HFSA 2010 Comprehensive Heart Failure Practice Guideline Key Recommendations.

HFSA 2010 Comprehensive Heart Failure Practice Guideline

Key Recommendations

Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194.

HFSA 2010 Comprehensive Heart Failure Practice Guideline Strength of Recommendation

“Is recommended”

“Should be considered”

“May be considered”

“Is not recommended”

Part of routine care

Exceptions should be minimized

Majority of patients should receive intervention

Some discretion allowed

Individualization of therapy is indicated

Therapy should not be used


HFSA 2010 Comprehensive Heart Failure Practice Guideline

Strength of Evidence

A

B

C

Randomized controlled trials

May be assigned on results of 1 trial

Cohort and case control studies

Includes sub group analyses, meta-analyses, observational studies, registries

Expert opinion

Includes observational, epidemiological findings; in-practice safety reporting


HFSA 2010 Practice Guideline (3.1)

Heart Failure Prevention

A careful and thorough clinical assessment, with appropriate investigation for known or potential risk factors, is recommended in an effort to prevent development of LV remodeling, cardiac dysfunction, and HF. Strength of Evidence = A

Adapted from:



HF Risk Factor Treatment GoalsRisk Factor Goal

Hypertension Generally < 130/80

Diabetes See ADA guidelines1

Hyperlipidemia See NCEP guidelines2

Inactivity 20-30 min. aerobic 3-5 x wk.

Obesity Weight reduction < 30 BMI

Alcohol Men ≤ 2 drinks/day, women ≤ 1

Smoking Cessation

Dietary Sodium Maximum 2-3 g/day 1Diabetes Care 2006; 29: S4-S42

2JAMA 2001; 285:2486-97

Adapted from:

Treating Hypertension to Prevent HF

Aggressive blood pressure control:

Aggressive BP control in patients with prior MI:

Decreasesrisk of new HF

by ~ 80%


by ~ 50%56% in DM2


by ~ 50%56% in DM2

Lancet 1991;338:1281-5 (STOP-HypertensionJAMA 1997;278:212-6 (SHEP)UKPDS Group. UKPDS 38. BMJ 1998;317:703-713


HFSA 2010 Practice Guideline (3.3-3.4)

Prevention—ACEI and Beta Blockers

ACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with:

Coronary artery disease

Peripheral vascular disease

Stroke Diabetes and another major risk factor

Strength of Evidence = A

ACE inhibitors and beta blockers are recommended for all patients with prior MI.


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.

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

Placebo

Ramipril

Placebo

Perindopril

20% rel. risk red. p = .0003

22% rel. risk red. p < .001

HOPE

EUROPA

Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF ≤ 40%)

SAVE Study

All-cause mortality ↓19%

CV mortality ↓21%

HF development ↓37%

Recurrent MI ↓25% 0

0.1

0.2

0.3

0 0.5 1 1.5 2 2.5 3 3.5 4

Placebo

Captopril

Years

MortalityRate

19% rel. risk reduction

p = 0.019

Pfeffer et al. NEJM 1992;327:669-77

The Additional Value of Beta Blockers Post-MI: CAPRICORN

Studied impact of beta blocker (carvedilol) on post-MI patients with LVEF ≤ 40% already receiving contemporary treatments, including revascularization, anticoagulants, ASA, and ACEI:

All-cause mortality reduced (HR = 0.077; p = 0.03)

Cardiovascular mortality reduced (HR = 0.75; p = .024)

Recurrent non-fatal MIs reduced (HR =.59; p = .014)

Dargie HJ. Lancet 2001;357:1385-90


HFSA 2010 Practice Guideline (4.8, 4.10)

Heart Failure Patient EvaluationRecommended evaluation for patients with a diagnosis of HF:

Assess clinical severity and functional limitation by history, physical examination, and determination of functional class*

Assess cardiac structure and function

Determine the etiology of HF

Evaluate for coronary disease and myocardial ischemia

Evaluate the risk of life threatening arrhythmia

Identify any exacerbating factors for HF

Identify co-morbidities which influence therapy Identify barriers to adherence and compliance Strength of Evidence = C

