Low-Output Heart Failure Systolic Heart Failure (HFREF):

Chronic Congestive Heart FailureChronic Congestive Heart Failure


• Low-Output Heart Failure– Systolic Heart Failure (HFREF):

– Decreased Left ventricular ejection fraction

– Diastolic Heart Failure (HFPEF): – Elevated Left and Right ventricular end-diastolic pressures– Normal LVEF

• High-Output Heart Failure– Seen with peripheral shunting, low-systemic vascular resistance,

hyperthryoidism, beri-beri, carcinoid, anemia– Often have normal cardiac output

• Right-Ventricular Failure– Seen with pulmonary hypertension, large RV infarctions.

Chronic Congestive Heart FailureChronic Congestive Heart FailureCauses of Low-Output Heart Failure

• Systolic Dysfunction• Coronary Artery Disease• Idiopathic dilated cardiomyopathy (DCM)

» 50% idiopathic (at least 25% familial)» 9 % myocarditis (viral)» tachycardia, peripartum, hypertension, HIV, connective tissue

disease, substance abuse (alcohol), doxorubicin/herceptin• Hypertension• Valvular Heart Disease

• Diastolic Dysfunction• Hypertension• Coronary artery disease• Hypertrophic obstructive cardiomyopathy (HCM)• Restrictive cardiomyopathy

Chronic Congestive Heart FailureChronic Congestive Heart Failure(Mal)adaptation-hemodynamic

Chronic Congestive Heart FailureChronic Congestive Heart Failure(Mal) adaptation-neurohormonal

• Activation of the sympathetic nervous system– Vasoconstriction/increased afterload– Tolerance– Arhythmogenic


• Activation of renin-angiotensin system– Na resorption– Vasoconstriction– Apoptosis/fibrosis


• Antidiuretic hormone

• Proinflammatory cytokines– TNFalpha– IL-6

Chronic Congestive Heart FailureChronic Congestive Heart FailureClinical Presentation of Heart Failure

• Due to excess fluid accumulation:– Dyspnea (most sensitive symptom)

– Edema

– Hepatic congestion

– Ascites

– Orthopnea, Paroxysmal Nocturnal Dyspnea (PND)

• Due to reduction in cardiac ouput:– Fatigue (especially with exertion)

– Weakness


• S3 gallop – Low sensitivity, but highly specific

• Cool, pale, cyanotic extremities– Have sinus tachycardia, diaphoresis and peripheral vasoconstriction

• Crackles or decreased breath sounds at bases (effusions) on lung exam

• Elevated jugular venous pressure• Lower extremity edema• Ascites• Hepatomegaly• Splenomegaly• Displaced PMI

• Apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement>

Chronic Congestive Heart FailureChronic Congestive Heart FailureLab Analysis in Heart Failure

• CBC– Since anemia can exacerbate heart failure

• Serum electrolytes and creatinine– before starting high dose diuretics

• Fasting Blood glucose– To evaluate for possible diabetes mellitus

• Thyroid function tests– Since thyrotoxicosis can result in A. Fib, and hypothyroidism can results in HF.

• Iron studies– To screen for hereditary hemochromatosis as cause of heart failure.

• ANA– To evaluate for possible lupus

• Viral studies – If viral mycocarditis suspected

Chronic Congestive Heart FailureChronic Congestive Heart FailureLaboratory Analysis (cont.)

• BNP– With chronic heart failure, atrial mycotes secrete increase

amounts of atrial natriuretic peptide (ANP) and brain natriuretic pepetide (BNP) in response to high atrial and ventricular filling pressures

– Usually is > 400 pg/mL in patients with dyspnea due to heart failure.

