Outpatient Management of Heart Failure

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Outpatient Management of Heart Failure

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  • In the HOPE study (9297 patients, relative risk of the composite outcome of MI, stroke, or death from CV causes in the ramipril group as compared with the placebo group was 0.78 at five years. The risk of HF was decreased by 23%. Results independent of BP. In EUROPA the relative risk reduction of CV death, MI, or cardiac arrest was 20%.
  • In the HOPE study (9297 patients, relative risk of the composite outcome of MI, stroke, or death from CV causes in the ramipril group as compared with the placebo group was 0.78 at five years. The risk of HF was decreased by 23%. Results independent of BP. In EUROPA the relative risk reduction of CV death, MI, or cardiac arrest was 20%.
  • In the HOPE study (9297 patients, relative risk of the composite outcome of MI, stroke, or death from CV causes in the ramipril group as compared with the placebo group was 0.78 at five years. The risk of HF was decreased by 23%. Results independent of BP. In EUROPA the relative risk reduction of CV death, MI, or cardiac arrest was 20%.
  • 2231 Post- MI asymptomatic LV dysfunction (EF<40%). CV mortality 21% RR, HF development 37% RR, recurrent MI 25%RR
  • 1959 post-MI patients with EF< or= 40%, on ACE-I, ASA, revascularization. Carvedilol vs. Placebo.
  • In the HOPE study (9297 patients, relative risk of the composite outcome of MI, stroke, or death from CV causes in the ramipril group as compared with the placebo group was 0.78 at five years. The risk of HF was decreased by 23%. Results independent of BP. In EUROPA the relative risk reduction of CV death, MI, or cardiac arrest was 20%.
  • In the HOPE study (9297 patients, relative risk of the composite outcome of MI, stroke, or death from CV causes in the ramipril group as compared with the placebo group was 0.78 at five years. The risk of HF was decreased by 23%. Results independent of BP. In EUROPA the relative risk reduction of CV death, MI, or cardiac arrest was 20%.
  • 2569 patients with EF<35% and HF symptoms- enalapril vs. placebo
  • Val-Heft- 366 patients not on ACE-I without a reason Charm-Alternative- 2028 symptomatic HF patients with EF<40% not on ACE because of previous intolerance
  • 1050 AA patients with class 3 or 4 HF. Stopped early
  • MUSTT (Multicenter Unsustained Tachycardia Trial)- 700 patients LVEF≤40% and NSVT- EP guided induced VT- antiarrhythmic therapy (ICD vs drugs) vs placebo - antiarrhytmic vs ICD: RR-24% Unlike MADIT, there was no EP study before randomization.
  • Class 1A indication Class 2A indication with Atrial fibrillation Class 2B with EF≤35% class I or II, if other indication for pacing present.
  • In the HOPE study (9297 patients, relative risk of the composite outcome of MI, stroke, or death from CV causes in the ramipril group as compared with the placebo group was 0.78 at five years. The risk of HF was decreased by 23%. Results independent of BP. In EUROPA the relative risk reduction of CV death, MI, or cardiac arrest was 20%.
