MEDTRONIC DISCLOSURE STATEMENT

MEDTRONIC DISCLOSURE STATEMENT
Disclaimer MEDTRONIC DISCLOSURE STATEMENT Please take a moment to review the Medtronic Disclosure Statement. This training is provided for general educational purposes only and should not be considered the exclusive source for this type of information. The device data presented in this module is fictional and is designed for educational purposes. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in a particular situation. Changes in a patient’s disease and/or medications may alter the efficacy of a device’s programmed parameters or related features and results may vary. The device functionality and programming described in this course are based on Medtronic products and can be referenced in the published device manuals. Medtronic is not responsible for the content on websites linked from this course. Please note that the content on linked sites may change over time. This training is intended only for users in markets where Medtronic products and therapies are approved or available for use as indicated within the respective product manuals. Content on specific Medtronic products and therapies is not intended for users in markets that do not have authorization for use. Please review the following disclosure statements.

× RESOURCES Here are some useful links and documents: Brief Statements
Common medications used to treat HF on heart.org Heart Failure Treatment Strategies References

Indications, Safety, and Warnings
If you are located in the United States, please refer to the brief statement(s) below to review applicable indications, safety and warning information. See the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential complications/adverse events. For further information, please call Medtronic at and/or consult the Medtronic website at For residents of the United States, please reference the relevant safety information (i.e. indications, contraindications, warnings/precautions, and potential complications) associated with the devices covered in this course by clicking here. If you are located outside the United States, see the device manual for detailed information regarding the implant procedure, indications, contraindications, warnings, precautions, and potential adverse events. If using an MRI SureScan device, see the MRI SureScan™ technical manual before performing an MRI. For further information, contact your local Medtronic representative and/or consult the Medtronic website at Consult instructions for use at this website. Manuals can be viewed using a current version of any major Internet browser. For best results, use Adobe Acrobat Reader® with the browser. Review the following indications, safety, and warnings. Select next to acknowledge that you have access to the relevant safety information and manuals.

HEART FAILURE TREATMENT STRATEGIES
Menu Audio ON Video START the module Flowchart EXIT the module Click for more information Topics: HF treatment guidelines Categories of HF treatment Case Studies Length: 30 minutes This course is for healthcare professionals (HCPs) who want a foundational level of knowledge of the treatment strategies for heart failure patients . Welcome to the course, Heart Failure Treatment Strategies. This course has been developed for health care professionals who want a foundational level of knowledge of the treatment strategies for heart failure patients. The icons displayed here describe the types of interactions available in this course. Select start to begin the course.

Visit each module to complete the course
TABLE OF CONTENTS GENERAL MEASURES OF HEART FAILURE TREATMENT CATEGORIES FOR HF TREATMENT CASE STUDY EXAMPLES Visit each module to complete the course

HEART FAILURE TREATMENT GOALS
Reduce the clinical symptoms of edema and dyspnea Improve cardiac function Enhance organ perfusion Increase exercise capacity Reduce mortality and HF hospitalizations Achieve this by An important part of heart failure management is identifying and treating factors that are known to encourage heart failure and its progression. A patients classification status can change over time. In general the goal is to reduce clinical symptoms, improve cardiac function, enhance organ perfusion, increase exercise capacity, and reduce mortality and heart failure hospitalizations. Learn More about the Stages of Heart Failure

Diastolic Dysfunction (LV preserved Ejection Fraction) HFpEF
× Types of heart failure A complex clinical syndrome in which the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return. It is caused by abnormality of cardiac function. Two common types of left-sided heart failure (HF): A third type was identified in 2016 - HFpEF (EF: % ) – borderline or intermediate group earned its official title when the 2016 ESC Guidelines revealed this new classification HFrEF (EF<40%) and HFpEF (EF>50%) each make up about half of the overall HF burden Yancy CW, Jessup M, Bozkurt B, et al ACCF/AHA Guideline for the Management of Heart Failure. JACC 2013;62:e + HF with preserved ejection fraction (HFpEF) or diastolic dysfunction – LV loses its ability to relax normally and the heart is not able to fill properly (EF> 50%) + HF with reduced ejection fraction (HFrEF) or systolic dysfunction – LV loses its ability to contract normally (EF< 40%) Normal Heart EF 50-70% Diastolic Dysfunction (LV preserved Ejection Fraction) HFpEF EDV (end diastolic volume) Stroke Volume (SV) = EDV-ESV EF = SV/EDV LV contracts normally Stiff ventricles fill with less blood EDV Diastole Systole Diastole Systole

Systolic Dysfunction (LV reduced Ejection Fraction) HFrEF
× Types of heart failure A complex clinical syndrome in which the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return. It is caused by abnormality of cardiac function. Two common types of left-sided heart failure (HF): A third type was identified in 2016 - HFpEF (EF: % ) – borderline or intermediate group earned its official title when the 2016 ESC Guidelines revealed this new classification HFrEF (EF<40%) and HFpEF (EF>50%) each make up about half of the overall HF burden Yancy CW, Jessup M, Bozkurt B, et al ACCF/AHA Guideline for the Management of Heart Failure. JACC 2013;62:e + HF with preserved ejection fraction (HFpEF) or diastolic dysfunction – LV loses its ability to relax normally and the heart can’t fill properly (EF> 50%) + HF with reduced ejection fraction (HFrEF) or systolic dysfunction – LV loses its ability to contract normally (EF< 40%) Normal Heart EF 50-70% Systolic Dysfunction (LV reduced Ejection Fraction) HFrEF EDV (end diastolic volume) Stroke Volume (SV) = EDV-ESV EF = SV/EDV LV does not contract effectively Enlarged ventricles fill with blood EDV ESV Diastole Systole Diastole Systole

General Measures of HF Treatment
ACHIEVE THIS BY: Decreasing blood volume Decreasing cardiac dilation, thus increasing mechanical efficiency Decreasing afterload, thus increasing SV and CO Increasing contractility Adopting healthy lifestyle modifications These goals can be achieved by decreasing the stresses on the heart, increasing contractility, and encouraging patients to adopt lifestyle changes such as diet, weight control and exercise. Select each guidelines flow chart to learn more about the ACC/AHA/HFSA and ESC guidelines. ESC Guidelines Flowchart ACCF/AHA Guidelines Flowchart ACCF/AHA/HFSA Treatment of HFrEF Stage C & D

Patient with symptomatica HFrEFb
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Therapy with ACE-Ic and beta-blocker (Up-titrate to maximum tolerated evidence-based doses) Still symptomatic and LVEF ≤35% Able to tolerate ACEI (or ARB)f,g Yes ARNI to replace ACE-I Patient with symptomatica HFrEFb Still symptomatic and LVEF ≤35% Add MR antagonistd,e (up-titrate to maximum tolerated evidence-based dose) Sinus rhythm, QRS duration ≥ 130 msec Evaluate need for CRTi,j Yes Yes Yes Yes Sinus rhythm,h HR ≥70 bpm Ivabradine Diuretics to relieve symptoms and signs of congestion If LVEF ≤35% despite OMT or a history of symptomatic VT/VF, implant ICD No No Class I These above treatments may be combined if indicated Resistant symptoms No No further action required Consider reducing diuretic dose Class IIa Yes Consider digoxin or H-ISDN or LVAD, or heart transplantation Definitions of abbreviations > Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Patient with symptomatica HFrEFb
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Therapeutic algorithm for a patient with symptomatic heart failure with reduced ejection fraction. Therapy with ACE-Ic and beta-blocker (Up-titrate to maximum tolerated evidence-based doses) Still symptomatic and LVEF ≤35% Able to tolerate ACEI (or ARB)f,g Yes ARNI to replace ACE-I Patient with symptomatica HFrEFb Still symptomatic and LVEF ≤35% Add MR antagonistd,e (up-titrate to maximum tolerated evidence-based dose) Yes Yes Yes Sinus rhythm, QRS duration ≥ 130 msec Evaluate need for CRTi,j Dark blue indicates a class I recommendation; light blue indicates a class IIa recommendation. ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARNI = angiotensin receptor neprilysin inhibitor; BNP = B-type natriuretic peptide; CRT = cardiac resynchronization therapy; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; H-ISDN = hydralazine and isosorbide dinitrate; HR = heart rate; ICD = implantable cardioverter defibrillator; LBBB = left bundle branch block; LVAD = left ventricular assist device; LVEF = left ventricular ejection fraction; MR = mineralocorticoid receptor; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; OMT = optimal medical therapy; VF = ventricular fibrillation; VT = ventricular tachycardia. aSymptomatic = NYHA Class II-IV. bHFrEF = LVEF <40%. cIf ACE inhibitor not tolerated/contra-indicated, use ARB. dIf MR antagonist not tolerated/contra-indicated, use ARB. eWith a hospital admission for HF within the last 6 months or with elevated natriuretic peptides (BNP > 250 pg/ml or NT proBNP > 500 pg/ml in men and 750 pg/ml in women). fWith an elevated plasma natriuretic peptide level (BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL, or if HF hospitalization within recent 12 months plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL). gIn doses equivalent to enalapril 10 mg b.i.d. hWith a hospital admission for HF within the previous year. iCRT is recommended if QRS ≥ 130 msec and LBBB (in sinus rhythm). jCRT should/may be considered if QRS ≥ 130 msec with non-LBBB (in a sinus rhythm) or for patients in AF provided a strategy to ensure bi-ventricular capture in place (individualized decision). For further details, see Sections 7 and 8 and corresponding web pages. Yes Sinus rhythm,h HR ≥70 bpm Ivabradine Diuretics to relieve symptoms and signs of congestion If LVEF ≤35% despite OMT or a history of symptomatic VT/VF, implant ICD Class I No No Class IIa These above treatments may be combined if indicated Resistant symptoms No No further action required Consider reducing diuretic dose Yes Consider digoxin or H-ISDN or LVAD, or heart transplantation Definitions of abbreviations > Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Select each button before proceeding
× STAGE A STAGE B STAGE C STAGE D Select each button to view the recommended therapy by stage of heart failure. Select each button before proceeding Adapted from : Hunt SA, Abraham WT, Chin MH. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult – Summary Article. Circulation.2005; 112: Yancy CW, Jessup M, Bozkurt B, et al. ACCF/AHA Guideline for the Management of Heart Failure. Circulation. 2013; 128: e240-e327.

