CHFmanagement

DEFINITION nf HEART FAILURE DEFINITION nf HEART FAILURE
Hcart FaI!urc Is a pathnphysIn!ngIca! statc In whIch an

abnnrma!Ity nf cardIac functInn tn pump thc b!nnd at a
ratc cnmmcnsuratc wIth rcquIrcmcnts nf mctabn!IzIng
tIssuc.
GuideIines for the diagnosis and treatment of chronic heart faiIure
European Heart JournaI (2001) 22, 1528
EpidemioIogy
Europe
The prevalence of symptomatic HF range from 0.4-2%.
10 million HF pts in 900 million total population
USA
nearly 5 million HF pts.
500,000 pts are D/ HF for the 1
st
time each year.
Last 10 years number of hospitalizations has
increased.
Nearly 300,000 patients die of HF each year.
European Heart JournaI (2001) 22, 1527-1560
ACC/AHA GuideIines for the
EvaIuation and Management of Chronic Heart FaiIure in the AduIt 2001
Aims of treatment
1. Prevention
a) Prevention and/or controlling of diseases leading
to cardiac dysfunction and heart failure
b) Prevention of progression to heart failure once
cardiac dysfunction is established
. Morbidity
Maintenance or improvement in quality of life
3. Mortality
ncreased duration of life
Management outIine
stablish that the patient has HF.
Ascertain presenting features: pulmonary oedema, exertional
breathlessness, fatigue, peripheral oedema
Assess severity of symptoms
Determine aetiology of heart failure
dentify precipitating and exacerbating factors
dentify concomitant diseases
stimate prognosis
Anticipate complications
Counsel patient and relatives
Choose appropriate management
Monitor progress and manage accordingly
Ncw Ynrk Hcart AssncIatInn (NYHA) Ncw Ynrk Hcart AssncIatInn (NYHA)
C!assIfIcatInn nf Hcart FaI!urc C!assIfIcatInn nf Hcart FaI!urc
CIass - I
No Iinilalion : oidinaiy physicaI oxoiciso doos
nol causo unduo faliguo, dyspnooa oi paIpila-
lions.
CIass - II
SIighl Iinilalion of physicaI aclivily : confoi-
lalIo al iosl lul oidinaiy aclivily iosuIls in
faliguo, dyspnooa, oi paIpilalion.
CIass - III
Maikod Iinilalion of physicaI aclivily : confoi-
lalIo al iosl lul Ioss lhan oidinaiy aclivily
iosuIls in synplons.
CIass - IV
UnalIo lo caiiy oul any physicaI aclivily vilh-
oul disconfoil : synplons of hoail faiIuio aio
piosonl ovon al iosl vilh incioasod disconfoil
vilh any physicaI aclivily.
ACC/AHA - A New Approach To The CIassification of HF
Stage Descriptions ExampIes
A Patient who is at high risk for
developing HF but has no
structural disorder of the heart.
Hypertension; CAD; DM;
rheumatic fever; cardiomyopathy.
B Patient with a structural disorder
of the heart but who has never
developed symptoms of HF.
LV hypertrophy or fibrosis;
LV dilatation; asymptomatic VHD;
M.
C patient with past or current
symptoms of HF associated with
underlying structural heart
disease.
Dyspnea or fatigue ec LV systolic
dysfunction; asymptomatic
patients with HF.
D Patient with end-stage disease Frequently hospitalized pts ; pts
awaiting heart transplantation etc
A!gnrIthm fnr thc DIagnnsIs nf Hcart FaI!urc
5uspcctcd Hcart FaI!urc
Bccausc nf symptnms and sIgns
Asscss prcscncc nf cardIac dIscascs by ECG, X-ray nr
NatrIurctIc pcptIdc (whcrc avaI!ab!c)
Tcst Abnnrma!
ImagIng by EchncardIngraphy
(Nuc!car angIngraphy nr MRI
Whcrc avaI!ab!c)
Tcst Abnnrma!
Asscss ctIn!ngy, dcgrcc, prccIpItatIng
Factnrs and typc nf cardIac dysfunctInn
Chnnsc Thcrapy
Nnrma!
Hcart FaI!urc
Un!Ickc!y
Nnrma!
Hcart FaI!urc
Un!Ickc!y
AddItnna! dIagnnsIs tcsts
whcrc apprnprIatc
(c.g. cnrnnary angIngraphy)
Stage A Stage B Stage C Stage D
Pts with :
