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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
By
Nik Nikam, M.D.Interventional Cardiologist
Sugar Land Texas
May 2010
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER Epidemiology
Approximately 4.9 million people have CHF
More than 550,000 cases detected annually
Account for 5 to 10% of all hospitalizations
250,000 deaths per year related to CHF
Five year mortality as high as 60% in men & 45%
in women
Median survival is 3.5 years for men and 5.4 yearsfor women
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
CHF precipitating factors
Non Compliance with Meds and Diet
Acute MI
Arrhythmia
Pneumonia
Increased Sodium Diet (Holiday Failure)
AnxietyPregnancy
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HEART CENTER
Rhythm problems leading to CHF
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Pathophysiology
Hemodynamic changes
Neurohormonal changes
Cellular changes
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HEART CENTER
Neurohormonal changes in CHF
RAS, renin-angiotensin system; SNS, sympathetic nervous system.
Myocardial injury to the heart (CAD, HTN, CMP, Valvular disease)
Morbidity and mortality
Arrhythmias
Pump failure
Peripheral vasoconstriction
Hemodynamic alterations
Heart failure symptoms
Remodeling and progressive
worsening of LV function
Initial fall in LV performance, wall stress
Activation of RAAS and SNS
Fibrosis, apoptosis,
hypertrophy, cellular/
molecular alterations,
myotoxicity
Fatigue
Activity altered
Chest congestion
Edema
Shortness of breath
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HEART CENTER
Neurohormonal changes
N/H changes Favorable effect Unfavor. effect
Sympathetic activityHR ,contractility,
vasoconst.V return,
filling
Arteriolar constriction
After loadworkload
O2consumption
Renin-Angiotensin
Aldosterone
Salt & water retentionVR Vasoconstriction
after load
Vasopressin Same effect Same effect
interleukins &TNF May have roles in myocytehypertrophy
Apoptosis
EndothelinVasoconstrictionVR After load
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Cardiovascular physiology
Frank-Starling Length: Tension Ratio
Ejection Fraction
End diastolic volume/end systolic volumeCardiac Output
Stroke volume x heart rate
Preload
Volume of blood delivered to heart during diastole
Afterload Peripheral vascular resistance
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Volume overload: Regurgitate valveHigh output status
Pressure overload: Systemic hypertension
Outflow obstructionAS
Loss of muscles: Post MI, Chronic ischemiaConnective tissue diseases
Infection, Poisons(alcohol,cobalt,Doxorubicin)
Restricted Filling: Pericardial diseases,Restrictive cardiomyopathy
Tachyarrhythmia
Causes of CHF
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Types of CHF
Systolic & Diastolic
High Output Failure
Pregnancy, anemia, thyrotoxicosis, A/V fistula, Beriberi, Pagetsdisease
Low Output Failure
Acute large MI, aortic valve dysfunction---
Chronic
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HEART CENTER
Types of CHF
Right v. Left sided heart failure
Right sided heart failure :
Most common cause is left sided failure
Other causes included : Pulmonary embolisms
Other causes of pulmonary HTN
RV infarction
MS
Usually presents with: LL edema, ascities
Hepatic congestion
Cardiac cirrhosis (on the long run)
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HEART CENTER
New York Heart Association (NYHA)
Functional Classification
Class % of pts Symptoms
I 35% No symptoms or limitations in ordinary physical
activity
II 35% Mild symptoms and slight limitation during
ordinary activity
III 25% Marked limitation in activity even during minimal
activity. Comfortable only at rest
IV 5% Severe limitation. Experiences symptoms even at
rest
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Physical Exam
Anxious
Pale
Clammy
Tachypnea
Confusion
EdemaHypertension
Diaphoretic
Rales
Rhonchi
Tachycardia
S3Gallop
JVD
Pink Frothy Sputum
CyanosisDisplaced PMI
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER Measurement of Jugular Venous pressure
Jugular Venous Distention
not directly related to LVF.