× STAGE A THESE INCLUDE PATIENTS WITH: THERAPY
AT RISK FOR HEART FAILURE STAGE A At high risk for HF but without structural heart disease or symptoms of HF THESE INCLUDE PATIENTS WITH: THERAPY Hypertension OR PATIENTS Atherosclerotic disease Using cardiotoxins Diabetes With family history of cardiomyopathy Obesity Metabolic syndrome If patient has structural heart disease progress to STAGE B Definitions of abbreviations >

× × STAGE A E.G., PATIENTS WITH: THERAPY AT RISK FOR HEART FAILURE
At high risk for HF but without structural heart disease or symptoms of HF Definitions of abbreviations Stages in the development of HF and recommended therapy by stage. ACEI indicates angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin-receptor blocker; CAD, coronary artery disease; CRT, cardiac resynchronization therapy; DM, diabetes mellitus; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HRQOL, health-related quality of life; HTN, hypertension; ICD, implantable cardioverter-defibrillator; LV, left ventricular; LVH, left ventricular hypertrophy; MCS, mechanical circulatory support; and MI, myocardial infarction. E.G., PATIENTS WITH: THERAPY × HTN Patients Atherosclerotic disease Using cardiotoxins DM With family history of cardiomyopathy Obesity Metabolic syndrome OR Structural heart disease STAGE B

× STAGE A THESE INCLUDE PATIENTS WITH: THERAPY
AT RISK FOR HEART FAILURE STAGE A At high risk for HF but without structural heart disease or symptoms of HF THESE INCLUDE PATIENTS WITH: THERAPY Goals Drugs Heart healthy lifestyle ACEI or ARB in appropriate patients for vascular disease or DM Prevent vascular, coronary disease Prevent LV structural abnormalities Statins as appropriate Definitions of abbreviations >

× STAGE B THESE INCLUDE PATIENTS WITH: THERAPY
AT RISK FOR HEART FAILURE STAGE B Structural heart disease but without signs or symptoms of HF THESE INCLUDE PATIENTS WITH: THERAPY Previous MI LV remodeling including LV and low EF Asymptomatic valvular disease If patient develops HF symptoms they progress to STAGE C Definitions of abbreviations >

× STAGE B THESE INCLUDE PATIENTS WITH: THERAPY
AT RISK FOR HEART FAILURE STAGE B Structural heart disease but without signs or symptoms of HF THESE INCLUDE PATIENTS WITH: THERAPY Goals Prevent HF symptoms In selected patients Prevent further cardiac remodeling ICD Drugs Revascularization or valvular surgery as appropriate ACEI or ARB as appropriate Beta blockers as appropriate Definitions of abbreviations >

× STAGE C THESE INCLUDE PATIENTS WITH: HFpEF THERAPY HFrEF THERAPY
HEART FAILURE STAGE C Structural heart disease with prior or current symptoms of HF THESE INCLUDE PATIENTS WITH: HFpEF THERAPY HFrEF THERAPY Known structural heart disease and HF signs and symptoms If patient has refractory symptoms of HF at rest, despite GDMT they progress to STAGE D Definitions of abbreviations >

× STAGE C THESE INCLUDE PATIENTS WITH: HFpEF THERAPY THERAPY
HEART FAILURE STAGE C Structural heart disease with prior or current symptoms of HF THESE INCLUDE PATIENTS WITH: HFpEF THERAPY THERAPY HFrEF THERAPY Goals Treatment Control symptoms Diuresis to relieve symptoms of congestion Improve health related quality of life Prevent hospitalization Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Prevent mortality Drugs Revascularization or valvular surgery as appropriate Identification of comorbidities Definitions of abbreviations >

× STAGE C THESE INCLUDE PATIENTS WITH: HFpEF THERAPY THERAPY
HEART FAILURE STAGE C Structural heart disease with prior or current symptoms of HF THESE INCLUDE PATIENTS WITH: HFpEF THERAPY THERAPY HFrEF THERAPY Goals Drugs for use in selected patients Control symptoms Hydralazine/isosorbide dinitrate Patient education ACEI and ARB Prevent hospitalization Digitalis Prevent mortality In selected patients Drugs for routine use CRT Diuretics for fluid retention ICD ACEI or ARB Revascularization or valvular surgery as appropriate Beta blockers Aldosterone antagonists Check the meaning of abbreviation >

× STAGE D THESE INCLUDE PATIENTS WITH: THERAPY HEART FAILURE
Refractory HF THESE INCLUDE PATIENTS WITH: THERAPY Marked HF symptoms at rest Recurrent hospitalizations despite GDMT Definitions of abbreviations >

× STAGE D THESE INCLUDE PATIENTS WITH: THERAPY HEART FAILURE
Refractory HF THESE INCLUDE PATIENTS WITH: THERAPY Goals Options Control symptoms Advanced care measures Improve HRQOL Heart transplant Reduce hospital readmissions Chronic inotropes Establish patient’s end-of-life goals Temporary or permanent MCS Experimental surgery or drugs Palliative care and hospice ICD deactivation Definitions of abbreviations >

× ACC/AHA/HFSA TREATMENT STAGE C AND D STEP 1 STEP 2 STEP 3 STEP 4
Establish Dx of HREF; assess volume; initiate GDMT STEP 2 Consider the following patient scenarios STEP 3 Implement indicated GDMT. Choices are not mutually exclusive, and no order is inferred STEP 4 Reassess symptoms STEP 5 Consider additional therapy Continue GDMT with serial reassessment & optimized dosing/adherence Definitions of abbreviations > Select each STEP before proceeding Adapted from: Yancy CW, Jessup M, Bozkurt B, et al ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation. 2017; 136(6):e137-e161.

ESTABLISH DX OF HREF; ASSESS VOLUME; INITIATE GDMT HFrEF NYHA class I-IV (Stage C) ACEI or ARB AND GDMT beta blocker; diuretics as needed (COR I) Continue GDMT with serial reassessment & optimized dosing/adherence 2017 Updates on HF Management: Yancy CW, Jessup M, Bozkurt B, et al ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Circulation. 2017; 136(6):e137-e161 Definitions of abbreviations >

× × ACC/AHA/HFSA TREATMENT STAGE C AND D STEP 1 STEP 2 STEP 3 STEP 4
Definitions of abbreviations > Treatment of HFrEF Stage C and D. For all medical therapies, dosing should be optimized and serial assessment exercised. *See text for important treatment directions. †Hydral-Nitrates green box: The combination of ISDN/HYD with ARNI has not been robustly tested. BP response should be carefully monitored. ‡See 2013 HF guideline. §Participation in investigational studies is also appropriate for stage C, NYHA class II and III HF. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor-blocker; ARNI, angiotensin receptor-neprilysin inhibitor; BP, blood pressure; bpm, beats per minute; C/I, contraindication; COR, Class of Recommendation; CrCl, creatinine clearance; CRT-D, cardiac resynchronization therapy–device; Dx, diagnosis; GDMT, guideline-directed management and therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; ISDN/HYD, isosorbide dinitrate hydral-nitrates; K+, potassium; LBBB, left bundle-branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NSR, normal sinus rhythm; and NYHA, New York Heart Association. ESTABLISH DX OF HREF; ASSESS VOLUME; INITIATE GDMT × HFrEF NYHA class I-IV (Stage C) ACEI or ARB AND GDMT beta blocker; diuretics as needed (COR I) Continue GDMT with serial reassessment & optimized dosing/adherence 2017 Updates on HF Management: Yancy CW, Jessup M, Bozkurt B, et al ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Circulation. 2017; 136(6):e137-e161 Check the meaning of abbreviation >

