1. Management of Heart Failure Guideline 2013 provides recommendations for treating heart failure based on evidence from clinical trials and guidelines.
2. Heart failure is classified into stages based on symptoms and ejection fraction. Recommended treatments include drugs that have been shown to decrease mortality such as beta blockers, ACE inhibitors, and aldosterone antagonists.
3. Device therapies such as implantable cardioverter defibrillators and cardiac resynchronization therapy are recommended for selected patients to reduce mortality and hospitalizations based on results from major clinical trials.
Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICDs) can help optimize heart failure management. CRT improves symptoms, reduces hospitalizations, and increases survival in patients with reduced ejection fraction, left bundle branch block, and wide QRS duration. ICDs prevent sudden cardiac death in high-risk patients with prior heart failure, low ejection fraction, or history of dangerous arrhythmias. New devices use adaptive and multi-point pacing to better resynchronize the left ventricle. Device therapy improves outcomes when guided by clinical evidence and used in appropriate heart failure patients.
This document summarizes key information about device therapy in heart failure, including implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT). It discusses major clinical trials that have evaluated the benefits of these devices for primary and secondary prevention of sudden cardiac death. Factors influencing the benefits of ICD therapy are summarized, as well as predictors of mortality after ICD implantation. Complications related to ICDs and CRT devices are also briefly outlined.
ACE inhibitors were originally synthesized from compounds found in pit viper venom. They work by blocking the conversion of angiotensin I to angiotensin II, lowering blood pressure. Landmark trials showed that ACE inhibitors reduce mortality and hospitalization in heart failure and hypertension. They are now first-line treatment for these conditions as well as post-MI and diabetic kidney disease due to their cardiovascular and renal protective effects. However, trials in low risk patients like PEACE and IMAGINE found no additional benefit of ACE inhibitors beyond standard therapy.
This document summarizes several studies on the use of ACE inhibitors and angiotensin receptor blockers (ARBs) in treating heart failure and reducing cardiovascular risk. The HOPE trial showed that the ACE inhibitor ramipril reduced cardiovascular events in high-risk patients. The CHARM trial found that the ARB candesartan reduced cardiovascular outcomes in heart failure patients, both alone and in combination with ACE inhibitors. The ONTARGET trial aimed to compare the ARB telmisartan to ramipril, and their combination, to determine if telmisartan was non-inferior to ramipril and if their combination provided additional benefit.
This document provides an overview of the updated management of chronic heart failure. It defines heart failure and discusses its classification, diagnosis, etiologies, investigations, and management strategies. For heart failure with reduced ejection fraction, the major goals of treatment are to reduce mortality and prevent hospitalizations through use of pharmacotherapy including angiotensin receptor-neprilysin inhibitors, SGLT2 inhibitors, beta-blockers, and MRAs. Device therapies like ICDs and CRT may also be considered. For heart failure with mid-range and preserved ejection fraction, no treatments have proven to reduce mortality, but targeting comorbidities is recommended.
This document summarizes two cases presented at a cardiology grand rounds meeting. Case 1 involves a 55-year-old male with ischemic dilated cardiomyopathy, heart failure with reduced ejection fraction, and coronary artery disease. Case 2 involves a 36-year-old male with non-ischemic dilated cardiomyopathy and heart failure with reduced ejection fraction. The document then reviews heart failure epidemiology, etiology, evaluation, classification, management, complications, and prognosis.
The document provides an overview of congestive heart failure (CHF), including its pathophysiology, diagnosis, classification, and treatment recommendations. It discusses how CHF results from neurohumoral and remodeling processes in the heart. Successful treatment requires addressing the sympathetic nervous system and renin-angiotensin-aldosterone system. Evidence shows that ACE inhibitors, beta-blockers, ARBs, and diuretics can improve outcomes when used appropriately based on the patient's stage of CHF.
The document discusses congestive heart failure (CHF), including its definition, epidemiology, pathophysiology, diagnosis, classification, and treatment approaches. It notes that CHF affects over 5 million Americans and costs over $10 billion annually. The main causes are coronary artery disease and hypertension. Treatment focuses on reducing preload and afterload through ACE inhibitors, beta-blockers, and aldosterone antagonists. Other therapies include diuretics, digoxin, resynchronization devices, and ventricular assist devices.
Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICDs) can help optimize heart failure management. CRT improves symptoms, reduces hospitalizations, and increases survival in patients with reduced ejection fraction, left bundle branch block, and wide QRS duration. ICDs prevent sudden cardiac death in high-risk patients with prior heart failure, low ejection fraction, or history of dangerous arrhythmias. New devices use adaptive and multi-point pacing to better resynchronize the left ventricle. Device therapy improves outcomes when guided by clinical evidence and used in appropriate heart failure patients.
This document summarizes key information about device therapy in heart failure, including implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT). It discusses major clinical trials that have evaluated the benefits of these devices for primary and secondary prevention of sudden cardiac death. Factors influencing the benefits of ICD therapy are summarized, as well as predictors of mortality after ICD implantation. Complications related to ICDs and CRT devices are also briefly outlined.
ACE inhibitors were originally synthesized from compounds found in pit viper venom. They work by blocking the conversion of angiotensin I to angiotensin II, lowering blood pressure. Landmark trials showed that ACE inhibitors reduce mortality and hospitalization in heart failure and hypertension. They are now first-line treatment for these conditions as well as post-MI and diabetic kidney disease due to their cardiovascular and renal protective effects. However, trials in low risk patients like PEACE and IMAGINE found no additional benefit of ACE inhibitors beyond standard therapy.
This document summarizes several studies on the use of ACE inhibitors and angiotensin receptor blockers (ARBs) in treating heart failure and reducing cardiovascular risk. The HOPE trial showed that the ACE inhibitor ramipril reduced cardiovascular events in high-risk patients. The CHARM trial found that the ARB candesartan reduced cardiovascular outcomes in heart failure patients, both alone and in combination with ACE inhibitors. The ONTARGET trial aimed to compare the ARB telmisartan to ramipril, and their combination, to determine if telmisartan was non-inferior to ramipril and if their combination provided additional benefit.
This document provides an overview of the updated management of chronic heart failure. It defines heart failure and discusses its classification, diagnosis, etiologies, investigations, and management strategies. For heart failure with reduced ejection fraction, the major goals of treatment are to reduce mortality and prevent hospitalizations through use of pharmacotherapy including angiotensin receptor-neprilysin inhibitors, SGLT2 inhibitors, beta-blockers, and MRAs. Device therapies like ICDs and CRT may also be considered. For heart failure with mid-range and preserved ejection fraction, no treatments have proven to reduce mortality, but targeting comorbidities is recommended.
This document summarizes two cases presented at a cardiology grand rounds meeting. Case 1 involves a 55-year-old male with ischemic dilated cardiomyopathy, heart failure with reduced ejection fraction, and coronary artery disease. Case 2 involves a 36-year-old male with non-ischemic dilated cardiomyopathy and heart failure with reduced ejection fraction. The document then reviews heart failure epidemiology, etiology, evaluation, classification, management, complications, and prognosis.
The document provides an overview of congestive heart failure (CHF), including its pathophysiology, diagnosis, classification, and treatment recommendations. It discusses how CHF results from neurohumoral and remodeling processes in the heart. Successful treatment requires addressing the sympathetic nervous system and renin-angiotensin-aldosterone system. Evidence shows that ACE inhibitors, beta-blockers, ARBs, and diuretics can improve outcomes when used appropriately based on the patient's stage of CHF.
