Heart Failure PIT 2013

Workshop PIT 2013

Management of Heart Failure   Erika  Maharani   Sardjito  General  Hospital   Yogyakarta    

Symptoms  that  may  occur  with  heart  failure  …..    

Stages of Heart Failure At Risk At for Heart Risk forFailure Heart Failure At Risk for Heart Failure STAGE ASTAGE A

risk for HF but At high risk At forhigh HF but withoutheart structural heart without structural disease orof symptoms of HF sease or symptoms HF

STAGE BSTAGE B Structural heart disease Structural heart disease without but withoutbut signs or signs or of HF symptoms symptoms of HF

Heart Failure e.g., Patients with: Failure Heart .g., Patients with: Heart Failure ·∙  HTN  HTN ·∙  Atherosclerotic disease  Atherosclerotic disease e.g., Patients with: STAGE C GE C e.g., Patients with: ·∙  DM  DM ·∙MI  Previous STAG Structural heart disease STAGE D MI art disease·∙  Obesity ·∙  Previous  Obesity Developm ·∙  LV remodeling including Structural·∙heart with prior or current Refract or current ·∙  Metabolic Refractory HF  LV remodeling including Structural heart syndrome  Metabolic syndrome disease LVH and low EF symptom symptoms of HF disease ms of HF LVH and low EF or or ·∙  Asymptomatic ·∙  Asymptomatic valvular valvular Patients atients disease disease ·∙  Using cardiotoxins

Stages, Phenotypes and Treatment of HF At Risk for Heart Failure

Heart Failure

STAGE A

STAGE B

STAGE C

At high risk for HF but without structural heart disease or symptoms of HF

Structural heart disease but without signs or symptoms of HF

Structural heart disease with prior or current symptoms of HF

e.g., Patients with: ·∙  HTN ·∙  Atherosclerotic disease ·∙  DM ·∙  Obesity ·∙  Metabolic syndrome or Patients ·∙  Using cardiotoxins ·∙  With family history of cardiomyopathy

Structural heart disease

e.g., Patients with: ·∙  Previous MI ·∙  LV remodeling including LVH and low EF ·∙  Asymptomatic valvular disease

Development of symptoms of HF

e.g., Patients with: ·∙   Known structural heart disease and ·∙   HF signs and symptoms

HFpEF THERAPY Goals ·∙  Heart healthy lifestyle ·∙  Prevent vascular, coronary disease ·∙  Prevent LV structural abnormalities Drugs ·∙  ACEI or ARB in appropriate patients for vascular disease or DM ·∙  Statins as appropriate

THERAPY Goals ·∙   Prevent HF symptoms ·∙   Prevent further cardiac remodeling

Drugs ·∙   ACEI or ARB as appropriate

·∙   Beta blockers as appropriate

In selected patients ·∙   ICD ·∙   Revascularization or valvular surgery as appropriate

STAGE D Refractory HF

THERAPY Goals ·∙  Control symptoms ·∙  Improve HRQOL ·∙  Prevent hospitalization ·∙  Prevent mortality Strategies ·∙  Identification of comorbidities Treatment ·∙  Diuresis to relieve symptoms of congestion ·∙  Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM ·∙  Revascularization or valvular surgery as appropriate

Refractory symptoms of HF at rest, despite GDMT

e.g., Patients with: ·∙  Marked HF symptoms at rest ·∙  Recurrent hospitalizations despite GDMT

HFrEF THERAPY Goals ·∙  Control symptoms ·∙  Patient education ·∙  Prevent hospitalization ·∙  Prevent mortality Drugs for routine use ·∙  Diuretics for fluid retention ·∙  ACEI or ARB ·∙  Beta blockers ·∙  Aldosterone antagonists Drugs for use in selected patients ·∙  Hydralazine/isosorbide dinitrate ·∙  ACEI and ARB ·∙  Digoxin In selected patients ·∙  CRT ·∙  ICD ·∙  Revascularization or valvular surgery as appropriate

THERAPY Goals ·∙  Control symptoms ·∙  Improve HRQOL ·∙  Reduce hospital readmissions ·∙  Establish patient’s endof-life goals Options ·∙  Advanced care measures ·∙  Heart transplant ·∙  Chronic inotropes ·∙  Temporary or permanent MCS ·∙  Experimental surgery or drugs ·∙  Palliative care and hospice ·∙  ICD deactivation

Definition of Heart Failure Heart  Failure  with   REDUCED       Ejec?on  Frac?on     (HFrEF)   EF  ≤  40%  

Heart  Failure  with   PRESERVED   Ejec?on  Frac?on   (HFpEF)   EF  ≥  50%  

HFpEF     Borderline     EF  41%  to  49%  

HFpEF   Improved   EF  >40%    

Initial and Serial Evaluation of the HF Patient

• 

Clinical Evaluation

• 

History and Physical Examination

• 

Diagnostic Tests

Diagnostic Tests •  Ini6al  laboratory  evalua6on:  complete  blood  count,   urinalysis,  serum  electrolytes,  blood  urea  nitrogen,  serum   crea?nine,  glucose,  fas?ng  lipid  profile,  liver  func?on  tests,   and  thyroid-­‐s?mula?ng  hormone.     •  A  12-­‐lead  ECG     •  Diagnos?c  tests  for  rheumatologic  diseases,  amyloidosis,  or   pheochromocytoma   •  Measurement  of  BNP  or  N-­‐terminal  pro-­‐B-­‐type  natriure?c   pep?de  (NT-­‐proBNP)  

Noninvasive Cardiac Imaging •  Chest  x-­‐ray   •  Echocardiogram  with  Doppler     •  Imaging  for  myocardial  ischemia  and  viability   •  Radionuclide  ventriculography  or  MRI      

