HEART FAILURE 2013

7,637 views

Published on

Published in: Health & Medicine
12 Comments
48 Likes
Statistics
Notes
No Downloads
Views
Total views
7,637
On SlideShare
0
From Embeds
0
Number of Embeds
74
Actions
Shares
0
Downloads
34
Comments
12
Likes
48
Embeds 0
No embeds

No notes for slide
  • 380624 slide 37
  • 380624 slide 37
  • 380624 slide 37
  • 380624 slide 37
  • 380624 slide 37
  • 380624 slide 37
  • 380624 slide 37
  • 380624 slide 37
  • 380624 slide 37
  • HEART FAILURE 2013

    1. 1. 2013 Focused UpdateACCF/AHA/ESC/HFA Guidelinesfor the Diagnosis and Managementof Heart Failure
    2. 2. Sir THOMAS LEWIS ,1933
    3. 3. Change before you have toJack WelchBetter a low dose than no dose
    4. 4. ESC Guidelines - update
    5. 5. ESC Guidelines - update- Patients with acute heart failure frequentlydevelop chronic heart failure.- Patients with chronic heart failure frequentlydecompensate acutely.
    6. 6. ESC Guidelines - update
    7. 7. ESC Guidelines - update
    8. 8. Stages of Heart FailureAt Risk for Heart Failure:STAGE A High risk for developing HFSTAGE B Asymptomatic LV dysfunctionHeart Failure:STAGE C Past or current symptoms of HFSTAGE D End-stage HF
    9. 9. Stages of Heart Failure• Designed to emphasize preventability of HF• Designed to recognize the progressivenature of LV dysfunction
    10. 10. ACCF-AHA 2013
    11. 11. ESC Guidelines - update
    12. 12. OutlineInitial and Serial Evaluation of the HF Patient(including HFpEF)Treatment of Stage A thru D Heart Failure(including HFpEF)The Hospitalized PatientSurgical/Percutaneous/TranscatheterInterventional TreatmentsCoordinating Care for Patients With Chronic HFQuality Metrics/Performance Measures
    13. 13. Diagnosis of heart failure 2012
    14. 14. AHA 2013
    15. 15. 2013
    16. 16. History and PhysicalExaminationInitial and Serial Evaluation of the HFPatient
    17. 17. A thorough history and physical examination should beobtained/performed in patients presenting with HF toidentify cardiac and noncardiac disorders or behaviorsthat might cause or accelerate the development orprogression of HF.In patients with idiopathic DCM, a 3-generational familyhistory should be obtained to aid in establishing thediagnosis of familial DCM.Volume status and vital signs should be assessed ateach patient encounter. This includes serial assessmentof weight, as well as estimates of jugular venouspressure and the presence of peripheral edema ororthopnea.History and Physical ExaminationI IIa IIb IIII IIa IIb IIII IIa IIb III
    18. 18. Risk ScoringInitial and Serial Evaluation of the HFPatient
    19. 19. Risk ScoringValidated multivariable risk scores can beuseful to estimate subsequent risk of mortalityin ambulatory or hospitalized patients with HF.I IIa IIb III
    20. 20. Risk Scores to Predict Outcomes in HFRisk Score Reference (from full-text guideline)/LinkChronic HFAll patients with chronic HFSeattle Heart Failure Model (204) / http://SeattleHeartFailureModel.orgHeart Failure Survival Score (200) / http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc-37354.shtmlCHARM Risk Score (207)CORONA Risk Score (208)Specific to chronic HFpEFI-PRESERVE Score (202)Acutely Decompensated HFADHERE Classification and RegressionTree (CART) Model(201)American Heart Association Get With theGuidelines Score(206) /http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidelinesHFStroke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-The-Guidelines-Heart-Failure-Home- %20Page_UCM_306087_SubHomePage.jspEFFECT Risk Score (203) / http://www.ccort.ca/Research/CHFRiskModel.aspxESCAPE Risk Model and Discharge Score (215)OPTIMIZE HF Risk-Prediction Nomogram (216)
    21. 21. Diagnostic TestsInitial laboratory evaluation of patients presenting with HFshould include complete blood count, urinalysis, serumelectrolytes (including calcium and magnesium), bloodurea nitrogen, serum creatinine, glucose, fasting lipidprofile, liver function tests, and thyroid-stimulatinghormone.Serial monitoring, when indicated, should include serumelectrolytes and renal function.I IIa IIb IIII IIa IIb III
    22. 22. Diagnostic Tests (cont.)A 12-lead ECG should be performed initially on allpatients presenting with HF.Screening for hemochromatosis or HIV is reasonable inselected patients who present with HF.Diagnostic tests for rheumatologic diseases, amyloidosis,or pheochromocytoma are reasonable in patientspresenting with HF in whom there is a clinical suspicion ofthese diseases.I IIa IIb IIII IIa IIb IIII IIa IIb III
    23. 23. BiomarkersAmbulatory/OutpatientInitial and Serial Evaluation of the HFPatient
    24. 24. Ambulatory/OutpatientIn ambulatory patients with dyspnea, measurement ofBNP or N-terminal pro-B-type natriuretic peptide (NT-proBNP) is useful to support clinical decision makingregarding the diagnosis of HF, especially in the setting ofclinical uncertainty.Measurement of BNP or NT-proBNP is useful forestablishing prognosis or disease severity in chronic HF.I IIa IIb IIII IIa IIb III
    25. 25. Ambulatory/Outpatient (cont.)BNP- or NT-proBNP guided HF therapy can be useful toachieve optimal dosing of GDMT in select clinicallyeuvolemic patients followed in a well-structured HFdisease management program.The usefulness of serial measurement of BNP or NT-proBNP to reduce hospitalization or mortality in patientswith HF is not well established.Measurement of other clinically available tests such asbiomarkers of myocardial injury or fibrosis may beconsidered for additive risk stratification in patients withchronic HF.I IIa IIb IIII IIa IIb IIII IIa IIb III
    26. 26. BiomarkersHospitalized/AcuteInitial and Serial Evaluation of the HFPatient
    27. 27. Hospitalized/AcuteMeasurement of BNP or NT-proBNP is useful to supportclinical judgment for the diagnosis of acutelydecompensated HF, especially in the setting ofuncertainty for the diagnosis.Measurement of BNP or NT-proBNP and/or cardiactroponin is useful for establishing prognosis or diseaseseverity in acutely decompensated HF.I IIa IIb IIII IIa IIb III
    28. 28. Hospitalized/Acute (cont.)The usefulness of BNP- or NT-proBNP guided therapyfor acutely decompensated HF is not well-established.Measurement of other clinically available tests such asbiomarkers of myocardial injury or fibrosis may beconsidered for additive risk stratification in patients withacutely decompensated HF.I IIa IIb IIII IIa IIb III
    29. 29. Recommendations for Biomarkers in HFBiomarker, Application Setting COR LOENatriuretic peptidesDiagnosis or exclusion of HFAmbulatory,AcuteI APrognosis of HFAmbulatory,AcuteI AAchieve GDMT Ambulatory IIa BGuidance of acutely decompensatedHF therapyAcute IIb CBiomarkers of myocardial injuryAdditive risk stratificationAcute,Ambulatory I ABiomarkers of myocardial fibrosisAdditive risk stratificationAmbulatoryIIb BAcuteIIb A
    30. 30. Causes for Elevated NatriureticPeptide LevelsCardiac NoncardiacHeart failure, including RVsyndromesAcute coronary syndromeHeart muscle disease, includingLVHValvular heart diseasePericardial diseaseAtrial fibrillationMyocarditisCardiac surgeryCardioversionAdvancing ageAnemiaRenal failurePulmonary causes: obstructivesleep apnea, severe pneumonia,pulmonary hypertensionCritical illnessBacterial sepsisSevere burnsToxic-metabolic insults, includingcancer chemotherapy andenvenomation
    31. 31. ESC Guidelines - update
