adams kf, lindenfeld j, et al. hfsa 2006 comprehensive

2006 HFSA Comprehensive Heart Failure Practice Guideline

Key Recommendations

Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

HFSA 2006 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 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, epidemiological

findings; in-practice safety reporting


HFSA 2006 Practice Guideline (3.1)

Heart Failure Prevention

Strength of Evidence = A

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.

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.


HF Risk Factor Treatment Goals

Maximum 2-3 g/dayDietary Sodium

CessationSmoking

Men 2 drinks/day, women 1Alcohol

Weight reduction < 30 BMIObesity

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

See NCEP guidelines2Hyperlipidemia

See ADA guidelines1Diabetes

Generally < 130/80Hypertension

GoalRisk Factor


1. Diabetes Care 2006; 29: S4-S42.2. JAMA 2001; 285:2486-97.

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


HFSA 2006 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 factorStrength 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.

Placebo

Ramipril

Placebo

Perindopril

20% rel. risk red. p = .0003

22% rel. risk red. p < .001

HOPE

EUROPA

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

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

02468

10121416

0 1 2 3 4Years

% MI,Stroke,

CV Death

0

3

6

9

12

15

0 1 2 3 4 5Years

% MI,CV Death,

Cardiac Arrest

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

MortalityRate

19% relative risk reductionp = 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

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 2006 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



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

Patient understanding of and compliance with medical regimen

History of arrhythmia, syncope, pre-syncope or palpitation

Compliance 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


HFSA 2006 Practice Guideline (7.1, 7.4)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


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 ofstudy

No difference in incidence of sudden cardiac death

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

(Chronic Heart Failure)SOLVD Treatment

16% mortality


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 due to 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.



HFSA 2006 Practice Guideline (7.3, 7.4)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

↓23% mortality (p =.031)25 BIDpost-MI LVD

carvedilolCAPRICORN5

↓35% mortality (p = .0014)25 BIDseverecarvedilolCOPERNICUS4

↓34% mortality (p = .0062)200 QDmild/ moderate

metoprololsuccinate

MERIT-HF3

↓34% mortality (p <.0001)10 QDmoderate/ severe

bisoprololCIBIS-II2

↓48% disease progression (p= .007)

6.25-25 BID

mild/ moderate

carvedilolUS Carvedilol1Outcome

Target Dose (mg)

HF SeverityDrugStudy

1. Colucci WS et al. Circulation 1196;94:2800-6. 2. CIBIS II Investigators. Lancet 1999;353:9-13.3. MERIT-HF Study Group. Lancet 1999;353:2001-7.

4. Packer M et al. N Engl J Med 2001;3441651-8. 5. The CAPRICORN Investigators. Lancet 2001;357:1385-90.


Pharmacologic Therapy: Beta Blockers

RECENT DECOMPENSATION OR EXACERBATION

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

Continuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment. Strength of Evidence = C

If necessary, consider temporary dose reduction

Avoid abrupt discontinuation

Reinstate or gradually increase before discharge


0000

2020

1010

% o

f Pat

ient

s W

ith E

vent

% o

f Pat

ient

s W

ith E

vent

22 44 66 88

Carvedilol

Placebo

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

Weeks After RandomizationWeeks After Randomization

3030

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

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

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

CarvedilolPredischarge Initiation

(n=185)

Physician DiscretionPostdischarge Initiation*

(n=178)

18%18%ImprovementImprovement

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

91%

73%

0

25

50

75

100

Patie

nts

(%)

P < .0001



CONCOMITANT DISEASE

Beta blocker therapy is recommended in the great majority of patients with LV systolic dysfunction—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 diabetesMERIT-HF (ER metoprolol succinate)2

With diabetes

Without diabetes

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

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



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


In the absence of contraindications, these therapies are alsorecommended in the very elderly (age > 80 years). Strength of Evidence = C


HFSA 2006 Practice Guideline

Pharmacologic Therapy: Beta Blocker Overview*

Prolong titration interval

Reduce target dose

Consider referral to a HF specialist

If up-titration continues to be difficult

Adjust dose of diuretic or concomitant vasoactive med.

Continue titration to target after symptoms return to baseline

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 considerations

* Consult language of specific recommendations



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-AlternativeVal-HeFT

Valsartan

Placebo

p = 0.017

Months

Surv

ival

%

CV

Dea

th o

r HF

Hos

p % Placebo

Candesartan

CHARM-Alternative

HR 0.77, p = 0.0004

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

50

60

70

80

90

100

0 3 6 9 12 15 18 21 24 270

10

20

30

40

50

0 9 18 27 36 42


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)

due to LV systolic dysfunction (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 an ARB. Strength of Evidence = A


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.

Prob

abili

ty o

f Sur

viva

l

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 33 360.40

0.50

0.60

0.70

0.80

0.90

1.00

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

HFSA 2006 Practice Guideline (7.16-7.18)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 diureticsStrength 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



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 LV systolic dysfunction: NYHA III or IV HF Strength of Evidence = A

NYHA II HF Strength of Evidence = B


A-HeFT Outcomes

0.02-2.7-5.5Change in quality-of-life score at 6 months**

0.00124.416.41st HF hospitalization (%)

0.0210.26.2All-cause mortality (%)

0.01-0.5-0.1 Primary end point composite score

pPlacebo (n=532)

ISDN-HDZN (n=518)

End point

Taylor AL et al. N Engl J Med 2004; 351;2049-2057.