The document discusses congestive heart failure (CHF), including its definition, epidemiology, pathophysiology, diagnosis, classification, and treatment approaches. It notes that CHF affects over 5 million Americans and costs over $10 billion annually. The main causes are coronary artery disease and hypertension. Treatment focuses on reducing preload and afterload through ACE inhibitors, beta-blockers, and aldosterone antagonists. Other therapies include diuretics, digoxin, resynchronization devices, and ventricular assist devices.
Heart Failure Care: How World-Class Performance is Within Your ReachHealth Catalyst
Less than 1% of heart failure (HF) patients with reduced ejection fraction are on target doses of all four drug classes within 12 months of an index hospitalization, yet these protocols have been proven to improve symptoms, slow disease progression, reduce costly admissions, and increase life expectancy. This data point must serve as a rallying cry in the nation’s quest to combat heart failure as a leading cause of death.
In this webinar, Dr. John Janas will:
Review the current HF treatment gaps
Discuss the latest evidence-based recommendations for changes to guideline-directed medical therapy (GDMT) and key changes to prior CHF guidelines
Explore the role that technology could play in improving HF care while reducing the burden on care teams
Refractory heart failure - Diagnosis, Management, Device TherapyImran Ahmed
This document summarizes information about heart failure (HF), including:
1) HF is a major public health problem worldwide, affecting over 23 million people, with rates increasing with age.
2) Stages of HF range from risk factors to end-stage disease and influence treatment approaches.
3) Implantable devices like ICDs and CRT have been shown to improve symptoms and reduce mortality in HF, though guidelines around their use continue to be refined.
4) Ongoing research is exploring expanding the use of CRT to additional patient populations like those with narrow QRS complexes or milder disease.
Lipid management in peripheral artrerial disease .slidesashwani mehta
Peripheral arterial disease (PAD) is a manifestation of atherosclerosis associated with high mortality. Lipid-lowering therapy, especially statin drugs, has proven effective in treating PAD patients by reducing cardiovascular risk. Guidelines recommend a target LDL-C level below 100 mg/dL for all PAD patients, and below 70 mg/dL for high-risk patients. Statins provide benefits beyond lipid lowering, including reducing inflammation and improving walking ability in PAD. More intensive statin therapy targeting lower LDL-C levels is associated with better long-term outcomes for PAD patients.
MADIT-CRT was a randomized controlled trial of 1820 patients with asymptomatic or mildly symptomatic heart failure that compared cardiac resynchronization therapy with a defibrillator (CRT-D) to an implantable cardioverter-defibrillator (ICD) alone. The trial found that among patients with left bundle branch block, CRT-D reduced the risk of the combined primary endpoint of death from any cause or a heart failure event by 57% compared to ICD alone. This benefit was driven by a 35% reduction in all-cause mortality and a 63% reduction in heart failure events. Based on these results, the FDA approved an expanded indication for CRT-D devices to include patients with left bundle branch
The unmet needs of patients with heart failure meeting 17 Feb 2022.pptxAdelSALLAM4
This document summarizes a case study of a 45-year-old male with non-ischemic heart failure and reduced ejection fraction of 40% who is on multiple heart failure medications. He has several questions about his medications and symptoms of dizziness, fatigue, and scrotal swelling. The document provides guidance on how to address his questions and concerns while balancing optimal medical therapy and side effects.
The unmet needs of patients with heart failure meeting 17 Feb 2022.pptxAdelSALLAM4
This document summarizes a case study of a 45-year-old male with non-ischemic heart failure and reduced ejection fraction of 40% who is on multiple heart failure medications. He has several questions about his medications and symptoms of dizziness, fatigue, and scrotal swelling. The document provides guidance on how to address his questions and concerns while balancing optimal medical therapy and potential side effects.
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...ahvc0858
This document provides information on new guidelines and therapies for heart failure patients. It begins by outlining the challenges of managing heart failure patients and their high mortality rates. It then discusses the history of heart failure treatments from ACE inhibitors in the 1990s to newer drugs like ARNi's. The document defines the different types of heart failure - HFrEF, HFmrEF, and HFpEF - and their diagnostic criteria. It explains how neprilysin inhibition enhances natriuretic peptides while simultaneously suppressing the RAAS. Finally, it summarizes that the new drug LCZ696 combines neprilysin inhibition with an ARB to reduce mortality and hospitalization in heart failure patients beyond existing neurohormonal therapies
This document summarizes guidelines for managing chronic heart failure. It discusses evaluating patients, lifestyle modifications including diet and exercise, and pharmacological treatments. Key drugs discussed are ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and digoxin. Several clinical trials are summarized that demonstrate the mortality benefits of these drug classes in heart failure.
The document discusses congestive cardiac failure (heart failure) and its management. It provides details on:
- The high prevalence and mortality of heart failure.
- Current medical therapies including ACE inhibitors, beta-blockers, and aldosterone antagonists that have been shown to improve survival.
- Device therapies like cardiac resynchronization therapy and implantable cardioverter defibrillators that treat symptoms and reduce mortality.
- The benefits of multidisciplinary and integrated care approaches including telehealth monitoring in improving outcomes for heart failure patients.
This document discusses interventional heart failure therapies including heart transplantation, ventricular assist devices, closure devices for defects, valve repair/replacement procedures, defibrillators, and cardiac resynchronization therapy. It provides details on outcomes of these therapies and notes limitations such as limited organ availability for transplantation. Guidelines for use of defibrillators and cardiac resynchronization therapy are summarized. Ongoing research into treating patients with narrow QRS complexes and those in NYHA class IV is also reviewed.
Beta blockers are the most effective therapy for heart failure according to clinical trials. Long term use of beta blockers such as bisoprolol, carvedilol, and sustained release metoprolol succinate can reduce mortality, heart failure hospitalizations, and improve ejection fraction and symptoms of heart failure. While initiation requires slow uptitration, discontinuation of beta blockers during heart failure hospitalization is generally not necessary and may worsen outcomes.
This document discusses pharmacological management options for heart failure with reduced ejection fraction (HFrEF). The goals of treatment are to reduce symptoms, prolong survival, improve quality of life, and prevent disease progression. Key drug therapies recommended for prognosis include ACE inhibitors, ARBs, beta blockers, and mineralocorticoid receptor antagonists. Diuretics and digoxin are recommended to treat symptoms. Ivabradine may also be used for symptom control. Clinical trials have demonstrated the benefits of these drug classes in reducing mortality and hospitalizations.
This document summarizes a presentation given by Prof Kyaw Soe Win on arterial health in hypertension. The presentation covered:
- Cardiovascular diseases are now major causes of mortality, with hypertension as a common risk factor.
- Lifestyle changes like urbanization have led to increased stress and sedentary lifestyles, contributing to rising hypertension rates globally.
- Treating hypertension can significantly reduce cardiovascular outcomes. More intensive control of blood pressure through 24-hour coverage can further reduce risks.
- Choosing antihypertensive drugs that improve arterial health in addition to blood pressure control may maximize cardiovascular protection. Perindopril was highlighted as having properties that protect the endothelium.
Horizontal or Vertical Approach in Starting Fantastic Four.pptxParikshitMishra15
- The guidelines recommend quadruple medical therapy (ARB/ACEi, beta blocker, MRA, SGLT2i) as the standard of care for patients with HFrEF. This represents an evolution from prior recommendations of triple therapy.
- For patients with HFpEF or HFmrEF, the guidelines recommend use of ARB/ACEi, with ARNI preferred over ACEi/ARB when possible.
