Heart Failure: ACC Heart Failure: ACC Guidelines for Dx and Guidelines for Dx and

ManagementManagement

Steven W. Harris MHS PACSteven W. Harris MHS PAC

EpidemiologyEpidemiology

Approximately 5 million patients in this country have HF

Over 550,000 patients are diagnosed with HF for the first time each year

Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year

In 2001, nearly 53,000 patients died of HF as a primary cause

EpidemiologyEpidemiology

The incidence of HF approaches 10 per 1000 population after age 65

HF is the most common Medicare diagnosis-related group

More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare

ACC GuidelinesACC Guidelines

Focus on : Prevention of HF Diagnosis and management of chronic HF

in the adult.

DefinitionDefinition

HF is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.

Because not all patients have volume overload at the time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive heart failure.”

• Use terms: Compensated Heart Failure: euvolemic Decompensated Heart Failure: fluid overload

EtiologyEtiology

For a substantial proportion of patients, causes are:

Coronary artery disease Hypertension Dilated cardiomyopathy

Signs and SymptomsSigns and Symptoms

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SymptomsSymptoms

Decreased Perfusion:Decreased Perfusion:• WeaknessWeakness• FatigueFatigue• ConfusionConfusion• RestlessnessRestlessness• AnxietyAnxiety• PalpitationsPalpitations• Cold ExtremitiesCold Extremities

SymptomsSymptoms

Increased LV preload:Increased LV preload:• DOEDOE• PNDPND• Cough: often positionalCough: often positional• WheezeWheeze• OrthopneaOrthopnea• Abdominal DistensionAbdominal Distension• edemaedema

SignsSigns

Increased Preload/Decreased perfusionIncreased Preload/Decreased perfusion Pedal edemaPedal edema Hepatic congestionHepatic congestion JVDJVD RalesRales WheezingWheezing S3 S3 TachycardiaTachycardia CyanosisCyanosis Cold extremitiesCold extremities

New York Heart Association New York Heart Association ClassesClasses

NYHA I: NYHA I: no symptomsno symptoms w/ physical activity, w/ physical activity, but known diseasebut known disease

NYHA II: NYHA II: slight limitationsslight limitations, symptoms w/ , symptoms w/ normal activities, but able to walk 3 blocksnormal activities, but able to walk 3 blocks

NYHA III: symptoms w. minimal activity and NYHA III: symptoms w. minimal activity and marked limitation of activitymarked limitation of activity

NYHA IV: symptoms NYHA IV: symptoms at restat rest and any activity and any activity

Stages of Heart FailureStages of Heart Failure

Designed to emphasize preventability of HF through treatment therapies.

Designed to recognize the progressive nature of LV dysfunction.

Stages of HFStages of HF

COMPLEMENT, DO NOT REPLACE NYHA CLASSES

NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)

Stages - progress in one direction due to cardiac remodeling

Stages of HFStages of HF

At Risk for Heart Failure: STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction Heart Failure: STAGE C Past or current symptoms of

HF STAGE D End-stage HF

Management of Patients with Known Atherosclerotic Disease But No HF

Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest.

Placebo

Ramipril

Placebo

Perindopril

20% rel. risk red. p = .0003

22% rel. risk red. p < .001

HOPE

EUROPA

NEJM 2000;342:145-53 (HOPE).

Lancet 2003;362:782-8 (EUROPA).

02468

10121416

0 1 2 3 4

Years

% MI,Stroke,

CV Death

0

3

6

9

12

15

0 1 2 3 4 5

Years

% MI,CV Death,

Cardiac Arrest

ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative

Val-HeFT

Valsartan

Placebo

p = 0.017

Months

Su

rviv

al %

CV

Dea

th o

r H

F H

osp

%

Placebo

Candesartan

CHARM-Alternative

HR 0.77, p = 0.0004

Months

Maggioni AP et al. JACC 2002;40:1422-4.Granger CB et al. Lancet 2003;362:772-6.

50

60

70

80

90

100

0 3 6 9 12 15 18 21 24 270

10

20

30

40

50

0 9 18 27 36 42

0000

2020

1010

% o

f P

atie

nts

Wit

h E

ven

t%

of

Pat

ien

ts W

ith

Eve

nt

22 44 66 88

Carvedilol

Placebo

HR = 0.67 (CI = 0.47HR = 0.67 (CI = 0.47--0.96)0.96)

Weeks After RandomizationWeeks After Randomization

3030

COPERNICUS: Death, Hospitalization, or Study Drug Withdrawal in High Risk Patients

Krum H et al. JAMA 2003;289:754-6.