Chronic Congestive Heart FailureChronic Congestive Heart FailureChest X-ray in Heart Failure

• Cardiomegaly

• Cephalization of the pulmonary vessels

• Kerley B-lines

• Pleural effusions

Chronic Congestive Heart FailureChronic Congestive Heart FailureCardiomegaly

Chronic Congestive Heart FailureChronic Congestive Heart FailurePulmonary Edema due to Heart Failure

Chronic Congestive Heart FailureChronic Congestive Heart FailureKerley B lines

Chronic Congestive Heart FailureChronic Congestive Heart FailureCardiac Testing in Heart Failure

• Electrocardiogram:– May show specific cause of heart failure:

– Ischemic heart disease– Dilated cardiomyopathy: first degree AV block, LBBB,

Left anterior fascicular block– Amyloidosis: pseudo-infarction pattern– Idiopathic dilated cardiomyopathy: LVH

• Echocardiogram:– Left ventricular ejection fraction– Structural/valvular abnormalities

Chronic Congestive Heart FailureChronic Congestive Heart FailureFurther Cardiac Testing in Heart Failure

• Coronary arteriography– Should be performed in patients presenting with heart failure who

have angina or significant ischemia– Reasonable in patients who have chest pain that may or may not

be cardiac in origin, in whom cardiac anatomy is not known, and in patients with known or suspected coronary artery disease who do not have angina.

– Measure cardiac output, degree of left ventricular dysfunction, and left ventricular end-diastolic pressure.

Chronic Congestive Heart FailureChronic Congestive Heart FailureFurther testing in Heart Failure

• Endomyocardial biopsy• Not frequently used

• Amyloidosis, giant-cell myocarditis

Chronic Congestive Heart FailureChronic Congestive Heart FailureClassification of Heart Failure

ACCF/AHA Stages of HF NYHA Functional ClassificationA At high risk for HF but without structural

heart disease or symptoms of HF.None

B Structural heart disease but without signs or symptoms of HF.

I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.

C Structural heart disease with prior or current symptoms of HF.

I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.

II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.

III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.

IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

D Refractory HF requiring specialized interventions.


Aggravating FactorsAggravating Factors• Medications

• New heart disease• Myocardial ischemia

• Medications• New heart disease

• Myocardial ischemia

• Endocarditis

• Obesity

• Hypertension

• Physical activity

• Dietary excess

• Endocarditis

• Obesity

• Hypertension

• Physical activity

• Dietary excess

• Pregnancy

• Arrhythmias (AF)

• Infections

• Thromboembolism

• Hyper/hypothyroidism

• Pregnancy

• Arrhythmias (AF)

• Infections

• Thromboembolism

• Hyper/hypothyroidism


Heart Failure and Myocardial IschemiaHeart Failure and Myocardial Ischemia

• Coronary HD is the cause of 2/3 of HFCoronary HD is the cause of 2/3 of HF

• Segmental wall motion abnormalities are not Segmental wall motion abnormalities are not specific if ischemiaspecific if ischemia

• Angina coronary angio and revascularizationAngina coronary angio and revascularization

• No anginaNo angina• Search for ischemia and viability in all Search for ischemia and viability in all ??• Coronary angiography in all Coronary angiography in all ??


VASOCONSTRICTIONVASOCONSTRICTION VASODILATATION VASODILATATION

KininogenKininogen

KallikreinKallikrein

Inactive FragmentsInactive Fragments

AngiotensinogenAngiotensinogen

Angiotensin IAngiotensin I

RENINRENIN

Kininase IIKininase IIInhibitorInhibitor

ALDOSTERONEALDOSTERONE

SYMPATHETICSYMPATHETICVASOPRESSINVASOPRESSIN

PROSTAGLANDINSPROSTAGLANDINS

tPAtPA

ANGIOTENSIN IIANGIOTENSIN II

BRADYKININBRADYKININ

ACE-i. Mechanism of ActionACE-i. Mechanism of Action

A.C.E.A.C.E.