    32. 32. Noninvasive Cardiac ImagingPatients with suspected or new-onset HF, or those presenting with acutedecompensated HF, should undergo a chest x-ray to assess heart size andpulmonary congestion, and to detect alternative cardiac, pulmonary, andother diseases that may cause or contribute to the patients’ symptoms.A 2-dimensional echocardiogram with Doppler should be performed duringinitial evaluation of patients presenting with HF to assess ventricularfunction, size, wall thickness, wall motion, and valve function.Repeat measurement of EF and measurement of the severity of structuralremodeling are useful to provide information in patients with HF who havehad a significant change in clinical status; who have experienced orrecovered from a clinical event; or who have received treatment, includingGDMT, that might have had a significant effect on cardiac function; or whomay be candidates for device therapy.I IIa IIb IIII IIa IIb IIII IIa IIb III
    33. 33. Noninvasive Cardiac Imaging(cont.)Noninvasive imaging to detect myocardial ischemia andviability is reasonable in patients presenting with de novoHF who have known CAD and no angina unless thepatient is not eligible for revascularization of any kind.Viability assessment is reasonable in select situationswhen planning revascularization in HF patients with CAD.Radionuclide ventriculography or magnetic resonanceimaging can be useful to assess LVEF and volume whenechocardiography is inadequate.I IIa IIb IIII IIa IIb IIII IIa IIb III
    34. 34. Noninvasive Cardiac Imaging(cont.)Magnetic resonance imaging is reasonable whenassessing myocardial infiltrative processes orscar burden.Routine repeat measurement of LV functionassessment in the absence of clinical statuschange or treatment interventions should not beperformed.I IIa IIb IIINo BenefitI IIa IIb III
    35. 35. Recommendations for Noninvasive ImagingRecommendation COR LOEPatients with suspected, acute, or new-onset HF should undergo a chest x-rayI CA 2-dimensional echocardiogram with Doppler should be performed forinitial evaluation of HFI CRepeat measurement of EF is useful in patients with HF who have had asignificant change in clinical status or received treatment that might affectcardiac function, or for consideration of device therapyI CNoninvasive imaging to detect myocardial ischemia and viability isreasonable in HF and CADIIa CViability assessment is reasonable before revascularization in HF patientswith CADIIa BRadionuclide ventriculography or MRI can be useful to assess LVEF andvolumeIIa CMRI is reasonable when assessing myocardial infiltration or scarIIa BRoutine repeat measurement of LV function assessment should not beperformedIII: NoBenefitB
    36. 36. Invasive EvaluationInvasive hemodynamic monitoring with a pulmonary arterycatheter should be performed to guide therapy in patients whohave respiratory distress or clinical evidence of impaired perfusionin whom the adequacy or excess of intracardiac filling pressurescannot be determined from clinical assessment.Invasive hemodynamic monitoring can be useful for carefullyselected patients with acute HF who have persistent symptomsdespite empiric adjustment of standard therapies anda. whose fluid status, perfusion, or systemic or pulmonaryvascular resistance is uncertain;b. whose systolic pressure remains low, or is associated withsymptoms, despite initial therapy;c. whose renal function is worsening with therapy;d. who require parenteral vasoactive agents; ore. who may need consideration for MCS or transplantation.I IIa IIb IIII IIa IIb III
    37. 37. Invasive Evaluation (cont.)When ischemia may be contributing to HF, coronaryarteriography is reasonable for patients eligible forrevascularization.Endomyocardial biopsy can be useful in patientspresenting with HF when a specific diagnosis is suspectedthat would influence therapy.I IIa IIb IIII IIa IIb III
    38. 38. Invasive Evaluation (cont.)Routine use of invasive hemodynamic monitoring is notrecommended in normotensive patients with acutedecompensated HF and congestion with symptomaticresponse to diuretics and vasodilators.Endomyocardial biopsy should not be performed in theroutine evaluation of patients with HF.I IIa IIb IIINo BenefitI IIa IIb IIIHarm
    39. 39. Recommendations for Invasive EvaluationRecommendation COR LOEMonitoring with a pulmonary artery catheter should be performed in patientswith respiratory distress or impaired systemic perfusion when clinicalassessment is inadequateI CInvasive hemodynamic monitoring can be useful for carefully selectedpatients with acute HF with persistent symptoms and/or when hemodynamicsare uncertainIIa CWhen coronary ischemia may be contributing to HF, coronary arteriographyis reasonableIIa CEndomyocardial biopsy can be useful in patients with HF when a specificdiagnosis is suspected that would influence therapyIIa CRoutine use of invasive hemodynamic monitoring is not recommended innormotensive patients with acute HFIII: NoBenefitBEndomyocardial biopsy should not be performed in the routine evaluation ofHFIII: Harm C
    40. 40. ESC Guidelines - update
    41. 41. heart failure 2012
    42. 42. ESC Guidelines - update
    43. 43. A total score of ≥ 6 has a highpredictive accuracy for thediagnosis of acute HFInterpretation1Absence of cough1Rales on lung examination1Age > 75 years1Current loop diuretic use2Absence of fever2Orthopnea2Interstitial edema on chest X-ray4Elevated NT-proBNPPointsPredictorhttp://www.biomerieux-diagnostics.com/servlet/srt/bio/clinical-diagnostics/dynPage?node=Heart_Failure
    44. 44. Initial and Serial Evaluation of the HF Patient(including HFpEF)Treatment of Stage A thru D Heart Failure(including HFpEF)The Hospitalized PatientSurgical/Percutaneous/TranscatheterInterventional TreatmentsCoordinating Care for Patients With ChronicHFQuality Metrics/Performance Measures
    45. 45. ESC Guidelines - update
    46. 46. Stage AHypertension and lipid disorders should be controlled inaccordance with contemporary guidelines to lower the riskof HF.Other conditions that may lead to or contribute to HF, suchas obesity, diabetes mellitus, tobacco use, and knowncardiotoxic agents, should be controlled or avoided.I IIa IIb IIII IIa IIb III
    47. 47. Stage BIn all patients with a recent or remote history of MI or ACSand reduced EF, ACE inhibitors should be used to preventsymptomatic HF and reduce mortality. In patientsintolerant of ACE inhibitors, ARBs are appropriate unlesscontraindicated.In all patients with a recent or remote history of MI or ACSand reduced EF, evidence-based beta blockers should beused to reduce mortality.In all patients with a recent or remote history of MI or ACS,statins should be used to prevent symptomatic HF andcardiovascular events.I IIa IIb IIII IIa IIb IIII IIa IIb III
    48. 48. Stage B (cont.)In patients with structural cardiac abnormalities, includingLV hypertrophy, in the absence of a history of MI or ACS,blood pressure should be controlled in accordance withclinical practice guidelines for hypertension to preventsymptomatic HF.ACE inhibitors should be used in all patients with areduced EF to prevent symptomatic HF, even if they donot have a history of MI.Beta blockers should be used in all patients with areduced EF to prevent symptomatic HF, even if they donot have a history of MI.I IIa IIb IIII IIa IIb IIII IIa IIb III