Establish Dx of HREF; assess volume; initiate GDMT STEP 2 STEP 3 Implement indicated GDMT. Choices are not mutually exclusive, and no order is inferred STEP 4 Reassess symptoms STEP 5 Consider additional therapy CONSIDER THE FOLLOWING PATIENT SCENARIOS NYHA class II-IV, provided est. CrCl > 30 mL/min & K+<5.0 mEq/L NYHA class II-III HF Adequate BP on ACEI or ARB*; No C/I to ARB or sacubitril NYHA class III-IV, in black patients NYHA class II-III, LVEF ≤35%; (caveat: >1 y survival, >40 d post MI) NYHA class II-IV, LVEF ≤35%, NSR & QRS ≥150 ms with LBBB pattern NYHA class II-III, NSR, heart rate ≥70 bpm on maximally tolerated dose beta blocker Continue GDMT with serial reassessment & optimized dosing/adherence 2017 Updates on HF Management: Yancy CW, Jessup M, Bozkurt B, et al ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Circulation. 2017; 136(6):e137-e161 Definitions of abbreviations >

Establish Dx of HREF; assess volume; initiate GDMT STEP 2 Consider the following patient scenarios STEP 3 Implement indicated GDMT. Choices are not mutually exclusive, and no order is inferred STEP 4 Reassess symptoms STEP 5 Consider additional therapy IMPLEMENT INDICATED GDMT. CHOICES ARE NOT MUTUALLY EXCLUSIVE AND NO ORDER IS INFERRED Aldosterone antagonist (COR I) Discontinue ACEI or ARB; initiate ARNI* (COR I) Hydral-Nitrates †‡ (COR I) ICD‡ (COR I) CRT or CRT-D‡ (COR I) Ivabradine (COR IIa) Continue GDMT with serial reassessment & optimized dosing/adherence 2017 Updates on HF Management: Yancy CW, Jessup M, Bozkurt B, et al ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Circulation. 2017; 136(6):e137-e161 Definitions of abbreviations >

Establish Dx of HREF; assess volume; initiate GDMT STEP 2 Consider the following patient scenarios STEP 3 Implement indicated GDMT. Choices are not mutually exclusive, and no order is inferred STEP 4 STEP 5 Consider additional therapy REASSESS SYMPTOMS Refractory NYHA class III-IV (Stage D) Symptoms improved Continue GDMT with serial reassessment & optimized dosing/adherence 2017 Updates on HF Management: Yancy CW, Jessup M, Bozkurt B, et al ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Circulation. 2017; 136(6):e137-e161 Definitions of abbreviations >

Establish Dx of HREF; assess volume; initiate GDMT STEP 2 Consider the following patient scenarios STEP 3 Implement indicated GDMT. Choices are not mutually exclusive, and no order is inferred STEP 4 Reassess symptoms STEP 5 CONSIDER ADDITIONAL THERAPY Palliative care‡ (COR I) Transplant‡ (COR I) LVAD‡ (COR IIa) Investigational studies§ Continue GDMT with serial reassessment & optimized dosing/adherence 2017 Updates on HF Management: Yancy CW, Jessup M, Bozkurt B, et al ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Circulation. 2017; 136(6):e137-e161 Definitions of abbreviations >

Heart Failure Treatment Categories
Non- Pharmacologic Therapy Pharmacologic Therapy Device Therapy Surgical/ Interventional Therapy Treatment for heart failure can be grouped into four main categories: nonpharmacologic, pharmacologic, device therapy and surgical procedures. Click each button to learn more about each type. Select each button to learn more about treatment options

Non-pharmacologic Therapy
Lifestyle Modifications Medical Considerations Patient Education Materials Self-Check Plan Nonpharmacologic therapies can be further categorized into lifestyle modifications and medical considerations. Click each button to learn more. Select each button before proceeding

Lifestyle Modifications Medical Considerations Patient Education Materials Self-Check Plan Sodium restriction Alcohol use Appropriate fluid intake Weight reduction Exercise Psychosocial support Smoking cessation × The patient can play a role in reducing symptoms and the progression of heart failure by maintaining appropriate fluid balance, undertaking regular exercise, eliminating smoking, avoiding excess alcohol, maintaining a healthy body weight and reducing anxiety by obtaining psychosocial support.

Lifestyle Modifications Medical Considerations Patient Education Materials Self-Check Plan Hypertension, hyperlipidemia, diabetes, and arrhythmia treatment Immunizations Sleep apnea, continuous positive air pressure (CPAP) × Medical considerations include treating comorbidities that can exacerbate heart failure, receiving immunizations against influenza and pneumonia, and treating sleep disorders such as sleep apnea.

Lifestyle Modifications Medical Considerations Patient Education Materials Self-Check Plan The American Heart Association HeartFailureMatters.org (UK) × Additional patient education materials can be found from the following organizations: Click the links provided to access patient education materials.

SELF-CHECK PLAN FOR HF MANAGEMENT
EXCELLENT Keep Up the Good Work! × SELF-CHECK PLAN FOR HF MANAGEMENT This self check plan for heart failure management can be used to educate patients how to monitor their own heart failure status. PAY ATTENTION Use Caution! MEDICAL ALERT Warning! Breathing okay (not short of breath) Physical activity level is normal No noticeable swelling Weight check normal No sign of chest pain GREAT! CONTINUE: Daily Weight Check Meds as Directed Low Sodium Eating Follow-up Visits Adapted from the AHA/ASA Rise Above Heart Failure Self-Check Plan for HF Management

PAY ATTENTION Use Caution! × SELF-CHECK PLAN FOR HF MANAGEMENT This self check plan for heart failure management can be used to educate patients how to monitor their own heart failure status. EXCELLENT Keep Up the Good Work! MEDICAL ALERT Warning! Dry, hacking cough Shortness of breath with activity Increased swelling of legs, feet, and ankles Sudden weight gain of more than 2-3 lbs* *in a 24 hour period (5 lbs in a week) Discomfort or swelling in the abdomen Trouble Sleeping HEADS UP! Your symptoms may indicate: A change in medications A call to your physician Adapted from the AHA/ASA Rise Above Heart Failure Self-Check Plan for HF Management

MEDICAL ALERT Warning! × SELF-CHECK PLAN FOR HF MANAGEMENT This self check plan for heart failure management can be used to educate patients how to monitor their own heart failure status. EXCELLENT Keep Up the Good Work! PAY ATTENTION Use Caution! Frequent dry, Hacking cough Shortness of breath at rest Increased discomfort or swelling in the lower body Sudden weight gain of more than 2-3 lbs* *in a 24 hour period (5 lbs in a week) Dizziness confusion, sadness or depression Loss of appetite Increased trouble sleeping; cannot lie flat WARNING! You need to be evaluated right away. Call your physician or call 911 Adapted from the AHA/ASA Rise Above Heart Failure Self-Check Plan for HF Management

Select each button to learn more
COMMON HF DRUGS FOR HFrEF Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Research studies on heart failure provide evidence supporting the use of the following pharmacological treatments. These medications treat different causes or symptoms and may be prescribed at different stages of the heart failure disease lifecycle. For more information on specific use and dosing guidelines, please follow your local clinical guidelines. Select each medication to learn more. Select each button to learn more Hunt, SA, Baker DW, Chin MH ,et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. Circulation.2001; 104(24):

COMMON HF DRUGS FOR HFrEF Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Blocks the conversion of angiotensin I to angiotensin II. Results in blood vessel dilation and reduced blood pressure. For example: Captopril, Enalapril, Fosinopril, Lisinopril, Perindopril, Quinapril ,Ramipril, and Trandolapril. Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Select each button to learn more Hunt, SA, Baker DW, Chin MH ,et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. Circulation.2001; 104(24):

COMMON HF DRUGS FOR HFrEF Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Blocks the action of angiotensin II by preventing it from binding to receptors on the muscles surrounding blood vessels. Results in blood vessel dilation and reduced blood pressure. For example: Candesartan, Losartan, and Valsartan. Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Select each button to learn more Hunt, SA, Baker DW, Chin MH ,et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. Circulation.2001; 104(24):

COMMON HF DRUGS FOR HFrEF Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Relieves fluid by inhibiting sodium resorption in the kidneys. These are potassium sparing diuretics. For example: Spironolactone and Eplerenone. Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Select each button to learn more Hunt, SA, Baker DW, Chin MH ,et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. Circulation.2001; 104(24):

COMMON HF DRUGS FOR HFrEF Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Blocks the effects of epinephrine. Decreases heart rate and blood pressure. For example: Bisoprolol, Carvedilol, and Metoprolol. Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Select each button to learn more Hunt, SA, Baker DW, Chin MH ,et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. Circulation.2001; 104(24):

COMMON HF DRUGS FOR HFrEF Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Consists of the neprilysin inhibitor sacubitril and the angiotensin receptor blocker valsartan. Replaces an ACE inhibitor or an angiotensin receptor blocker. For example: Sacubitril and Valsartan. Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Select each button to learn more Hunt, SA, Baker DW, Chin MH ,et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. Circulation.2001; 104(24):

COMMON HF DRUGS FOR HFrEF Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Lowers the heart rate by blocking If (funny) channels in the sinus node. For example: Ivabradine Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Select each button to learn more Hunt, SA, Baker DW, Chin MH ,et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. Circulation.2001; 104(24):

COMMON HF DRUGS FOR HFrEF
Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Relieves fluid retention. For example: Furosemide

Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Reduces cardiac preload and afterload by achieving both venous and arterial vasodilation. Hydralazine is an arterial vasodilator. Nitrates are predominantly venodilators.