ACE-I. Clinical EffectsACE-I. Clinical Effects

• Improve symptoms

• Reduce remodelling / progression

• Reduce hospitalization

• Improve survival


• Reduce remodelling / progression

• Reduce hospitalization

• Improve survival


Mortality Reduction with ACE-iMortality Reduction with ACE-i

StudyStudy ACE-iACE-i Clinical SetingClinical Seting

CONSENSUSCONSENSUS EnalaprilEnalapril CHFCHF

SOLVD treatment SOLVD treatment EnalaprilEnalapril CHFCHF

AIREAIRE RamiprilRamipril CHFCHF

Vheft-IIVheft-II EnalaprilEnalapril CHFCHF

TRACETRACE TrandolaprilTrandolapril CHF / LVDCHF / LVD

SAVESAVE CaptoprilCaptopril LVDLVD

SMILESMILE ZofenoprilZofenopril High risk High risk

HOPEHOPE RamiprilRamipril High risk High risk


PlaceboPlacebo

EnalaprilEnalapril

1212111110109988776655

ProbabiilityofDeath

ProbabiilityofDeath

MonthsMonths

0.10.1

0.80.8

00

0.20.2

0.30.3

0.70.7

0.40.4

0.50.5

0.60.6p< 0.001p< 0.001

p< 0.002p< 0.002

CONSENSUSN Engl J Med 1987;316:1429CONSENSUSN Engl J Med 1987;316:1429

4433221100

ACE-iACE-i


Mortality,%

Mortality,%

44SAVEN Engl J Med 1992;327:669

SAVEN Engl J Med 1992;327:669 YearsYears

3030

2020

1010

0011 22 33

PlaceboPlacebo

CaptoprilCaptopril

00

n=1115n=1115

n=1116n=1116

p=0.019p=0.019² -19%² -19%

n = 22313 - 16 days post AMIEF < 4012.5 --- 150 mg / day

n = 22313 - 16 days post AMIEF < 4012.5 --- 150 mg / day

Asymptomatic ventriculardysfunction post MI

Asymptomatic ventriculardysfunction post MI

ACE-iACE-i


• Symptomatic heart failure

• Asymptomatic ventricular dysfunction- LVEF < 35 - 40 %

• Selected high risk subgroups

• Symptomatic heart failure

• Asymptomatic ventricular dysfunction- LVEF < 35 - 40 %

• Selected high risk subgroups

ACE-i. IndicationsACE-i. Indications

AHA / ACC HF guidelines 2001 AHA / ACC HF guidelines 2001

ESC HF guidelines 2001ESC HF guidelines 2001


ACE-i. Practical UseACE-i. Practical Use

• Start with very low doseStart with very low dose

• Increase dose if well toleratedIncrease dose if well tolerated

• Renal function & serum KRenal function & serum K++ after 1-2 w after 1-2 w

• Avoid fluid retention / hypovolemia Avoid fluid retention / hypovolemia (diuretic use)(diuretic use)

• Dose NOT determined by symptomsDose NOT determined by symptoms


ACE-i. Dose (mg)ACE-i. Dose (mg) InitialInitial MaximumMaximum

CaptoprilCaptopril 6.25 / 8h 6.25 / 8h 50 / 8h50 / 8h

EnalaprilEnalapril 2.5 / 12 h 2.5 / 12 h 10 to 20 / 12h10 to 20 / 12h

FosinoprilFosinopril 5 to 10 / day 5 to 10 / day 40 / day40 / day

LisinoprilLisinopril 2.5 to 5.0 / day 2.5 to 5.0 / day 20 to 40 / day20 to 40 / day

QuinaprilQuinapril 10 / 12 h10 / 12 h 40 / 12 h40 / 12 h

RamiprilRamipril 1.25 to 2.5 / day 1.25 to 2.5 / day 10 / day10 / day



ACE-I. Adverse EffectsACE-I. Adverse Effects

• Hypotension (1st dose effect)Hypotension (1st dose effect)

• Worsening renal functionWorsening renal function

• HyperkalemiaHyperkalemia

• CoughCough

• AngioedemaAngioedema

• Rash, ageusia, neutropenia, …Rash, ageusia, neutropenia, …


ACE-I. ContraindicationsACE-I. Contraindications

• Intolerance (angioedema, anuric renal fail.)

• Bilateral renal artery stenosis

• Pregnancy

• Renal insufficiency (creatinine > 3 mg/dl)

• Hyperkalemia (> 5,5 mmol/l)

• Severe hypotension

ACE-I. ContraindicationsACE-I. Contraindications

• Intolerance (angioedema, anuric renal fail.)