- The guidelines emphasize initiating guideline-directed medical therapy prior to hospital discharge and optimizing medical regimens for comorbidities like hypertension, anemia, sleep disorders, and diabetes. Early initiation of evidence-based therapies aims to improve long-term outcomes.
Heart failure results from left ventricular dysfunction and is a common outcome of many cardiovascular diseases. It is characterized by symptoms like dyspnea and fatigue. The main causes are coronary artery disease, hypertension, valvular heart disease and cardiomyopathy. Treatment involves drugs like ACE inhibitors, beta-blockers, diuretics and digoxin to improve symptoms, reduce disease progression and mortality risk. These drugs act via different mechanisms such as neurohormonal inhibition and reducing preload and afterload.
Horizontal or Vertical Approach in Starting Fantastic Four (Revised).pptxParikshitMishra15
Horizontal or Vertical Approach in Starting Fantastic Four
Heart failure is a progressive disease characterized by worsening cardiac function and quality of life over time due to ongoing cardiac injury. While patients may experience periods of clinical stability, they always face residual risks of hospitalization or sudden cardiac death due to the underlying progressive nature of the disease, even when receiving optimal treatment. Recent guidelines recommend initiating treatment with quadruple therapy including an ARNI, beta blocker, MRA, and SGLT2 inhibitor in eligible patients with HFrEF to more comprehensively target the disease and improve outcomes. Initiating multiple evidence-based medications simultaneously early in treatment, such as prior to hospital discharge, may help accelerate adoption of best practices and maximize benefits for
Primary Prevention Of Sudden Cardiac Death - Role Of DevicesArindam Pande
ICD is most cost‑effective when used for patients at high‑risk of arrhythmic death and low‑risk of other causes of death.
Specific patient populations are now recognized for whom the benefit of ICD therapy outweighs any risks
Categorizing patients on the basis of only LVEF and NYHA Functional Class can aid in identification of patients who have highest benefit from primary preventions
1) The EAST-AFNET trial compared an early rhythm control strategy to usual care for patients with recent-onset atrial fibrillation.
2) The early rhythm control strategy involved early use of antiarrhythmic drugs or ablation to maintain sinus rhythm, while usual care followed guidelines.
3) The trial was stopped early as early rhythm control reduced the composite outcome of death, stroke, or hospitalization compared to usual care over 5 years of follow-up.
Therapeutic drug monitoring PHARMACY sAA.pptssuser497f37
Therapeutic drug monitoring (TDM) involves measuring drug concentrations in a patient's blood to optimize drug dosing and ensure concentrations are within a therapeutic range. TDM is useful for drugs with a narrow therapeutic index that can be toxic above the upper limit or ineffective below the lower limit. It helps individualize treatment regimens and assess efficacy and safety. Common drugs monitored include antiepileptics, antiarrhythmics, antibiotics, and immunosuppressants. Interpretation of levels considers pharmacokinetic and pharmacodynamic factors as well as clinical information to guide dosing adjustments. TDM provides insights to improve patient outcomes by achieving maximum benefit while minimizing toxicity risks.
Heart Failure Care: How World-Class Performance is Within Your ReachHealth Catalyst
Less than 1% of heart failure (HF) patients with reduced ejection fraction are on target doses of all four drug classes within 12 months of an index hospitalization, yet these protocols have been proven to improve symptoms, slow disease progression, reduce costly admissions, and increase life expectancy. This data point must serve as a rallying cry in the nation’s quest to combat heart failure as a leading cause of death.
In this webinar, Dr. John Janas will:
Review the current HF treatment gaps
Discuss the latest evidence-based recommendations for changes to guideline-directed medical therapy (GDMT) and key changes to prior CHF guidelines
Explore the role that technology could play in improving HF care while reducing the burden on care teams
Refractory heart failure - Diagnosis, Management, Device TherapyImran Ahmed
This document summarizes information about heart failure (HF), including:
1) HF is a major public health problem worldwide, affecting over 23 million people, with rates increasing with age.
2) Stages of HF range from risk factors to end-stage disease and influence treatment approaches.
3) Implantable devices like ICDs and CRT have been shown to improve symptoms and reduce mortality in HF, though guidelines around their use continue to be refined.
4) Ongoing research is exploring expanding the use of CRT to additional patient populations like those with narrow QRS complexes or milder disease.
Lipid management in peripheral artrerial disease .slidesashwani mehta
Peripheral arterial disease (PAD) is a manifestation of atherosclerosis associated with high mortality. Lipid-lowering therapy, especially statin drugs, has proven effective in treating PAD patients by reducing cardiovascular risk. Guidelines recommend a target LDL-C level below 100 mg/dL for all PAD patients, and below 70 mg/dL for high-risk patients. Statins provide benefits beyond lipid lowering, including reducing inflammation and improving walking ability in PAD. More intensive statin therapy targeting lower LDL-C levels is associated with better long-term outcomes for PAD patients.
MADIT-CRT was a randomized controlled trial of 1820 patients with asymptomatic or mildly symptomatic heart failure that compared cardiac resynchronization therapy with a defibrillator (CRT-D) to an implantable cardioverter-defibrillator (ICD) alone. The trial found that among patients with left bundle branch block, CRT-D reduced the risk of the combined primary endpoint of death from any cause or a heart failure event by 57% compared to ICD alone. This benefit was driven by a 35% reduction in all-cause mortality and a 63% reduction in heart failure events. Based on these results, the FDA approved an expanded indication for CRT-D devices to include patients with left bundle branch
The unmet needs of patients with heart failure meeting 17 Feb 2022.pptxAdelSALLAM4
This document summarizes a case study of a 45-year-old male with non-ischemic heart failure and reduced ejection fraction of 40% who is on multiple heart failure medications. He has several questions about his medications and symptoms of dizziness, fatigue, and scrotal swelling. The document provides guidance on how to address his questions and concerns while balancing optimal medical therapy and side effects.
The unmet needs of patients with heart failure meeting 17 Feb 2022.pptxAdelSALLAM4
This document summarizes a case study of a 45-year-old male with non-ischemic heart failure and reduced ejection fraction of 40% who is on multiple heart failure medications. He has several questions about his medications and symptoms of dizziness, fatigue, and scrotal swelling. The document provides guidance on how to address his questions and concerns while balancing optimal medical therapy and potential side effects.
Guidelines and beyond new drug therapy for heart failure with reduced ejectio...ahvc0858
This document provides information on new guidelines and therapies for heart failure patients. It begins by outlining the challenges of managing heart failure patients and their high mortality rates. It then discusses the history of heart failure treatments from ACE inhibitors in the 1990s to newer drugs like ARNi's. The document defines the different types of heart failure - HFrEF, HFmrEF, and HFpEF - and their diagnostic criteria. It explains how neprilysin inhibition enhances natriuretic peptides while simultaneously suppressing the RAAS. Finally, it summarizes that the new drug LCZ696 combines neprilysin inhibition with an ARB to reduce mortality and hospitalization in heart failure patients beyond existing neurohormonal therapies
This document summarizes guidelines for managing chronic heart failure. It discusses evaluating patients, lifestyle modifications including diet and exercise, and pharmacological treatments. Key drugs discussed are ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and digoxin. Several clinical trials are summarized that demonstrate the mortality benefits of these drug classes in heart failure.
The document discusses congestive cardiac failure (heart failure) and its management. It provides details on:
- The high prevalence and mortality of heart failure.