Angiotensin Converting Enzyme (ACE) Inhibitors Angiotensin II Receptor Blocker (ARB) Aldosterone Antagonists (mineralocorticoid receptor antagonist (MRA)) Beta Blockers Angiotensin receptor neprilysin inhibitor (ARNI) If Channel Blocker Diuretics Hydralazine + Isosorbide Dinitrate Digoxin Enhances inotropy (contractility) of cardiac muscle and, at the same time, reduces activation of the sympathetic nervous system (SNS) and renin-angiotensin system (RAAS).

ESC and ACC/AHA/HFSA guidelines 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2017 ACC/AHA/HFSA Update: Drugs Commonly Used for HFrEF (Stage C HF) It’s important to refer to the guidelines for evidence based pharmacological treatments. Select each button to learn more about the medical therapy guidelines for heart failure patients with a reduced EF. Select each button before proceeding

× ESC Guidelines for HFrEF
Evidence-based doses of disease-modifying drugs in key randomized trials in heart failure with reduced ejection fraction (or after myocardial infarction) Doses of diuretics commonly used in patients with heart failure ACE-I Beta-blockers ARBs ARNI Captoprila Bisoprolol Candesartan Sacubitril/valsartan Enalapril Carvedilol Valsartan Lisinoprilb Metoprolol succinate (CR/XL) Losartanb,c Iƒ-channel blocker Ramipril Ivabradine Trandolaprila Nebivololc MRAs Eplerenone Spironolactone ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; ARNI = angiotensin receptor neprilysin inhibitor; b.i.d. = bis in die (twice daily); MRA = mineralocoricoid receptor antagonist; o.d. = omne in die (once daily); t.i.d = ter in die (three times a day). aIndicates an ACE-I where the dosing target is derived from post-myocardial infarction trials. blndcates drugs where a higher dose has been shown to reduce morbidity/ mortality compared with a lower dose of the same drug, but there is no substantive randomized, placebo-controlled trial and the optimum dose is uncertain. cIndicates a treatment not shovel to reduce cardiovascular or all-cause mortality in patients with heart failure (or shown to be non-inferior to a treatment that does). dA maximum dose of 50 mg twice daily can be administered to patients weighing over 85 kg Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Evidence-based doses of disease-modifying drugs in key randomized trials in heart failure with reduced ejection fraction (or after myocardial infarction) Diuretics commonly used in patients with heart failure Loop diureticsa Thiazidesb Potassium-sparing diureticsd Furosemide Bendroflumethiazide Spironolactone/eplerenone Bumcumdo Hydrochlorothiazide Amiloride Toraswmdo Metolazone Triamterene Indapamidec ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; aOral or intravenous; dose might need to be adjusted according to volume status/ weight: excessive doses may cause renal impairment and ototoxicity. bDo not use thiazides if estimated glomerular filtration rate <30mL/min/1.73 m2 , except when prescribed synerustically with loop diuretics. cIndapamide is a non-thiazide sulfonamide. dA mineralocorticoid antagonist (MRA), i.e. spironolactone/eplerenone is always preferred. Amiloride and triamterene should not be combined with an MRA. Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; bpm = beet per minute; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; PUFA = polyunsaturated fatty acid; OMT = optimal medical therapy (for HFrEF this mostly comprises an ACEI or sacubrtril/valsartan, a beta-blocker and an MRA). aClass of recommendation. bLevel of evidence. cReference(s) supporting recommendations. dPatient should have elevated natriuretic peptides (plasma BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL or if HF hospitalization within the last 12 months, plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL) and able to tolerate enalapril 10 mg b.i.d. eApplies only to preparation studied in cited trial. ARB Hydralazine and isosorbide dinitrate N-3 PUFA If-channel inhibitor Diuretics Digoxin Angiotensin receptor neprilysin inhibitor Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; bpm = beet per minute; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; PUFA = polyunsaturated fatty acid; OMT = optimal medical therapy (for HFrEF this mostly comprises an ACEI or sacubrtril/valsartan, a beta-blocker and an MRA). aClass of recommendation. bLevel of evidence. cReference(s) supporting recommendibons. dPatient should have elevated natriuretic peptides (plasma BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL or if HF hospitalization within the last 12 months, plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL) and able to tolerate enalapril 10 mg b.i.d. eApplies only to preparation studied in cited trial. Diuretics Angiotensin receptor neprilysin inhibitor If-channel inhibitor ARB Hydralazine and isosorbide dinitrate Digoxin N-3 PUFA Recommendations Classa Levelb Refc Diuretics are recommended in order to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion. I B Diuretics should be considered to reduce the risk of HF hospitalization in patients with signs and/or symptoms of congestion. IIa B Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; bpm = beet per minute; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; PUFA = polyunsaturated fatty acid; OMT = optimal medical therapy (for HFrEF this mostly comprises an ACEI or sacubrtril/valsartan, a beta-blocker and an MRA). aClass of recommendation. bLevel of evidence. cReference(s) supporting recommendibons. dPatient should have elevated natriuretic peptides (plasma BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL or if HF hospitalization within the last 12 months, plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL) and able to tolerate enalapril 10 mg b.i.d. eApplies only to preparation studied in cited trial. Diuretics Angiotensin receptor neprilysin inhibitor If-channel inhibitor ARB Hydralazine and isosorbide dinitrate Digoxin N-3 PUFA Recommendations Classa Levelb Refc Sacubitril/valsartan is recommended as a replacement for an ACE-I to further reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker and an MRA. I B 162 Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; bpm = beet per minute; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; PUFA = polyunsaturated fatty acid; OMT = optimal medical therapy (for HFrEF this mostly comprises an ACEI or sacubrtril/valsartan, a beta-blocker and an MRA). aClass of recommendation. bLevel of evidence. cReference(s) supporting recommendibons. dPatient should have elevated natriuretic peptides (plasma BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL or if HF hospitalization within the last 12 months, plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL) and able to tolerate enalapril 10 mg b.i.d. eApplies only to preparation studied in cited trial. Diuretics Angiotensin receptor neprilysin inhibitor Iƒ-channel inhibitor ARB Hydralazine and isosorbide dinitrate Digoxin N-3 PUFA Recommendations Classa Levelb Refc Ivabradine should be considered to reduce the risk of HF hospitalization or cardiovascular death in symptomatic patients with LVEF ≤35% in sinus rhythm and a resting heart rate ≥70 bpm despite treatment with an evidence-based dose of beta-blocker (or maximum tolerated dose below that). ACE-I (or ARB), and an MRA (or ARB). IIa B 180 Ivabradine should be considered to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with LVEF ≤35% in sinus rhythm and a resting heart rate ≥70 bpm who are enable to tolerate or have contra-indications for a beta-blocker. Patients should also receive an ACE-I (or ARB) and an MRA (or ARB). IIa C 181 Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; bpm = beet per minute; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; PUFA = polyunsaturated fatty acid; OMT = optimal medical therapy (for HFrEF this mostly comprises an ACEI or sacubrtril/valsartan, a beta-blocker and an MRA). aClass of recommendation. bLevel of evidence. cReference(s) supporting recommendibons. dPatient should have elevated natriuretic peptides (plasma BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL or if HF hospitalization within the last 12 months, plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL) and able to tolerate enalapril 10 mg b.i.d. eApplies only to preparation studied in cited trial. Diuretics Angiotensin receptor neprilysin inhibitor Iƒ-channel inhibitor ARB Hydralazine and isosorbide dinitrate Digoxin N-3 PUFA Recommendations Classa Levelb Refc An ARB is recommended to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients unable to tolerate an ACE-I (patients should also receive a beta-blocker and an MRA). I B 182 An ARB may be considered to reduce the risk of HF hospitalization and death in patients who are symptomatic despite treatment with a beta-blocker who are unable to tolerate an MRA. IIb C - Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; bpm = beet per minute; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; PUFA = polyunsaturated fatty acid; OMT = optimal medical therapy (for HFrEF this mostly comprises an ACEI or sacubrtril/valsartan, a beta-blocker and an MRA). aClass of recommendation. bLevel of evidence. cReference(s) supporting recommendibons. dPatient should have elevated natriuretic peptides (plasma BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL or if HF hospitalization within the last 12 months, plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL) and able to tolerate enalapril 10 mg b.i.d. eApplies only to preparation studied in cited trial. Diuretics Angiotensin receptor neprilysin inhibitor Iƒ-channel inhibitor ARB Hydralazine and isosorbide dinitrate Digoxin N-3 PUFA Recommendations Classa Levelb Refc Hydralazine and isosorbide dinitrate should be considered in self-identified black patients with LVEF ≤35% or with an LVEF <45% combined with a dialed LV in NYHA Class III-IV despite treatment with an ACE-I a beta-blocker and an MRA to reduce the risk of HF hospitalization and death. IIa B 183 Hydralazine and isosorbide dinitrate may be considered in symptomatic patients with HFrEF who can tolerate neither an ACE-I nor an ARB (or they are contra-indicated) to reduce the risk of death. IIb B 184 Other treatments with less-certain benefits. Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; bpm = beet per minute; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; PUFA = polyunsaturated fatty acid; OMT = optimal medical therapy (for HFrEF this mostly comprises an ACEI or sacubrtril/valsartan, a beta-blocker and an MRA). aClass of recommendation. bLevel of evidence. cReference(s) supporting recommendibons. dPatient should have elevated natriuretic peptides (plasma BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL or if HF hospitalization within the last 12 months, plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL) and able to tolerate enalapril 10 mg b.i.d. eApplies only to preparation studied in cited trial. Diuretics Angiotensin receptor neprilysin inhibitor Iƒ-channel inhibitor ARB Hydralazine and isosorbide dinitrate Digoxin N-3 PUFA Recommendations Classa Levelb Refc Digoxin may be considered in symptomatic patients in sinus rhythm despite treatment with an ACE-I (or ARB), a beta-blocker and an MRA. to reduce the risk of hospitalization (both all-cause and HF-hospitalizations). IIb B 185 Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Other pharmacological treatments recommended in selected patients with symptomatic (NYHA Class II-IV) heart failure with reduced ejection fraction ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; bpm = beet per minute; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NT-proBNP = N-terminal pro-B type natriuretic peptide; NYHA = New York Heart Association; PUFA = polyunsaturated fatty acid; OMT = optimal medical therapy (for HFrEF this mostly comprises an ACEI or sacubrtril/valsartan, a beta-blocker and an MRA). aClass of recommendation. bLevel of evidence. cReference(s) supporting recommendibons. dPatient should have elevated natriuretic peptides (plasma BNP ≥ 150 pg/mL or plasma NT-proBNP ≥ 600 pg/mL or if HF hospitalization within the last 12 months, plasma BNP ≥ 100 pg/mL or plasma NT-proBNP ≥ 400 pg/mL) and able to tolerate enalapril 10 mg b.i.d. eApplies only to preparation studied in cited trial. Diuretics Angiotensin receptor neprilysin inhibitor Iƒ-channel inhibitor ARB Hydralazine and isosorbide dinitrate Digoxin N-3 PUFA Recommendations Classa Levelb Refc An n-3 PUFAe preparation may be considered in symptomatic HF patients to reduce the risk of cardiovascular hospitalization and cardiovascular death. IIb B 186 Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