Recommendations for Invasive Evaluation

Invasive Evaluation Recommendation

Monitoring with a pulmonary artery catheter should be performed in patients with respiratory distress or impaired systemic perfusion when clinical assessment is inadequate Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF with persistent symptoms and/or when hemodynamics are uncertain When coronary ischemia may be contributing to HF, coronary arteriography is reasonable Endomyocardial biopsy can be useful in patients with HF when a specific diagnosis is suspected that would influence therapy Routine use of invasive hemodynamic monitoring is not recommended in normotensive patients with acute HF Endomyocardial biopsy should not be performed in the routine evaluation of HF

COR

LOE

I

C

IIa

C

IIa

C

IIa

C

III: No Benefit

B

III: Harm

C

Guideline for HF

Treatment of Stages A to D

Stages A I IIa IIb III

I IIa IIb III

Hypertension  and  lipid  disorders  should  be  controlled  in   accordance  with  contemporary  guidelines  to  lower  the  risk  of   HF.       Other  condi?ons  that  may  lead  to  or  contribute  to  HF,  such  as   obesity,  diabetes  mellitus,  tobacco  use,  and  known  cardiotoxic   agents,  should  be  controlled  or  avoided.    

Stages B

Stages B I IIa IIb III

I IIa IIb III

I IIa IIb III

In  all  pa?ents  with  a  recent  or  remote  history  of  MI  or  ACS  and   reduced  EF,  ACE  inhibitors  should  be  used  to  prevent   symptoma?c  HF  and  reduce  mortality.  In  pa?ents  intolerant  of   ACE  inhibitors,  ARBs  are  appropriate  unless  contraindicated.     In  all  pa?ents  with  a  recent  or  remote  history  of  MI  or  ACS  and   reduced  EF,  evidence-­‐based  beta  blockers  should  be  used  to   reduce  mortality.     In  all  pa?ents  with  a  recent  or  remote  history  of  MI  or  ACS,   sta6ns  should  be  used  to  prevent  symptoma?c  HF  and   cardiovascular  events.  

Stages B I IIa IIb III

I IIa IIb III

I IIa IIb III

In  pa?ents  with  structural  cardiac  abnormali?es,  including  LV   hypertrophy,  in  the  absence  of  a  history  of  MI  or  ACS,  blood   pressure  should  be  controlled  in  accordance  with  clinical   prac?ce  guidelines  for  hypertension  to  prevent  symptoma?c  HF     ACE  inhibitors  should  be  used  in  all  pa?ents  with  a  reduced  EF   to  prevent  symptoma?c  HF,  even  if  they  do  not  have  a  history   of  MI     Beta  blockers  should  be  used  in  all  pa?ents  with  a  reduced  EF   to  prevent  symptoma?c  HF,  even  if  they  do  not  have  a  history   of  MI  

Stages B I IIa IIb III

I IIa IIb III

Harm

To  prevent  sudden  death,  placement  of  an  ICD  is  reasonable  in   pa?ents  with  asymptoma?c  ischemic  cardiomyopathy  who  are   at  least  40  days  post-­‐MI,  have  an  LVEF  of  30%  or  less,  are  on   appropriate  medical  therapy  and  have  reasonable  expecta?on   of  survival  with  a  good  func?onal  status  for  more  than  1  year.     Nondihydropyridine  calcium  channel  blockers  with  nega6ve   inotropic  effects  may  be  harmful  in  asymptoma?c  pa?ents  with   low  LVEF  and  no  symptoms  of  HF  a_er  MI.      

Stages C

Stages C Non Pharmacological Interventions I IIa IIb III

I IIa IIb III

I IIa IIb III

Pa?ents  with  HF  should  receive  specific  educa?on  to   facilitate  HF  self-­‐care       Exercise  training  (or  regular  physical  ac6vity)  is   recommended  as  safe  and  effec?ve  for  pa?ents  with  HF  who   are  able  to  par?cipate  to  improve  func?onal  status       Sodium  restric6on  is  reasonable  for  pa?ents  with   symptoma?c  HF  to  reduce  conges?ve  symptoms    

Stages C Non Pharmacological Interventions I IIa IIb III

I IIa IIb III

Con6nuous  posi6ve  airway  pressure  (CPAP)  can  be   beneficial  to  increase  LVEF  and  improve  func?onal  status  in   pa?ents  with  HF  and  sleep  apnea.       Cardiac  rehabilita6on  can  be  useful  in  clinically  stable   pa?ents  with  HF  to  improve  func?onal  capacity,  exercise   dura?on,  HRQOL,  and  mortality  

Stages C Pharmacological Interventions I IIa IIb III

See recommendations for stages A, B, and C LOE for LOE

I IIa IIb III

Measures  listed  as  Class  I  recommenda?ons  for  pa?ents  in   stages  A  and  B  are  recommended  where  appropriate  for   pa?ents  in  stage  C.  (Levels  of  Evidence:  A,  B,  and  C  as   appropriate)         GDMT  (guideline-­‐directed  medical  therapy)  as  depicted  in   Figure  1  should  be  the  mainstay  of  pharmacological  therapy   for  HFrEF  

Pharmacologic Treatment for Stage C HFrEF HFrEF Stage C NYHA Class I – IV Treatment:

Class I, LOE A ACEI or ARB AND Beta Blocker

For all volume overload, NYHA class II-IV patients

For persistently symptomatic African Americans, NYHA class III-IV

For NYHA class II-IV patients. Provided estimated creatinine >30 mL/min and K+ 40 d after MI, or with implantation of pacing or defibrillation device for special indications

LVEF