due to cardiac remodeling

Stages of HF At Risk for Heart Failure: STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction Heart Failure: STAGE C Past or current symptoms of HF STAGE D End-stage HF

Stage A: at risk for HF  Therapy Treat Hypertension Treat Hypertension Encourage Smoking cessation Encourage Smoking cessation Treat lipid disorders Treat lipid disorders Encourage regular exercise Encourage regular exercise Discourage ETOH, drugs Discourage ETOH, drugs Control Metabolic Syndrome Control Metabolic Syndrome ACE or ARB in appropriate patents for vasc dz or diabetes ACE or ARB in appropriate patents for vasc dz or diabetes

Stage B: Structural disease/No Sx  Therapy: All measures under Stage A All measures under Stage A ACE or ARB in appropriate patients ACE or ARB in appropriate patients Beta-blockers in appropriate patients Beta-blockers in appropriate patients ICDs in appropriate patients ICDs in appropriate patients

Stage C: Structural Disease with current or prior sx  Therapy: All measures under Stages A and B All measures under Stages A and B Routine Use Routine Use ACE, Beta-blockerACE, Beta-blocker Diuretics for fluid retentionDiuretics for fluid retention Selected Patients Selected Patients Aldosterone antagonistAldosterone antagonist ARBARB DigitalisDigitalis Hydralazine/nitratesHydralazine/nitrates Devices: BI-V, ICD Devices: BI-V, ICD

Stage D: refractory HF  Therapy All measures from stages A, B, C All measures from stages A, B, C Decision: Decision: Appropriate level of careAppropriate level of care Compassionate end-of-life careCompassionate end-of-life care TransplantTransplant Chronic Inotropes: neo, epi, dopamine.Chronic Inotropes: neo, epi, dopamine. Permanent Mechanical Support: LVADPermanent Mechanical Support: LVAD Experimental surgery /drugs.Experimental surgery /drugs.

Devices  An implantable cardioverter-defibrillator (ICD) for secondary prevention to prolong survival in patients with a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia.

Devices  An ICD for primary prevention to reduce total mortality by preventing sudden cardiac death (SCD) in patients with ischemic heart disease who meet the following criteria: at least 40 days post-myocardial infarction, an LVEF 30 percent, New York Heart Association functional class II or III symptoms despite optimal chronic medical therapy, and a reasonable expectation of survival with a good functional status for more than one year.

Devices  An ICD for primary prevention to reduce total mortality by preventing SCD in patients with nonischemic cardiomyopathy who meet the following criteria: an LVEF less than 30 percent, New York Heart Association functional class II or III symptoms despite optimal chronic medical therapy, and a reasonable expectation of survival with a good functional status for more than one year.

Devices  Cardiac resynchronization therapy, unless contraindicated, in patients who meet the following criteria: cardiac dyssynchrony as defined by a QRS duration >120 msec, LVEF 35 percent, sinus rhythm, and New York Heart Association functional class III or ambulatory class IV symptoms despite optimal chronic medical therapy.

Patient Surveilance  MAWDS Medicine Medicine Activity Activity Weight Weight Diet Diet Symptoms Symptoms

CASE 1  56 y/o female DM DM BP 146/84 BP 146/84 LDL 150 LDL 150 Non-smoker Non-smoker Exercises daily Exercises daily

Case 2  63 y/o male AWMI 1 year ago AWMI 1 year ago EF 28% EF 28% Diabetic Diabetic BP 128/72 BP 128/72 Smoker Smoker DOE with strenuous activity DOE with strenuous activity

Case 3  44 y/o male DM DM CHD, prior Inferior MI CHD, prior Inferior MI EF 46% EF 46% BP 132/78 BP 132/78 Walks daily. Unable to walk up inclines. Walks daily. Unable to walk up inclines. C/o LE edema and weight gain of 10 lbs C/o LE edema and weight gain of 10 lbs

Case 4  60 y/o female H/o BRCA treated with adriamycin H/o BRCA treated with adriamycin BP 110/68 on ACE, Coreg BP 110/68 on ACE, Coreg EF 30% EF 30% Non-diabetic Non-diabetic Symptoms with minimal activity Symptoms with minimal activity LBBB LBBB