× From 2017 ACC/AHA/HFSA Updates HFrEF Stage C
Drugs Commonly Used for HFrEF (Stage C HF) ACE inhibitors ARBs Aldosterone antagonists Isosorbide dinitrate and hydralazine Captopril Candesartan Spironolactone Enalapril Losartan Eplerenone Fixed-dose combination Fosinopril Valsartan Lisinopril Beta blocker Perindopril ARNI Bisoprolol Quinapril Sacubitril/valsartan Carvedilol Ramiphl Carvedilol CR Trandolapril If channel inhibitor Metoprolol succinate extended release (metoprolol CR/XL) Ivabradine Modified (Table 15) from the 2013 HF guideline. ACE indicates angiotensin-converting enzyme; ARB. angiotensin receptor blocker; ARNI. angiotensin receptor-neprilysin inhibitor, BID, twice daily; CR. controlled release; CR/XL, controlled release/extended release; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; N/A, not applicable; QD. once daily; and HD. 3 times daily. Yancy CW, Jessup M, Bozkurt B, et al ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Circulation. 2017; 136(6):e137-e161.

DEVICE Therapy for Heart Failure Patients HFrEF
LEFT VENTRICULAR ASSIST DEVICE (LVAD) IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) CARDIAC RESYNCHRONIZATION THERAPY (CRT) CRT-D OR CRT-P Device therapy can provide circulatory support, such as LVADs, or pacing therapy, such as CRT. Select each button to learn more. Select each button before proceeding

LEFT VENTRICULAR ASSIST DEVICE (LVAD) IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) CARDIAC RESYNCHRONIZATION THERAPY (CRT) CRT-D OR CRT-P Mechanical circulatory support (MCS) system used to maintain end-organ perfusion ESC AND ACC/AHA GUIDELINES FOR IMPLANTATION OF LVAD DEVICE > Left Ventricular Assist Devices or LVADs provide circulatory support for the failing ventricle. Initially, LVADs were used as a bridge to transplant in patients with refractory, chronic heart failure, but more recently have been used as an alternative to heart transplantation. Data indicates that patients with LVAD support on the transplant waiting list have improved survival.1 Park SJ, Tector A, Piccioni W, et al. Left Ventricular Assist Devices as Destination Therapy: A New Look at Survival. J Thorac Cardiovasc Surg. 2005; 129(1): 9-17.

× Guidelines for implantation of LVAD ESC GUIDELINES
Recommendations for implantation of mechanical circulatory support in patients with refractory heart failure HF = heart failure; HFrEF = heart failure with reduced ejection fraction; LVAD = left ventricular assist device. aClass of recommendation. bLevel of evidence. Recommendations Classa Levelb An LVAD should be considered in patients who have end- stage HFrEF despite optimal medical and device therapy and who are eligible for heart transplantation in order to improve symptoms, reduce the risk of HF hospitalization and the risk of premature death (Bridge to transplant indication). IIa C An LVAD should be considered in patients who have end-stage HFrEF despite optimal medical and device therapy and who are not eligible for heart transplantation to reduce the risk of premature death. IIa B Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

× Guidelines for implantation of LVAD ESC GUIDELINES
Patients potentially eligible for implantation of a left ventricular assist device CI = cardiac index; HF = heart failure; i.v. = intravenous; LVEF = left ventricular ejection fraction; PCWP = pulmonary capillary wedge pressure; SBP = systolic blood pressure; VO2 = oxygen consumption. Patients with >2 months of severe symptoms despite optimal medical and device therapy and more than one of the following: LVEF <25% and, if measured, peak VO2 <12 mL/kg/min. ≥3 HF hospitalizations in previous 12 months without an obvious precipitating cause. Dependence on i.v. inotropic therapy. Progressive end-organ dysfunction (worsening renal and/or hepatic function) due to reduced perfusion and not to inadequate ventricular filling pressure (PCWP ≥20 mmHg and SBP ≤80-90 mmHg or CI ≤2 L/min/m2). Absence of severe right ventricular dysfunction together with severe tricuspid regurgitation. Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

× Guidelines for implantation of LVAD ACC/AHA GUIDELINES
Mechanical Circulatory Support Recommendations CLASS IIa 1. MCS is beneficial in carefully selected‡ patients with stage D HFrEF in whom definitive management (e.g.. cardiac transplantation) or cardiac recovery is anticipated or planned ( ). (Level of Evidence: B) 2. Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices (VADs), is reasonable as a “bridge to recovery” or “bridge to decision” for carefully selected patients with HFrEF with acute, profound hemodynamic compromise ( ). (Level of Evidence: B) 3. Durable MCS is reasonable to prolong survival for carefully selected patients with stage D HFrEF ( ). (Level of Evidence: B) ‡ Although optimal patient selection for MCS remains an active area of investigation, general indications for referral for MCS therapy include patients with LVEF Yancy CW, Jessup M, Bozkurt B, et al ACCF/AHA Guideline for the Management of Heart Failure. JACC. 2013; 62(16):e

LEFT VENTRICULAR ASSIST DEVICE (LVAD) IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) CARDIAC RESYNCHRONIZATION THERAPY (CRT) CRT-D OR CRT-P Implantable devices that provide therapy for brady- and tachyarrhythmias. Reduces the risk of sudden cardiac death ESC ACC/AHA GUIDELINES FOR IMPLANTATION OF ICD DEVICE > In patients with heart failure, sudden death occurs at four times the rate of the general population.2 Clinical studies have demonstrated a significant risk reduction in all-cause mortality in heart failure patients with a reduced EF who were implanted with an ICD.3,4 ICDs monitor the heart rhythm for both brady- and tachyarrhythmias and provide both pacing and defibrillation therapy. American Heart Association. Heart and Stroke Statistical – 2003 Update. Dallas, Tex.: American Heart Association: 2002.