Comes from backpressure buildingfrom right heart into
venous circulation
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Framingham Criteria for CHF
Major Criteria:
PND
JVD Rales
Cardiomegaly
Acute Pulmonary Edema
S3 Gallop Positive hepatic Jugular reflex
venous pressure >16 cm H2O
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HEART CENTER
Lab Tests
Anemia
Hyperthyroid
Chronic renal insuffiency
Electrolyte abnormality-Na, K, Mag, Calcium
Pre-renal azotemia
Hemochromatosis
BNP
TSH
HgA1c
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HEART CENTER
EKG
Old MI or recent MI
Arrhythmia
Some forms of Cardiomyopathy are tachycardiarelated
LBBBmay help in management
Heart Block
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HEART CENTER
Chest X-ray
Look for Heart size
Pulmonary vascular markings
COPD, pneumonia, Pneumothorax, widened mediastinum
Pleural effusions
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HEART CENTER
Echocardiogram
Function of both ventricles
Wall motion abnormality that may signify CAD
Valvular abnormality
Intra-cardiac shunts
Pericardial effusion
Restrictive pericarditis
Pulmonary hypertension
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Cardiac Catheterization
Coronary artery disease
Dilated ventricle
Hyperdynamic small ventricle
Wall motion abnormality that may signify CAD
Valvular abnormalityIntra-cardiac shunts
Pulmonary hypertension
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Differential Diagnosis of CHF
Pericardial diseases
Liver diseasesNephrotic syndrome
Protein losing enteropathy
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HEART CENTER
Differential Diagnosis of CHF
COPD CHF Pneumonia
Cough Frequent Occasional Frequent
Wheeze Frequent Occasional Frequent
Sputum Thick Thin/white Thick/yellow/brown
Hemoptysis Occasionally Pink frothy occasionally
PND Sometimes after
a few hours
Often within 1
hour
Rare
Smoking Common Less common Less common
Pedal edema Occasional Common with
chronic
none
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Differential Diagnosis of CHF
COPD CHF Pneumonia
Onset Often URI with
cough
Orthopnea at
night
Gradual with
fever, cough
Chest Pain pleuritic Substernal,crushing Pleuritic, oftenlocalized
Clubbing Often Rare Rare
Cyanosis Often and severe Initially mild but
progresses
May be present
Diaphoresis May be present Mild to heavy Dry to moist
Pursed Lips Often Rare Rare unless
COPD
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
HFSA 2006 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, epidemiologicalfindings; in-practice safety reporting
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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HEART CENTER
Goals for CHF management in a hospital
1. Relieve symptoms rapidly
2. Reverse hemodynamic abnormalities
3. Prevent end-organ dysfunction
4. Initiate patient education and survival-enhancingmedications before discharge
5. Optimize survival-enhancing oral medications (ACEinhibitor, beta blocker, aldosterone receptor antagonist)
6. Optimize patient education and HF disease management
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
CHF treatment-Acute
NTG- SL and IV infusion
Morphine sulfate: 2-6 mg IV
Lasix 40-80 mg IV
O2High flow O2
CPAP
Foley catheter
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
CHF Management
Beta Blocker
Diuretics for fluid retention
Aldosterone antagonists in
select patient
Digoxin to reduce
hospitalizations
Hydralazine/nitrate or ARB if
BP allows + sxs
Bi-Vv pacing if sxs CRT
ACE-I (or ARB if ACE intolerant)
Regular exercise program
Sodium restriction
ICD
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Treatment of CHF
Correction of reversible causes
Medications
Diuretics, ACE inhibitors, beta blokers etc. Ischemia
Arrhythmia: A fib, flutter, PJRT
Valvular heart disease
Thyrotoxicosis and other high output status Shunts
SUGAR LAND
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
CHF treatment-Acute
Pharmacological
Morphine sulfate
NitratesDiuretics
ACE inhibitors
Beta blockers
Aspirin therapy
statinsVasodilators
Neurohormonal antagonists
Anticoagulant therapy
Antiarrhymics
SUGAR LAND
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Diet and Activity
Salt restriction (2 grams per day)
Fluid restriction (Less than 1-2 liters per day)
Daily weight (tailor therapy)
Gradual exercise programs
Blood sugar monitoring
SUGAR LAND
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Adams KF, Lindenfeld J, et al. HFSA 2006 ComprehensiveHeart Failure Guideline. J Card Fail 2006;12:e1-e122.