*Metrics to consider include the 6-minute walk test and NYHA functional class

Adapted from:



Evaluation—Follow Up AssessmentsRecommended Components of Follow-Up Visits

Signs and symptoms evaluated during initial visit

Functional capacity and activity level

Changes in body weight

Patient understanding of and compliance with dietary sodium restriction and medical regimen

History of arrhythmia, syncope, pre-syncope, palpitation, or ICD discharge

Adherence and response to therapeutic interventions

Exacerbating factors for HF, including worsening ischemic heart disease, hypertension, and new or worsening valvular disease Strength of Evidence = B



Pharmacologic Therapy: ACE Inhibitors

ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.


ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C

ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.

Post MI Strength of Evidence = B

Non Post-MI Strength of Evidence = C

Adapted from:

ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF

SOLVD Prevention (Asymptomatic LVD)

20% death or HF hosp.

29% death or new HF

CONSENSUS (Severe Heart Failure)

40% mortality at 6 mos.

31% mortality at 1 year

27% mortality at end of study

No difference in incidence of sudden cardiac death

SOLVD Investigators. N Engl J Med 1992;327:685-91SOLVD Investigators. N Engl J Med 1991;325:293-302CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35

(Chronic Heart Failure)SOLVD Treatment

16% mortality


ACE Inhibitors Used in Clinical Trials

Generic Name Trade Name Initial Daily Dose

Target Dose Mean Dose in Clinical Trials

Captopril Capoten 6.25 mg tid 50 mg tid 122.7 mg/day

Enalapril Vasotec 2.5 mg bid 10 mg bid 16.6 mg/day

Fosinopril Monopril 5-10 mg qd 80 mg qd N/A

Lisinopril Zestril, Prinivil

2.5-5 mg qd 20 mg qd 4.5 mg/day, 33.2 mg/day*

Quinapril Accupril 5 mg bid 80 mg qd N/A

Ramipril Altace 1.25-2.5 mg qd 10 mg qd N/A

Trandolapril Mavik 1 mg qd 4 mg qd N/A

*No mortality difference between high and low dose groups, but 12% lower risk of death or hospitalization in high dose group vs. low dose group.



Pharmacologic Therapy: Substitutes for ACEI

It is recommended that other therapy be substituted for ACE inhibitors in the following circumstances:

In patients who cannot tolerate ACE inhibitors due to cough, ARBs are recommended. Strength of Evidence = A

The combination of hydralazine and an oral nitrate may be considered in such patients not tolerating ARBs.

Strength of Evidence = C

Patients intolerant to ACE inhibitors from hyperkalemia or renal insufficiency are likely to experience the same side effects with ARBs. In these cases, the combination of hydralazine and an oral nitrate should be considered. Strength of Evidence = C



Pharmacologic Therapy: Beta Blockers

Beta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.


Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.

Post MI Strength of Evidence = B

Non Post-MI Strength of Evidence = C

Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD

Study Drug

HF Severity

Target Dose (mg)

Outcome

US Carvedilol1 carvedilol mild/ moderate

6.25- 25 BID

↓48% disease progression (p= .007)

CIBIS-II2 bisoprolol moderate/ severe

10 QD ↓34% mortality (p <.0001)

MERIT-HF3 metoprolol succinate

mild/ moderate

200 QD ↓34% mortality (p = .0062)

COPERNICUS4 carvedilol severe 25 BID ↓35% mortality (p = .0014)

CAPRICORN5 carvedilol post-MI LVD

25 BID ↓23% mortality (p =.031)

1Colucci WS et al. Circulation 1196;94:2800-6. 2CIBIS II Investigators. Lancet 1999;353:9-13.3MERIT-HF Study Group. Lancet 1999;353:2001-7. 4Packer M et al. N Engl J Med 2001;3441651-8. 5The CAPRICORN Investigators. Lancet 2001;357:1385-90.




RECENT DECOMPENSATION

Beta blocker therapy is recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of IV diuretics and vasoactive agents.