× Secondary prevention Primary prevention
Recommendations for ICD IN PATIENTS WITH HEART FAILURE ESC GUIDELINES Secondary prevention Primary prevention Patients who have recovered from a ventricular arrhythmia causing hemodynamic instability, and are expected to survive longer than one year with good functional status. Class I - level of evidence A ICD ALL PATIENTS SHOULD BE ON OPTIMAL PHARMACOLOGICAL THERAPY Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

× Secondary prevention Primary prevention
Recommendations for ICD IN PATIENTS WITH HEART FAILURE ESC GUIDELINES Secondary prevention Primary prevention Patients with symptomatic HF (if NYHA Class II–III) and LVEF ≤35% despite ≥3 months of OMT, expected to survive longer than one year with good functional status, and with: Ischemic Heart Disease - IHD (unless they have had an MI in the prior 40 days) Dilated Cardiomyopathy - DCM Class I - level of evidence A (IHD) Class I - level of evidence A (DCM) ICD ALL PATIENTS SHOULD BE ON OPTIMAL PHARMACOLOGICAL THERAPY Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

Post-revascularization
× 2017 AHA/ACC/HRS Guidelines for Implantable Defibrillators Class I recommendations Primary Prevention of SCD ≥ 90 days Post-revascularization ≥ 40 days Post MI LVEF ≤ 30% NYHA Class: I ICD Indicated CLASS I, LEVEL OF EVIDENCE A Ischemic Patient MI LVEF ≤ 35% NYHA Class: II - III Non-ischemic Patient LVEF ≤ 35% NYHA Class: II - III Ischemic Patient MI NSVT LVEF ≤ 40% Inducible sustained VT/VF at EPS ICD Indicated CLASS I, LEVEL OF EVIDENCE B-R Tracy CM, Epstein AE, Darbar D, et al ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol. October 2, 2012;60(14):

× 2017 AHA/ACC/HRS Guidelines for Implantable Defibrillators Class I recommendations Secondary Prevention of SCD Survivor of SCA due to VT/VF or experience hemodynamically unstable VT (LOE: B-R) or stable VT* (LOE: B-NR) ICD Indicated CLASS I, LEVEL OF EVIDENCE B-R AND B-NR Ischemic Patient Unexplained syncope who have inducible sustained monomorphic VT at EPS ICD Indicated CLASS I, LEVEL OF EVIDENCE B-R *not due to reversible causes. Tracy CM, Epstein AE, Darbar D, et al ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol. October 2, 2012;60(14):

LEFT VENTRICULAR ASSIST DEVICE (LVAD) IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) CARDIAC RESYNCHRONIZATION THERAPY (CRT) CRT-D OR CRT-P Pacing therapy intended to resynchronize the ventricular activation sequence and to better coordinate atrial-ventricular timing to improve pumping efficiency. ESC ACC/AHA GUIDELINES FOR IMPLANTATION OF CRT DEVICE > Cardiac Resynchronization Therapy, with (CRT-D) and without (CRT-P) defibrillation capability, are indicated for patients with heart failure and ventricular dyssynchrony. The intent of the therapy is to resynchronize the ventricular activation sequence and to better coordinate atrial-ventricular timing to improve pumping efficiency.

× 2013 ACC/AHA guidelines for crt1
Patient with cardiomyopathy on GDMT for ≥ 3 months or on GDMT and ≥ 40 days after MI, or with implantation of pacing or defibrillation devices for special indications LVEF ≤ 35% Comorbidities and/or frailty limit survival with good functional capacity to < 1 year Continue GDMT Without Implanted device Evaluate general health status Acceptable noncardiac health Evaluate NYHA clinical status NYHA class I NYHA class II NYHA class III & Ambulatory class IV Special CRT Indications LVEF ≤ 30% QRS ≥ 150 ms LBBB pattern Ischemic cardiomyopathy LVEF ≤ 35% QRS ≥ 150 ms LBBB pattern Sinus rhythm LVEF ≤ 35% QRS ≥ 150 ms LBBB pattern Sinus rhythm Anticipated to require frequent ventricular pacing (> 40%) Atrial fibrillation, if ventricular pacing is required and rate control will result in near 100% ventricular pacing with CRT LVEF ≤ 35% QRS ms LBBB pattern Sinus rhythm LVEF ≤ 35% QRS ms LBBB pattern Sinus rhythm QRS ≤ 150 ms Non-LBBB pattern LVEF ≤ 35% QRS ≥ 150 ms Non-LBBB pattern Sinus rhythm LVEF ≤ 35% QRS ≥ 150 ms Non-LBBB pattern Sinus rhythm Class I. Should be performed Class IIa. Reasonable to perform Class IIb. May be considered Class III. No benefit QRS ≤ 150 ms Non-LBBB pattern LVEF ≤ 35% QRS ms Non-LBBB pattern Sinus rhythm Tracy CM, Epstein AE, Darbar D, et al ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol. October 2, 2012;60(14):

× 2013 ACC/AHA guidelines for crt1
Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along with long-term HF consequences. There are no trials that support CRT pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival. Yancy CW, Jessup M, Bozkurt B, et al ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. October 15, 2013;62(16):e

× Recommendations for CRT IN PATIENTS WITH HEART FAILURE ESC GUIDELINES Sinus Rhythm Permanent AF Need For Pacing Select each button before proceeding Ponikowski P, Voors AA, Anker SD, et al ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal. July 2016; 37(27):

× Recommendations for CRT IN PATIENTS WITH HEART FAILURE
ESC GUIDELINES Sinus Rhythm Permanent AF Need For Pacing QRS > 150 ms Class I - level of evidence A CRT-D/CRT-P* LBBB QRS ms Class I - level of evidence B CRT-D/CRT-P* Symptomatic HF EF ≤ 35% QRS > 150 ms Class IIa - level of evidence B CRT-D/CRT-P* Non-LBBB QRS ms Class IIb - level of evidence B CRT-D/CRT-P* All patients should be on optimal pharmacological therapy * If a patient is scheduled to receive an ICD and is in sinus rhythm with a QRS duration ≥130 ms, CRT-D should be considered if QRS is between 130 and 149 ms and is recommended if QRS is ≥150 ms. However, fi the primary reason for implanting a CRT is for the relief of symptoms, then the clinician should choose CRT-P or CRT-D, whichever they consider appropriate.

ESC GUIDELINES Sinus Rhythm Permanent AF Need For Pacing Strategy to ensure BiV capture or patient expected to return to SR NYHA III/IV± EF ≤ 35% QRS≥ 130 ms Class IIa - level of evidence B CRT-D/CRT-P ± Use judgment in end-stage HF

ESC GUIDELINES Sinus Rhythm Permanent AF Need For Pacing Upgrade all NYHA EF ≤ 35% QRS≥ 130 ms Worsening HF & High % V. Pacing Class IIa - level of evidence B CRT-D/CRT-P Indication for V. Pacing & High degree AV block De Novo+ all NYHA EF ≤ 35% QRS≥ 130 ms Class IIa - level of evidence B CRT-D/CRT-P + Including AF patients

Surgical/Interventional Therapy
REVASCULARIZA -TION PROCEDURES VALVE REPLACEMENT OR REPAIR ARRHYTHMIA TREATMENT SURGICAL VENTRICULAR RESTORATION HEART TRANSPLANT Surgical interventions may be considered for heart failure patients. Select each therapy type to learn more.

REVASCULARIZA -TION PROCEDURES VALVE REPLACEMENT OR REPAIR ARRHYTHMIA TREATMENT SURGICAL VENTRICULAR RESTORATION HEART TRANSPLANT Coronary Artery Bypass Graft (CABG) involves the use of a blood vessel graft to bypass one or more blocked coronary arteries. The bypass restores normal blood flow to the heart muscle Percutaneous Coronary Intervention (PCI) is a procedure used to treat narrowing (stenosis) of the coronary arteries of the heart found in coronary artery disease. Surgical therapies and percutaneous interventions are commonly integrated into heart failure management. 5 Heart failure can develop when blockages in the coronary arteries restrict the blood supply to the heart muscle. Removing these blockages, also known as revascularization, can improve overall heart function, which may improve or resolve heart failure symptoms. Revascularization can be achieved through the use of coronary artery bypass graft or percutaneous coronary intervention procedures. Devices and Surgical Procedures to Treat Heart Failure. Updated May 9, Accessed July 20, 2018.

REVASCULARIZA -TION PROCEDURES VALVE REPLACEMENT OR REPAIR ARRHYTHMIA TREATMENT SURGICAL VENTRICULAR RESTORATION HEART TRANSPLANT Valves can either leak or become narrowed, or both. If they don't work properly this puts extra strain on the heart and can lead to heart failure. Repairing or replacing a malfunctioning heart valve can help to regulate the flow of blood inside the heart to relieve heart failure symptoms. Heart failure can be caused by a defective or disease heart valve Heart valves regulate the flow of blood inside the heart, and when they don’t work properly it puts extra strain on the heart and can lead to heart failure.5 Some valve issues can be medically treated first. Correcting the problem surgically, by either repairing or replacing the valve, can help to improve the flow of blood through the heart. Devices and Surgical Procedures to Treat Heart Failure. Updated May 9, Accessed July 20, 2018.