Sodium Equivalents
2400 mg6100 mg1 tsp
1800 mg4650 mg tsp
1200 mg3100 mg tsp
600 mg1550 mg tsp
SodiumSodium ChlorideSalt
SUGAR LAND
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HEART CENTER
Diuretics
The most effective symptomatic relief
Mild symptoms
HCTZ Chlorthalidone
Metolazone
Block Na reabsorbtion in loop of henle and distal
convoluted tubules
Thiazides are ineffective with GFR < 30 --/min
SUGAR LAND
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Thiazide Diuretics
36 hrsMetabolic5 mg2.5 mg qdIdapamide
12-24 hrs80% Renal,10% into Bile,
10% Unknown
20 mg2.5 mg qdMetolazone
6-12 hrsRenal200 mg25 mg qd
or bid
Hydrochloro-
thiazide
24-72 hrs65% Renal,
10% into Bile,
25% Unknown
100 mg12.5-25 mg
qd
Chlorthalidone
6-12 hrsRenal1000 mg250-500 mg
qd or bid
Chlorothiazide
Duration
of Action
EliminationMax Total
Daily Dose
Initial Daily
Dose
Agent
SUGAR LAND
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Diuretics
Loop diuretics for more severe heart failure
Lasix (20320 mg QD), Furosemide
Bumex (Bumetanide 1-8mg)
Torsemide (20-200mg)
Mechanism of action: Inhibit chloride reabsortion in ascendinglimb of loop of Henle results in natriuresis, kaliuresis andmetabolic alkalosis
Adverse reaction:pre-renal azotemia
Hypokalemia
Skin rash
Ototoxicity
SUGAR LAND
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Adams KF, Lindenfeld J, et al. HFSA 2006 ComprehensiveHeart Failure Guideline. J Card Fail 2006;12:e1-e122.
Loop Diuretics
6 hrs67%R/33%M200 mg25-50 mg qd
or bid
Ethacrynic
acid
12-16 hrs20%R/80%M200 mg10-20 mg qdTorsemide
6-8 hrs62%R/38%M10 mg0.5-1.0 mg
qd or bid
Bumetanide
4-6 hrs65%R/35%M600 mg20-40mg qdor bid
Furosemide
Duration of
Action
Elimination:
Renal Met.
Max Total
Daily Dose
Initial Daily
Dose
Agent
SUGAR LAND
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Diuretics
Side Effects Pre-renal azotemia
Skin rashes
Neutropenia
Thrombocytopenia
Hyperglycemia
Uric Acid
Hepatic dysfunction
Loss of K and Mag
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
Diuretics
K sparing diuretics
Triamterene
Amilorideacts on distal tubules to K secretion
Spironolactone(Aldosterone inhibitor)
Recent evidence suggests that it may improve survival in CHFpatients due to the effect on renin-angiotensin-aldosterone system withsubsequent effect on myocardial remodeling and fibrosis
SUGAR LAND
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HEART CENTER
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Potassium-Sparing Diuretics
7-9 hrsMetabolic200 mg50-75 mg
bid
Triamterene
24 hrsRenal20 mg5 mg qdAmilioride
Renal,
Metabolic
100 mg25-50 mg
qd
Eplerenone
48-72 hrsMetabolic50 mg12.5-25 mg
qd
Spironolactone
Duration
of Action
EliminationMax Total
Daily Dose
Initial Daily
Dose
Agent
SUGAR LAND
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HEART CENTER
LV size and thickness in CHF
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HEART CENTER
Increases pressure withinairway.
Airways at risk for collapsefrom excess fluid are keptopen.
Gas exchange minimizesthe Increased work ofbreathing.