A-HeFT All-Cause MortalitySu

rviv

al %

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


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 pressuresStrength of Evidence = A

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




Loop Diuretics

6 hrs67%R-33%M200 mg25-50 mg qdor bid

Ethacrynicacid

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



Potassium-Sparing Diuretics

7-9 hrsMetabolic200 mg50-75 mg bid

Triamterene

24 hrsRenal20 mg5 mg qdAmiloride

UnknownRenal, 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



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 noncompliance, a direct effect of diuretic use on the kidney, or progression ofunderlying dysfunction.



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 in

those with NYHA II-III HF (LVEF 30%)

Prophylactic ICD placement may be considered in those with NYHA II-III HF (LVEF 31-35%)


Concomitant placement should be considered in NYHA III-IV patients undergoing implantation of a biventricular pacing device. Strength of Evidence = B


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

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

Number at Risk

0 1 2 3

.7

.8

.9

1.0Pr

obab

ility

of S

urvi

val

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

.007.62-.96.77ICD vs Placebo.53.86-1.301.06Amiodarone vs Placebo

P Value97.5% ClHR

Months of Follow-Up

Mor

talit

y

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.


Device Therapy:Biventricular Pacing

Biventricular pacing therapy should be consideredfor patients with 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 optimal medical therapy.



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

SRCO

NTAK

CD

MIR

ACLE

ICD

* P < .05Control CRT

* ** *

NYHA: Proportion Improving by 1 or More Class

0

20

40

60

80

MIRACLE CONTAKCD

MIRACLEICD

**

*

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 Therapy889213351376409CRT

Number at risk0 500 1,000 1,500

25

50

75

100

% E

vent

-Fre

e Su

rviv

al

Medical Therapy

CRT

Days0

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 recommendedin 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)



Figure 11.1. Diagnostic Categories of Heart Failure with Preserved LVEF

Figure courtesy of Marvin Konstam MD and Marvin Kronenberg MD.

Heart Failure with Preserved LVEF

Dilated LVDilated LV NonNon--dilated LVdilated LV

Valvular diseaseValvular diseaseAR; MRAR; MR

No valvular No valvular diseasedisease

High output HFHigh output HFIncreased thicknessIncreased thickness Normal thicknessNormal thickness Right Ventricular Dysfunction*Right Ventricular Dysfunction*

Mitral obstructionMitral obstructionMS; Atrial myxomaMS; Atrial myxoma

Normal or Increased Normal or Increased QRS voltage QRS voltage

Hypertrophic diseaseHypertrophic disease

No mitral No mitral obstructionobstruction

Pulmonary Pulmonary HypertensionHypertension

Hypertensive Hypertensive HxHx or PEor PE

HypertensiveHypertensive--hypertrophichypertrophiccardiomyopathycardiomyopathy

Isolated or Isolated or predominant RVMIpredominant RVMI

Low QRS voltageLow QRS voltageInfiltrative myopathyInfiltrative myopathy

No Aortic valve No Aortic valve diseasedisease

Inducible ischemiaInducible ischemiaIntermittent/activeIntermittent/active

ischemiaischemia

No inducible ischemiaNo inducible ischemiaFibrotic; collagenFibrotic; collagen--vascular;vascular;Restrictive CM; carcinoid; Restrictive CM; carcinoid;

Reconsider diagnosis of HFReconsider diagnosis of HF

No pericardial No pericardial diseasedisease

Pericardial diseasePericardial diseaseTamponade /ConstrictionTamponade /Constriction

Aortic valve diseaseAortic valve diseaseAortic stenosisAortic stenosis

No Hypertensive No Hypertensive HxHx or or PEPE

Hypertrophic Hypertrophic cardiomyopathycardiomyopathy

LVEF=left ventricular ejection fraction; HF=heart failure; QRS=electrocardiographic ventricular depolarization; AR= aortic regurgitation; MR=mitral regurgitation; MS=mitral stenosis; RVMI=right ventricular myocardial infarction; Hx=history; PE= physical examination.

* Some patients with right ventricular dysfunction have LV dysfunction due to ventricular interaction.


HFSA 2006 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

• Educate patients concerning medication and HF self-assessment

• Consider enrollment in a disease management program



HFSA 2006 Practice Guideline (12.5-12.18)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 2006 Practice Guideline (12.23, 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 achieved

Transition from IV to oral diuretic completed

Near optimum pharmacologic therapy achieved

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 to a disease management program Strength of Evidence =C


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.



The Potential Impact of Effective Education on Patient Compliance

81.8%60.0%Alcohol

90.4%60.0%Smoking

84.5%76.4%Activity

55.8%23.6%Diet

66.7%8.7%Medications

Don’t recall adviceRecall MD advice

Noncompliance rate when patients . . .

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.



HF Disease Management and the Risk of Readmission

ClineJ 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 and nonpharmacologic therapy, as evidenced by one or more of the following: Frequent hospitalizations (3 or more per year)

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

Need for intermittent or continuous intravenous support

Consideration of assist devices as destination therapyStrength 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

adams kf, lindenfeld j, et al. hfsa 2006 comprehensive

Documents