Whenever possible, beta blocker therapy should be initiated in the hospital at a low dose prior to discharge of stable patients. Strength of Evidence = B

Adapted from:




SYMPTOMATIC EXACERBATION

Continuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment, unless they develop cardiogenic shock, refractory volume overload, or symptomatic bradycardia. Strength of Evidence = C

Temporary dose reduction may be considered

Avoid abrupt discontinuation

Reinstate or gradually increase prior to discharge

Titrate dose to previously tolerated dose as soon as possible

Adapted from:

00

00

2020

1010

% o

f P

atie

nts

Wit

h E

ve

nt

% o

f P

atie

nts

Wit

h E

ve

nt

22 44 66 88

CarvedilolCarvedilol

PlaceboPlacebo

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

Weeks After RandomizationWeeks After Randomization

3030

Krum et al. JAMA 2003;289

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

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

IMPACT-HF Primary End Point:Patients Receiving Beta Blocker at 60 Days

91%

73%

0%

25%

50%

75%

100%

Pat

ient

s

P<.0001

CarvedilolPredischarge Initiation

(n=185)

Physician DiscretionPostdischarge Initiation*

(n=178)

18%18%ImprovementImprovement

Gattis WA et al. JACC 2004;43:1534-41




CONCOMITANT DISEASE

Beta blocker therapy is recommended in the great majority of patients with HF and reduced LVEF—even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease.

Use with caution in patients with: Diabetes with recurrent hypoglycemia Asthma or resting limb ischemia.

Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).

Not recommended in patients with asthma with active bronchospasm. Strength of Evidence = C

Diabetes and the Use of Beta Blockers for HF: Relative Risk for Mortality and Hospitalization for Heart Failure

0 0.5 1.0 1.5 2.0

COPERNICUS (carvedilol)1

With diabetes

Without diabetes

MERIT-HF (ER metoprolol succinate)2

With diabetes

Without diabetes

Mohacsi. Circulation. 2001;104(17):abstr 3551.

Hjalmarson. JAMA. 2000;283(10):1295.




PRESERVED LVEF

Beta blocker treatment is recommended in patients with HF and preserved LVEF who have:

Prior MI Strength of Evidence = A

Hypertension Strength of Evidence = B

Atrial fib. requiring control of ventricular rate Strength of Evidence = B

THE ELDERLY

Beta-blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction.

Strength of Evidence = B

In the absence of contraindications, these therapies are also recommended in the very elderly (age > 80 years).



HFSA 2010 Practice Guideline

Pharmacologic Therapy: Beta Blocker Overview*

General considerations

Initiate at low doses

Up-titrate gradually, generally no sooner than at 2 week intervals

Use target doses shown to be effective in clinical trials

Aim to achieve target dose in 8-12 weeks

Maintain at maximum tolerated dose

If symptoms worsen or other side effects appear

Adjust dose of diuretic or concomitant vasoactive med.

Continue titration to target after symptoms return to baseline

If up-titration continues to be difficult

Prolong titration interval

Reduce target dose

Consider referral to a HF specialist

*Consult language of specific recommendations

Adapted from:


Beta Blockers Used in Clinical Trials



Bisoprolol Zebeta 1.25 mg qd 10 mg qd 8.6 mg/day

Carvedilol Coreg 3.125 mg bid 25 mg bid 37 mg/day

Carvedilol Coreg CR 10 mg qd 80 mg qd

Metoprolol succinate CR/XL

Toprol XL 12.5-25 mg qd 200 mg qd 159 mg/day



Pharmacologic Therapy: Angiotensin Receptor Blockers

ARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency.


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

50

60

70

80

90

100

0 3 6 9 12 15 18 21 24 27

Val-HeFT

Valsartan

Placebo

p = 0.017

Months

Su

rviv

al %

0

10

20

30

40

50

0 9 18 27 36

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


Angiotensin Receptor Blockers Used in Clinical Trials



Candesartan Atacand 4-8 mg qd 32 mg qd 24 mg/day

Losartan Cozaar 12.5-25 mg qd 150 mg qd 129 mg/day

Valsartan Diovan 40 mg bid 160 mg bid 254 mg/day



Pharmacologic Therapy: Aldosterone Antagonists

An aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have:

NYHA class IV HF (or class III, previously class IV) HF from

reduced LVEF (≤ 35%)

One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor (or ARB) and a beta blocker.