    49. 49. Stage B (cont.)To prevent sudden death, placement of an ICD isreasonable in patients with asymptomatic ischemiccardiomyopathy who are at least 40 days post-MI, have anLVEF of 30% or less, are on appropriate medical therapyand have reasonable expectation of survival with a goodfunctional status for more than 1 year.Nondihydropyridine calcium channel blockers withnegative inotropic effects may be harmful in asymptomaticpatients with low LVEF and no symptoms of HF after MI.I IIa IIb IIII IIa IIb IIIHarm
    50. 50. Recommendations for Treatment of Stage B HFRecommendations COR LOEIn patients with a history of MI and reduced EF, ACE inhibitors orARBs should be used to prevent HFI AIn patients with MI and reduced EF, evidence-based beta blockersshould be used to prevent HFI BIn patients with MI, statins should be used to prevent HF I ABlood pressure should be controlled to prevent symptomatic HF I AACE inhibitors should be used in all patients with a reduced EF toprevent HFI ABeta blockers should be used in all patients with a reduced EF toprevent HFI CAn ICD is reasonable in patients with asymptomatic ischemiccardiomyopathy who are at least 40 d post-MI, have an LVEF ≤30%,and on GDMTIIa BNondihydropyridine calcium channel blockers may be harmful inpatients with low LVEFIII: Harm C
    51. 51. Stage C: NonpharmacologicalInterventionsPatients with HF should receive specific education tofacilitate HF self-care.Exercise training (or regular physical activity) isrecommended as safe and effective for patients with HFwho are able to participate to improve functional status.Sodium restriction is reasonable for patients withsymptomatic HF to reduce congestive symptoms.I IIa IIb IIII IIa IIb IIII IIa IIb III
    52. 52. Stage C: NonpharmacologicalInterventions (cont.)Continuous positive airway pressure (CPAP) can bebeneficial to increase LVEF and improve functionalstatus in patients with HF and sleep apnea.Cardiac rehabilitation can be useful in clinically stablepatients with HF to improve functional capacity, exerciseduration, HRQOL, and mortality.I IIa IIb IIII IIa IIb III
    53. 53. Pharmacological Treatment forStage C HFrEFMeasures listed as Class I recommendations forpatients in stages A and B are recommended whereappropriate for patients in stage C. (Levels of Evidence:A, B, and C as appropriate)GDMT as depicted in Figure 1 should be the mainstay ofpharmacological therapy for HFrEF.I IIa IIb IIII IIa IIb IIISeerecommendationsfor stages A, B,and C LOE forLOE
    54. 54. Pharmacologic Treatment for Stage C HFrEFHFrEF Stage CNYHA Class I – IVTreatment:For NYHA class II-IV patients.Provided estimated creatinine>30 mL/min and K+ <5.0 mEq/dLFor persistently symptomaticAfrican Americans,NYHA class III-IVClass I, LOE AACEI or ARB ANDBeta BlockerClass I, LOE CLoop DiureticsClass I, LOE AHydral-NitratesClass I, LOE AAldosteroneAntagonistAddAdd AddFor all volume overload,NYHA class II-IV patients
    55. 55. Pharmacological Treatment forStage C HFrEF (cont.)Diuretics are recommended in patients with HFrEF whohave evidence of fluid retention, unless contraindicated, toimprove symptoms.ACE inhibitors are recommended in patients with HFrEFand current or prior symptoms, unless contraindicated, toreduce morbidity and mortality.ARBs are recommended in patients with HFrEF withcurrent or prior symptoms who are ACE inhibitor-intolerant, unless contraindicated, to reduce morbidity andmortality.I IIa IIb IIII IIa IIb IIII IIa IIb III
    56. 56. BRAUNWALDS HEART DISEASErenal juxtaglomerularRenin-Angiotensin MechanismACEIARBBeta-blocker
    57. 57. Drugs Commonly Used for HFrEF(Stage C HF)Drug Initial Daily Dose(s) Maximum Doses(s)Mean Doses Achieved inClinical TrialsACE InhibitorsCaptopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d (421)Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/d (412)Fosinopril 5 to 10 mg once 40 mg once ---------Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg/d (444)Perindopril 2 mg once 8 to 16 mg once ---------Quinapril 5 mg twice 20 mg twice ---------Ramipril 1.25 to 2.5 mg once 10 mg once ---------Trandolapril 1 mg once 4 mg once ---------ARBsCandesartan 4 to 8 mg once 32 mg once 24 mg/d (419)Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d (420)Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d (109)Aldosterone AntagonistsSpironolactone 12.5 to 25 mg once 25 mg once or twice 26 mg/d (424)Eplerenone 25 mg once 50 mg once 42.6 mg/d (445)
    58. 58. Drugs Commonly Used for HFrEF(Stage C HF) (cont.)Drug Initial Daily Dose(s) Maximum Doses(s)Mean Doses Achieved inClinical TrialsBeta BlockersBisoprolol 1.25 mg once 10 mg once 8.6 mg/d (118)Carvedilol 3.125 mg twice 50 mg twice 37 mg/d (446)Carvedilol CR 10 mg once 80 mg once ---------Metoprolol succinateextended release(metoprolol CR/XL)12.5 to 25 mg once 200 mg once 159 mg/d (447)Hydralazine & Isosorbide DinitrateFixed dose combination(423)37.5 mg hydralazine/20 mg isosorbidedinitrate 3 times daily75 mg hydralazine/40 mg isosorbidedinitrate 3 times daily~175 mg hydralazine/90 mgisosorbide dinitrate dailyHydralazine andisosorbide dinitrate (448)Hydralazine: 25 to 50mg, 3 or 4 times dailyand isorsorbidedinitrate:20 to 30 mg3 or 4 times dailyHydralazine: 300 mgdaily in divided dosesand isosorbide dinitrate120 mg daily individed doses---------
    59. 59. Pharmacological Treatment forStage C HFrEF (cont.)ARBs are reasonable to reduce morbidity and mortality asalternatives to ACE inhibitors as first-line therapy forpatients with HFrEF, especially for patients already takingARBs for other indications, unless contraindicated.Addition of an ARB may be considered in persistentlysymptomatic patients with HFrEF who are already beingtreated with an ACE inhibitor and a beta blocker in whoman aldosterone antagonist is not indicated or tolerated.I IIa IIb IIII IIa IIb III
    60. 60. Pharmacological Treatment forStage C HFrEF (cont.)Routine combined use of an ACE inhibitor, ARB, andaldosterone antagonist is potentially harmful for patientswith HFrEF.Use of 1 of the 3 beta blockers proven to reduce mortality(i.e., bisoprolol, carvedilol, and sustained-releasemetoprolol succinate) is recommended for all patients withcurrent or prior symptoms of HFrEF, unlesscontraindicated, to reduce morbidity and mortality.I IIa IIb IIII IIa IIb IIIHarm
    61. 61. Pharmacological Treatment forStage C HFrEF (cont.)Aldosterone receptor antagonists [or mineralocorticoidreceptor antagonists (MRA)] are recommended in patientswith NYHA class II-IV and who have LVEF of 35% or less,unless contraindicated, to reduce morbidity and mortality.Patients with NYHA class II should have a history of priorcardiovascular hospitalization or elevated plasma natriureticpeptide levels to be considered for aldosterone receptorantagonists. Creatinine should be 2.5 mg/dL or less in men or2.0 mg/dL or less in women (or estimated glomerular filtrationrate >30 mL/min/1.73m2) and potassium should be less than5.0 mEq/L. Careful monitoring of potassium, renal function,and diuretic dosing should be performed at initiation andclosely followed thereafter to minimize risk of hyperkalemiaand renal insufficiency.I IIa IIb III
    62. 62. Pharmacological Treatment forStage C HFrEF (cont.)Aldosterone receptor antagonists are recommended toreduce morbidity and mortality following an acute MI inpatients who have LVEF of 40% or less who developsymptoms of HF or who have a history of diabetesmellitus, unless contraindicated.Inappropriate use of aldosterone receptor antagonists ispotentially harmful because of life-threateninghyperkalemia or renal insufficiency when serum creatininegreater than 2.5 mg/dL in men or greater than 2.0 mg/dL inwomen (or estimated glomerular filtration rate <30mL/min/1.73m2), and/or potassium above 5.0 mEq/L.I IIa IIb IIII IIa IIb IIIHarm