CPAP Mechanism
SUGAR LAND
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Congestive Heart Failure CHFSUGAR LAND
HEART CENTER
CPAP
Non-invasive
Easily discontinued Easily adjusted
Does not require
sedation
Comfortable
Intubation
InvasivePotential for infectionTraumatic
CPAP Mechanism
SUGAR LAND
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Congestive Heart Failure CHFSUG
HEART CENTER
Renin, angiotensin, aldasterone blockers
Renin-angiotensin-aldosterone systemis activation early
in the course of heart failure and plays an important
rolein the progression of the syndrome:
Angiotensin converting enzyme inhibitors
(ACE inhibitors)
Angiotensin receptors blockers (ARBS)
Spironolactone
SUGAR LAND
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Congestive Heart Failure CHFHEART CENTER
Renin Angiotensin Blockers
Common ACE inhibitors
CaptoprilLisinopril
Vasotec
Monopril
Accupril
SUGAR LAND
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Congestive Heart Failure CHFHEART CENTER
Renin-angiotensin blockers
They block the R-A-A system by inhibiting theconversion of angiotensin I to angiotensin II:
Vasodilation
Na retention
DecreasedBradykinin degradation its level PG secretion & nitric oxide
Ace Inhibitors improve survival in CHF patients Delay onset & progression of HF in pts with
asymptomatic LV dysfunction
cardiac remodeling
C CSUGAR LAND
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Renin-angiotensin blockers
Side Effects of ACE inhibitors
AngioedemaHypotension
Renal insuffiency
Rash
cough
C i H F il CHFSUGAR LAND
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Sleep related problems in CHF
Affects 40-50% of pts with systolic HF
Central sleep apnea Cheyne Stokes respiration
Does not correlate with ejection fractionOvernight oximetry- easy diagnostic test
Treatment with supplemental oxygen
May also need mild sleeping pills, acetazolamide
May need Full sleep study -BiPap
Nocturnal 02 lowers BNP and catecholamine levels
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Beta Blockers
Has been traditionally contraindicated in pts withCHF
Now they are the main stay in treatment on CHF &may be the only medication that shows substantialimprovement in LV function
In addition to improved LV function multiple
studies show improved survival
The only contraindication is severedecompensated CHF
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Beta Blocker therapy outcomes
*Adjusted for baseline age, sex, race, HF etiology, LVEF, systolic blood pressure, smoking, signs of
congestion, laboratory values, discharge medications, in-hospital invasive procedures, and history of
diabetes and cardiovascular, neurological, pulmonary, and renal diseases
End point LV systolic
dysfunction, n=3001
Preserved LV systolic
function, n=4153
Mortality 0.77 (0.680.87) 0.94 (0.841.07)
Readmission 0.89 (0.800.99) 0.98 (0.901.06)
Mortality or
readmission
0.87 (0.790.96) 0.98 (0.911.06)
Hernandez AF et al.J Am Coll Cardiol 2009; 53:184-192.
Adjusted* hazard ratios (95% CI) for one-year outcomes, beta
blocker therapy vs no beta blocker therapy, by LV functional status
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Congestive Heart Failure CHFHEART CENTER
Inotropic agents-Digoxin
The role of digitalis has declined somewhat because
of safety concern
Recent studies have shown that digitals does notaffect mortality in CHF patients but causes
significant
Reduction in hospitalization
Reduction in symptoms of HF
Rate control in At fib.
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Congestive Heart Failure CHFHEART CENTER
Inotropic agent-Digoxin action
+ve inotropic effect by intracellular Ca &
enhancing actin-myosin cross bride formation
(binds to the Na-K ATPase inhibits Na pump intracellular Na Na-Ca exchange
Vagotonic effect
Arrhythmogenic effect
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Congestive Heart Failure CHFHEART CENTER
Inotropic agent-Digitalis toxicity
Cardiac manifestations
Sinus bradycardia and arrest A/V block (usually 2nddegree)
Atrial tachycardia with A/V Block
Development of junctional rhythm in patients with a
fib
PVCs, VT/ V fib (bi-directional VT)
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Congestive Heart Failure CHFHEART CENTER
Inotropic agent-Digitalis toxicity
Narrow therapeutic to toxic ratio
Non cardiac manifestations
Anorexia,
Nausea, vomiting,
Headache,
Xanthopsia sotoma,
Disorientation
Treatment: Digibind (Fab antibody)
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Antiarrhythmics
Most common cause of SCD in these patients is
ventricular tachyarrhythmia
Patients with h/o sustained VT or SCD ICD implant
Patients with CHF with an ejection fraction of less than
30% may receive ICD implant
Amiodarone for patients with frequent VPCs and at fib
Dranedone for patients with recurrent paroxysmal at fib.
