heart failure pit 2013

8/13/2019 Heart Failure PIT 2013

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Workshop PIT 2013

Management of Heart Failure

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STAGE A At high risk for HF butwithout structural heart

disease or symptoms of HF

STAGE BStructural heart disease

but without signs orsymptoms of HF

THERAPY

Goals! 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 valvularsurgery as appropriate

STAGE CStructural heart disease

with prior or currentsymptoms 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

THERAPY

Goals! 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 asappropriate

e.g., Patients with:! Known structural heart disease and!

HF signs and symptoms

HF p EF HF r EF

THERAPY

Goals! Heart healthy lifestyle! Prevent vascular,

coronary disease!

Prevent LV structuralabnormalities

Drugs! ACEI or ARB in

appropriate patients forvascular 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

Refrac torysymptom s of HF at re st, de spite

GDMT

At Risk for Heart Failure Heart Failure

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

rest

! Recurrent hospitalizationsdespite GDMT

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

LVH and low EF! Asymptomatic valvulardisease

e.g., Patients with:! HTN! Atherosclerotic disease! DM! Obesity! Metabolic syndrome or

Patients! Using cardiotoxins! With family history of

cardiomyopathy

Develop ment o f sympto ms of HF

Structural heartdisease

Stages, Phenotypes and Treatment of HF


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Definition of Heart Failure


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• Clinical Evaluation

• History and Physical Examination

• Diagnostic Tests

Initial and Serial Evaluationof the HF Patient


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Diagnostic Tests

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Noninvasive Cardiac Imaging

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Recommendations for Invasive Evaluation

Recommendation COR LOE

Monitoring with a pulmonary artery catheter should be performed in patients with respiratory distress or impaired systemic perfusion whenclinical assessment is inadequate

I C

Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF with persistent symptoms and/or whenhemodynamics are uncertain

IIa C

When coronary ischemia may be contributing to HF, coronaryarteriography is reasonable

IIa C

Endomyocardial biopsy can be useful in patients with HF when aspecific diagnosis is suspected that would influence therapy IIa C

Routine use of invasive hemodynamic monitoring is not recommended innormotensive patients with acute HF

III: NoBenefit

B

Endomyocardial biopsy should not be performed in the routineevaluation of HF

III: Harm C

Invasive Evaluation


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Treatment of Stages to D

Guideline for HF


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Stages B


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Stages C


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Stages CNon Pharmacological Interventions

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Stages CPharmacological Interventions

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I IIa IIb III

I IIa IIb III

Seerecommendations

for stages A, B,and C LOE for

LOE


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Pharmacologic Treatment for Stage C HF r EF

HFrEF Stage CNYHA Class I – IV

Treatment:

For NYHA class II-IV patients.Provided estimated creatinine

>30 mL/min and K+


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Medical Therapy for Stage C HF r EF:

Magnitude of Benefit Demonstrated in RCTs

GDMT RR Reductionin Mortality

NNT for MortalityReduction

(Standardized to 36 mo)

RR Reduction in HF

Hospitalizations

ACE inhibitor orARB

17% 26 31%

Beta blocker 34% 9 41%Aldosteroneantagonist 30% 6 35%

Hydralazine/nitrate 43% 7 33%


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Recommendations COR LOE Systolic and diastolic blood pressure should be controlledaccording to published clinical practice guidelines I B

Diuretics should be used for relief of symptoms due tovolume overload I C

Coronary revascularization for patients with CAD inwhom angina or demonstrable myocardial ischemia is

present despite GDMT

IIaC

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

IIa C

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

ARBs might be considered to decrease hospitalizations inHFpEF IIb B

Nutritional supplementation is not recommended inHFpEF

III: NoBenefit C

Stages CDrugs Commonly Used for HF pEF


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European Society of Cardiology 2012


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The Two Lower Chambers Of The Heart Do Not Beat At The Same Time

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Indications for CRT Therapy Patient 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


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Stage D


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Clinical Events and Findings Useful forIdentifying Patients With Advanced HF

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Stage D Water Restriction

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I IIa IIb III

Stage DCardiac Transplantation

heart failure pit 2013

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