    63. 63. Pharmacological Treatment forStage C HFrEF (cont.)The combination of hydralazine and isosorbide dinitrate isrecommended to reduce morbidity and mortality forpatients self-described as African Americans with NYHAclass III–IV HFrEF receiving optimal therapy with ACEinhibitors and beta blockers, unless contraindicated.A combination of hydralazine and isosorbide dinitrate canbe useful to reduce morbidity or mortality in patients withcurrent or prior symptomatic HFrEF who cannot be givenan ACE inhibitor or ARB because of drug intolerance,hypotension, or renal insufficiency, unless contraindicated.I IIa IIb IIII IIa IIb III
    64. 64. Pharmacological Treatment forStage C HFrEF (cont.)Digoxin can be beneficial in patients with HFrEF, unlesscontraindicated, to decrease hospitalizations for HF.Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk factor forcardioembolic stroke (history of hypertension, diabetesmellitus, previous stroke or transient ischemic attack, or≥75 years of age) should receive chronic anticoagulanttherapy (in the absence of contraindications toanticoagulation).I IIa IIb IIII IIa IIb III
    65. 65. Pharmacological Treatment forStage C HFrEF (cont.)The selection of an anticoagulant agent (warfarin,dabigatran, apixaban, or rivaroxaban) forpermanent/persistent/paroxysmal AF should beindividualized on the basis of risk factors, cost, tolerability,patient preference, potential for drug interactions, andother clinical characteristics, including time in theinternational normalized rate therapeutic ration if thepatient has been taking warfarin.Chronic anticoagulation is reasonable for patients withchronic HF who have permanent/persistent/paroxysmalAF but are without an additional risk factor forcardioembolic stroke (in the absence of contraindicationsto anticoagulation).I IIa IIb IIII IIa IIb III
    66. 66. Pharmacological Treatment forStage C HFrEF (cont.)Anticoagulation is not recommended in patients withchronic HFrEF without AF, a prior thromboembolic event,or a cardioembolic source.Statins are not beneficial as adjunctive therapy whenprescribed solely for the diagnosis of HF in the absence ofother indications for their use.Omega-3 polyunsaturated fatty acid (PUFA)supplementation is reasonable to use as adjunctivetherapy in patients with NYHA class II-IV symptoms andHFrEF or HFpEF, unless contraindicated, to reducemortality and cardiovascular hospitalizations.I IIa IIb IIINo BenefitI IIa IIb IIINo BenefitI IIa IIb III
    67. 67. Pharmacological Treatment forStage C HFrEF (cont.)Nutritional supplements as treatment for HF are notrecommended in patients with current or prior symptomsof HFrEF.Hormonal therapies other than to correct deficiencies arenot recommended for patients with current or priorsymptoms of HFrEF.Drugs known to adversely affect the clinical status ofpatients with current or prior symptoms of HFrEF arepotentially harmful and should be avoided or withdrawnwhenever possible (e.g., most antiarrhythmic drugs, mostcalcium channel blocking drugs (except amlodipine),NSAIDs, or TZDs).No BenefitI IIa IIb IIII IIa IIb IIII IIa IIb IIINo BenefitHarm
    68. 68. Pharmacological Treatment forStage C HFrEF (cont.)Long-term use of infused positive inotropic drugs ispotentially harmful for patients with HFrEF, except aspalliation for patients with end-stage disease who cannotbe stabilized with standard medical treatment (seerecommendations for stage D).Calcium channel blocking drugs are not recommended asroutine treatment for patients with HFrEF.HarmI IIa IIb IIII IIa IIb IIINo Benefit
    69. 69. Pharmacological Treatment forStage C HFpEFSystolic and diastolic blood pressure should be controlledin patients with HFpEF in accordance with publishedclinical practice guidelines to prevent morbidity.Diuretics should be used for relief of symptoms due tovolume overload in patients with HFpEF.Coronary revascularization is reasonable in patients withCAD in whom symptoms (angina) or demonstrablemyocardial ischemia is judged to be having an adverseeffect on symptomatic HFpEF despite GDMT.I IIa IIb IIII IIa IIb IIII IIa IIb III
    70. 70. Pharmacological Treatment forStage C HFpEF (cont.)Management of AF according to published clinical practiceguidelines in patients with HFpEF is reasonable toimprove symptomatic HF.The use of beta-blocking agents, ACE inhibitors, andARBs in patients with hypertension is reasonable tocontrol blood pressure in patients with HFpEF.I IIa IIb IIII IIa IIb III
    71. 71. Pharmacological Treatment forStage C HFpEF (cont.)The use of ARBs might be considered to decreasehospitalizations for patients with HFpEF.Routine use of nutritional supplements is notrecommended for patients with HFpEF.I IIa IIb IIINo BenefitI IIa IIb III
    72. 72. Pharmacological Therapy forManagement of Stage C HFrEFRecommendations COR LOEDiureticsDiuretics are recommended in patients with HFrEF with fluidretentionI CACE InhibitorsACE inhibitors are recommended for all patients with HFrEFI AARBsARBs are recommended in patients with HFrEF who are ACEinhibitor intolerantI AARBs are reasonable as alternatives to ACE inhibitor as firstline therapy in HFrEFIIa AThe addition of an ARB may be considered in persistentlysymptomatic patients with HFrEF on GDMTIIb ARoutine combined use of an ACE inhibitor, ARB, andaldosterone antagonist is potentially harmfulIII: Harm C
    73. 73. Pharmacological Therapy forManagement of Stage C HFrEF (cont.)Recommendations COR LOEBeta BlockersUse of 1 of the 3 beta blockers proven to reduce mortality isrecommended for all stable patientsI AAldosterone AntagonistsAldosterone receptor antagonists are recommended inpatients with NYHA class II-IV HF who have LVEF ≤35%I AAldosterone receptor antagonists are recommended inpatients following an acute MI who have LVEF ≤40% withsymptoms of HF or DMI BInappropriate use of aldosterone receptor antagonists may beharmfulIII:HarmBHydralazine and Isosorbide DinitrateThe combination of hydralazine and isosorbide dinitrate isrecommended for African-Americans, with NYHA class III–IV HFrEF on GDMTI AA combination of hydralazine and isosorbide dinitrate can beuseful in patients with HFrEF who cannot be given ACEinhibitors or ARBsIIa B
    74. 74. Pharmacologic Therapy forManagement of Stage C HFrEF (cont.)Recommendations COR LOEDigoxinDigoxin can be beneficial in patients with HFrEF IIa BAnticoagulationPatients with chronic HF with permanent/persistent/paroxysmal AF and anadditional risk factor for cardioembolic stroke should receive chronicanticoagulant therapy*I AThe selection of an anticoagulant agent should be individualized I CChronic anticoagulation is reasonable for patients with chronic HF who havepermanent/persistent/paroxysmal AF but without an additional risk factor forcardioembolic stroke*IIa BAnticoagulation is not recommended in patients with chronic HFrEF withoutAF, prior thromboembolic event, or a cardioembolic sourceIII: NoBenefitBStatinsStatins are not beneficial as adjunctive therapy when prescribed solely for HF III: NoBenefitAOmega-3 Fatty AcidsOmega-3 PUFA supplementation is reasonable to use as adjunctive therapy inHFrEF or HFpEF patientsIIa B