Hypertension
CAD
DM
Cardiotoxins
FHx CM
THERAPY
Treat Hypertension
Stop smoking
Treat lipid disorders
ncourage regular
exercise
Stop alcohol
& drug use
AC inhibition
Pts with :
Previous M
LV systolic
dysfunction
Asymptomatic
Valvular disease
THERAPY
All measures under
stage A
AC inhibitor
Beta-blockers
THERAPY
All measures under
stage A
Drugs for routine use:
diuretic
AC inhibitor
Beta-blockers
digitalis
THERAPY
All measures under
stage A,B and C
Mechanical assist
device
Heart transplantation
Continuous V
inotrphic infusions for
palliation
Pts who have
marked symptoms
at rest despite
maximal medical
therapy.
Pts with :
Struct. HD
Shortness of
breath and fatigue,
reduce exercise
tolerance
Struct.
Heart
Disease
DeveIop
Symp.of
HF
Refract.
Symp.of
HF at rest
Stages in the evoIution of HF and recommended therapy by stage
%reatment options
Non-pharmacoIogicaI management
eneral advice and measures
xercise and exercise training
PharmacoIogicaI therapy
Angiotensin-converting enzyme (AC) inhibitors
Diuretics
Beta-adrenoceptor antagonists
Aldosterone receptor antagonists
Angiotensin receptor antagonists
Cardiac glycosides
Vasodilator agents (nitrates/hydralazine)
Positive inotropic agents
Anticoagulation
Antiarrhythmic agents
Oxygen
Devices and surgery
Revascularization (catheter interventions and surgery), other forms of surgery
Pacemakers
mplantable cardioverter defibrillators (CD)
Heart transplantation, ventricular assist devices, artificial heart
Ultrafiltration, haemodialysis
PhurmucoIogicuI therupy PhurmucoIogicuI therupy
Angiotensin-converting enzyme inhibitors
Recommended as first-Iine therapy.
Should be uptitrated to the dosages shown to be
effective in the Iarge, controIIed triaIs, and not
titrated based on symptomatic improvement.
Moderate renal insufficiency and a relatively low blood
pressure (serum creatinine < 250 mol.l
-1
and systolic
BP > 90 mmHg) are not contraindications.
AbsoIute contraindications: bilateral renal artery
stenosis and angioedema.
iuretics
ssential for symptomatic treatment when
fIuid overIoad is present and manifest.
Always be administered in combination
with ACE inhibitors if possible.
Recommended in advanced HF (NYHA -V),
in addition to AC inhibition and diuretics to
improve survival and morbidity
Aldosterone receptor antagonists - spironolactone
%he RALES mortality trial
Low dose spironolactone (12.550 mg) on top
of an AC inhibitor and a loop diuretic
improved survival of patients in advanced
heart failure (NYHA class or V).
Aldosterone receptor antagonists - spironolactone
Recommended for the treatment of aII pts
with stabIe, mild, moderate and severe heart
failure on standard treatment, unless there is
a contraindication.
Patients with LV systolic dysfunction, with or
without symptomatic HF, following an AM
Iong-term betabIockade is recommended
in addition to AC inhibitor.
eta-adrenoceptor antagonists
CarvediIoI
(n=696)
PIacebo
(n=398)
SurvivaI
Days
0 50 100 150 200 250 300 350 400
1.0
0.9
0.8
0.7
0.6
0.5
Risk reduction = 65% Risk reduction = 65%
P<0.001
Packer et aI (1996)
Lancet (1999)
0 200 400 600 800
1.0
0.8
0.6
0
BisoproIoI
PIacebo
Time after incIusion (days)
P<0.0001
SurvivaI
The MRT-HF Study roup (1999)
Months of foIIow-up
MortaIity %
0 3 6 9 12 15 18 21
20
15
10
5
0
PIacebo
MetoproIoI CR/XL
P=0.0062
US CarvediIoI Study US CarvediIoI Study
..- -B BIockers in CHF Iockers in CHF - -
AII AII- -cause cause M MortaIity ortaIity
CIBIS CIBIS- -II II
MERIT MERIT- -HF HF
%