- Current medical therapies including ACE inhibitors, beta-blockers, and aldosterone antagonists that have been shown to improve survival.
- Device therapies like cardiac resynchronization therapy and implantable cardioverter defibrillators that treat symptoms and reduce mortality.
- The benefits of multidisciplinary and integrated care approaches including telehealth monitoring in improving outcomes for heart failure patients.
This document discusses interventional heart failure therapies including heart transplantation, ventricular assist devices, closure devices for defects, valve repair/replacement procedures, defibrillators, and cardiac resynchronization therapy. It provides details on outcomes of these therapies and notes limitations such as limited organ availability for transplantation. Guidelines for use of defibrillators and cardiac resynchronization therapy are summarized. Ongoing research into treating patients with narrow QRS complexes and those in NYHA class IV is also reviewed.
Beta blockers are the most effective therapy for heart failure according to clinical trials. Long term use of beta blockers such as bisoprolol, carvedilol, and sustained release metoprolol succinate can reduce mortality, heart failure hospitalizations, and improve ejection fraction and symptoms of heart failure. While initiation requires slow uptitration, discontinuation of beta blockers during heart failure hospitalization is generally not necessary and may worsen outcomes.
This document discusses pharmacological management options for heart failure with reduced ejection fraction (HFrEF). The goals of treatment are to reduce symptoms, prolong survival, improve quality of life, and prevent disease progression. Key drug therapies recommended for prognosis include ACE inhibitors, ARBs, beta blockers, and mineralocorticoid receptor antagonists. Diuretics and digoxin are recommended to treat symptoms. Ivabradine may also be used for symptom control. Clinical trials have demonstrated the benefits of these drug classes in reducing mortality and hospitalizations.
This document summarizes a presentation given by Prof Kyaw Soe Win on arterial health in hypertension. The presentation covered:
- Cardiovascular diseases are now major causes of mortality, with hypertension as a common risk factor.
- Lifestyle changes like urbanization have led to increased stress and sedentary lifestyles, contributing to rising hypertension rates globally.
- Treating hypertension can significantly reduce cardiovascular outcomes. More intensive control of blood pressure through 24-hour coverage can further reduce risks.
- Choosing antihypertensive drugs that improve arterial health in addition to blood pressure control may maximize cardiovascular protection. Perindopril was highlighted as having properties that protect the endothelium.
Horizontal or Vertical Approach in Starting Fantastic Four.pptxParikshitMishra15
- The guidelines recommend quadruple medical therapy (ARB/ACEi, beta blocker, MRA, SGLT2i) as the standard of care for patients with HFrEF. This represents an evolution from prior recommendations of triple therapy.
- For patients with HFpEF or HFmrEF, the guidelines recommend use of ARB/ACEi, with ARNI preferred over ACEi/ARB when possible.
- The guidelines emphasize initiating guideline-directed medical therapy prior to hospital discharge and optimizing medical regimens for comorbidities like hypertension, anemia, sleep disorders, and diabetes. Early initiation of evidence-based therapies aims to improve long-term outcomes.
Heart failure results from left ventricular dysfunction and is a common outcome of many cardiovascular diseases. It is characterized by symptoms like dyspnea and fatigue. The main causes are coronary artery disease, hypertension, valvular heart disease and cardiomyopathy. Treatment involves drugs like ACE inhibitors, beta-blockers, diuretics and digoxin to improve symptoms, reduce disease progression and mortality risk. These drugs act via different mechanisms such as neurohormonal inhibition and reducing preload and afterload.
Horizontal or Vertical Approach in Starting Fantastic Four (Revised).pptxParikshitMishra15
Horizontal or Vertical Approach in Starting Fantastic Four
Heart failure is a progressive disease characterized by worsening cardiac function and quality of life over time due to ongoing cardiac injury. While patients may experience periods of clinical stability, they always face residual risks of hospitalization or sudden cardiac death due to the underlying progressive nature of the disease, even when receiving optimal treatment. Recent guidelines recommend initiating treatment with quadruple therapy including an ARNI, beta blocker, MRA, and SGLT2 inhibitor in eligible patients with HFrEF to more comprehensively target the disease and improve outcomes. Initiating multiple evidence-based medications simultaneously early in treatment, such as prior to hospital discharge, may help accelerate adoption of best practices and maximize benefits for
Primary Prevention Of Sudden Cardiac Death - Role Of DevicesArindam Pande
ICD is most cost‑effective when used for patients at high‑risk of arrhythmic death and low‑risk of other causes of death.
Specific patient populations are now recognized for whom the benefit of ICD therapy outweighs any risks
Categorizing patients on the basis of only LVEF and NYHA Functional Class can aid in identification of patients who have highest benefit from primary preventions
1) The EAST-AFNET trial compared an early rhythm control strategy to usual care for patients with recent-onset atrial fibrillation.
2) The early rhythm control strategy involved early use of antiarrhythmic drugs or ablation to maintain sinus rhythm, while usual care followed guidelines.
3) The trial was stopped early as early rhythm control reduced the composite outcome of death, stroke, or hospitalization compared to usual care over 5 years of follow-up.
Therapeutic drug monitoring PHARMACY sAA.pptssuser497f37
Therapeutic drug monitoring (TDM) involves measuring drug concentrations in a patient's blood to optimize drug dosing and ensure concentrations are within a therapeutic range. TDM is useful for drugs with a narrow therapeutic index that can be toxic above the upper limit or ineffective below the lower limit. It helps individualize treatment regimens and assess efficacy and safety. Common drugs monitored include antiepileptics, antiarrhythmics, antibiotics, and immunosuppressants. Interpretation of levels considers pharmacokinetic and pharmacodynamic factors as well as clinical information to guide dosing adjustments. TDM provides insights to improve patient outcomes by achieving maximum benefit while minimizing toxicity risks.
1) Diluents like lactose are used to increase tablet size and bulk for low dose drugs. Binders like starch promote cohesion during compression and ensure tablets remain intact.
2) Disintegrants like sodium starch glycolate facilitate tablet breakup in the GI tract for rapid drug dissolution. Lubricants like magnesium stearate reduce friction during ejection while glidants like colloidal silica improve powder flow.
3) Excipients are added at different stages - as intragranular or extragranular components - and play key roles in tablet manufacturing and performance.
The autonomic nervous system has two main divisions - the sympathetic and parasympathetic nervous systems. The sympathetic nervous system is responsible for the "fight or flight" response and activates processes like increased heart rate and dilation of bronchioles. The parasympathetic nervous system is responsible for "rest and digest" functions like decreased heart rate and activation of gastrointestinal and genitourinary functions. Both systems use neurohumoral transmission using acetylcholine and norepinephrine as neurotransmitters which act on nicotinic and muscarinic receptors. There are many drugs that can selectively target components of the autonomic nervous system including parasympathomimetics, parasympatholytics, sympathomimetics, and sympathol
This document discusses the basic elements of medical terminology: word roots, combining forms, suffixes, and prefixes. It provides examples of each element and how they are combined to form medical terms. Word roots usually refer to a body part and are often derived from Latin or Greek. Combining forms link word roots together and make pronunciation easier by inserting a vowel. Suffixes modify or change the meaning of the word root or combining form. Prefixes are added before a word or root to alter or create a new word. Understanding these elements allows one to determine the meaning of complex medical terms.
This document discusses autonomic nervous system drugs that act on the sympathetic and parasympathetic nervous systems. It categorizes drugs as agonists or antagonists that work on alpha, beta, and muscarinic receptors. Examples are given of natural, semi-synthetic, and synthetic drugs for each receptor type including their actions and uses.