    75. 75. Pharmacological Therapy forManagement of Stage C HFrEF (cont.)Recommendations COR LOEOther DrugsNutritional supplements as treatment for HF are not recommendedin HFrEFIII: NoBenefitBHormonal therapies other than to replete deficiencies are notrecommended in HFrEFIII: NoBenefitCDrugs known to adversely affect the clinical status of patients withHFrEF are potentially harmful and should be avoided orwithdrawnIII: Harm BLong-term use of an infusion of a positive inotropic drug is notrecommended and may be harmful except as palliationIII: Harm CCalcium Channel BlockersCalcium channel blocking drugs are not recommended as routinein HFrEFIII: NoBenefitA
    76. 76. Medical Therapy for Stage C HFrEF:Magnitude of Benefit Demonstrated in RCTsGDMTRR Reductionin MortalityNNT for MortalityReduction(Standardized to 36 mo)RR Reductionin HFHospitalizationsACE inhibitor orARB17% 26 31%Beta blocker 34% 9 41%Aldosteroneantagonist30% 6 35%Hydralazine/nitrate 43% 7 33%
    77. 77. Treatment of HFpEFRecommendations COR LOESystolic and diastolic blood pressure should be controlledaccording to published clinical practice guidelines I BDiuretics should be used for relief of symptoms due tovolume overloadI CCoronary revascularization for patients with CAD inwhom angina or demonstrable myocardial ischemia ispresent despite GDMTIIaCManagement of AF according to published clinicalpractice guidelines for HFpEF to improve symptomaticHFIIa CUse of beta-blocking agents, ACE inhibitors, and ARBsfor hypertension in HFpEF IIa CARBs might be considered to decrease hospitalizations inHFpEFIIb BNutritional supplementation is not recommended inHFpEFIII: NoBenefitC
    78. 78. Device Therapy for Stage C HFrEFICD therapy is recommended for primary prevention of SCD toreduce total mortality in selected patients with nonischemic DCMor ischemic heart disease at least 40 days post-MI with LVEF of35% or less, and NYHA class II or III symptoms on chronicGDMT, who have reasonable expectation of meaningful survivalfor more than 1 year.CRT is indicated for patients who have LVEF of 35% or less,sinus rhythm, left bundle-branch block (LBBB) with a QRSduration of 150 ms or greater, and NYHA class II, III, orambulatory IV symptoms on GDMT.I IIa IIb IIII IIa IIb IIINYHA Class III/IVI IIa IIb IIINYHA Class II
    79. 79. Device Therapy for Stage C HFrEF(cont.)ICD therapy is recommended for primary prevention ofSCD to reduce total mortality in selected patients at least40 days post-MI with LVEF less than or equal to 30%, andNYHA class I symptoms while receiving GDMT, who havereasonable expectation of meaningful survival for morethan 1 year.CRT can be useful for patients who have LVEF of 35% orless, sinus rhythm, a non-LBBB pattern with a QRSduration of 150 ms or greater, and NYHA classIII/ambulatory class IV symptoms on GDMT.I IIa IIb IIII IIa IIb III
    80. 80. Device Therapy for Stage C HFrEF(cont.)CRT can be useful for patients who have LVEF of 35% orless, sinus rhythm, LBBB with a QRS duration of 120 to149 ms, and NYHA class II, III, or ambulatory IVsymptoms on GDMT.CRT can be useful in patients with AF and LVEF of 35%or less on GDMT if a) the patient requires ventricularpacing or otherwise meets CRT criteria and b)atrioventricular nodal ablation or pharmacological ratecontrol will allow near 100% ventricular pacing with CRT.I IIa IIb IIII IIa IIb III
    81. 81. Device Therapy for Stage C HFrEF(cont.)CRT can be useful for patients on GDMT who have LVEFof 35% or less, and are undergoing placement of a new orreplacement device placement with anticipatedrequirement for significant (>40%) ventricular pacing.The usefulness of implantation of an ICD is of uncertainbenefit to prolong meaningful survival in patients with ahigh risk of nonsudden death as predicted by frequenthospitalizations, advanced frailty, or comorbidities such assystemic malignancy or severe renal dysfunction.I IIa IIb IIII IIa IIb III
    82. 82. Device Therapy for Stage C HFrEF(cont.)CRT may be considered for patients who have LVEF of35% or less , sinus rhythm, a non-LBBB pattern with aQRS duration of 150 ms or greater, and NYHA class IIsymptoms on GDMT.CRT may be considered for patients who have LVEF of30% or less, ischemic etiology of HF, sinus rhythm, LBBBwith a QRS duration of 150 ms or greater, and NYHAclass I symptoms on GDMT.I IIa IIb IIII IIa IIb III
    83. 83. Device Therapy for Stage C HFrEF(cont.)CRT is not recommended for patients with NYHA class Ior II symptoms and non-LBBB pattern with a QRS durationof less than 150 ms.CRT is not indicated for patients whose comorbiditiesand/or frailty limit survival with good functional capacity toless than 1 year.I IIa IIb IIII IIa IIb IIINo BenefitNo Benefit
    84. 84. Indications for CRT TherapyPatient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, orwith implantation of pacing or defibrillation device for special indicationsLVEF <35%Evaluate general health statusComorbidities and/or frailtylimit survival with goodfunctional capacity to <1 yContinue GDMT withoutimplanted deviceAcceptable noncardiac healthEvaluate NYHA clinical statusNYHA class ILVEF ≤30%QRS ≥150 msLBBB patternIschemiccardiomyopathyQRS ≤150 msNon-LBBB patternNYHA class IILVEF ≤35%QRS 120-149 msLBBB patternSinus rhythmQRS ≤150 msNon-LBBB patternLVEF ≤35%QRS ≥150 msLBBB patternSinus rhythmLVEF ≤35%QRS ≥150 msNon-LBBB patternSinus rhythmColors correspond to the class of recommendations in the ACCF/AHA Table 1.Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided alongwith long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-Dunless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons andpersonal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival.NYHA class III &Ambulatory class IVLVEF ≤35%QRS 120-149 msLBBB patternSinus rhythmLVEF ≤35%QRS 120-149 msNon-LBBB patternSinus rhythmLVEF ≤35%QRS ≥150 msLBBB patternSinus rhythmLVEF≤35%QRS ≥150 msNon-LBBB patternSinus rhythmAnticipated to requirefrequent ventricularpacing (>40%)Atrial fibrillation, ifventricular pacing isrequired and ratecontrol will result innear 100%ventricular pacingwith CRTSpecial CRTIndications
    85. 85. Device Therapy for Stage C HFrEF (cont.)Recommendations COR LOEICD therapy is recommended for primary prevention of SCD in selectedpatients with HFrEF at least 40 days post-MI with LVEF ≤35%, and NYHAclass II or III symptoms on chronic GDMT, who are expected to live ≥1 year*I ACRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB witha QRS ≥150 msIA (NYHAclass III/IV)B (NYHAclass II)ICD therapy is recommended for primary prevention of SCD in selectedpatients with HFrEF at least 40 days post-MI with LVEF ≤30%, and NYHAclass I symptoms while receiving GDMT, who are expected to live ≥1 year*I BCRT can be useful for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with a QRS ≥150 ms, and NYHA class III/ambulatory class IVsymptoms on GDMT.IIa ACRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBBwith a QRS 120 to 149 ms, and NYHA class II, III or ambulatory IV symptomson GDMTIIaBCRT can be useful in patients with AF and LVEF ≤35% on GDMT if a) thepatient requires ventricular pacing or otherwise meets CRT criteria and b) AVnodal ablation or rate control allows near 100% ventricular pacing with CRTIIa B