S
u
r
v
i
v
a
I
%

S
u
r
v
i
v
a
I
0 0
0 0
3 3 6 6 9 9 12 12 15 15 18 18 21 21
Months Months
100 100
90 90
80 80
60 60
70 70
P=0.00013 P=0.00013
CarvediIoI CarvediIoI
PIacebo PIacebo
COPRNCUS
AII AII- -cause mortaIity cause mortaIity
eta-adrenoceptor antagonists
CIIS II, MERI% HF, US CARVEILOL AN
COPERNICUS study
Reduction in total mortality, cardiovascular
mortality, sudden death and death due to
progression of heart failure in patients in func.
class -V.
reduces hospitalizations
improves the functional class and leads to
less worsening of heart failure.
ARBs could be considered in patients who do not
tolerate AC inhibitors for symptomatic
treatment.
t is unclear whether ARBs are as effective as
AC inhibitors for mortality reduction.
n combination with AC inhibition, ARBs may
improve heart failure symptoms and reduce
hospitalizations for worsening heart failure.
Angiotensin II receptor antagonists
VAL-H
Patients were randomized to placebo or
valsartan on top of standard therapy.
The results showed no difference in overall
mortality, but a reduction in the combined end-
point all-cause mortality or morbidity
expressed as hospitalization because of
worsening heart failure.
Angiotensin II receptor antagonists
indicated in atrial fibrillation and any degree of
symptomatic heart failure.
A combination of digoxin and beta-blockade
appears superior than either agent alone.
n sinus rhythm, digoxin is recommended to
improve the clinical status of patients with
persisting heart failure despite AC inhibitor and
diuretic treatment.
Cardiac glycosides
IG trial
Long-term digoxin did not improve survival.
The primary benefit and indication for digoxin
in heart failure is to reduce symptoms and
improve clinical status decrease the risk of
hospitalization for heart failure without an
impact on survival.
Cardiac glycosides
No specific role for vasodilators in the treatment of HF
Used as adjunctive therapy for angina or concomitant
hypertension.
n case of intolerance to AC inhibitors ARBs are
preferred to the combination hydralazinenitrates.
HYDRALAZINE-ISOSORBIDE DINITRATE
Hydralazine (up to 300 mg) in combination with SDN (up to 160
mg) without AC inhibition may have some beneficial effect on
mortality, but not on hospitalization for HF.
Nitrates may be used for the treatment of concomitant angina or
relief of acute dyspnoea.
Vasodilator agents in chronic heart failure
Commonly used to limit severe episodes of
HF or as a bridge to heart transplantation
in end-stage HF.
Repeated or prolonged treatment with oral
inotropic agents increases mortality.
Currently, insuffcient data are available to
recommend dopaminergic agents for heart
failure treatment.
Positive inotropic therapy
POSITIVE INOTROPHIC AGENTS
Dobutamin
Milrinone
Levosimendan
DOPAMINERGIC AGENTS
Ibopamine is not recommended for the treatment of
chronic HF due to systolic LV dysfunction.
ntravenous dopamine is used for the sort-term
correction of haemodynamic disturbances of severe
episodes of worsening HF.
Positive inotropic therapy
No indication for the use of antiarrhythmic agents in HF
ndications for antiarrhythmic drug therapy include AF
(rarely flutter), non-sustained or sustained VT.
CLASS I ANTIARRHYTHMICS
should be avoided
CLASS II ANTIARRHYTHMICS
Beta-blockers reduce sudden death in heart failure
CLASS III ANTIARRHYTHMICS
Amiodarone is the only antiarrhythmic drug without
clinically relevant negative inotropic effects.
Antiarrhythmics
Recommendation
1. All pts with HF and AF should be treated with
warfarin unless contraindicated.
2. Patients with LVF 35% or less.
Anticoagulation
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
Antiplatelet rugs
Recommendation
There is insufficient evidence concerning the
potential negative therapeutic interaction
between ASA and ACE inhibitors.
Antiplatelet agent for pts with HF who have
underlying CAD.