1. Biopharmaceutics encompasses the relationship between physical, chemical and biological properties of drugs and drug products and their effects on the body.
2. Key considerations in biopharmaceutics include drug formulation, dosage form, route of administration, and physico-chemical properties which influence drug bioavailability.
3. The goal of biopharmaceutics is to optimize drug delivery and therapeutic effects through rational design of drug products based on an understanding of biopharmaceutic principles.
1. The document analyzes the probability of achieving the pharmacokinetic/pharmacodynamic target of time above the minimum inhibitory concentration for various antibiotics used to treat otitis media caused by Streptococcus pneumoniae in children.
2. Using Monte Carlo simulation and published drug concentration and MIC distribution data, the probability of amoxicillin, clarithromycin, and ceftriaxone regimens achieving over 80% time above the MIC was calculated to be high.
3. In contrast, oral cephalosporin regimens showed lower and more variable probabilities of achieving therapeutic drug levels, with no regimen surpassing 65% probability of target attainment.
This document introduces basic terms and concepts related to clinical pharmacology. It defines a drug as a chemical that causes changes in living organisms. Medicines are the vehicles that deliver drugs to the body, such as tablets or injections. Drugs can come from plant, animal, mineral, microbial, or synthetic sources. The document discusses the mechanisms of drug action, including drug-receptor interactions and agonists vs antagonists. It also covers basic pharmacokinetic concepts such as absorption, distribution, metabolism and excretion of drugs in the body.
This document discusses several physiologic factors related to drug absorption including:
1) Drugs can be administered via various routes that affect absorption rate and onset of action based on blood flow and characteristics of the drug/product and absorption site.
2) Membranes pose a barrier to drug delivery that can be crossed via passive diffusion, active transport, or facilitated diffusion depending on the drug's properties.
3) Absorption involves drugs crossing intestinal epithelial cells through transcellular or paracellular pathways using carrier-mediated transport systems or vesicular transport.
This document discusses different types of parenteral injections and equipment used. It describes syringes, needles, and various injection sites for intramuscular, intradermal, and subcutaneous injections. Key details are provided on needle gauge and length selection based on injection type and depth. Diagrams illustrate proper techniques for different injections. Nursing diagnoses that may apply to patients receiving injections are also listed.
Pharmacokinetics is the study of what the body does to a drug, including absorption, distribution, metabolism, and excretion. Absorption involves a drug entering systemic circulation, which can be impacted by factors like solubility, ionization, and first-pass metabolism. Distribution of drugs is determined by properties like volume of distribution, plasma protein binding, and ability to cross membranes like the blood-brain barrier. Metabolism, usually by the liver, makes drugs more polar through Phase I and Phase II reactions to facilitate excretion. The major routes of excretion are renal and biliary, and metabolism is necessary to make many drugs water-soluble enough to be excreted from the body.
This document discusses endocrine pharmacology, including adrenalcorticoids, sex hormones, thyroid hormones, drugs affecting bone mineralization, and treatment of diabetes mellitus. It describes the naturally occurring hormones, their effects, and pharmacologic agents used for hormone replacement or to treat hormone-related conditions. Side effects of medications are addressed. Tight glycemic control through diet, exercise, oral medications, and insulin is important to prevent diabetes complications.
Iodine is essential for synthesizing thyroid hormones like thyroxine (T4) and triiodothyronine (T3) from thyroglobulin in the thyroid gland. Only a small fraction of T4 and T3 in the bloodstream are not bound to carrier proteins and are biologically active. T3 is the most potent hormone as it is not tightly bound and has high receptor affinity. Thyroid function tests include measuring TSH, total T4 and T3 to detect dysfunction, and thyroid antibodies and thyroglobulin to determine the cause. Interpreting the patterns of TSH and thyroid hormone levels indicates primary hypo- or hyperthyroidism, or secondary disorders of the pituitary or thyroid gland
Iodine is essential for synthesizing thyroid hormones like thyroxine (T4) and triiodothyronine (T3) from thyroglobulin in the thyroid gland. Nearly all T4 and T3 in the bloodstream are bound to thyroid hormone binding proteins, with only a small fraction unbound and biologically active. T3 is more potent than T4 due to binding less tightly to proteins. Thyroid function tests like TSH, total T4, free T4, total T3 and free T3 help diagnose thyroid disorders by indicating whether the thyroid is overactive (hyperthyroidism) or underactive (hypothyroidism). Interpreting the pattern of test results is important to
Transitions of care refer to the movement of patients between different healthcare settings or providers. Medication errors are common during transitions of care and can negatively impact patient outcomes. Three studies found high rates of medication errors or discrepancies during hospital admissions and discharges. Rates of unintended medication discrepancies ranged from 53.6-60% and a significant portion were considered clinically important. Hospital pharmacists can play an important role in reducing medication errors during transitions. Activities like medication reconciliation at admission and discharge can identify up to 486 discrepancies per 100 patients discharged. Pharmacist involvement is associated with reduced rates of medication errors and improved patient outcomes.
Analytical chemistry is the study of determining the composition of substances both qualitatively and quantitatively. It has applications in quality control, forensic analysis, environmental analysis, and clinical analysis. Two important techniques described are thin layer chromatography and gas chromatography. Thin layer chromatography separates substances based on their solubility and affinity to the stationary and mobile phases. Gas chromatography uses an inert solid support and a gaseous mobile phase to separate substances based on their partitioning between the phases. Atomic spectroscopy techniques are also used to analyze heavy metals in samples by observing their absorption and emission of radiation.
This document provides information on diagnosing and managing congestive heart failure (CHF). It discusses:
1. Defining CHF and explaining how it develops.
2. Diagnostic methods including symptoms, signs, labs, echocardiogram and functional classification systems.
3. Treatment approaches including lifestyle changes, medications, and referral criteria. Optimal medical therapy for reduced ejection fraction CHF is outlined.
4. Considerations for managing preserved ejection fraction CHF are also briefly covered.
This document discusses drugs used to treat hypertension. It defines hypertension and describes its causes. It then discusses several classes of antihypertensive drugs, including diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, renin inhibitors, and calcium channel blockers. For each drug class, it provides details on mechanisms of action, therapeutic uses, and potential adverse effects. The overall goal of antihypertensive treatment is to lower blood pressure and reduce risks of chronic kidney disease and heart disease.
This document discusses various central nervous system (CNS) pharmacology agents including sedative-hypnotics, antianxiety agents, antidepressants, bipolar agents, antipsychotics, anti-seizure agents, antiparkinsonian agents. It describes the examples, mechanisms of action, therapeutic effects, and side effects of different drug classes that act on the CNS, such as benzodiazepines, barbiturates, selective serotonin reuptake inhibitors, atypical antipsychotics, carbamazepine, and levodopa. The document provides an overview of how these drug classes are used to treat conditions like insomnia, anxiety, depression, seizures, schizophrenia, bipolar disorder, and Parkinson's
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
How to Add Chatter in the odoo 17 ERP ModuleCeline George
In Odoo, the chatter is like a chat tool that helps you work together on records. You can leave notes and track things, making it easier to talk with your team and partners. Inside chatter, all communication history, activity, and changes will be displayed.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
Leveraging Generative AI to Drive Nonprofit InnovationTechSoup
In this webinar, participants learned how to utilize Generative AI to streamline operations and elevate member engagement. Amazon Web Service experts provided a customer specific use cases and dived into low/no-code tools that are quick and easy to deploy through Amazon Web Service (AWS.)