Stage A: at risk for HFStage A: at risk for HF

TherapyTherapy Treat Hypertension Treat Hypertension Encourage Smoking cessationEncourage Smoking cessation Treat lipid disordersTreat lipid disorders Encourage regular exerciseEncourage regular exercise Discourage ETOH, drugsDiscourage ETOH, drugs Control Metabolic SyndromeControl Metabolic Syndrome ACE or ARB in appropriate patents for vasc dz or ACE or ARB in appropriate patents for vasc dz or

diabetesdiabetes

Stage B: Structural disease/No SxStage B: Structural disease/No Sx

Therapy:Therapy: All measures under Stage AAll measures under Stage A ACE or ARB in appropriate patientsACE or ARB in appropriate patients Beta-blockers in appropriate patientsBeta-blockers in appropriate patients ICDs in appropriate patientsICDs in appropriate patients

Stage C: Structural Disease with Stage C: Structural Disease with current or prior sx current or prior sx

TherapyTherapy:: All measures under Stages A and BAll measures under Stages A and B Routine UseRoutine Use

• ACE, Beta-blockerACE, Beta-blocker• Diuretics for fluid retentionDiuretics for fluid retention

Selected PatientsSelected Patients• Aldosterone antagonistAldosterone antagonist• ARBARB• DigitalisDigitalis• Hydralazine/nitratesHydralazine/nitrates

Devices: BI-V, ICDDevices: BI-V, ICD

Stage D: refractory HFStage D: refractory HF

TherapyTherapy All measures from stages A, B, CAll measures from stages A, B, C Decision: Decision:

• Appropriate level of careAppropriate level of care• Compassionate end-of-life careCompassionate end-of-life care• TransplantTransplant• Chronic Inotropes: neo, epi, dopamine.Chronic Inotropes: neo, epi, dopamine.• Permanent Mechanical Support: LVADPermanent Mechanical Support: LVAD• Experimental surgery /drugs. Experimental surgery /drugs.

DevicesDevices

    An implantable cardioverter-defibrillator An implantable cardioverter-defibrillator (ICD) for secondary prevention to prolong (ICD) for secondary prevention to prolong survival in patients with a history of cardiac survival in patients with a history of cardiac arrest, ventricular fibrillation, or arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular hemodynamically destabilizing ventricular tachycardia. tachycardia.

DevicesDevices

    An ICD for primary prevention to reduce An ICD for primary prevention to reduce total mortality by preventing sudden cardiac total mortality by preventing sudden cardiac death (SCD) in patients with death (SCD) in patients with ischemic heart ischemic heart diseasedisease who meet the following criteria: at who meet the following criteria: at least least 40 days40 days post-myocardial infarction, an post-myocardial infarction, an LVEF 30 percentLVEF 30 percent, New York Heart , New York Heart Association functional class II or III Association functional class II or III symptoms despite optimal chronic medical symptoms despite optimal chronic medical therapy, and a reasonable expectation of therapy, and a reasonable expectation of survival with a good functional status for survival with a good functional status for more than one year.more than one year.

DevicesDevices

    An ICD for primary prevention to reduce An ICD for primary prevention to reduce total mortality by preventing SCD in patients total mortality by preventing SCD in patients with with nonischemic cardiomyopathynonischemic cardiomyopathy who meet who meet the following criteria: an the following criteria: an LVEF less than 30LVEF less than 30 percent, New York Heart Association percent, New York Heart Association functional class II or III symptoms despite functional class II or III symptoms despite optimal chronic medical therapy, and a optimal chronic medical therapy, and a reasonable expectation of survival with a reasonable expectation of survival with a good functional status for more than one good functional status for more than one year. year.

DevicesDevices

    Cardiac resynchronization therapy, Cardiac resynchronization therapy, unless contraindicated, in patients who unless contraindicated, in patients who meet the following criteria: cardiac meet the following criteria: cardiac dyssynchrony as defined by a dyssynchrony as defined by a QRS QRS duration >120duration >120 msec, msec, LVEF 35 percentLVEF 35 percent, , sinus rhythm, and New York Heart sinus rhythm, and New York Heart Association functional class III or Association functional class III or ambulatory class IV symptoms despite ambulatory class IV symptoms despite optimal chronic medical therapy. optimal chronic medical therapy.

Patient SurveilancePatient Surveilance

MAWDSMAWDS MedicineMedicine ActivityActivity WeightWeight DietDiet SymptomsSymptoms

CASE 1CASE 1

56 y/o female 56 y/o female DMDM BP 146/84BP 146/84 LDL 150LDL 150 Non-smokerNon-smoker Exercises dailyExercises daily

Case 2Case 2

63 y/o male63 y/o male AWMI 1 year agoAWMI 1 year ago EF 28%EF 28% DiabeticDiabetic BP 128/72BP 128/72 SmokerSmoker DOE with strenuous activityDOE with strenuous activity

Case 3Case 3

44 y/o male44 y/o male DMDM CHD, prior Inferior MICHD, prior Inferior MI EF 46%EF 46% BP 132/78BP 132/78 Walks daily. Unable to walk up inclines.Walks daily. Unable to walk up inclines. C/o LE edema and weight gain of 10 lbsC/o LE edema and weight gain of 10 lbs

Case 4Case 4

60 y/o female60 y/o female H/o BRCA treated with adriamycinH/o BRCA treated with adriamycin BP 110/68 on ACE, CoregBP 110/68 on ACE, Coreg EF 30%EF 30% Non-diabeticNon-diabetic Symptoms with minimal activitySymptoms with minimal activity LBBBLBBB