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VasodilatorsHydralazine and Nitrates
Reduction of afterloadby arteriolar vasodilatation
(hydralazin)reduce LVEDP, O2 consumption,improvemyocardial perfusion, stroke volume and COP
Reduction of preload Byvenous dilation
( Nitrate) the venous return the load on bothventricles.
Usually the maximum benefit is achieved by usingagents with both action.
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Anticoagulation
Atrial fibrillation
H/o embolic episodes
Left ventricular apical thrombus
Low LV ejection fraction
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Inotropic Agents
These are the drugs that improve myocardial
contractility ( adrenergic agonists, dopaminergic agents,
phosphodiesterase inhibitors),
Dopamine
Dobutamine
Milrinone,
Aamrinone
Several studies showed mortality with oral inotropic agents
So the only use for them now is in acute sittings such as cardiogenic
shock
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ICD placement
HFSA 2006 Practice Guideline (9.1, 9.4)
Device Therapy:Prophylactic ICD Placement
In patients on optimal medical therapy (ideally 3-6 months)
with or without concomitant coronary artery disease(including a prior MI > 1 month ago):
Prophylactic ICD placement should be considered inthose with NYHA II-III HF (LVEF 30%)
Prophylactic ICD placement may be considered in thosewith NYHA II-III HF (LVEF 31-35%)
Strength of Evidence = A
Concomitant placement should be considered in NYHA III-IV patients undergoing implantation of a biventricularpacing device. Strength of Evidence = B
Adapted from: Adams KF, Lindenfe ld J, et al. HFSA 2006 ComprehensiveHeart Failure Guideline. J Card Fail 2006;12:e1-e122.
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New Treatment Choices
Implantable ventricular assist devices
Biventricular pacing(only in patient with
LBBB & CHF)
Artificial Heart
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Achieving Cardiac ResynchronizationMechanical Goal: Atrial-synchronized bi-ventricular pacing
Standard pacing lead in RA
Standard pacing or defibrillation lead in RV
Specially designed left heart lead placed in a left ventricular cardiacvein via the coronary sinus
Right Atrial
Lead
Right Ventricular
Lead
Left Ventricular
Lead
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CHFLong term prognosis
1Framingham Heart Study (1948-1988) in Atlas of Heart Diseases.
2American Heart Association.Heart Disease and Stroke Statistics2005 Update.
100
90
80
70
60
5040
30
20
10
0
ProbabilityofSurvival(%) Men (N=237)
Time After CHF Diagnosis (Years)0 2 4 6 8 10
80% of men and 70% of
women who have CHF will
die within 8 years.2
Women (N=230)
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Cardiac transplant
It has become more widely used since the advances
in immunosuppressive treatment
Survival rate
1 year 80% - 90% 5 years 70%
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Prognosis
Annual mortality rate depends on patients
symptoms and LV function
5% in patients with mild symptoms and mild inLV function
30% to 50% in patient with advances LV
dysfunction and severe symptoms
40%50% of death is due to SCD
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Modes of death in CHF based on NYHA class
1 MERIT-HF Study Group.LANCET. 1999;353:2001-2007.
12%
24%64%
CHF
Other
SuddenDeath(N = 103)
NYHA II
26%
15%
59%
CHF
Other
SuddenDeath(N = 103)
NYHA III
56%
11%
33%
CHF
Other
SuddenDeath(N = 27)
NYHA IV
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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 inhospitalized 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.
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CHF Prognosis based on BUN
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CHF Prognosis based on Serum sodium
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Diastolic CHF
Impaired LV relaxation
Increase passive LV stiffness
Endocardial and pericardial disordersw
Microvascular flow
Myocardial turgor
Neurohormonal regulation
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Diagnosis of diastolic CHF
Increased ventricular filling pressure with
normal systolic function
Incresed ventricular pressure with preserved
systolic function and normal ventricular
volumes
Increased left atrial and pulmonary capillary
wedge pressure
Clinical symptoms and signs.