• Bilateral renal artery stenosis

• Pregnancy

• Renal insufficiency (creatinine > 3 mg/dl)

• Hyperkalemia (> 5,5 mmol/l)

• Severe hypotension


ß-Adrenergic BlockersMechanism of actionß-Adrenergic BlockersMechanism of action• Density of ß1 receptors

• Inhibit cardiotoxicity of catecholamines

• Neurohormonal activation

• HR

• Antiischemic

• Antihypertensive

• Antiarrhythmic

• Antioxidant, Antiproliferative

• Density of ß1 receptors

• Inhibit cardiotoxicity of catecholamines

• Neurohormonal activation

• HR

• Antiischemic

• Antihypertensive

• Antiarrhythmic

• Antioxidant, Antiproliferative


100100

9090

8080

6060

7070

5050242400 2020161612128844 2828

PlaceboPlacebo

CarvedilolCarvedilol

MonthsMonths

N = 2289N = 2289III-IV NYHAIII-IV NYHA

COPERNICUSCOPERNICUSNEJM 2001;344:1651NEJM 2001;344:1651

SurvivalSurvival%%

ß-Adrenergic Blockersß-Adrenergic Blockers

pp=0.00014=0.0001435% RR 35% RR


• Patient Patient stablestable• No physical evidence of fluid retentionNo physical evidence of fluid retention• No need for i.v. inotropic drugsNo need for i.v. inotropic drugs

• No contraindicationsNo contraindications

• In hospital or notIn hospital or not

ß-Adrenergic Blockersß-Adrenergic BlockersWhen to startWhen to start


InitialInitial TargetTarget

BisoprololBisoprolol 1.25 / 24h1.25 / 24h 10 / 24h 10 / 24h

CarvedilolCarvedilol 3.125 / 12h3.125 / 12h 25 / 12h25 / 12h

Metoprolol Metoprolol succinnatesuccinnate 12,5-25 / 24h12,5-25 / 24h 200 / 24h200 / 24h

• Start Low, Increase SlowlyStart Low, Increase Slowly• Increase the dose every 2 - 4 weeksIncrease the dose every 2 - 4 weeks

ß-Adrenergic Blockersß-Adrenergic BlockersDose (mg)Dose (mg)


• HypotensionHypotension• Fluid retention / worsening heart failureFluid retention / worsening heart failure• FatigueFatigue• Bradycardia / heart blockBradycardia / heart block

ß-Adrenergic Blockersß-Adrenergic BlockersAdverse EffectsAdverse Effects


ALDOSTERONEALDOSTERONE

• Retention Na+

• Retention H2O

• Excretion K+

• Excretion Mg2+

• Retention Na+

• Retention H2O

• Excretion K+

• Excretion Mg2+

• Collagen Collagen depositiondeposition

FibrosisFibrosis - - myocardiummyocardium

- - vesselsvessels

SpironolactoneSpironolactone

Edema Edema

Arrhythmias Arrhythmias

Competitive antagonist of thealdosterone receptor(myocardium, arterial walls, kidney)

Competitive antagonist of thealdosterone receptor(myocardium, arterial walls, kidney)

Aldosterone InhibitorsAldosterone Inhibitors

-


Aldactone

Placebo

SurvivalSurvival

1.0

0.9

0.8

0.7

0.6

0.5

0 6 12 18 24 30 36

months

p < 0.0001

Annual MortalityAldactone 18%; Placebo 23%

N = 1663N = 1663NYHA III-IVNYHA III-IV

Mean follow-up 2 yMean follow-up 2 y

RALESRALESNEJM 1999;341:709NEJM 1999;341:709

SpironolactoneSpironolactone


Spironolactone.Spironolactone. IndicationsIndications

• Recent or current symptoms despite Recent or current symptoms despite ACE-i, diuretics, dig. and ACE-i, diuretics, dig. and -blockers-blockers

AHA / ACC HF guidelines 2001AHA / ACC HF guidelines 2001

• Recommended in advanced heart failure Recommended in advanced heart failure (III-IV), in addition to ACE-i and diuretics(III-IV), in addition to ACE-i and diuretics

• HypokalemiaHypokalemiaESC HF guidelines 2001ESC HF guidelines 2001


Spironolactone.Spironolactone. Practical use Practical use

• Do not use if hyperkalemia, renal insuf.Do not use if hyperkalemia, renal insuf.

