Sandra Rodriguez Internal Medicine TTUHSC

1. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the adult Sandra Rodriguez Internal Medicine TTUHSC

2. Introduction • Approximately 5 million patients in this country have Heart Failure (HF) • 550 000 are diagnosed annually with HF • The incidence has been increasing • due to salvage of patients with Myocardial Infarction (MI) • due to better treatments • due to recognition of HF with normal ejection fraction (EF) • Death is about 40% at 5 years • although has decreased in the last decade

3. Introduction • About 80% of patients hospitalized with HF are more than 65 years old • Heart failure is the most common Medicare hospital discharge diagnosis • Educating patients regarding diagnosis and prognosis is important in helping them plan for their future and is a crucial part of management

4. Definition of Heart Failure • Progressive clinical syndrome characterized by specific symptoms in the medical history and signs on the physical examination. • Starts with cardiac remodeling and progresses to impaired ability of the ventricle to fill with or eject blood. • CAD, HTN, dilated cardiomyopathy and valvular heart disease are the causes of HF in most of the patients.

5. Classification of HF • At risk for heart failure • Stage A: Patients with risk factors for development of HF • Coronary artery disease (CAD, 2/3 of HF patients) • Hypertension (HTN) • Diabetes Mellitus (DM) • Normal left ventricular (LV) function • Stage B: Patients asymptomatic but with LV hypertrophy (LVH) and/or impaired LV function

6. Classification of HF • Heart Failure • Stage C: Patients with current or past symptoms of HF associated with underlying structural disease • Stage D: Patients with refractory HF • NYHA will be used for subjective functional assessment of patients in stages C and D

7. Classification of Heart Failure

8. Discordance between EF and functional impairment • Ventricular distensibility • Valvular regurgitation • Pericardial restrain • Cardiac rhythm • Conduction abnormalities • Right Ventricular function • Pulmonary dynamics • Peripheral vascular resistance • Renal sodium handling • Neurohormonal and reflex autonomic activity

10. Initial Clinical Assessment of HF • Class I • A thorough H & P to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate HF • Jugular venous distention and S3 are prognostic • Document history or current use of alcohol, illicit drugs, alternative therapies, chemotherapy drugs, family history of cardiomyopathy • Assess Activities of daily living • Assess volume status, weight, BMI, BP • Laboratory evaluation, electrocardiogram and chest radiograph

11. Initial Clinical Assessment of HF • Class I (continued) • Echocardiogram with Doppler • Radionuclide ventriculography • provide highly accurate measurements of LV and RV ejection fractions • Angiogram if angina or significant ischemia in patients with impaired ventricular function • Revascularization • if significant ischemic chest pain or large areas of ischemia • left main disease in patients without chest pain

12. Initial Clinical Assessment of HF • Class IIa • Angiogram if chest pain typical or atypical that has not been evaluated before because revascularization will be indicated if large coronary disease is found • Angiogram if patient has known or suspected CAD without angina • Noninvasive imaging to detect ischemia and viability is reasonable • Maximal exercise testing w or w/o measurement of respiratory gas exchange to determine if dyspnea is secondary to HF

13. Initial Clinical Assessment of HF • Class IIa (continued) • Maximal exercise testing with gas exchange to identify candidates for cardiac transplant • Screening for hemochromatosis, OSA, HIV, rheumatologic diseases, amyloidosis, or pheochromocytoma, Chagas • Endomyocardial biopsy if would influence therapy • N-proBNP in whom clinical diagnosis is uncertain

14. Initial Clinical Assessment of HF • Class IIb • In young patients with HF due to LV dysfunction who do not have chest pain or history of CAD, angiogram is reasonable to exclude congenital coronary abnormalities • Noninvasive imaging to define the likelihood of CAD in patients with HF and LV dysfunction • Holter monitoring if history of MI with HF to document VT • CAD should be excluded whenever possible, in DM or other states associated to silent myocardial ischemia

15. Serial Clinical Assessment of HF • Class I • Assess ability to perform routine and desired ADL’s, NYHA functional class • Volume status and weight • Diet and sodium intake, alcohol, tobacco, illicit drugs, “alternative therapies”, chemotherapy drugs

16. Serial Clinical Assessment of HF • Class IIa • Repeat EF in patients with change in clinical status or who have experienced event or received treatment that might have a significant effect on cardiac function • Six minutes walk distance may have prognostic significance and may help to assess level of impairment • Class IIb • Serial BNP’s to guide therapy not well established

17. Prognostic variables • Decreasing LVEF. • Worsening NYHA functional status. • Hyponatremia. • Decreased peak exercise O2 uptake. • Anemia. • Wide QRS. • Chronic hypotension. • Resting tachycardia. • Renal Insuficiency. • Refractory volume overload. • BNP levels inpatient may predict readmission and death, and adverse events after MI.