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...
11472874.ppt
1. Management of Heart Failure
Guideline 2013
Dr. Vinod Sharma
National Heart Institute
New Delhi
2. Heart Failure
“Clinical practice guidelines are
systematically developed statements that
aim to help physicians and patients reach
the best healthcare decisions”.
3. Relative place of clinical guidelines in the spectrum of drug or
Interventional discovery and development to clinical trials and
practice
Discovery and development of
intervention Phases I, II, and III
Clinical trials
Statistical analyses
Trial results and interpretations
Regulatory authority approval,
Publicity, marketing & sales
Adoption into clinical practice
Clinical Guidelines
Therapeutic decisions
Standards and quality
of care clinical audits
5. Heart Failure
• Heart Failure is a complex clinical
syndrome that results from any structural
or functional impairment of ventricular
filling or ejection of blood.
6. Heart Failure
• The life time risk of developing heart failure is
about 20% for people above age of 40 years.
• Heart Failure incidence increases with age rising
from approximately 20 / 1000 individuals 65-69
years of age to > 80 /1000 individuals above the
age of 85 years.
8. Definitions of HFrEF & HFpEF
Classification EF (%)
I. Heart Failure with reduced
ejection fraction (HFrEF)
< 40
II. Heart failure with
preserved ejection fraction
(HFpEF)
> 50
a. HFpEF, borderline 41 to 49
b. HFpEF, improved > 40
9. Heart Failure
Stages of HF Survival rate @ 5 years
A At high risk for HF but without
structural heart disease or symptoms
of HF.
NYHA 97%
B Structural heart disease but without
signs or symptoms of HF.
I 96%
C Structural heart disease with prior or
current symptoms of HF.
I 75%
II
III
D Refractory HF requiring specialized
interventions
IV 20%
10. Diagnosis of Heart Failure
“There is no single diagnostic test for
Heart Failure. It is largely a clinical
diagnosis based on careful history &
physical examination”.
11. Recommendations for Biomarkers
in Heart Failure
Biomarker, Application Setting COR LOE
Natriuretic peptides
Diagnosis or exclusion of HF
Ambulatory,
Acute
I A
Prognosis of HF
Ambulatory,
Acute
I A
Achieve GDMT Ambulatory IIa B
Guidance of acutely
decompensated HF therapy
Acute IIb C
Biomarkers of myocardial injury
Additive risk stratification
Acute,
Ambulatory I A
Biomarkers of myocardial fibrosis
Additive risk stratification
Ambulatory
IIb B
Acute
IIb A
12. Chronic therapy and outcomes
in HF
• Drugs that decrease mortality:
– β -AR blockers
– ACE inhibitors
– Angio receptor blockers
– Aldosterone antagonists
– Isosorbide and hydralazine
in blacks
• Drugs that may improve
symptoms without worsening
outcome:
– Cardiac glycosides
– Loop diuretics
• Drugs that increase mortality:
– Dobutamine
– Xamoterol
– Pimobendam
– Flosequinan
– Vesnarinone
– Ibopamine
– Inamrinone
– Milrinone
– Enoximone
13. 1. Surgical or Percutaneous revascularization
2. Surgical or Trans Catheter Aortic valve replacement.
3. Surgical reverse remodelling or LV aneurysmectomy.
4. Parachute device (Cardio Kinetix) (Catheter based LV
partitioning)
5. Hemodynamic support with PVAD’s
6. Cardiac Transplantation
7. Renal denervation
8. Use of Mitra Clip (Percutaneous Mitral valve repair)
9. Stem Cell therapy
Surgical / Percutaneous / Trans Catheter
Interventions in Heart Failure
15. Selected clinical trials establishing the benefit of angiotensin-
converting enzyme inhibitors in symptomatic and
asymptomatic LV systolic function
Trial (Ref) (No. of
patients; average
follow up)
Study
population
ACE inhibitor
and dose
Key results
CONSENSUS I [22] (n = 253; 6
mo)
NYHA IV Enalapril vs Placebo 2.5
mg twice daily titrated to
20 mg twice daily
6 month mortality decreased 40%
1-year mortality decreased 31%
Improvement in NYHA class
Decrease in cardiac size
V-HeFT II [24]
(n=804; 2.5 y)
NYHA II – IV
LVEF < 45%
Target enalapril 10 mg
twice daily vs
hydralazine 75 mg four
times daily + isosorbide
dinitrate 40 mg four
times daily
2 year mortality decreased 28%
No difference in HF hospitalization
Lesser improvement in exercise
capacity and ventricular function with
enalapril
SOLVD Treatment Trial [65]
(n = 2569; 41 mo)
NYHA II – IV (90% II
– III)
LVEF < 35%
Enalapril vs placebo 2.5
mg twice daily titrated to
10 mg twice daily
16% decrease in mortality
22% decrease in progressive HF
mortality
26% decrease in either death or HF
hospitalization
8.6 month increase in median life
expectancy [76]
SOLVD Prevention Trial [29]
( n = 4228; 37.4 month)
NYHA I
LVEF < 35%
Enalapril vs placebo 2.5
mg twice daily titrated to
10 mg twice daily
20% decrease in either death or HF
hospitalization
29% decrease in either death or
development of HF
16. Effects of Beta-blockers on mortality compared with placebo in the
four positive landmark studies. US Carvedilol program,
COPERNICUS, CIBIS II and MERIT-HF
17. Randomized, Controlled Trials of ARBs in HF
TRIAL N AGENT ENTRY
CRITERIA
FOLLOW
UP
PERIOD
PRIMARY
ENDPOINT
FINDINGS
HEART FAILURE TRIALS
ELITE-II 3152 Losartan vs
Captopril
Age > 60 yrs
LVEF < 40%
NYHA II – IV
1.5 years Death Losartan 18%
Captopril 16%
(13% ↓, P =
.16)
Val-HeFT 5010 Valsartan vs
Placebo
LVEF < 40%
LVID > 2.9 cm/m2
NYHA II - IV
23 months Death
Death and
complications
Placebo 19%
Valsartan 20%
(P = .80)
Placebo 32%
Valsartan 29%
(13% ↓)
CHARM-Added 2548 Candesartan vs
Placebo
LVEF < 40%
NYHA II – IV
Treatment with
ACEIs
41 months CV death or HF
hospitalization
Placebo 42%
Candesartan
38%
(15% ↓)
CHARM –
Alternative
2028 Candesartan vs
Placebo
LVEF < 40%
NYHA II – IV
Intolerance to
ACEIs
34 months CV death or HF
hospitalization
Placebo 40%
Candesartan
33%
(23% ↓)
POSTINFARCTION TRIALS
VALIENT 14,808 Valsartan vs
Valsartan plus
Captopril Vs
Captopril
0.5 – 10 days
after MI
HF, LVEF < 35%,
or both
25 months Death Valsartan 20%
Valsartan plus
Captorpril 19%
Captopril 20%
18. RALES (Randomized Aldactone
Evaluation Study)
• 30% reduction in all cause mortality as well as a reduced risk of
SCD & HF hospitalization with use of Spironolactone in patient
with chronic HFrEF and LVEF < 35%.
NEJM 1999: 339: 387-95
• Eplerenone reduces all cause deaths, CV deaths or HF
hospitalization in a under range of patients with HFrEF.
NEJM 2011: 364: 11-21
19. Hydralazine & ISDN Combination in
Heart Failure
• This combination reduced Mortality but not hospitalization in
patients with HF treated with Diuretics & Digoxin but not an
ACEI or Beta-blockers.
