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2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults p.o.box 54904 zip code 21524 Done by: Dr.Amin Zagzoog Dr.Ayman Bukhari Supervised by: Dr. Ahmed Abuosa Consultant Cardiologist. Epidemiology Initial clinical assessment Investigation Drugs

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2009Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adultsp.o.box 54904 zip code 21524Done by:Dr.AminZagzoogDr.AymanBukhariSupervised by:Dr. Ahmed AbuosaConsultant Cardiologist

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Epidemiology

  • Initial clinical assessment
  • Investigation
  • Drugs
  • Devices
prevalence
Prevalence
  • CHF is the fastest-growing clinical cardiac disease entity in the USA.
  • 2% of the population.
  • Nearly 1 million hospital admissions for acute decompensated CHF occur in the USA yearly.

ACC/AHA Task Force

mortality morbidity
Mortality/Morbidity
  • An estimated 5-year mortality rate of 50%.
  • The most recent estimates of inpatient mortality rates indicate that death occurs in up to 5-20% of patients.

ACC/AHA Task Force

the hospitalized patient
The Hospitalized Patient

New Recommendation

History and Examination

  • The diagnosis of HF is primarily based on signs and symptoms derived from a thorough history and physical examination. Clinicians should determine the following:

a. adequacy of systemic perfusion

b. volume status

c. the contribution of precipitating factors and/or co morbidities

d. If the heart failure is new onset or an exacerbation of chronic disease; and whether it is associated with preserved ejection fraction.

the hospitalized patient1
The Hospitalized Patient

New recommendation

History

  • It is recommended that the following common potential precipitating factors for acute HF be identified as recognition of these comorbidities is critical to guide therapy:

● Acute coronary syndromes/coronary ischemia

● Severe hypertension

● Atrial and ventricular arrhythmias

● Infections

● Pulmonary emboli

● Renal failure

● Medical or dietary noncompliance. (Level of Evidence: C)

the hospitalized patient2
The Hospitalized Patient

New Recommendation

Investigation

Chest radiographs, electrocardiogram, and echocardiography are key tests in this assessment

initial and serial clinical assessment of patients presenting with heart failure
Initial and Serial Clinical Assessment ofPatients Presenting With Heart Failure

Modified Recommendation

BNP

  • BNP measurement can be useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain.
  • Measurement of natriuretic peptides (BNP and NT-proBNP) can be useful in risk stratification(Class IIa) (A)
the hospitalized patient3
The Hospitalized Patient

New recommendation

Loop Diuretics

Patients admitted with HF and with evidence of significant fluid overload should be treated with intravenous loop diuretics. Therapy should begin in the emergency department or outpatient clinic without delay, as early intervention may be associated with better outcomes for patients hospitalized with decompensated HF. (ClassI) (C)

the hospitalized patient4
The Hospitalized Patient

New recommendation

Diuretics

  • When diuresisis inadequate to relieve congestion, as evidenced by clinical evaluation, the diuretic regimen should be intensified using either:

a. higher doses of loop diuretics

b. addition of a second diuretic (such as metolazone, spironolactone or

intravenous chlorothiazide)

c. continuous infusion of a loop diuretic. (Class I)(C)

patients with reduced ef
Patients With Reduced EF

New recommendation

Hydralazine and Nitrates

Combination of hydralazine and nitratesis recommended to improve outcomes for patients self described as African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics (Class I)(B)

patients with reduced ef1
Patients With Reduced EF

New recommendation

Atrial fibrillation

It is reasonable to treat patients with atrial fibrillation and HFwith a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone (Class IIa)(A)

patients with reduced ef2
Patients With Reduced EF %

Modified recommendation

ICD

Implantable cardioverter-defibrillator therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality:

  • Patients with non-ischemic dilated cardiomyopathyor ischemic heart disease at

least 40 days post-MI,

  • LVEF less than or equal to 35%,
  • NYHA functional class II or III symptoms
  • Receiving chronic optimal medical therapy
  • Who have reasonable expectation of survival with a good functional status for

more than 1 year (Class I) (A)

patients with reduced left ventricular ejection fraction
Patients With Reduced Left Ventricular Ejection Fraction

Clarified recommendation

ICD

  • LVEF of less than or equal to 35%
  • Sinus rhythm
  • NYHA functional class III or ambulatory class IV symptoms
  • optimal medical therapy and

have cardiac dyssynchrony, which is currently defined as a QRS duration greater than or equal to 0.12 seconds, should receive cardiac resynchronization therapy, with or without an ICD, unless contraindicated (Class I) (A)

patients with reduced left ventricular ejection fraction1
Patients With Reduced Left Ventricular Ejection Fraction

New recommendation

CRT

  • LVEF less than or equal to 35%
  • QRS duration of greater than or equal to 0.12 seconds
  • Atrial fibrillation (AF)

CRT with or without an ICD is reasonable for the treatment of NYHA functional class III or ambulatory class IV heart failure symptoms on optimal recommended medical therapy (Class IIa) (B)

patients with refractory end stage heart failure
Patients With Refractory End-Stage Heart Failure

Modified recommendation

Inotropic support

Routine intermittent infusions of vasoactive and positive inotropic agents are not recommended for patients with refractory end-stage (ClassIII)(A)

the hospitalized patient5
The Hospitalized Patient

New recommendation

Cardiac Catheterization

When patients present with acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion, urgent cardiac catheterization and revascularization is reasonable where it is likely to prolong meaningful survival. (Class IIa)(C)

the hospitalized patient6
The Hospitalized Patient

New recommendation

Ultrafiltration

Ultrafiltrationis reasonable for patients with refractory congestion not responding to medical therapy (Class IIa)(B)