    86. 86. Recommendations COR LOECRT can be useful for patients on GDMT who have LVEF ≤35%, and areundergoing new or replacement device with anticipated (>40%) ventricularpacingIIa CAn ICD is of uncertain benefit to prolong meaningful survival in patients withhigh risk of nonsudden death such as frequent hospitalizations, frailty, or severecomorbidities*IIbBCRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS 120 to 149 ms, and NYHA class III/ambulatory class IVon GDMTIIb BCRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with a QRS ≥150 ms, and NYHA class II symptoms on GDMTIIb BCRT may be considered for patients who have LVEF ≤30%, ischemic etiology ofHF, sinus rhythm, LBBB with a QRS ≥150 ms, and NYHA class I symptoms onGDMTIIb CCRT is not recommended for patients with NYHA class I or II symptoms andnon-LBBB pattern with QRS <150 msIII: NoBenefitBCRT is not indicated for patients whose comorbidities and/or frailty limitsurvival to <1 yearIII: NoBenefitCDevice Therapy for Stage C HFrEF (cont.)
    87. 87. Clinical Events and Findings Useful forIdentifying Patients With Advanced HFRepeated (≥2) hospitalizations or ED visits for HF in the past yearProgressive deterioration in renal function (e.g., rise in BUN and creatinine)Weight loss without other cause (e.g., cardiac cachexia)Intolerance to ACE inhibitors due to hypotension and/or worsening renal functionIntolerance to beta blockers due to worsening HF or hypotensionFrequent systolic blood pressure <90 mm HgPersistent dyspnea with dressing or bathing requiring restInability to walk 1 block on the level ground due to dyspnea or fatigueRecent need to escalate diuretics to maintain volume status, often reaching dailyfurosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapyProgressive decline in serum sodium, usually to <133 mEq/LFrequent ICD shocksAdapted from Russell et al. Congest Heart Fail. 2008;14:316-21.
    88. 88. Water RestrictionFluid restriction (1.5 to 2 L/d) is reasonable instage D, especially in patients withhyponatremia, to reduce congestive symptoms.I IIa IIb III
    89. 89. Inotropic SupportUntil definitive therapy (e.g., coronary revascularization,MCS, heart transplantation) or resolution of the acuteprecipitating problem, patients with cardiogenic shockshould receive temporary intravenous inotropic support tomaintain systemic perfusion and preserve end-organperformance.Continuous intravenous inotropic support is reasonable as“bridge therapy” in patients with stage D refractory toGDMT and device therapy who are eligible for andawaiting MCS or cardiac transplantation.I IIa IIb IIII IIa IIb III
    90. 90. Inotropic Support (cont.)Short-term, continuous intravenous inotropic support maybe reasonable in those hospitalized patients presentingwith documented severe systolic dysfunction who presentwith low blood pressure and significantly depressedcardiac output to maintain systemic perfusion andpreserve end-organ performance.Long-term, continuous intravenous inotropic support maybe considered as palliative therapy for symptom control inselect patients with stage D despite optimal GDMT anddevice therapy who are not eligible for either MCS orcardiac transplantation.I IIa IIb IIII IIa IIb III
    91. 91. Inotropic Support (cont.)Long-term use of either continuous or intermittent,intravenous parenteral positive inotropic agents, in theabsence of specific indications or for reasons other thanpalliative care, is potentially harmful in the patient with HF.Use of parenteral inotropic agents in hospitalized patientswithout documented severe systolic dysfunction, low bloodpressure, or impaired perfusion, and evidence ofsignificantly depressed cardiac output, with or withoutcongestion, is potentially harmful.I IIa IIb IIII IIa IIb IIIHarmHarm
    92. 92. Mechanical CirculatorySupportTreatment of Stages A to D
    93. 93. Mechanical Circulatory SupportMCS use is beneficial in carefully selected* patients withstage D HFrEF in whom definitive management (e.g.,cardiac transplantation) or cardiac recovery is anticipatedor planned.Nondurable MCS, including the use of percutaneous andextracorporeal ventricular assist devices (VADs), isreasonable as a “bridge to recovery” or a “bridge todecision” for carefully selected* patients with HFrEF withacute, profound hemodynamic compromise.Durable MCS is reasonable to prolong survival for carefullyselected* patients with stage D HFrEF.I IIa IIb IIII IIa IIb IIII IIa IIb III
    94. 94. Cardiac TransplantationEvaluation for cardiac transplantation is indicatedfor carefully selected patients with stage D HFdespite GDMT, device, and surgicalmanagement.I IIa IIb III
    95. 95. Initial and Serial Evaluation of the HF Patient(including HFpEF)Treatment of Stage A thru D Heart Failure(including HFpEF)The Hospitalized PatientSurgical/Percutaneous/TranscatheterInterventional TreatmentsCoordinating Care for Patients With ChronicHFQuality Metrics/Performance Measures
    96. 96. Normal blood pressure: VasodilatorsReduced blood pressure :Inotropics or vasopressors50 – 60%< 5%.20%,Dec G.W. Management of Acute Decompensated Heart Failure. Curr Probl Cardiol 2007; 32: 319 - 366
    97. 97. Precipitating Causes ofDecompensated HFACS precipitating acute HF decompensation should bepromptly identified by ECG and serum biomarkersincluding cardiac troponin testing, and treated optimally asappropriate to the overall condition and prognosis of thepatient.Common precipitating factors for acute HF should beconsidered during initial evaluation, as recognition of theseconditions is critical to guide appropriate therapy.I IIa IIb IIII IIa IIb III
    98. 98. Maintenance of GDMT DuringHospitalizationIn patients with HFrEF experiencing a symptomaticexacerbation of HF requiring hospitalization during chronicmaintenance treatment with GDMT, it is recommended thatGDMT be continued in the absence of hemodynamicinstability or contraindications.Initiation of beta-blocker therapy is recommended afteroptimization of volume status and successfuldiscontinuation of intravenous diuretics, vasodilators, andinotropic agents. Beta-blocker therapy should be initiated ata low dose and only in stable patients. Caution should beused when initiating beta blockers in patients who haverequired inotropes during their hospital course.I IIa IIb IIII IIa IIb III
    99. 99. Diuretics in Hospitalized PatientsPatients with HF admitted with evidence of significant fluidoverload should be promptly treated with intravenous loopdiuretics to reduce morbidity.If patients are already receiving loop diuretic therapy, theinitial intravenous dose should equal or exceed theirchronic oral daily dose and should be given as eitherintermittent boluses or continuous infusion. Urine outputand signs and symptoms of congestion should be seriallyassessed, and the diuretic dose should be adjustedaccordingly to relieve symptoms, reduce volume excess,and avoid hypotension.I IIa IIb IIII IIa IIb III
    100. 100. Diuretics in Hospitalized Patients(cont.)The effect of HF treatment should be monitored withcareful measurement of fluid intake and output, vital signs,body weight that is determined at the same time each day,and clinical signs and symptoms of systemic perfusion andcongestion. Daily serum electrolytes, urea nitrogen, andcreatinine concentrations should be measured during theuse of intravenous diuretics or active titration of HFmedications.When diuresis is inadequate to relieve symptoms, it isreasonable to intensify the diuretic regimen using either:a. higher doses of intravenous loop diuretics.b. addition of a second (e.g., thiazide) diuretic.I IIa IIb IIII IIa IIb III