• Monitor serum KMonitor serum K++ at “frequent intervals” at “frequent intervals”

• Start ACE-i firstStart ACE-i first

• Start with 25 mg / 24hStart with 25 mg / 24h

• If KIf K++ >5.5 mmol/L, reduce to 25 mg / 48h >5.5 mmol/L, reduce to 25 mg / 48h

• If KIf K++ is low or stable consider 50 mg / day is low or stable consider 50 mg / day

New studies in progressNew studies in progress


RENINRENIN

AngiotensinogenAngiotensinogen Angiotensin I

ANGIOTENSIN II

Angiotensin I

ANGIOTENSIN II

ACEACEOther pathwaysOther pathways

VasoconstrictionVasoconstriction Proliferative Action

Proliferative Action

VasodilatationVasodilatation Antiproliferative Action

Antiproliferative Action

AT1 AT1 AT2AT2

AT1 Receptor Blockers

AT1 Receptor Blockers

RECEPTORSRECEPTORS

Angiotensin II Receptor Blockers (ARB)Angiotensin II Receptor Blockers (ARB)


• Candesartan, Eprosartan, IrbesartanCandesartan, Eprosartan, IrbesartanLosartan, Telmisartan, ValsartanLosartan, Telmisartan, Valsartan

• Not indicated with beta blockersNot indicated with beta blockers

• Indicated in patients intolerant to ACE-IIndicated in patients intolerant to ACE-I

Angiotensin II Receptor Blockers (ARB)Angiotensin II Receptor Blockers (ARB)

AHA / ACC HF guidelines 2001AHA / ACC HF guidelines 2001ESC HF guidelines 2001ESC HF guidelines 2001


Positive InotropesPositive Inotropes

• DigitalisDigitalis

• SympathomimeticsSympathomimetics• CatecholaminesCatecholamines• B-adrenergic agonistsB-adrenergic agonists

• Phosphodiesterase inhibitorsPhosphodiesterase inhibitors• Amrinone, Milrinone, EnoximoneAmrinone, Milrinone, Enoximone

• Calcium sensitizersCalcium sensitizers• Levosimendan, PimobendanLevosimendan, Pimobendan


•May increase mortality Exception: Digoxin, Levosimendan

•Use only in refractory CHF

•NOT for use as chronic therapy

•May increase mortality Exception: Digoxin, Levosimendan

•Use only in refractory CHF

•NOT for use as chronic therapy

Positive Inotropic TherapyPositive Inotropic Therapy


Digitalis. Mechanism of ActionDigitalis. Mechanism of Action

Blocks NaBlocks Na++ / K / K++ ATPase => Ca ATPase => Ca+ ++ +

•• Inotropic effectInotropic effect

•• NatriuresisNatriuresis

•• Neurohormonal controlNeurohormonal control-- PlasmaPlasma NoradrenalineNoradrenaline

- - Peripheral nervous system activityPeripheral nervous system activity

-- RAAS activity RAAS activity

-- VagalVagal tonetone

-- Normalizes arterial baroreceptors Normalizes arterial baroreceptorsNEJM 1988;318:358 NEJM 1988;318:358


Digitalis. Clinical EffectsDigitalis. Clinical Effects


• Modest reduction in hospitalization

• Does not improve survival


• Modest reduction in hospitalization

• Does not improve survival


Digitalis. IndicationsDigitalis. Indications

• • When no adequate response toWhen no adequate response to ACE-i + diuretics + beta-blockersACE-i + diuretics + beta-blockers AHA / ACC Guidelines 2001AHA / ACC Guidelines 2001

• • In combination with ACE-i + diureticsIn combination with ACE-i + diuretics

if persisting symptomsif persisting symptoms ESC Guidelines 2001ESC Guidelines 2001

