heart failure guidelines patrice m. schneider rn bsn heart failure coordinator south jersey heart...
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Heart Failure Guidelines
Patrice M. Schneider RN BSNHeart Failure CoordinatorSouth Jersey Heart Group
Lourdes Cardiology Services
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Background
NHLBI estimates that @ any given time:35% of pts with heart failure are NYHA I35% of pts with heart failure are NYHA II25% of pts with heart failure are NYHA III5% of pts with heart failure are NYHA IV
Therefore > 85% pf pts with heart failure are treated primarily in the ambulatory setting
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CONGESTIVE HEART FAILUREScope of the Problem in U.S.
Prevalence of CHF: > 3,000,000 in U.S.
Worldwide >15,000,000
Incidence of CHF: > 400,000/year in U.S.
Most common hospital discharge diagnosis in patients over 65 years old
Mortality of CHF: Approx 200,000/yr in
U.S.
Cost of CHF: > $ 7 Billion/yr for Hospital Care
All of above are likely to increase with population aging
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Etiology of Heart FailureWhat causes heart failure?The loss of a critical quantity of
functioning myocardial cells after injury to the heart due to:
Ischemic Heart Disease Hypertension Infections (e.g., viral myocarditis, Chagas’ disease) Toxins (e.g., alcohol or cytotoxic drugs) Valvular Disease Prolonged Arrhythmias Peripartum Idiopathic Cardiomyopathy
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Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional
Class
Severe HF
Symptomsat rest
Mild and Moderate HF
Symptoms upon mild to moderate exertion
Asymptomatic HF
No symptoms
IVII–IIII
Refractory HF requiring specialized interventions
Structural heart disease with HF symptoms, either prior or current
Structural heart disease but without symptoms of HF
High risk of developing HF
DCBA
ACC/AHAHF Stage
NYHAFunctionalClass
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Challenging Tradition
NYHA class changes over time Increasing evidence that heart failure is a
cellular disease Despite symptomatic improvement
neurohormonal, cytokine and cellular changes continue to occur and allow heart failure to progress
Ejection Fraction (EF) does not correlate with functional capacity (NYHA class)
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Classification of HF: Comparison Between ACC/AHA HF Stage and NYHA Functional
Class
Severe HF
Symptomsat rest
Mild and Moderate HF
Symptoms upon mild to moderate exertion
Asymptomatic HF
No symptoms
IVII–IIII
Refractory HF requiring specialized interventions
Structural heart disease with HF symptoms, either prior or current
Structural heart disease but without symptoms of HF
High risk of developing HF
DCBA
ACC/AHAHF Stage
NYHAFunctionalClass
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Stages of Heart Failure
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Evaluation of The Patient With Cardiomyopathy
Historical Data Etiology Duration of symptoms
ECG Findings Biochemical parameters
Levels of various neurohormones Measurement of effect of NH activation
Hemodynamic parameters Initial After tailored therapy
Exercise Capacity Trends Risk of sudden deterioration
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Etiology of Cardiomyopathy Abnormal loading conditions
Valvular disease Hypertention Shunts
Toxins Chemotherapeutics Cobalt/heavy metal Acohol
Genetic familial Muscular dystrophies Mitochondrial disorders Hypertrophic ARVD
Insults Ischemia Tachycardia High PVC burden Viral Thyroid disease
Unclear etiology Peripartum Idiopathic HIV
Infiltrative Hemachromatosis Sarcoidosis amyloid
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Historical Data & Prognosis
Duration of illnessShorter duration of illness associated with a
greater likelihood of spontaneous improvementPatients with recent onset (<6-7 months
require close clinical surveillance)But signs of hemodynamic instabilityOr end organ underperfusion
Stevenson AM J Med 1987Steimle JACC 1994
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New York Heart AssociationFunctional Classification
I. No limitations of physical activity, no symptoms with ordinary activities
II. Mild/slight limitation, symptoms with ordinary activities
III. Moderate/marked limitation, symptoms with less than ordinary activities
IV. Severe limitation, symptoms of heart failure at rest
Symptoms: Dyspnea or fatigue
Adapted from Criteria Committee of the New York Heart Association, 1994.