    101. 101. Diuretics in Hospitalized Patients(cont.)Low-dose dopamine infusion may be consideredin addition to loop diuretic therapy to improvediuresis and better preserve renal function andrenal blood flow.I IIa IIb III
    102. 102. Renal Replacement TherapyThe Hospitalized Patient
    103. 103. Renal Replacement TherapyUltrafiltration may be considered for patients withobvious volume overload to alleviate congestivesymptoms and fluid weight.Ultrafiltration may be considered for patients withrefractory congestion not responding to medicaltherapy.I IIa IIb IIII IIa IIb III
    104. 104. Parenteral Therapy in Hospitalized HFIf symptomatic hypotension is absent,intravenous nitroglycerin, nitroprusside ornesiritide may be considered an adjuvant todiuretic therapy for relief of dyspnea in patientsadmitted with acutely decompensated HF.I IIa IIb III
    105. 105. Venous ThromboembolismProphylaxis in Hospitalized PatientsA patient admitted to the hospital withdecompensated HF should be treated for venousthromboembolism prophylaxis with ananticoagulant medication if the risk:benefit ratio isfavorable.I IIa IIb III
    106. 106. Arginine Vasopressin AntagonistsIn patients hospitalized with volume overload,including HF, who have persistent severehyponatremia and are at risk for or having activecognitive symptoms despite water restriction andmaximization of GDMT, vasopressin antagonistsmay be considered in the short term to improveserum sodium concentration in hypervolemic,hyponatremic states with either a V2 receptorselective or a nonselective vasopressinantagonist.I IIa IIb III
    107. 107. Arginine Vasopressin Antagonists• Risk of liver injury has been described in thosewith pre-existing liver disease when exposed toAVP antagonists• http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm336669.htm - accessed 06/04/13
    108. 108. Inpatient and Transitions ofCareThe Hospitalized Patient
    109. 109. Inpatient and Transitions of CareThe use of performance improvement systemsand/or evidence-based systems of care isrecommended in the hospital and earlypostdischarge outpatient setting to identifyappropriate HF patients for GDMT, provideclinicians with useful reminders to advanceGDMT, and to assess the clinical response.I IIa IIb III
    110. 110. Inpatient and Transitions of CareThroughout the hospitalization as appropriate, before hospitaldischarge, at the first postdischarge visit, and in subsequentfollow-up visits, the following should be addressed:a. initiation of GDMT if not previously established and notcontraindicated;b. precipitant causes of HF, barriers to optimal care transitions, andlimitations in postdischarge support;c. assessment of volume status and supine/upright hypotension withadjustment of HF therapy, as appropriate;d. titration and optimization of chronic oral HF therapy;e. assessment of renal function and electrolytes, where appropriate;f. assessment and management of comorbid conditions;g. reinforcement of HF education, self-care, emergency plans, andneed for adherence; andh. consideration for palliative care or hospice care in selectedpatients.I IIa IIb III
    111. 111. Inpatient and Transitions of CareMultidisciplinary HF disease-management programs arerecommended for patients at high risk for hospitalreadmission, to facilitate the implementation of GDMT, toaddress different barriers to behavioral change, and toreduce the risk of subsequent rehospitalization for HF.Scheduling an early follow-up visit (within 7 to 14 days) andearly telephone follow-up (within 3 days) of hospitaldischarge is reasonable.Use of clinical risk prediction tools and/or biomarkers toidentify patients at higher risk for postdischarge clinicalevents is reasonable.I IIa IIb IIII IIa IIb IIII IIa IIb III
    112. 112. Therapies in the Hospitalized HF PatientRecommendation COR LOEHF patients hospitalized with fluid overload should be treated withintravenous diureticsI BHF patients receiving loop diuretic therapy, should receive an initialparenteral dose greater than or equal to their chronic oral daily dose, thenshould be serially adjustedI BHFrEF patients requiring HF hospitalization on GDMT should continueGDMT unless hemodynamic instability or contraindicationsI BInitiation of beta-blocker therapy at a low dose is recommended afteroptimization of volume status and discontinuation of intravenous agentsI BThrombosis/thromboembolism prophylaxis is recommended for patientshospitalized with HFI BSerum electrolytes, urea nitrogen, and creatinine should be measuredduring the titration of HF medications, including diureticsI C
    113. 113. Therapies in the Hospitalized HF Patient(cont.)Recommendation COR LOEWhen diuresis is inadequate, it is reasonable toa) Give higher doses of intravenous loop diuretics; orb) add a second diuretic (e.g., thiazide)IIaBBLow-dose dopamine infusion may be considered with loop diuretics toimprove diuresisIIb BUltrafiltration may be considered for patients with obvious volumeoverloadIIb BUltrafiltration may be considered for patients with refractory congestion IIb CIntravenous nitroglycerin, nitroprusside or nesiritide may be considered anadjuvant to diuretic therapy for stable patients with HFIIb BIn patients hospitalized with volume overload and severe hyponatremia,vasopressin antagonists may be consideredIIb B
    114. 114. Hospital DischargeRecommendation or Indication COR LOEPerformance improvement systems in the hospital and early postdischarge outpatient settingto identify HF for GDMTI BBefore hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits,the following should be addressed:a) initiation of GDMT if not done or contraindicated;b) causes of HF, barriers to care, and limitations in support;c) assessment of volume status and blood pressure with adjustment of HF therapy;d) optimization of chronic oral HF therapy;e) renal function and electrolytes;f) management of comorbid conditions;g) HF education, self-care, emergency plans, and adherence; andh) palliative or hospice care.I BMultidisciplinary HF disease-management programs for patients at high risk for hospitalreadmission are recommendedI BA follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospitaldischarge is reasonableIIa BUse of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients isreasonableIIa B
    115. 115. heart failure 2012
    116. 116. Atrial fibrillation2012
    117. 117. heart failure 2012
    118. 118. Initial and Serial Evaluation of the HF Patient(including HFpEF)Treatment of Stage A thru D Heart Failure(including HFpEF)The Hospitalized PatientSurgical/Percutaneous/TranscatheterInterventional TreatmentsCoordinating Care for Patients With ChronicHFQuality Metrics/Performance Measures
    119. 119. Surgical/Percutaneous/TranscatheterInterventional Treatment of HFCoronary artery revascularization via CABG orpercutaneous intervention is indicated for patients (HFpEFand HFrEF) on GDMT with angina and suitable coronaryanatomy, especially for a left main stenosis (>50%) or leftmain equivalent disease.CABG to improve survival is reasonable in patients withmild to moderate LV systolic dysfunction (EF 35% to 50%)and significant (≥70% diameter stenosis) multivessel CADor proximal LAD coronary artery stenosis when viablemyocardium is present in the region of intendedrevascularization.I IIa IIb IIII IIa IIb III