NEJM 1986: 314: 1547 – 52
• ACEI has more favourable effect on survival than ISDN + HLZ.
• ISDN + HLZ is more effective in African – American population.
• Addition of fixed dose ISDN + HLZ to standard therapy with
ACEI / ARB + BB + Aldosterone Antagonist offers significant
benefit.
NEJM 2004: 351: 2049 - 57
20. Medical Therapy for Stage C HFrEF:
Magnitude of Benefit Demonstrated in RCTs
GDMT RR Reduction
in Mortality
(%)
NNT for Mortality
Reduction
(Standardized to
36 months)
RR Reduction in
HF
Hospitalizations
(%)
ACE Inhibitor or
ARB
17 26 31
Beta blocker 34 9 41
Aldosterone
antagonist
30 6 35
Hydralazine /
nitrate
43 7 33
22. Summary of Implantable cardioverter defibrillator
trials in patients with a cardiomyopathy due to CAD
Ischemic
Cardiomyopathy
Entry Criteria EF (%) Overall
mortality
(control;
ICDs [%])
Mortality
reduction
(relative;
absolute
[%])
MADIT 2 – year
analysis
EF 35%, nonsustained
or inducible VT
26 + 7 32; 13 59; 19
MUSTT 5 –year
analysis
EF < 40%, inducible
VT
30 (21-
35)
55; 24 58; 31
MADIT II 2 – year
analysis
EF < 30% 23 + 5 22; 16 28; 6
SCDHeFT 5 – year
analysis
EF < 35%, NYHA II, III,
52% CAD – CHF
25 (20 –
30)
36; 29 23; 7
23. Summary of Implantable cardioverter defibrillators trials
in patients with a nonischemic cardiomyopathy
Nonischemic
Cardiomyopathy
Entry Criteria EF %
(mean)
Overall
mortality
(control;
ICD [%])
DEFINITE 2 – year
analysis
EF < 36%, NSVT or >
10 PVCs / h
21.4 14.1; 7.9
SCDHeFT 5 – year
analysis
EF < 35%, NYHA II –
III; 48% nonischemic
CM
25 36; 29
24. Device Therapy for Stage C HFrEF (cont.)
Recommendations COR LOE
ICD therapy is recommended for primary prevention of
SCD in selected patients with HFrEF at least 40 days post-
MI with LVEF ≤35%, and NYHA class II or III symptoms on
chronic GDMT, who are expected to live ≥1 year*
I A
ICD therapy is recommended for primary prevention of
SCD in selected patients with HFrEF at least 40 days post-
MI with LVEF ≤30%, and NYHA class I symptoms while
receiving GDMT, who are expected to live ≥1 year*
I B
25. Cardiac Resynchronization Therapy
(CRT)
CRT – optimizing right and left ventricular
pacing, has been shown to improve
hemodynamic parameters, symptoms and
most recently mortality in patients with
symptoms of congestive heart failure and
depressed ejection fraction.
26. Summary of cardiac resynchronization therapy trials
TRIAL Inclusion
criteria : EF
(%); QRS (ms)
NYHA; mean
EF(%); mean
QRS (ms)
End points Primary end point
reduction cardiac
resynchronization
therapy control
MIRACLE
6-month f/u
(NEJM 2002)
< 35; > 130 III – IV; 22; 166 NYHA, 6 MW,
MLHFQ
RR: 40% CE
reduction
COMPANION
1 – year f/u
(NEJM 2004)
< 35; > 130 III – IV; 21; 160 Mortality + HF
events
RR: 12% CE
reduction; AR:
mortality: CRT-P 4.6%
CRT-D 11%
CARE-HF
2-year f/u
(NEJM 2005)
< 35; > 120 III – IV; 25; 160 Mortality RR: 36% reduction
AR: 20 vs 30%
MADIT CRT
4.5 – year f/u
(NEJM 2009)
< 30; > 130 I – II; 24; 158 HF events +
mortality
RR: 29% CE
reduction
AR: 17.2 vs 25.3%
RAFT
5-year f/u
(NEJM 2010)
< 30; > 120 II – III; 22.6; 158 Mortality RR 22% reduction
AR: 28.6% CRT – D
vs 34.6% ICD
6MW: 6-min walk; AR: Absolute reduction; CE: Combined end point; CRT-D: Cardiac resynchronization therapy defibrillator; CRT-P: cardiac
Resynchronization therapy-pacemaker only; MLHFQ: Minnesota living with heart failure questionnaire; RR: Relative reduction
27. Device Therapy for Stage C HFrEF:
Recommendations
CRT is indicated for patients who have LVEF of 35% or
less, sinus rhythm, left bundle-branch block (LBBB)
with a QRS duration of 150 ms or greater, and NYHA
class II, III, or ambulatory IV symptoms on GDMT (Level
of Evidence: A for NYHA Class III / IV; Level of Evidence: B for NYHA
class II).
28. CRT – Indications in Heart Failure
• LBBB (QRS > 150 msec)
- NYHA class III / IV - Class Ia
I / IV - Class Ib
• LBBB (QRS 120 – 149 msec)
- NYHA Class IV - Class IIa / B
Class III
• Non LBBB (QRS > 150 msec)
- NYHA Class III / IV - Class IIa
I/ II
• Non LBBB (QRS 120 – 149 msec)
- NYHA Class III / IV - Class IIb
I / II
30. Stage A
Hypertension and lipid disorders should be controlled
in accordance with contemporary guidelines to lower
the risk of HF.
Other conditions that may lead to or contribute to HF,
such as obesity, diabetes mellitus, tobacco use, and
known cardiotoxic agents, should be controlled or
avoided.
I IIa IIb III
I IIa IIb III
31. Recommendations for Treatment of Stage B HF
Recommendations COR LOE
In patients with a history of MI and reduced EF, ACE inhibitors or
ARBs should be used to prevent HF I A
In patients with MI and reduced EF, evidence-based beta
blockers should be used to prevent HF I B
In patients with MI, statins should be used to prevent HF I A
Blood pressure should be controlled to prevent symptomatic HF
I A
ACE inhibitors should be used in all patients with a reduced EF
to prevent HF I A
Beta blockers should be used in all patients with a reduced EF
to prevent HF I C
An ICD is reasonable in patients with asymptomatic ischemic
cardiomyopathy who are at least 40 d post-MI, have an LVEF
≤30%, and on GDMT
IIa B
Nondihydropyridine calcium channel blockers may be harmful in
patients with low LVEF III: Harm C
33. Stage C: Nonpharmacological
Interventions
Patients with HF should receive specific education
to facilitate HF self-care.
Exercise training (or regular physical activity) is
recommended as safe and effective for patients with
HF who are able to participate to improve functional
status.
Sodium restriction is reasonable for patients with
symptomatic HF to reduce congestive symptoms.
I IIa IIb III
I IIa IIb III
I IIa IIb III
34. Stage C: Nonpharmacological
Interventions (cont.)
Continuous positive airway pressure (CPAP) can be
beneficial to increase LVEF and improve functional
status in patients with HF and sleep apnea.
Cardiac rehabilitation can be useful in clinically
stable patients with HF to improve functional
capacity, exercise duration, HRQOL, and mortality.
I IIa IIb III
I IIa IIb III
35. Stage C HFrEF – Evidenced based guideline-
directed medical therapy
HFrEF Stage C
NYHA Class I – IV
Treatment:
For NYHA class II-IV patients.