• • AF, to slow AV conductionAF, to slow AV conduction

Dose 0.125 to 0.250 mg / dayDose 0.125 to 0.250 mg / day


5050

4040

3030

2020

1010

00

Placebon=3403

Placebon=3403

Digoxinn=3397

Digoxinn=3397

484800 1212 2424 3636

Mortality%Mortality%

DIGN Engl J Med 1997;336:525

DIGN Engl J Med 1997;336:525 MonthsMonths

p = 0.8p = 0.8

DigitalisDigitalis

N=6800

NYHA II-III

N=6800

NYHA II-III


Diuretics. IndicationsDiuretics. Indications1.1. Symptomatic HF, with fluid retentionSymptomatic HF, with fluid retention

• EdemaEdema• DyspneaDyspnea• Lung RalesLung Rales• Jugular distensionJugular distension• HepatomegalyHepatomegaly• Pulmonary edema (Xray)Pulmonary edema (Xray)




Loop Diuretics / Thiazides. Practical Use Loop Diuretics / Thiazides. Practical Use

• Start with variable dose. Titrate to achieve Start with variable dose. Titrate to achieve dry weightdry weight

• Monitor serum KMonitor serum K++ at “frequent intervals” at “frequent intervals”

• Reduce dose when fluid retention is controlledReduce dose when fluid retention is controlled

• Teach the patient when, how to change Teach the patient when, how to change dosedose

• Combine to overcome “resistance”Combine to overcome “resistance”

• Do not use aloneDo not use alone


Thiazides, Loop Diuretics. Adverse EffectsThiazides, Loop Diuretics. Adverse Effects

•• KK++, Mg, Mg++ (15 - 60%) (sudden death ???) (15 - 60%) (sudden death ???)

•• NaNa++

• • Stimulation of neurohormonal activityStimulation of neurohormonal activity

•• Hyperuricemia (15 - 40%)Hyperuricemia (15 - 40%)

•• Hypotension. Ototoxicity. Gastrointestinal. Hypotension. Ototoxicity. Gastrointestinal.

Alkalosis. MetabolicAlkalosis. MetabolicSharpe N. Heart failure. Martin Dunitz 2000;43Sharpe N. Heart failure. Martin Dunitz 2000;43Kubo SH , et al. Am J Cardiol 1987;60:1322Kubo SH , et al. Am J Cardiol 1987;60:1322MRFIT, JAMA 1982;248:1465MRFIT, JAMA 1982;248:1465Pool Wilson. Heart failure. Churchill Livinston 1997;635Pool Wilson. Heart failure. Churchill Livinston 1997;635


Diuretic ResistanceDiuretic Resistance• Neurohormonal activationNeurohormonal activation

• Rebound NaRebound Na++ uptake after volume loss uptake after volume loss

• Hypertrophy of distal nephronHypertrophy of distal nephron

• Reduced tubular secretion Reduced tubular secretion (renal failure, NSAIDs)(renal failure, NSAIDs)

• Decreased renal perfusion (low output)Decreased renal perfusion (low output)

• Altered absortion of diureticAltered absortion of diuretic

• Noncompliance with drugsNoncompliance with drugs

Brater NEJM 1998;339:387 Brater NEJM 1998;339:387 Kramer et al. Am J Med 1999;106:90Kramer et al. Am J Med 1999;106:90


Managing Resistance to DiureticsManaging Resistance to Diuretics

•• Restrict NaRestrict Na++/H/H22O intake (Monitor Natremia)O intake (Monitor Natremia)

•• Increase dose Increase dose (individual dose, frequency, i.v.)(individual dose, frequency, i.v.)