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Exercise Capacity
NYHA (Gradman Card Clinics 1994)Annual mortality
NYHA I 5%NYHA II 3-25 %NYHA III 10-45%NYHA IV 50-77%
Some overlap II/III likely related to differences in classification from center to center, subjective interpretation, II, predominantly better than III
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Cahalin Chest 1996
Exercise Capacity 6 minute walk test (6MWT)
Assess day-to-day efforts at submax exertionMeasures distance an individual able to
traverse over 6 minute period In moderate heart failure 6MWT has been
shown to be Inversely related to QOL score Inversely related to NYHAPredictive or mortality in moderate HF
In Severe HF (< 300 meters) Correlate to Peak VO2 Predictive of 6 month event-free survival
But not long term (>6 month) survival
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V-HeFT I and II data
Prognosis and CMP
TrendsSerial determination of LVEF may
enhance prognostic valueMortality @ 1 year
< - 5 29%
>1013 % *
< - 5
> 10
Survival based on change in EF
Months
24 48 72
.50
1.0
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Prognosis and CMP
TrendsDecrease in EFDecrease in exercise capacityIncrease in left ventricular diastolic
dimensionRisk of sudden Deterioration
Non-revascularizable coronary lesion with a high ischemic burden
Increase in number of arrhythmic events
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Treatment
Chronic Systolic Heart Failure
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Vasodilator TherapyAce-inhibitors & H/I
B-Blockers
ARBs AldosteroneInhibitors
CRT OHT DT
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Reduction in Mortality with ACE-I & B-Blocker therapy
65%½ yr
35%10 mos
SOLVDII/III
CONSENSUSIV
MERIT HFII/III
US CARVEDILOLII/III
COPERNICUSIIIB
16%3 yr
40 %1 yr 34 %
1 yr
ACE-I B-Blocker
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Which BB should we use? US CARVEDILOL Trial
Coreg Target 25 mg bid Caveats
> 70 kg: 50 mg bid Able to decrease vasodilator to allow uptitration to maximal dose
MERIT-HF Trial Metoprolol Succinate Target: 150 mg daily Caveat
Metoprolol Tartrate is inferior (however it was underdosed in the trial)
CIBIS II Trial Bisoprolol Target: approximately 7.5 mg daily Asthmatics
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Carvedilol Dose-Response Trial (MOCHA):Effect on Ejection Fraction and Morbidity
Carvedilol
Placebo 6.25 mg bid 12.5 mg bid 25 mg bid0
1
2
3
4
5
6
7
8
LV
EF (
EF u
nit
s)
Changes in LVEF
Carvedilol
Placebo 6.25 mg bid 12.5 mg bid 25 mg bid0
0.1
0.2
0.3
0.4
Mean
nu
mb
er/
su
bje
ct
Cardiovascular hospitalizations
P<.001 P=.01
Patients receiving diuretics, ACE inhibitors, ± digoxin; follow-up duration 6 months; placebo (n=84), carvedilol (n=261).Adapted from Bristow et al, 1996. P<.05 vs placebo
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Mortality in the placebo arm of Val-HeFT by treatment group: 23-month mean follow-up
0
10
20
30
40
ACEI-/BB- ACEI+/BB- ACEI-/BB+ ACEI+/BB+
HF Therapy
%
Mortality
Sudden death
Pump Failure
7.4
2.5
2.0
11.9
6.1
4.5
7.5
8.9
3.013.2
12.3
6.1
11.9
22.519.4
31.6
Slide courtesy of J. Cohn
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ARBs
ELITE II3152 NYHA III-IV
Losartan 50 mg QD vs Capoten 50 mg TIDNo difference in mortality, well toleratedPitt et al. Lancet 2000;355;1582-1587
Val-HeFT5010 NYHA II-IV
Valsartan 160 mg BID vs placeboNo difference in mortalitySignificant decrease in morbidity & mortalityCohn et al. NEJM 2001;345:1667-75
DeathHospitalizations for CHF*Cardiac arrestIntravenous therapyTriple therapy adverse effect on mortality
CHARM –added2548II-IV
Candesartan 24 mg QD vs Placebo all on ACE-ISignificant decrease in CVd and HF admitMcMurray The LANCET 2003:362;767
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Where Does Hydralazine/Isosorbide Fit in?ACE-I or ARB intolerant
ACE-I or ARB are supperiorBut if intolerant due to
CoughHyperkalemia, renal insufficiencyAngioedema
BIDIL (V-HeFT Trial)AA who still have NYHA II-IV HF despite
ACE/ARB and BBON TOP of baseline therapy, not instead of3 times a day
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Aldosterone Inhibitors RALES Trial
1663 NYHA III-IV 25 mg Aldactone vs
Placebo 30% reduction in
death* Progressive HF SCD
35% reduction in hospitalization
Significant improvement in NYHA functional class
Pitt et al. NEJM 1999;341:709
EPHESUS Trial 6632 pts 3-14 d after
AMI, EF < 40% And sign of HF Or DM with or
without signs of HF 50 mgQD Eplerenone
vs placebo Significant reduction
in: Death 14 % v 17% CVd/hosp 27% v 30% SCD 4.9% vs 6%
Pitt NEJM 2003;348:1309
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Ventricular Resynchronization
Ventricular dyssynchrony 30 - 50% CHF patients
with IVCD As QRS widens
Mortality increases Electrical delay
translates to mechanical delay/dyssynchrony
Improved A-V synchrony Interventricular
synchrony Intraventricular
synchrony Positive remodeling Reduction in heart
failure and all-cause morbidity and mortality
Sinus node
AVnode
Stimulation therapy
Conduction block
Abraham WT and Hayes DL, Circulation 2003; 108:2596-2603
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Chronic Heart Failure NYHA I
ACE-inhibitor- SOLVD Prevention Trial NYHA II/III
ACE-I – SOLVD, V-HeFT II Hydralazine/ISDN – V-HeFT B-Blocker – MERIT-HF, US Carvedilol, Angiotensin Receptor Blocker- Val-HeFT, CHARM
NYHA IV ACE-I- CONSENSUS B-Blocker- COPERNICUS
NYHA III/IV Aldosterone Blocker – RALES Resynchronization therapy (EF <35%, QRS > 130ms)
Post-AMI ACE-I SAVE Trial B-Blocker CAPRICORN Trial Eplerenone EPHESUS Trial
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Mechanism of Death in HF
MERIT-HF Study Group. Lancet 1999
NYHA IV NYHA II NYHA III
HF = mortality secondary to worsening heart failure SCD = sudden cardiac death
SCD64%
SCD59%
SCD33%
HF12%
HF26% HF
56%
Other11%Other
24%
Other15%
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Ultimate Goal
Delay progression of heart failure or death to the point where good quality and quantity of life is
achieved