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Treatment of diastolic CHF
Diureticsprovide the most symptoms relief if
fluid retentionn is a future
ACE inhibitors and Blockers complement
diuretics well
Central sympatholytics hypertensive episodes
Nitratespreventing ischemia
Trimetazidineas a metabolic support
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Treatment of diastolic CHF
Benefits of Calcium Channel Blockers
Slowing of heart rate
Reduction of MVO2
Control of BP
Regression of LVH
Dilation of coronary microcirculationAmelioration of intracellular calcium overload
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice GuidelineNonpharmacologicFluid Intake
Recommendation 6.3
Restriction of daily fluid intake to < 2 liters:
Is recommended in patients with severehyponatremia (serum sodium < 130 mEq/L)
Should be considered for all patientsdemonstrating fluid retention that is difficult to
control despite high doses of diuretic andsodium restriction.Strength o f Evidence = C
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice GuidelineNonpharmacologicVitamins
Recommendation 6.5
Patients with HF, especially those on diuretic
therapy and restricted diets,should be considered for daily multivitamin-mineral supplementation to ensure adequateintake of the recommended daily value ofessential nutrients.
Evaluation for specific vitamin or nutrient deficiencies israrely necessary.
Strength of Evidence = C
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice GuidelineBeta BlockersSummary of Recommendations
Maintain therapy if possible
Reduce dosage if necessary
Avoid abrupt discontinuation
If discontinued or reduced, reinstate gradually before discharge
If an acute exacerbation ofchronic HF occurs
Prolong titration interval
Reduce target dose
Consider referral to a HF specialist
Considerations if up-titrationcontinues to be difficult
Adjust dose of diuretic and/or other concomitant vasoactive
medication
Continue titration to target dose once symptoms return to baseline
Considerations if symptoms
worsen or other side effects
appear
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
General
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice GuidelineICD Placement
Recommendation 9.5
ICD placement is not recommended in
chronic, severe refractory HF when thereis no reasonable expectation forimprovement.
Strength of Evidence = C
Pacing
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Adams KF, Lindenfeld J, et al. HFSA 2006 ComprehensiveHeart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice GuidelineBiventricular Pacing
Recommendation 9.7
Biventricular pacing therapy should be considered for patientswith all of the following:
Sinus rhythm
A widened QRS interval (120 ms) Severe LV systolic dysfunction (LVEF < 35% with LV dilation >
5.5 cm)
Persistent, moderate to severe HF (NYHA III) despite optimalmedical therapy.
Strength of Evidence = A
Pacing
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice GuidelineBiventricular Pacing
Recommendation 9.9
Biventricular pacing therapy
is not recommended in patients who are
asymptomatic or have mild HF
symptoms.
Strength of Evidence = C
Pacing
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006 12:e1-e122.
HFSA 2006 Practice GuidelineHF in African Americans
Recommendation 15.9
A combination of hydralazine and
isosorbide dinitrate is recommended aspart of standard therapy in addition to beta-blockers and ACE-inhibitors for AfricanAmericans with LV systolic dysfunctionand:
NYHA III-IV HF Strength of Evidence = A
NYHA II HF Strength of Evidence = B
Vasodilator
s
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CHF treatment-Nursing Initiates
1. Recommend smoking cessation counseling
2. Initiate LV function determination
3. Patient education
4. Instructional video, printed materials
5. Vaccination initiatives
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Aldosterone Antagonists in HFRALES (Advanced HF) EPHESUS (Post-MI)
Spironolactone
Placebo
Months
RR = 0.70P < 0.001
Epleronone
Placebo
RR = 0.85P < 0.008
Pitt B. N Engl J Med 1999;341:709-17.
Pitt B. N Engl J Med 2003;348:1309-21.