Adapted from:


Aldosterone Antagonists in HF

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 3 6 9 12 15 18 21 24 27 30 33 36

RALES (Advanced HF)

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 3 6 9 12 15 18 21 24 27 30 33 36

EPHESUS (Post-MI)

Spironolactone

Placebo

Months

RR = 0.70P < 0.001

Eplerenone

Placebo

RR = 0.85P < 0.008

Pitt B. N Engl J Med 1999;341:709-17Pitt B. N Engl J Med 2003;348:1309-21

Pro

bab

ility

of

Su

rviv

al



Aldosterone Antagonists and Renal Function

Aldosterone antagonists are not recommended when:

Creatinine > 2.5mg/dL (or clearance < 30 mL/min)

Serum potassium> 5.0 mmol/L

Therapy includes other potassium-sparing diuretics Strength of Evidence = A

It is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 months


Supplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength of Evidence = A

Adapted from:



Pharmacologic Therapy:Hydralazine and Oral Nitrates

A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with HF and reduced LVEF: NYHA III or IV HF Strength of Evidence = A

NYHA II HF Strength of Evidence = B

A-HeFT Outcomes

End point

ISDN-HDZN (n=518)

Placebo (n=532)

p

Primary end point composite score

-0.1 -0.5 0.01

All-cause mortality (%) 6.2 10.2 0.02

1st HF hospitalization (%) 16.4 24.4 0.001

Change in quality-of-life score at 6 months**

-5.5 -2.7 0.02

Taylor AL et al. N Engl J Med 2004; 351;2049-57

A-HeFT All-Cause Mortality

85

90

95

100

0 100 200 300 400 500 600

Survival %

Days Since Baseline Visit

43% Decrease in Mortality

Fixed Dose ISDN/HDZN

Placebo

P = 0.01

Taylor AL et al. N Engl J Med 2004;351:2049-57



Pharmacologic Therapy: Diuretics

Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by:

Congestive symptoms

Signs of elevated filling pressures Strength of Evidence = A

Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF.




Pharmacologic Therapy: Diuretics Restoration of normal volume status may require multiple

adjustments.

Once a diuretic effect is achieved with short-acting loop diuretics, increase frequency to 2-3 times a day if necessary, rather than increasing a single dose. Strength of Evidence = B

Oral torsemide may be considered in patients exhibiting poor absorption of oral medication or erratic diuretic effect.


IV administration of diuretics may be necessary. Strength of

Evidence = A

Diuretic refractoriness may represent patient nonadherence, a direct effect of diuretic use on the kidney, or progression of underlying dysfunction.

Adapted from:


Loop Diuretics

Agent Initial Daily Dose

Max Total Daily Dose

Elimination: Renal – Met.

Duration of Action

Furosemide 20-40mg qd or bid

600 mg 65%R-35%M 4-6 hrs

Bumetanide 0.5-1.0 mg qd or bid

10 mg 62%R/38%M 6-8 hrs

Torsemide 10-20 mg qd 200 mg 20%R-80%M 12-16 hrs

Ethacrynic acid

25-50 mg qd or bid

200 mg 67%R-33%M 6 hrs


Potassium-Sparing Diuretics

Agent Initial Daily Dose

Max Total Daily Dose

Elimination Duration of Action

Spironolactone 12.5-25 mg qd

50 mg Metabolic 48-72 hrs

Eplerenone 25-50 mg qd

100 mg Renal, Metabolic

Unknown

Amiloride 5 mg qd 20 mg Renal 24 hrs

Triamterene 50-75 mg bid

200 mg Metabolic 7-9 hrs



Device Therapy:Prophylactic ICD Placement

Prophylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms: Ischemic etiology Strength of Evidence = A

Non-ischemic etiology Strength of Evidence = B

In patients who are undergoing implantation of a biventricular pacing device, use of a device that provides defibrillation should be considered. Strength of Evidence = B

Decisions should be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions, ideally after 3-6 mos. of optimal medical therapy.