REVASCULARIZA -TION PROCEDURES VALVE REPLACEMENT OR REPAIR ARRHYTHMIA TREATMENT SURGICAL VENTRICULAR RESTORATION HEART TRANSPLANT Episodes of tachyarrhythmias are common in patients with chronic HF and are associated with worsening of HF symptoms. Catheter or surgical ablation can help to reduce the incidence of these arrhythmias and regulate the heart’s rhythm. Tachyarrhythmias, especially atrial fibrillation, are common in patients with chronic HF and are associated with worsening hear failure symptoms.6 Catheter ablation uses radio frequency energy to destroy a small area of the heart tissue that is suspected of causing these arrhythmias. Surgical ablation is a more invasive way of trying to create scar tissue to prevent the arrhythmias from propagating.7 Watson RDS, Gibbs CR, Lip GYH. Clinical features and complications. BMJ Jan 22; 320 (7229): Ablation for Arrhythmias. Updated Jun 5, Accessed July

REVASCULARIZA -TION PROCEDURES VALVE REPLACEMENT OR REPAIR ARRHYTHMIA TREATMENT SURGICAL VENTRICULAR RESTORATION HEART TRANSPLANT A procedure designed to restore the LV to its normal, spherical shape. Surgical ventricular restoration is a surgical procedure to treat congestive heart failure caused by a myocardial infarction.8 The procedure is designed to restore the heart to a more normal size and shape, and therefore improving function. Surgical Ventricular Restoration. Accessed July

REVASCULARIZA -TION PROCEDURES VALVE REPLACEMENT OR REPAIR ARRHYTHMIA TREATMENT SURGICAL VENTRICULAR RESTORATION HEART TRANSPLANT Acceptable treatment for end-stage HF with severe symptoms, a poor prognosis and no remaining alternative treatment options. In some cases, when severe, progressive heart failure can’t be treated with medications, dietary, and lifestyle changes a heart transplant may be the only effective treatment option.9 Surgeons will replace the damaged heart with a healthy one taken from a donor. Devices and Surgical Procedures to Treat Heart Failure. Updated May 9, Accessed July 20, 2018.

Meet the patients in clinic today
Now that you have an understanding of each of the four categories of heart failure treatment, let’s apply what we have learned. The following four patients show up in your clinic today. Select each patient to practice following the guidelines to determine the next best steps for each patient. When assessing patients it is helpful to ask a standard set of questions to better understand the patient’s current clinical state. It’s important to ask the patient about their symptoms, medication compliance, diet and/or weight change, and any other lifestyle changes. Then review any pertinent physical examination, testing, and lab results. Mary David Sam Jane QUESTIONS TO ASK PATIENT Results from case studies are not predictive of results in other cases. Results in other cases may vary.

Sample Patient Questions: Any changes in symptoms? Any changes in medication? Are they compliant? Any changes in weight? Any change in lifestyle (exercise, diet, etc…)? Then: Conduct physical examination Review testing and lab results × Mary David Sam Jane QUESTIONS TO ASK PATIENT Results from case studies are not predictive of results in other cases. Results in other cases may vary.

Mary is 85 years old with a history of left ventricular systolic dysfunction (LVSD). She presents in clinic with increasing shortness of breath over the past 9 months. Mary David Sam Jane QUESTIONS TO ASK PATIENT Results from case studies are not predictive of results in other cases. Results in other cases may vary.

No prior history of ischemia Hx of NYHA Class II symptoms
MARY Worsening dyspnea No prior history of ischemia Hx of NYHA Class II symptoms No syncope or palpitations Current medication Bisoprolol 7.5mg OD Perindopril 4mg OD Spironolactone 50mg OD Furosemide 80mg BD Normal Sinus rhythm at 58 bpm Mary is 85 years old with a history of left ventricular systolic dysfunction (LVSD). She presents in clinic with increasing shortness of breath over the past 9 months. Mary is 85 years old and has a history of left ventricular systolic dysfunction. She is on guideline-directed medical therapy (GDMT). She presents to your clinic today complaining of increasing shortness of breath over the past 9 months. Review the following information and select next to continue.

What testing should be performed?
(Select) ⃝ A. 12-lead ECG ⃝ B. Echocardiogram ⃝ C. Serum chemistries (K+, BUN, Creatinine) ⃝ D. BNP ⃝ E. All of the above Answer: E Submit

CORRECT That’s right! You selected the correct response. These are all standard tests that are performed in the examination of the patient. What testing should be performed? (Select) ⃝ A. 12-lead ECG ⃝ B. Echocardiogram ⃝ C. Serum chemistries (K+, BUN, Creatinine) ⃝ D. BNP ⃝ E. All of the above SEE CORRECT ANSWER CONTINUE

TRY AGAIN That’s not the correct response, please try again! What testing should be performed? (Select) ⃝ A. 12-lead ECG ⃝ B. Echocardiogram ⃝ C. Serum chemistries (K+, BUN, Creatinine) ⃝ D. BNP ⃝ E. All of the above TRY AGAIN

INCORRECT You did not select the correct response. These are all standard tests that are performed in the examination of the patient. What testing should be performed? (Select) ⃝ A. 12-lead ECG ⃝ B. Echocardiogram ⃝ C. Serum chemistries (K+, BUN, Creatinine) ⃝ D. BNP ⃝ E. All of the above SEE CORRECT ANSWER CONTINUE

(Select) ⃝ A. 12-lead ECG ⃝ B. Echocardiogram ⃝ C. Serum chemistries (K+, BUN, Creatinine) ⃝ D. BNP ⃝ E. All of the above CONTINUE

ECG Test results What we found… MARY
Review Mary’s ECG and test results.

ECG Test results What we found… MARY Echocardiogram:
Severe LV systolic impairment + BNP 1854 pg/mL (abnormal BNP) - 12-lead ECG: LBBB, QRS duration >150ms - 24-hr Holter: SR, no NSVT - Normal stress test indicating no structural heart disease - Cardiac work up shows dilated cardiomyopathy with an EF of 25%

ECG Test results What we found… MARY Echocardiogram:
Severe LV systolic impairment - BNP 1854 pg/mL (abnormal BNP) A normal level of NT-proBNP, based on Cleveland Clinic’s Reference Range is: Less than 125 pg/mL for patients aged 0-74 years Less than 450 pg/mL for patients aged years If you have heart failure, the following NT-proBNP levels could mean your heart function is unstable: Higher than 450 pg/mL for patients under age 50 Higher than 900 pg/mL for patients age 50 and older NT-proB-type Natriuretic Peptide (BNP). Updated July Accessed August 28, 2018.

ECG Test results What we found… MARY
- LVSD was confirmed on both echo and cardiac catheterization (no coronary disease) - Continued use of optimal medical therapy - High BNP indicates symptoms are likely cardiac in origin - Physical Examination findings: BP unchanged from previous visit Lung sounds are clear No peripheral Edema 12-lead ECG shows a clear LBBB with QRS > 150 ms; no other high risk features evident, EF = 25% Based on these results we would re-examine her NYHA classification

What is her HF classification based on your findings?
NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit

CORRECT That’s right! You selected the correct response. NYHA Class III A CRT should be considered. Mary has a Class I indication for a CRT device. Low EF, Class III symptoms (symptoms at rest). What is her HF classification based on your findings? NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit SEE CORRECT ANSWER CONTINUE

TRY AGAIN That’s not the correct response, please try again! What is her HF classification based on your findings? NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit TRY AGAIN

INCORRECT You did not select the correct response. NYHA Class III A CRT should be considered. Mary has a Class I indication for a CRT device. Low EF, Class III symptoms (symptoms at rest). What is her HF classification based on your findings? NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit SEE CORRECT ANSWER CONTINUE

NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit CONTINUE

David is 75 years old with a previous MI. He presents in clinic with chest palpitations that interrupt his sleep. Mary David Sam Jane QUESTIONS TO ASK PATIENT Results from case studies are not predictive of results in other cases. Results in other cases may vary.

Non-insulin dependent diabetes Ex-smoker
DAVID Anterior MI 7 years ago Primary percutaneous coronary intervention (PPCI) to the left anterior descending (LAD) coronary artery Non-insulin dependent diabetes Ex-smoker Palpitations for last 3 months No angina or HF symptoms On GDMT for the past 6 months Denies chest pain Admits to SOB on exertion after asked David is 75 years old with a previous MI. He presents in clinic complaining of chest palpitations that interrupts his sleep. David is 75 years old. He had a myocardial infarction (MI) seven years ago. He presents to your clinic today complaining that his sleep is interrupted with feelings of palpitations.