  • Outpatient Management of Heart Failure

    1. 1. Outpatient Management of Heart Failure Guilherme Oliveira, MD Staff, Section of Heart Failure and Transplant Medicine Cleveland Clinic, Cleveland, OH
    2. 2. Definition of Heart Failure <ul><li>A clinical syndrome of neurohormonal abnormalities, congestive changes and progressive ventricular remodeling caused by cardiac molecular insults that render the heart unable to meet peripheral metabolic demands at normal filling pressures. </li></ul>Chronic Heart Failure
    3. 3. Prevalence of Heart Failure <ul><li>Chronic Heart Failure </li></ul>6 million people in the US (NHLBI 2009)
    4. 4. Incidence of Heart Failure <ul><li>Chronic Heart Failure </li></ul>550,000 persons/year people in the US (NHLBI 2009)
    5. 5. Classification of Heart Failure <ul><li>Chronic Heart Failure </li></ul>Systolic Diastolic Dilated CMP Infectious Adrenergic Tachyarrhythmic Chemotherapy Nutritional Restrictive CMP Hypertensive HCM Pericardial Ischemic Amyloid Diabetic
    6. 6. Downhill Cascade in Heart Failure <ul><li>Chronic Heart Failure </li></ul>Myocardial Insult Myocardial Dysfunction Hemodynamic Defense Systems Inflammation Reduced System Perfusion Altered Gene Expression Apoptosis Remodeling
    7. 7. Prognosis of Heart Failure-EF <ul><li>Chronic Heart Failure </li></ul>EF=26% EF=24% SOLVD Trials 2-year Mortality
    8. 8. Prognosis of Heart Failure- ICMP vs. NICMP <ul><li>Chronic Heart Failure </li></ul>
    9. 9. Prognosis of Heart Failure By Etiology <ul><li>Chronic Heart Failure </li></ul>NEJM 2000
    10. 10. Clinical Diagnosis of Heart Failure <ul><li>Chronic Heart Failure </li></ul>Sensitivity Specificity
    11. 11. Evaluation of Patients with Heart Failure <ul><li>Assess clinical severity (stage and class)- History and PE </li></ul><ul><li>Evaluate structure and function- 2D echoDoppler </li></ul><ul><li>Determine etiology- ischemic evaluation, specific dz, bx </li></ul><ul><li>Evaluate risk of life-threatening arrhythmia </li></ul><ul><li>Identify exacerbating/noxious precipitating factors </li></ul><ul><li>Identify co-morbidities </li></ul><ul><li>Attempt to prognosticate and identify barriers to compliance. </li></ul>Adapted from 2006 HFSA Guidelines
    12. 12. NYHA Class <ul><li>Chronic Heart Failure </li></ul>No physical limitation to ordinary physical exertion Mild SOB with ordinary physical exertion Significant SOB with less than ordinary physical exertion. Dyspnea or angina at rest. Inabilitu to perform any physical exertion
    13. 13. Stages of Heart Failure <ul><li>Chronic Heart Failure </li></ul>
    14. 14. Heart Failure Therapy by Stages <ul><li>Chronic Heart Failure </li></ul>Jessup M, Brozena S. N Engl J Med 2003;348:2007-2018.
    15. 15. Stage A Heart Failure <ul><li>At risk patients without known structural disease: </li></ul><ul><ul><li>Modify Risk Factors: </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Diet </li></ul></ul><ul><ul><li>Control BP </li></ul></ul><ul><ul><li>Treat Dyslipidemia </li></ul></ul><ul><ul><li>Discontinue Tobacco use </li></ul></ul><ul><ul><li>Investigate and treat OSA </li></ul></ul><ul><ul><li>ACE-I/ARB </li></ul></ul>
    16. 16. Stage A Heart Failure <ul><li>Chronic Heart Failure </li></ul>ACE-Inhibitors
    17. 17. Stage B Heart Failure <ul><li>Structural disease and no Symptoms </li></ul><ul><ul><li>Stage A strategy </li></ul></ul><ul><ul><li>ACE/ARB for all patients </li></ul></ul><ul><ul><li>Beta-blockers for: </li></ul></ul><ul><ul><ul><li>Existing CAD </li></ul></ul></ul><ul><ul><ul><li>Tachyarrhythmias </li></ul></ul></ul>
    18. 18. Stage B Heart Failure <ul><li>Chronic Heart Failure </li></ul>SAVE ACE-Inhibitors
    19. 19. Stage B Heart Failure <ul><li>Chronic Heart Failure </li></ul>CAPRICORN Lancet 2001 Beta-Blockers