ProbabilityofSurvival
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
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
Months
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MADIT II: Prophylactic ICD in
Ischemic LVD (LVEF 30%)
365 (.69)170 (.78)329 (.90)490Conventional
9110 (.78)274 (.84)503 (.91)742Defibrillator
Number at Risk
0 1 2 3
.7
.8
.9
1.0
ProbabilityofSurvival
Conventional
Therapy
Defibrillator
Year
.6
0 4
Moss AJ et al. N Engl J Med 2002;346:877-83.
Pacing
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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
%Event-Free
Survival
MedicalTherapy
CRT
Days
0
HR = 0.64 (95% CI = .48-.85)
p = .0019
Cleland JG et al. N Engl J Med 2005;352:1539-49.
Pacing
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CRT Improves Quality of Life and
NYHA Functional Class
(%)
Abraham WT et al. Circulation 2003;108:2596-2603.
Average Change in Score
(MLWHF)
-20
-15
-10
-5
0
MIR
ACLE
MUS
TIC
SR
CONT
AK
CD
MIRACLE
ICD
* P < .05Control CRT
* **
*
NYHA: Proportion Improving
by 1 or More Class
0
20
40
60
80
MIRACLE CONTAK
CD
MIRACLE
ICD
**
*
Pacing
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Co ges e ea a u e CHEART CENTER
ICD Therapy in the SCD-HeFT Trial:
Mortality by Intention-to-Treat
.007.62-.96.77ICD vs Placebo
.53.86-1.301.06Amiodarone vs Placebo
P Value97.5% ClHR
Months of Follow-Up
Mortality
0 6 12 18 24 30 36 42 48 54 600
.1
.2
.3
.4
Amiodarone
ICD TherapyPlacebo
17%
22%
Bardy GH et al. N Engl J Med 2005;352:225-37.
Pacing
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A-HeFT All-Cause Mortality
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.
85
90
95
100
0 100 200 300 400 500 600
ISDN/HDZ
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ARBS in Patients Not Taking ACE Inhibitors:
Val-HeFT & CHARM-AlternativeVal-HeFT
Valsartan
Placebo
p = 0.017
Months
Survival%
CVDeathorHFHo
sp%
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 27
0
10
20
30
40
50
0 9 18 27 36 42
ARBS
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Effect of Beta Blockade on Outcome
in Patients With HF and Post-MI LVD
23% mortality (p =.031)25 BIDpost-MILVD
carvedilolCAPRICORN5
35% mortality (p = .0014)25 BIDseverecarvedilolCOPERNICUS4
34% mortality (p = .0062)200 QDmild/moderate
metoprolol
succinate
MERIT-HF3
34% mortality (p
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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%
Placebo
Captopril
Years
Mortality
Rate
19% relative risk reduction
p = 0.019
Pfeffer et al. NEJM 1992;327:669-77.
0
0.1
0.2
0.3
0 0.5 1 1.5 2 2.5 3 3.5 4
ARBS
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CHF prognosis based on rhythm
SOLVD Investigators:J Am Coll Cardiol. 1998;32:695-703.
From: Shivkumar, Weiss, Fonarow, and Narula; eds.Braunwalds Atlas of EP in HF.
Arrhythmias
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CHF Management-long term
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Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice GuidelineHypertensionPreserved EF
Recommendation 14.1
In patients with symptomatic or symptomatic LV hypertrophy
or LV dysfunct ion without LV dilation (Preserved EF):
It is recommended that blood pressure be
aggressively treated to lower systolic and
usually diastolic levels. Target resting
levels should be
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CHF treatment-7 Core measures
1. Do you have a left ventricular function measurement?
2. If LVEF
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Sleep related problems in CHFHFSA 2006 Practice Guideline (8.13)
End-of-Life Care in Heart Failure
End-of-life care should be considered in patients who haveadvanced, persistent HF with symptoms at rest despiterepeated attempts to optimize pharmacologic and
nonpharmacologic therapy, as evidenced byone or more of the following:
Frequent hospitalizations (3 or more per year)
Chronic poor quality of life with inability to accomplishactivities of daily living
Need for intermittent or continuous intravenous support Consideration of assist devices as destination therapy
Strength of Evid ence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive
Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
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By
Nik Nikam, M.D.Interventional Cardiologist
The End