Adapted from:

MADIT II: Prophylactic ICD in Ischemic LVD (LVEF 30%)

Moss AJ, et al. N Engl J Med. 2002;346;877-883.

365 (.69)170 (.78)329 (.90)490Conventional9110 (.78)274 (.84)503 (.91)742Defibrillator

Number at Risk

0 1 2 3

.7

.8

.9

1.0P

rob

abil

ity

of

Su

rviv

al

ConventionalTherapy

Defibrillator

Year

.6

04

Moss AJ et al. N Engl J Med 2002;346:877-83

ICD Therapy in the SCD-HeFT Trial: Mortality by Intention-to-Treat

HR 97.5% Cl P Value

Amiodarone vs Placebo 1.06 .86-1.30 .53

ICD vs Placebo .77 .62-.96 .007

Months of Follow-Up

Mo

rtal

ity

0 6 12 18 24 30 36 42 48 54 600

.1

.2

.3

.4

Amiodarone

ICD Therapy

Placebo

17%

22%

Bardy GH et al. N Engl J Med 2005;352:225-37



Device Therapy:Biventricular Pacing

Biventricular pacing therapy is recommended for patients with all of the following:

Sinus rhythm

A widened QRS interval (≥120 ms)

Severe LV systolic dysfunction (LVEF < 35%)

Persistent, moderate-to-severe HF (NYHA III) despite optimal medical therapy.


CRT Improves Quality of Life and

NYHA Functional ClassAverage Change in Score

(MLWHF)

-20

-15

-10

-5

0

Control CRT

* * * *

*P<.05

NYHA: Proportion Improving by 1 or More Class

0

20

40

60

80

MIRACLE CONTAKCD

MIRACLEICD

Control CRT

**

*

(%)

Abraham WT et al. Circulation 2003;108:2596-603

CRT in Patients with Advanced HF and a Prolonged QRS Interval: COMPANION

Bristow MR et al. N Engl J Med 2004;350:2140-50

Primary End Point: All-Cause Mortality

Death or Hospitalization Due to HF

Risk of all-cause mortality reduced by 19%in group with CRT and ICD (p =.014)Risk of death or hospitalization from HFreduced by 34% in ICD group and by 40% inICD-CRT group (p < .001)

Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF

571192321365404Medical Therapy

889213351376409CRT

Number at risk

0 500 1,000 1,500

25

50

75

100

% E

ve

nt-

Fre

e S

urv

ival

Medical Therapy

CRT

Days

0

HR = 0.64 (95% CI = .48-.85)p = .0019

Cleland JG et al. N Engl J Med 2005;352:1539-49



HF with Preserved LVEF—Diagnosis

Careful attention to differential diagnosis is recommended in patients with HF and preserved LVEF.

Treatments may differ based on cardiac disorder.

Evaluation for ischemic disease and inducible myocardial ischemia should be included.

Recommended diagnostic tools:

Echocardiography

Electrocardiography

Stress imaging (via exercise or pharmacologic means, using myocardial perfusion or echocardiographic imaging)

Cardiac catheterization

Adapted from:



Figure 11.3. Diagnostic Algorithmfor HF with Preserved LVEF

HF with Preserved LVEF

Dilated LV Non-dilated LV

Valvular diseaseAR, MR

No valvular dis.High output HF

Increasedthickness

NormalThickness

Right vent.dysfunction

Pulmonaryhypertension

Isolated pre-dominant RVMI

No mitralobstruction

Mitral obstructionMS, atrial myxoma

Pericardial dis.Tamponade Constriction

No pericardial disease

Inducible ischemiaIntermittent/active

ischemia

Normal or increased QRS

Hypertrophic dis.

Low QRS voltageInfiltrative myopathy

No aortic valve disease

Aortic valve dis.Aortic stenosis

No hypertensive history of PE

HCM, Fabry dis.

Hypertensive history of PE

Hypertensive-HCM

Some patients with RV dysfunction have LV dysfunction due to ventricular interaction.