    20. 20. Stage B Heart Failure <ul><li>Practical Points: </li></ul><ul><ul><li>Check chemistry 2 weeks after ACE start </li></ul></ul><ul><ul><li>Start carvedilol or metoprolol at low doses </li></ul></ul><ul><ul><li>Increase medicines every 2-4 weeks to target </li></ul></ul><ul><ul><li>Ramipril target: 10 mg daily </li></ul></ul><ul><ul><li>Lisinopril target: 20 mg/daily </li></ul></ul><ul><ul><li>Enalapril target: 20 mg BID </li></ul></ul><ul><ul><li>Coreg target: 25 mg BID </li></ul></ul>
    21. 21. Stage C Heart Failure <ul><li>Structural disease with previous or current symptoms </li></ul><ul><ul><li>Investigate/treat precipitating causes (CAD, Afib) </li></ul></ul><ul><ul><li>Consider eligibility for advanced measures early </li></ul></ul><ul><ul><li>Maximize medical therapy- </li></ul></ul><ul><ul><ul><li>ACE/ARB </li></ul></ul></ul><ul><ul><ul><li>BB </li></ul></ul></ul><ul><ul><ul><li>Digoxin </li></ul></ul></ul><ul><ul><ul><li>Loop diuretics </li></ul></ul></ul><ul><ul><ul><li>Aldosterone inhibitors </li></ul></ul></ul><ul><ul><ul><li>Hydralazine + NTG for African Americans </li></ul></ul></ul><ul><ul><li>Consider ICD and Bi-ventricular pacing </li></ul></ul>
    22. 22. ACE-I for Stage C Heart Failure <ul><li>Chronic Heart Failure </li></ul>SOLVD treatment trial
    23. 23. BB for Stage C Heart Failure <ul><li>Chronic Heart Failure </li></ul>
    24. 24. ARBs for Stage C Heart Failure <ul><li>Chronic Heart Failure </li></ul>
    25. 25. Aldosterone Inhibitors for Stage C Heart Failure <ul><li>Chronic Heart Failure </li></ul>
    26. 26. Hydralazine and Nitrates for Stage C Heart Failure <ul><li>Chronic Heart Failure </li></ul>
    27. 27. Digitalis for Heart Failure <ul><li>No mortality benefit data </li></ul><ul><li>Improve QOL and prevents hospital admissions </li></ul><ul><li>Class 1A for symptomatic patients on OMT </li></ul><ul><li>Class 1B for CHF with atrial fibrillation </li></ul><ul><li>Chronic Heart Failure </li></ul>
    28. 28. Diuretics for Heart Failure <ul><li>No mortality benefit data </li></ul><ul><li>Class 1 recommendation to restore euvolemia </li></ul><ul><li>Loop diuretics preferable to other classes </li></ul><ul><li>Should be the first line of therapy in hypervolemic patients, before initiation of beta-blockers. </li></ul><ul><li>Chronic Heart Failure </li></ul>
    29. 29. Diuretics for Heart Failure <ul><li>Practical Tips: </li></ul><ul><ul><li>Increase doses to achieve euvolemia </li></ul></ul><ul><ul><li>Furosemide works best given BID or TID </li></ul></ul><ul><ul><li>Torsemide more potent and longer acting </li></ul></ul><ul><ul><li>Use thiazide to boost diuretics (HCTZ and metolazone) </li></ul></ul><ul><ul><li>Ensure good BP before increasing diuretics (may need to reduce doses of other drugs) </li></ul></ul><ul><li>Chronic Heart Failure </li></ul>
    30. 30. Diuretics for Heart Failure <ul><li>Practical Tips: </li></ul><ul><ul><li>Reach diuretic threshold (i.e. the poorer the renal function, the higher the required dose) </li></ul></ul><ul><ul><li>Torsemide for hypoalbuminemic patients </li></ul></ul><ul><ul><li>Accept some degree of azotemia to achieve adequate euvolemia </li></ul></ul><ul><ul><li>See patient frequently with blood work (weekly or every 2 weeks) </li></ul></ul><ul><li>Chronic Heart Failure </li></ul>
    31. 31. AICD for Primary Prevention in ICMP <ul><li>Chronic Heart Failure </li></ul>MADIT II- ICMP with EF ≤30%
    32. 32. AICD for Primary Prevention for NICMP <ul><li>Chronic Heart Failure </li></ul>DEFINITE NICMP and EF ≤35
    33. 33. CRT for Stage C Heart Failure <ul><li>Chronic Heart Failure </li></ul>CARE-HF (EF ≤35%, QRS >120ms, NYHA # or 4)
    34. 34. Stage D Heart Failure <ul><li>Structural disease with refractory symptoms: </li></ul><ul><ul><li>Stage B and C strategies </li></ul></ul><ul><ul><li>Try AV optimization </li></ul></ul><ul><ul><li>Reduce BB or ACE-I </li></ul></ul><ul><ul><li>Admit for hemodynamically tailored therapy and hemodynamic “re-setting” </li></ul></ul><ul><ul><li>Refer to Transplant/MCS center sooner rather than later </li></ul></ul><ul><ul><li>MCS </li></ul></ul><ul><ul><li>Transplant </li></ul></ul>
    35. 35. THANK YOU

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