• • Combine: Combine: furosemide + thiazide / spiro / metolazonefurosemide + thiazide / spiro / metolazone

•• Dopamine (increase cardiac output)Dopamine (increase cardiac output)

•• Reduce dose of ACE-iReduce dose of ACE-i

•• UltrafiltrationUltrafiltration

Motwani et al Circulation 1992;86:439Motwani et al Circulation 1992;86:439


• Inotropes, long term / intermittentInotropes, long term / intermittent

• Antiarrhythmics (except amiodarone)Antiarrhythmics (except amiodarone)

• Calcium antagonists (except amlodipine)Calcium antagonists (except amlodipine)

• Non-steroidal antiinflammatory drugs (NSAIDS)Non-steroidal antiinflammatory drugs (NSAIDS)

• Tricyclic antidepressantsTricyclic antidepressants

• CorticosteroidsCorticosteroids

• LithiumLithium

Drugs to Avoid Drugs to Avoid (may increase symptoms, mortality)(may increase symptoms, mortality)



Refractory End-Stage HFRefractory End-Stage HF• Review etiology, treatment & aggrav. factorsReview etiology, treatment & aggrav. factors

• Control fluid retentionControl fluid retention• Resistance to diureticsResistance to diuretics• Ultrafiltration ?Ultrafiltration ?

• iv inotropics / vasodilators during iv inotropics / vasodilators during decompensationdecompensation

• Consider resynchronizationConsider resynchronization

• Consider mechanical assist devicesConsider mechanical assist devices

• Consider heart transplantationConsider heart transplantation


Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure

• For patients who have left ventricular ejection fraction (LVEF) less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, cardiac resynchronization therapy (CRT) with or without an ICD is indicated for the treatment of New York Heart Association (NYHA) functional Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy

Chronic Congestive Heart FailureChronic Congestive Heart Failure Indications for CRT TherapyPatient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or

with implantation of pacing or defibrillation device for special indications

LVEF <35%

Evaluate general health statusComorbidities and/or frailty

limit survival with good functional capacity to <1 y

Continue GDMT without implanted device

Acceptable noncardiac health

Evaluate NYHA clinical status

NYHA class I

· LVEF ≤30%· QRS ≥150 ms· LBBB pattern· Ischemic

cardiomyopathy· QRS ≤150 ms· Non-LBBB pattern

NYHA class II

· LVEF ≤35%· QRS 120-149 ms· LBBB pattern· Sinus rhythm

· QRS ≤150 ms· Non-LBBB pattern

· LVEF ≤35%· QRS ≥150 ms· LBBB pattern· Sinus rhythm

· LVEF ≤35%· QRS ≥150 ms· Non-LBBB pattern· Sinus rhythm

Colors correspond to the class of recommendations in the ACCF/AHA Table 1.

Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survi val.

NYHA class III & Ambulatory class IV

· LVEF ≤35%· QRS 120-149 ms· LBBB pattern· Sinus rhythm

· LVEF ≤35%· QRS 120-149 ms· Non-LBBB pattern· Sinus rhythm

· LVEF ≤35%· QRS ≥150 ms· LBBB pattern· Sinus rhythm

· LVEF≤35%· QRS ≥150 ms· Non-LBBB pattern· Sinus rhythm

· Anticipated to require frequent ventricular pacing (>40%)

· Atrial fibrillation, if ventricular pacing is required and rate control will result in near 100% ventricular pacing with CRT

Special CRT Indications


Heart Transplant. IndicationsHeart Transplant. Indications• Refractory cardiogenic shockRefractory cardiogenic shock

• Documented dependence on IV inotropic support Documented dependence on IV inotropic support to maintain adequate organ perfusionto maintain adequate organ perfusion

• Peak VO2 < 10 ml / kg / min Peak VO2 < 10 ml / kg / min

• Severe symptoms of ischemia not amenable to Severe symptoms of ischemia not amenable to revascularizationrevascularization

• Recurrent symptomatic ventricular arrhythmias Recurrent symptomatic ventricular arrhythmias refractory to all therapeutic modalitiesrefractory to all therapeutic modalities

Contraindications: age, severe comorbidityContraindications: age, severe comorbidity


Ventricular Arrhythmias / Sudden DeathVentricular Arrhythmias / Sudden Death• Antiarrhythmics ineffective Antiarrhythmics ineffective (may increase mortality)(may increase mortality)

Amiodarone do not improve survivalAmiodarone do not improve survival

• -blockers reduce all cause mortality and SD-blockers reduce all cause mortality and SD

• Control ischemiaControl ischemia

• Control electrolyte disturbancesControl electrolyte disturbances

• ICD (Implantable Cardiac Defibrillator)ICD (Implantable Cardiac Defibrillator)• In secondary prevention of SDIn secondary prevention of SD• In sustained, hemodynamic destabilizing VTIn sustained, hemodynamic destabilizing VT• Ongoing research will establish new indicationsOngoing research will establish new indications

Chronic Congestive Heart FailureChronic Congestive Heart FailureDevice Therapy for Stage C HFrEF (cont.)