    120. 120. Surgical/Percutaneous/TranscatheterInterventional Treatment of HF (cont.)CABG or medical therapy is reasonable to improvemorbidity and cardiovascular mortality for patients withsevere LV dysfunction (EF <35%), HF, and significantCAD.Surgical aortic valve replacement is reasonable for patientswith critical aortic stenosis and a predicted surgicalmortality of no greater than 10%.Transcatheter aortic valve replacement after carefulcandidate consideration is reasonable for patients withcritical aortic stenosis who are deemed inoperable.I IIa IIb IIII IIa IIb IIII IIa IIb III
    121. 121. Surgical/Percutaneous/TranscatheterInterventional Treatment of HF (cont.)CABG may be considered with the intent of improvingsurvival in patients with ischemic heart disease with severeLV systolic dysfunction (EF <35%), and operable coronaryanatomy whether or not viable myocardium is present.Transcatheter mitral valve repair or mitral valve surgery forfunctional mitral insufficiency is of uncertain benefit andshould only be considered after careful candidate selectionand with a background of GDMT.Surgical reverse remodeling or LV aneurysmectomy maybe considered in carefully selected patients with HFrEF forspecific indications including intractable HF and ventriculararrhythmias.I IIa IIb IIII IIa IIb IIII IIa IIb III
    122. 122. Surgical/Percutaneous/TranscatheterInterventional Treatment of HFRecommendation COR LOECABG or percutaneous intervention is indicated for HF patients on GDMT withangina and suitable coronary anatomy especially, significant left main stenosis or leftmain equivalent diseaseI CCABG to improve survival is reasonable in patients with mild to moderate LVsystolic dysfunction and significant multivessel CAD or proximal LAD stenosiswhen viable myocardium is presentIIa BCABG or medical therapy is reasonable to improve morbidity and mortality forpatients with severe LV dysfunction (EF <35%), HF and significant CADIIa BSurgical aortic valve replacement is reasonable for patients with critical aorticstenosis and a predicted surgical mortality of no greater than 10%IIa BTranscatheter aortic valve replacement is reasonable for patients with critical aorticstenosis who are deemed inoperableIIa BCABG may be considered in patients with ischemic heart disease, severe LV systolicdysfunction and suitable coronary anatomy whether or not viable myocardium ispresentIIb BTranscatheter mitral valve repair or mitral valve surgery for functional mitralinsufficiency is of uncertain benefitIIb BSurgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF forspecific indications including intractable HF and ventricular arrhythmiasIIb B
    123. 123. Initial and Serial Evaluation of the HF Patient(including HFpEF)Treatment of Stage A thru D Heart Failure(including HFpEF)The Hospitalized PatientSurgical/Percutaneous/TranscatheterInterventional TreatmentsCoordinating Care for Patients With ChronicHFQuality Metrics/Performance Measures
    124. 124. Coordinating Care for Patients WithChronic HFEffective systems of care coordination with special attention tocare transitions should be deployed for every patient with chronicHF that facilitate and ensure effective care that is designed toachieve GDMT and prevent hospitalization.Every patient with HF should have a clear, detailed and evidence-based plan of care that ensures the achievement of GDMT goals,effective management of comorbid conditions, timely follow-upwith the healthcare team, appropriate dietary and physicalactivities, and compliance with Secondary Prevention Guidelinesfor cardiovascular disease. This plan of care should be updatedregularly and made readily available to all members of eachpatient’s healthcare team.Palliative and supportive care is effective for patients withsymptomatic advanced HF to improve quality of life.I IIa IIb IIII IIa IIb IIII IIa IIb III
    125. 125. Initial and Serial Evaluation of the HF Patient(including HFpEF)Treatment of Stage A thru D Heart Failure(including HFpEF)The Hospitalized PatientSurgical/Percutaneous/TranscatheterInterventional TreatmentsCoordinating Care for Patients With ChronicHFQuality Metrics/Performance Measures
    126. 126. Quality Metrics/PerformanceMeasuresPerformance measures based on professionallydeveloped clinical practice guidelines should beused with the goal of improving quality of care forHF.Participation in quality improvement programsand patient registries based on nationallyendorsed, clinical practice guideline-basedquality and performance measures may bebeneficial in improving quality of HF care.I IIa IIb IIII IIa IIb III
    127. 127. ACCF/AHA/AMA-PCPI 2011 HF PerformanceMeasurement SetMeasure Description* CareSettingLevel ofMeasurement1. LVEFassessmentPercentage of patients aged ≥18 y with a diagnosis of HF for whom thequantitative or qualitative results of a recent or prior (any time in thepast) LVEF assessment is documented within a 12 mo periodOutpatient Individualpractitioner2. LVEFassessmentPercentage of patients aged ≥18 y with a principal discharge diagnosisof HF with documentation in the hospital record of the results of anLVEF assessment that was performed either before arrival or duringhospitalization, OR documentation in the hospital record that LVEFassessment is planned for after dischargeInpatient IndividualpractitionerFacility3. Symptomand activityassessmentPercentage of patient visits for those patients aged ≥18 y with adiagnosis of HF with quantitative results of an evaluation of bothcurrent level of activity and clinical symptoms documentedOutpatientIndividualpractitioner*Please refer to the complete measures for comprehensive information, including measure exception.Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.
    128. 128. ACCF/AHA/AMA-PCPI 2011 HF Performance Measurement Set(cont.)Measure Description* CareSettingLevel ofMeasurement4. Symptommanagement†Percentage of patient visits for those patients aged ≥18 y with adiagnosis of HF and with quantitative results of an evaluation of bothlevel of activity AND clinical symptoms documented in which patientsymptoms have improved or remained consistent with treatment goalssince last assessment OR patient symptoms have demonstratedclinically important deterioration since last assessment with adocumented plan of careOutpatient Individualpractitioner5. Patient self-care education†‡Percentage of patients aged ≥18 y with a diagnosis of HF who wereprovided with self-care education on ≥3 elements of education during≥1 visits within a 12 mo periodOutpatient Individualpractitioner6. Beta-blockertherapy for LVSD(outpatient andinpatient setting)Percentage of patients aged ≥18 y with a diagnosis of HF with acurrent or prior LVEF <40% who were prescribed beta-blockertherapy with bisoprolol, carvedilol, or sustained release metoprololsuccinate either within a 12 mo period when seen in the outpatientsetting or at hospital dischargeInpatientandOutpatientIndividualpractitionerFacility*Please refer to the complete measures for comprehensive information, including measure exception.†Test measure designated for use in internal quality improvement programs only. These measures are not appropriate for any otherpurpose, e.g., pay for performance, physician ranking or public reporting programs.‡New measure.Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.

    ×