HFSA Guidelines for Management of Patients With Heart Failure Caused by Left
Ventricular Systolic Dysfunction - Pharmacological Approaches 2000
Chronic heart failure - choice of
pharmacological therapy
LV systoIic dysfunction ACE inhibitor Diuretic Beta-bIocker
AIdosterone
Antagonist
Asymptomatic LV
dysfunction
Indicated Not indicated Post MI Not indicated
Symptomatic HF (NYHA II) Indicated
Indicated if
FIuid retention
Indicated Not indicated
Worsening HF (NYHA III-IV) Indicated
Indicated
comb. diuretic
Indicated
Indicated
End-stage HF (NYHA IV) Indicated
Indicated
comb. diuretic
Indicated
Indicated
A
Chronic heart failure - choice of
pharmacological therapy
LV systoIic dysfunction
Angiotensin
II receptor
antagonists
Cardiac gIycosides
VasodiIator
(hydraIazine/
isosorbide
dinitrate)
Potassium -sparing
diuretic
Asymptomatic LV
dysfunction
Not indicated With AF Not indicated Not indicated
Symptomatic HF (NYHA II)
f AC inhibitors
are not tolerated
and not on beta-
blockade
(a) when AF
(b) when improved
from more severe
HF in sinus
rhythm
f AC inhibitors
and angiotensin
antagonists
are not
tolerated
f persisting
hypokalaemia
Worsening HF (NYHA III-IV)
f AC inhibitors
are not tolerated
and not on beta-
blockade
indicated
f AC inhibitors
and angiotensin
antagonists
are not
tolerated
f persisting
hypokalaemia
End-stage HF (NYHA IV)
f AC inhibitors
are not tolerated
and not on beta-
blockade
indicated
f AC inhibitors
and angiotensin
antagonists
are not
tolerated
f persisting
hypokalaemia
B
3terve3tio3 3terve3tio3
Pts with heart failure of ischaemic origin revascularization
symtomatic improvement.
A strong negative correlation of operative mortality and LVF,
a Iow LVEF (<25%) was associated with increased
operative mortaIity. Advance HF symptoms (NYHA V)
resulted in a greater mortality rate.
Off pump coronary revascularization may lower the surgical
risk for HF.
Heart TranspIantation is an accepted mode of treatment for
end-stage HF.
RevascuIarization
SurgicaI
Non SurgicaI
Care and FoIIow-up
Recommended components of programs
use a team approach
vigilant follow-up, first follow-up within 10 days of
discharge
discharge planning
increased access to health care
optimizing medical therapy with guidelines
intense education and counselling inpatient and
outpatient
strategies address barriers to compliance
early attention to signs and symptoms
flexible diuretic regimen
Resume
PharmacoIogicaI Treatment :
I. Asymptomatic SystoIic LV dysfunction :
AC nhibitor
.-Blocker (in CAD)
II. Symptomatic SystoIic LV dysfunction
A. No fIuid retention
AC nhibitor
.-Blocker
f ischaemia (+) nitrate / revascularization
B. FIuid retention
Diuretic
AC nhibitor (ARBs if not tolerated)
.-Blocker
Digitalis
Resume
III. Worsening HF
Standard treatment : AC nhibitor, .-Blocker
Diuretic : doses + loop diuretic
Low dose spironolactone
Digitalis
Consider :
Revascularization
Valve surgery
Heart transplant
IV. End-stage HF
ntermittent inotrophic support
Circulatory support (ABP, Ventr.Assist Devices)
Haemofiltration on dialysis
briddging to heart transplantation
ConcIusion
Management of HF must be starting from
the earIier stage (AHA/ACC stage A).
Treatment at each stage can reduce
morbidity and mortality.
Before initiating therapy :
stablished the correct diagnose.
Consider management outline.
ConcIusion
Non pharmacoIgicaI intervention are heIpfuII in :
improving quality of life
reducing readmission
lowering cost.
Organize muIti-discipIinary care :
HF clinic, HF nurse specialist, pts telemonitoring.
Health care system.
To optimize HF management
Treatment should be according to the uidelines,
intensive education, and behavioral change efforts.
Thank YoU

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DEFINITION nf HEART FAILURE DEFINITION nf HEART FAILURE

Hcart FaI!urc Is a pathnphysIn!ngIca! statc In whIch an

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