No inducible ischemia, fibrotic, collagen-Vascular, RCM, cardinoid, diabetes,Radiation or chemotherapy induced heart disease, infiltrative disease, co-morbid conditions, reconsider diagnosisof HF


HFSA 2010 Practice Guideline (12.3, Table 12.3) Acute Decompensated Heart Failure (ADHF)—

Treatment Goals for Hospitalized Patients

• Improve symptoms, especially congestion and low-output symptoms

• Optimize volume status

• Identify etiology

• Identify precipitating factors

• Optimize chronic oral therapy; minimize side effects

• Identify who might benefit from revascularization

• Education patients concerning medication and HF self-assessment

• Consider enrollment in a disease management program



HFSA 2010 Practice Guideline (12.5-12.20) Overview of Treatment Options for Patients with

Acute Decompensated HF

Fluid and sodium restriction

Diuretics, especially loop diuretics

Ultrafiltration/renal replacement therapy (in selected patients only)

Parenteral vasodilators * (nitroglycerin, nitroprusside, nesiritide)

Inotropes * (milrinone or dobutamine)*See recommendations for stipulations and restrictions.


HFSA 2010 Practice Guideline (12.25, Table 12.7)Discharge Criteria for Hospitalized ADHF Patients

Recommended prior to discharge for all patients with HF:

Exacerbating factors addressed

Near optimum fluid status and pharmacologic therapy achieved

Transition from IV to oral diuretic completed

Patient education completed with clear discharge instructions

Follow-up clinic visit scheduled, usually 7-10 days

Should be considered prior to discharge for patients with advanced HF or a history of recurrent admissions:

Oral regimen stable for 24 hours

No IV inotrope or vasodilator for 24 hours

Ambulation before discharge to assess functional capacity

Plans for post-discharge management

Referral for disease management, if available

Strength of Evidence =C

Adapted from:

Predictors of Mortality Based on Analysis of ADHERE Database

Classification and Regression Tree (CART) analysis of ADHERE data shows:

Three variables are the strongest predictors of mortality in hospitalized ADHF patients:

BUN > 43 mg/dL

Systolic blood pressure < 115 mmHg

Serum creatinine > 2.75 mg/dL

BUN > 43 mg/dL

Systolic blood pressure < 115 mmHg

Serum creatinine > 2.75 mg/dL

Fonarow GC et al. JAMA 2005;293:572-80



Heart Failure Patient Education

It is recommended that patients with HF and their family members or caregivers receive individualized education and counseling that emphasizes self-care.

This education and counseling should be delivered by providers using a team approach.

Teaching should include skill building and target behaviors.


Adapted from:

The Potential Impact of Effective Education on Patient Compliance

Nonadherence rate when patients . . .

Recall MD advice Don’t recall advice

Medications 8.7% 66.7%

Diet 23.6% 55.8%

Activity 76.4% 84.5%

Smoking 60.0% 90.4%

Alcohol 60.0% 81.8%

Kravitz et al. Arch Int Med 1993;153:1869-78

Sample Target Behavior: Be Able to Read and Understand Food Labels

Labels from cups of soup



Heart Failure Disease Management

Patients recently hospitalized for HF and other patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care.


Adapted from:

HF Disease Management and the Risk of Readmission

Cline

J aarsma

Rich

Naylor

Stewart

Rauh

Lasater

Ekman

Venner

Fonarow0.5

0.6

0.7

0.8

0.9

1

1.1

RiskRatio

Summary RR = 0.76 (95% CI .68-.87)Summary RR for randomized only = 0.75 (CI = .60-.95)



End-of-Life Care in Heart Failure

End-of-life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic, device, and other therapies, as evidenced by one or more of the following:

HF hospitalization Strength of Evidence = C

Chronic poor quality of life with inability to accomplish activities of daily living


Need for continuous IV inotropic therapy support Strength of Evidence = C

Evidence-Based Treatment Across the Continuum of Systolic LVD and HF

Control Volume Improve Clinical Outcomes

DiureticsRenal ReplacementTherapy*

Digoxin

-BlockerACEIor ARB

AldosteroneAntagonist

or ARB

Treat Residual Symptoms

CRT an ICD*

HDZN/ISDN**In selected patients

HFSA 2010 Comprehensive Heart Failure Practice Guideline Key Recommendations.

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