18. Therapy for Stage A • Class I • Systolic and diastolic HTN control following JNC guidelines • It decreases risk of new HF by 50% in any patient, and by 81% in patients who had prior MI • The consequent LVH is an independent CV risk factor as is age or SBP predicting MI, stroke, sudden death or HF. (ALLHAT, Fragmingham, SHEP) • Lipid disorders control • Reduces likelihood of death and of HF in patients with history of MI. (CARE, LIPID)

19. Therapy for Stage A • Class I (continued) • DM control • DM modestly increases risk of HF for men, and increases relative risk in women more than 3-fold • Microalbuminuria greater than 200 mg/dl is associated with HF development and death. (SOLVD, HOPE) • Metabolic syndrome • Any 3 of abdominal adiposity, hypertriglyceridemia, low HDL, HTN, and fasting hyperglycemia • Prevalence exceed 40% of population older than 40 years of age • Obesity and insulin resistance are important risk factors for the development of HF

20. Therapy for Stage A • Class I (continued) • Tobacco, amphetamines and illicit drugs cessation and alcohol moderate use • Ventricular rate control or sinus rhythm restoration • Thyroid disorders treatment • Secondary atherosclerotic disease prevention • ACEI now class IIa due to failure to find significant reduction in new onset HF in patients with CVD

21. Therapy for Stage A • Class IIa: • ACE Inhibitors to prevent HF in patients with history of atherosclerotic disease, DM, or HTN. Level A • ARB to prevent HF in patient with history of atherosclerotic disease, DM or HTN. Level C.

22. Therapy for Stage B • Class I: All for Stage A plus: • BB and ACEI for all post MI patients reduces the risk of reinfarction or death when initiated even days or weeks after the event (CAPRICORN, AIRE, SAVE, ISIS-4) • BB and ACEI for all reduced LVEF patients regardless history of MI or HF symptoms • Long term ACEI delay onset of HF symptoms and decrease the risk of death and hospitalization for HF in asymptomatic patients with reduced LVEF due or not to MI (SOLVD, FEST) • Use the BB that were employed in the large HF trials.

23. Therapy for Stage B • Class I: All for Stage A plus (continued): • ARB post-MI if ACEI intolerant • Revascularization even w/o symptoms in patients with reduced LVEF (CASS) • Valvular repair should be considered if severe aortic or mitral valve stenosis or regurgitation regardless of symptoms and even when VF is impaired • In severe AR hydralazine and nifedipine might delay need for surgery but doesn’t reduce death or risk of HF

24. Therapy for Stage B • Class IIa: • ACEI or ARB in HTN with LVH (LIFE) • ICD in ischemic CMP, at least 40 days post-MI, with EF 30% or less, on optimal medical therapy, NYHA class I, with more than 1 year of expected survival (MADIT-II) • Class IIb: • ICD in nonischemic CMP, with EF 30% or less, NYHA class I, on optimal medical therapy, with more than 1 year of expected survival

25. Therapy for Stage C • With reduced LVEF: • Class I recommendations • Measures as for Stages A and B • Diuretics and salt restriction • ACEI in all patients, unless contraindicated, captopril, enalapril, fosinopril, quinapril (CONSENSUS, ATLAS) • BB: Bisoprolol, carvedilol, or SR metoprolol in all patients, unless contraindicated (CIBIS, COMET, CAPRICORN, IMPACT, MERIT-HF)

26. Therapy for Stage C • With reduced LVEF: • Class I recommendations: • ARB: Candesartan or valsartan (CHARM, Val-HeFT) • Discontinue NSAID’s, most antiarrhymic drugs (CAST, PROMISE, SWORD, CHF-STAT), and most calcium channel blockers • Maximal exercise testing to guide exercise program • Exercise training • ICD if history of cardiac arrest, VF, or unstable VT

27. Therapy for Stage C • With reduced LVEF: • Class I recommendations: • ICD in nonischemic cardiomyopathy, EF 30% or less, NYHA II or III on optimal therapy, >1yr life expectancy • CRT in pts with QRS wider than 120msecs, with EF 35% or less, sinus rhythm and NYHA III or IV in spite of optimal medical therapy (MIRACLE) • Aldosterone antagonist if Cr 2.5 mg/dl or less in men, 2.0 or less in women, and potassium less than 5.0 mEq/L • 30% relative risk death reduction in heart failure • 35% reduction in heart failure hospitalization when added to ACEI therapy for patients Class III or IV(RALES).

28. Therapy for Stage C • With reduced LV function: • Class IIa: • ARB as alternative for ACEI as first line therapy (CHARM, STRETCH) • Digitalis can decrease hospitalizations for HF (PROVED, RADIANCE) • Hydralazine and nitrate if persistent symptoms after ACEI and BB • ICD if EF 30 to 35% of any origen, NYHA II or III • Class IIb: • Hydralazine and nitrate in patients intolerant to ACEI or ARB’s • Addition of and ARB to conventional therapy (RESOLVED)

29. Board-type Questions • The only antiarrhythmic agents that have not shown to decrease survival are: • Amiodarone and milrinone • Procainamide and milrinone • Propafenone and flecainide • Amiodarone and dofetilide

30. Board-type Questions • Which is the only false statement regarding diuretics: • Produce symptomatic benefit more rapidly than any other HF drug. • Are the only drugs that can adequately control fluid retention. • Should be used with an ACEI or ARB plus BB in most patients with HF. • Decrease morbidity and mortality.

31. Board-type Question • Of the following recommendations for HF which have demonstrated to improve morbidity and mortality? • Routine combined use of an ACEI, ARB, and Aldosterone antagonist. (Level C). • CCB with negative inotropic effects. • Long term use of an infusion of a positive inotropic drug. • Hormonal therapies and nutritional suplements. • Use of bisoprolol, or carvedilol or SR metoprolol.

32. Board-type Question • 49-years-old man, for yearly PE, found cardiomegaly in CXR. All ROS is negative as well as the PE. All lab values are normal. Echocardiogram showed EF 40%, angiogram is normal, what to do next? • No treatment, f/u in 6 months. • Carvedilol titrate up to 25mg BID. • Start Atenolol plus Valsartan. • Start Enalapril BID plus SR metoprolol. • Start Losartan once a day.