Based on David’s past history and current symptoms, select the next tests to perform:
(Select all that apply) ⃝ A. Echocardiogram ⃝ B. ECG ⃝ C. CMRI ⃝ D. BNP ⃝ E. Cardiac Catheterization ⃝ F. 24-hr Holter Answer: A, B, F Submit

CORRECT That’s right! You selected the correct response.
In this case, we would like to determine whether David’s palpitations are from acute ischemia or shortness of breath (SOB) on exertion. We want to know whether an ischemic event is causing the palpitations or an arrhythmia. David had an angioplasty 7 years ago, so it is important to determine if this is new onset ischemia. Based on David’s past history and current symptoms, select the next tests to perform: (Select) ⃝ A. Echocardiogram ⃝ B. ECG ⃝ C. CMRI ⃝ D. BNP ⃝ E. Cardiac Catheterization ⃝ D. 24-hr Holter SEE CORRECT ANSWER CONTINUE

TRY AGAIN That’s not the correct response, please try again! TRY AGAIN
Based on David’s past history and current symptoms, select the next tests to perform: (Select) ⃝ A. Echocardiogram ⃝ B. ECG ⃝ C. CMRI ⃝ D. BNP ⃝ E. Cardiac Catheterization ⃝ D. 24-hr Holter TRY AGAIN Submit

INCORRECT You did not select the correct response. SEE CORRECT ANSWER
In this case, we would like to determine whether David’s palpitations are from acute ischemia or shortness of breath (SOB) on exertion. We want to know whether an ischemic event is causing the palpitations or an arrhythmia. David had an angioplasty 7 years ago, so it is important to determine if this is new onset ischemia. Based on David’s past history and current symptoms, select the next tests to perform: (Select) ⃝ A. Echocardiogram ⃝ B. ECG ⃝ C. CMRI ⃝ D. BNP ⃝ E. Cardiac Catheterization ⃝ D. 24-hr Holter SEE CORRECT ANSWER CONTINUE Submit

INCORRECT You did not select the correct response. CONTINUE Submit
Based on David’s past history and current symptoms, select the next tests to perform: (Select) ⃝ A. Echocardiogram ⃝ B. ECG ⃝ C. CMRI ⃝ D. BNP ⃝ E. Cardiac Catheterization ⃝ D. 24-hr Holter CONTINUE Submit

ECG Test results What we found… DAVID
Review the David’s ECG and test results.

ECG Test results What we found… DAVID ECG: 24-hr Holter Echocardiogram
Normal sinus rhythm (NSR) with left bundle branch block (LBBB) QRS duration 160 ms 24-hr Holter Sinus rhythm for most of the recording with one episode of wide complex regular tachycardia – rate 180/min lasting 28 beats Echocardiogram Severe LVSD with anterior wall thinning and hypokinesia EF 30% Moderate MR No need for revascularization identified

ECG Test results What we found… DAVID
David has a number of high risk features for arrhythmia including his ischemic etiology, severe LVSD, and LBBB.

What is his HF classification based on your findings?
NYHA classification (Drag and Drop) Class I Class II Class III Class IV Answer: Class II Submit

What is hIS HF classification based on your findings?
CORRECT That’s right! You selected the correct response. David is a NYHA Class II. He is an ideal primary prevention candidate for a CRT-D device. What is hIS HF classification based on your findings? NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit SEE CORRECT ANSWER CONTINUE

TRY AGAIN That’s not the correct response, please try again! What is hIS HF classification based on your findings? NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit TRY AGAIN

INCORRECT You did not select the correct response. David is a NYHA Class II. He is an ideal primary prevention candidate for a CRT-D device. What is hIS HF classification based on your findings? NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit SEE CORRECT ANSWER CONTINUE

NYHA classification (Drag and Drop) Class I Class II Class III Class IV Submit CONTINUE

Sam is 81 years old and walked unassisted into clinic today, three months after beginning treatment for HFpEF. He reports having had a syncopal episode. Mary David Sam Jane QUESTIONS TO ASK PATIENT Results from case studies are not predictive of results in other cases. Results in other cases may vary.

PAF (paroxysmal atrial fibrillation)
SAM History: HTN (hypertension) PAF (paroxysmal atrial fibrillation) Been on GDMT for the past 6 months Subsequently, an ECG, echo, BNP and 24-hr Holter were performed. Sam is 81 years old and walked unassisted into clinic today, three months after beginning treatment for HFpEF. He reports having had a syncopal episode. Sam is 81 years old and walks unassisted into your clinic today after beginning treatment for diastolic dysfunction. He is being seen today after having reported a recent syncopal episode.

Treatment considerations
SAM ECG Test results Treatment considerations Review Sam’s ECG and test results.

SAM ECG Test results Treatment considerations ECG: First degree AVB, narrow QRS Echo: EF 55% with mild LVH BNP: 130 pg/mL (normal) 24Hr Holter: First degree AVB Intermittent Type 1 and 2 second degree AVB with symptoms + What device should Sam be offered?

What device should Sam be offered?
(Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. Dual chamber Pacemaker Answer: D Submit

CORRECT That’s right! You selected the correct response. Sam doesn’t meet the criteria for CRT or ICD. His EF is not within the criteria and he is not having heart failure like symptoms. His symptoms appear to be related to the AV block observed in the ECG. In this case he is indicated for a dual chamber pacemaker. What device should Sam be offered? (Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. Dual chamber Pacemaker SEE CORRECT ANSWER CONTINUE Submit

TRY AGAIN That’s not the correct response, please try again! What device should Sam be offered? (Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. Dual chamber Pacemaker TRY AGAIN Submit

INCORRECT You did not select the correct response. Sam doesn’t meet the criteria for CRT or ICD. His EF is not within the criteria and he is not having heart failure like symptoms. His symptoms appear to be related to the AV block observed in the ECG. In this case he is indicated for a dual chamber pacemaker. What device should Sam be offered? (Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. Dual chamber Pacemaker SEE CORRECT ANSWER CONTINUE Submit

(Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. Dual chamber Pacemaker CONTINUE Submit

SAM ECG Test results Treatment considerations - Sam’s blood pressure and fluid status appear stable with current medications for HFpEF (absence of symptoms). - ICD and CRT therapy are not indicated due to his normal EF (55%) - A pacemaker should be considered for documented evidence of symptomatic AV block. - The device should have algorithms that minimize RV pacing since Holter confirms some AV conduction. Review the trials linked below to learn more about the role of reduced RV pacing for pacemaker patients Reference SAVE PACE Trial Reference DAVID Trial

Jane is 36 years old and has had HF symptoms for over a year post-partum. She is in clinic today for her routine follow-up. Mary David Sam Jane QUESTIONS TO ASK PATIENT Results from case studies are not predictive of results in other cases. Results in other cases may vary.

Developed HF symptoms 19 months ago (1 month post partum)
Jane History: Developed HF symptoms 19 months ago (1 month post partum) Presumed dilated cardiomyopathy (DCM) or post-partum cardiomyopathy (PPCM) NYHA Class II symptoms Serial echocardiograms reveal minimal improvement in EF She is currently on GDMT for the past 6 months. Jane is 36 years old and has had HF symptoms for over a year. She comes to the clinic today for her routine follow-up. Jane is 36 years old and developed heart failure symptoms while pregnant. They have continued 1 month post partum.

JANE ECG Test results Treatment considerations Review Jane’s ECG and test results.

JANE ECG Test results Treatment considerations ECG: Normal Sinus Rhythm (NSR) Echo reveals an EF of 25% + What device should Jane be offered?

What device should JANE be offered?
(Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. PPM Answer: C Submit

CORRECT That’s right! You selected the correct response. Jane does not qualify for a CRT device because she has a narrow QRS. Given her age and EF, she should be considered for a single chamber ICD. What device should JANE be offered? (Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. PPM SEE CORRECT ANSWER CONTINUE Submit

TRY AGAIN That’s not the correct response, please try again! What device should JANE be offered? (Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. PPM TRY AGAIN Submit

INCORRECT You did not select the correct response. Jane does not qualify for a CRT device because she has a narrow QRS. Given her age and EF, she should be considered for a single chamber ICD. What device should JANE be offered? (Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. PPM SEE CORRECT ANSWER CONTINUE Submit

(Select) ⃝ A. CRT-D ⃝ B. CRT-P ⃝ C. ICD ⃝ D. PPM CONTINUE Submit

JANE ECG Test results Treatment considerations She does not qualify for a CRT given her narrow QRS. Given her age and EF, she should be considered for a single chamber ICD.

SUMMARY The general goals of treating heart failure are to reduce clinical symptoms, improve cardiac function, enhance organ perfusion, increase exercise capacity and reduce mortality and heart failure hospitalizations. This can be accomplished by decreasing the stresses on the heart, increasing contractility, and encouraging patients to adopt lifestyle changes such as diet, weight control and exercise. There are four main heart failure treatment strategies. These include: nonpharmacologic, pharmacologic, device therapy and surgical procedures. Use the menu button to return to any part of the course to review these treatment strategies and the associated professional guidelines. In this course, we reviewed the general goals of treating heart failure. They include reducing clinical symptoms, improving cardiac function, enhancing organ perfusion, increasing exercise capacity and reducing mortality and heart failure hospitalizations. These goals can be accomplished by decreasing the stresses on the heart, increasing contractility, and encouraging patients to adopt lifestyle changes such as diet, weight control and exercise. This course discussed the different types of heart failure treatment categories and provided guidelines from professional organizations on when their use may be appropriate. In this course you were provided links to the ESC, ACCF, AHA, and HFSA guidelines in the diagnosis and treatment of heart failure as well as indications to specific heart failure treatment options. Finally, the four patient scenarios allowed you to practice applying the guidelines you reviewed in this course.

congratulations for completing the COURSE!
heart failure MANAGEMENT STRATEGIES Congratulations you have completed the course. Select exit to exit the course. EXIT THE MODULE

MEDTRONIC DISCLOSURE STATEMENT

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MEDTRONIC DISCLOSURE STATEMENT

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