Recommendations COR LOEICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-MI with LVEF ≤35%, and NYHA class II or III symptoms on chronic GDMT, who are expected to live ≥1 year*

I A

CRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS ≥150 ms

I

A (NYHA class III/IV)

B (NYHA class II)

ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-MI with LVEF ≤30%, and NYHA class I symptoms while receiving GDMT, who are expected to live ≥1 year*

I B

CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with a QRS ≥150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT.

IIa A

CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS 120 to 149 ms, and NYHA class II, III or ambulatory IV symptoms on GDMT

IIa

B

CRT can be useful in patients with AF and LVEF ≤35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation or rate control allows near 100% ventricular pacing with CRT

IIa B


Diastolic Heart FailureDiastolic Heart Failure• Incorrect diagnosis of HFIncorrect diagnosis of HF• Inaccurate measurement of LVEFInaccurate measurement of LVEF• Primary valvular diseasePrimary valvular disease• Restrictive (infiltrative) cardiomyopathies (Amyloidosis…)Restrictive (infiltrative) cardiomyopathies (Amyloidosis…)• Pericardial constrictionPericardial constriction• Episodic or reversible LV systolic dysfunctionEpisodic or reversible LV systolic dysfunction• Severe hypertension, ischemiaSevere hypertension, ischemia• High output states: Anemia, thyrotoxicosis, etcHigh output states: Anemia, thyrotoxicosis, etc• Chronic pulmonary disease with right HFChronic pulmonary disease with right HF• Pulmonary hypertension Pulmonary hypertension • Atrial myxomaAtrial myxoma• LV HypertrophyLV Hypertrophy• Diastolic dysfunction of uncertain originDiastolic dysfunction of uncertain origin

Chronic Congestive Heart FailureChronic Congestive Heart FailureTreatment of HFpEF

Recommendations COR LOESystolic and diastolic blood pressure should be controlled according to published clinical practice guidelines I B

Diuretics should be used for relief of symptoms due to volume overload

I C

Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial ischemia is present despite GDMT

IIa

C

Management of AF according to published clinical practice guidelines for HFpEF to improve symptomatic HF

IIa C

Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFpEF IIa C

ARBs might be considered to decrease hospitalizations in HFpEF

IIb B

Nutritional supplementation is not recommended in HFpEF

III: No Benefit

C

Chronic Congestive Heart FailureChronic Congestive Heart FailureStages, Phenotypes and Treatment of HF

STAGE AAt high risk for HF but without structural heart

disease or symptoms of HF

STAGE BStructural heart disease

but without signs or symptoms of HF

THERAPYGoals· 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

STAGE CStructural heart disease

with prior or current symptoms of HF

THERAPYGoals· 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

STAGE DRefractory HF

THERAPYGoals· 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

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

HFpEF HFrEF

THERAPYGoals· 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

THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital

readmissions· Establish patient’s end-

of-life goals

Options· Advanced care

measures· Heart transplant· Chronic inotropes· Temporary or permanent

MCS· Experimental surgery or

drugs· Palliative care and

hospice· ICD deactivation

Refractory symptoms of HF at rest, despite GDMT

At Risk for Heart Failure Heart Failure

e.g., Patients with:· Marked HF symptoms at

rest · Recurrent hospitalizations

despite GDMT

e.g., Patients with:· Previous MI· LV remodeling including

LVH and low EF· Asymptomatic valvular

disease

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

cardiomyopathy

Development of symptoms of HF

Structural heart disease

Low-Output Heart Failure Systolic Heart Failure (HFREF):

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