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

41. 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:

42. 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

43. 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

44. 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

45. 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

46. 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

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

48. Stages in the Development of Heart Failure

49. Stages in the Development of Heart Failure

50. 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.

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

52. Diagnostic evaluation of patient should be focused on:

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

54. 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

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

56. 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

57. 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

58. 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

59. 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

60. 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

61. 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

62. Guidelines for Patients with Reduced Left Ventricular Systolic Function

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

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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

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

71. 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

72. 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”

73. 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%

74. 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.

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

76. 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

77. 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

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

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

80. 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

81. 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