Provided estimated creatinine
>30 mL/min and K+ <5.0 mEq/dL
For persistently symptomatic
African Americans,
NYHA class III-IV
Class I, LOE A
ACEI or ARB AND
Beta Blocker
Class I, LOE C
Loop Diuretics
Class I, LOE A
Hydral-Nitrates
Class I, LOE A
Aldosterone
Antagonist
Add
Add Add
For all volume overload,
NYHA class II-IV patients
36. Pharmacological Therapy for
Management of Stage C HFrEF
Recommendations COR LOE
Diuretics
Diuretics are recommended in patients with HFrEF with fluid
retention
I C
ACE Inhibitors
ACE inhibitors are recommended for all patients with HFrEF
I A
ARBs
ARBs are recommended in patients with HFrEF who are ACE
inhibitor intolerant
I A
ARBs are reasonable as alternatives to ACE inhibitor as first line
therapy in HFrEF
IIa A
The addition of an ARB may be considered in persistently
symptomatic patients with HFrEF on GDMT
IIb A
Routine combined use of an ACE inhibitor, ARB, and aldosterone
antagonist is potentially harmful
III: Harm C
37. Pharmacological Therapy for
Management of Stage C HFrEF (cont.)
Recommendations COR LOE
Beta Blockers
Use of 1 of the 3 beta blockers proven to reduce mortality is recommended
for all stable patients
I A
Aldosterone Antagonists
Aldosterone receptor antagonists are recommended in patients with NYHA
class II-IV HF who have LVEF ≤35%
I A
Aldosterone receptor antagonists are recommended in patients following an
acute MI who have LVEF ≤40% with symptoms of HF or DM I B
Inappropriate use of aldosterone receptor antagonists may be harmful
III: Harm B
Hydralazine and Isosorbide Dinitrate
The combination of hydralazine and isosorbide dinitrate is recommended
for African-Americans, with NYHA class III–IV HFrEF on GDMT I A
A combination of hydralazine and isosorbide dinitrate can be useful in
patients with HFrEF who cannot be given ACE inhibitors or ARBs IIa B
38. Pharmacologic Therapy for
Management of Stage C HFrEF (cont.)
Recommendations COR LOE
Digoxin
Digoxin can be beneficial in patients with HFrEF IIa B
Anticoagulation
Patients with chronic HF with permanent/persistent/paroxysmal AF and an
additional risk factor for cardioembolic stroke should receive chronic
anticoagulant therapy*
I A
The selection of an anticoagulant agent should be individualized I C
Chronic anticoagulation is reasonable for patients with chronic HF who have
permanent/persistent/paroxysmal AF but without an additional risk factor for
cardioembolic stroke*
IIa B
Anticoagulation is not recommended in patients with chronic HFrEF without
AF, prior thromboembolic event, or a cardioembolic source
III: No
Benefit
B
Statins
Statins are not beneficial as adjunctive therapy when prescribed solely for HF III: No
Benefit
A
Omega-3 Fatty Acids
Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy in
HFrEF or HFpEF patients
IIa B
39. Pharmacological Therapy for
Management of Stage C HFrEF (cont.)
Recommendations COR LOE
Other Drugs
Nutritional supplements as treatment for HF are not recommended in
HFrEF
III: No
Benefit
B
Hormonal therapies other than to replete deficiencies are not
recommended in HFrEF
III: No
Benefit
C
Drugs known to adversely affect the clinical status of patients with
HFrEF are potentially harmful and should be avoided or withdrawn III: Harm B
Long-term use of an infusion of a positive inotropic drug is not
recommended and may be harmful except as palliation III: Harm C
Calcium Channel Blockers
Calcium channel blocking drugs are not recommended as routine in
HFrEF
III: No
Benefit
A
41. Clinical Events and Findings Useful for
Identifying Patients With Advanced HF
Repeated (≥2) hospitalizations or ED visits for HF in the past year
Progressive 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 function
Intolerance to beta blockers due to worsening HF or hypotension
Frequent systolic blood pressure <90 mm Hg
Persistent dyspnea with dressing or bathing requiring rest
Inability to walk 1 block on the level ground due to dyspnea or fatigue
Recent need to escalate diuretics to maintain volume status, often reaching daily
furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapy
Progressive decline in serum sodium, usually to <133 mEq/L
Frequent ICD shocks
Adapted from Russell et al. Congest Heart Fail. 2008;14:316-21.
42. Therapies in the Hospitalized HF Patient
Recommendation COR LOE
HF patients hospitalized with fluid overload should be treated with
intravenous diuretics
I B
HF patients receiving loop diuretic therapy, should receive an initial
parenteral dose greater than or equal to their chronic oral daily dose, then
should be serially adjusted
I B
HFrEF patients requiring HF hospitalization on GDMT should continue
GDMT unless hemodynamic instability or contraindications
I B
Initiation of beta-blocker therapy at a low dose is recommended after
optimization of volume status and discontinuation of intravenous agents
I B
Thrombosis/thromboembolism prophylaxis is recommended for patients
hospitalized with HF
I B
Serum electrolytes, urea nitrogen, and creatinine should be measured
during the titration of HF medications, including diuretics
I C
43. Therapies in the Hospitalized HF Patient
(cont.)
Recommendation COR LOE
When diuresis is inadequate, it is reasonable to
a) Give higher doses of intravenous loop diuretics; or
b) add a second diuretic (e.g., thiazide)
IIa
B
B
Low-dose dopamine infusion may be considered with loop diuretics to
improve diuresis
IIb B
Ultrafiltration may be considered for patients with obvious volume
overload
IIb B
Ultrafiltration may be considered for patients with refractory congestion IIb C
Intravenous nitroglycerin, nitroprusside or nesiritide may be considered an
adjuvant to diuretic therapy for stable patients with HF
IIb B
In patients hospitalized with volume overload and severe hyponatremia,
vasopressin antagonists may be considered
IIb B
46. Surgical/Percutaneous/Transcatheter
Interventional Treatment of HF
Recommendation COR LOE
CABG or percutaneous intervention is indicated for HF patients on GDMT with
angina and suitable coronary anatomy especially, significant left main stenosis or left
main equivalent disease
I C
CABG to improve survival is reasonable in patients with mild to moderate LV
systolic dysfunction and significant multivessel CAD or proximal LAD stenosis
when viable myocardium is present
IIa B
CABG or medical therapy is reasonable to improve morbidity and mortality for
patients with severe LV dysfunction (EF <35%), HF and significant CAD
IIa B
Surgical aortic valve replacement is reasonable for patients with critical aortic
stenosis and a predicted surgical mortality of no greater than 10%
IIa B
Transcatheter aortic valve replacement is reasonable for patients with critical aortic
stenosis who are deemed inoperable
IIa B
CABG may be considered in patients with ischemic heart disease, severe LV systolic
dysfunction and suitable coronary anatomy whether or not viable myocardium is
present
IIb B
Transcatheter mitral valve repair or mitral valve surgery for functional mitral
insufficiency is of uncertain benefit
IIb B
Surgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF for
specific indications including intractable HF and ventricular arrhythmias
IIb B
48. Health Related Quality Of Life (HRQOL) &
Functional Status
• Heart Failure significantly decreases health related quality of life
especially in area of physical functioning & vitality.
• Lack of improvement in HRQOL is a powerful predictor of re-
hospitalization & mortality.
• Women have consistently been found to have poor HRQOL than men.
• Pharmacotherapy is not a consistent determinant of HRQOL. ACEI /
ARB’s improve HRQOL only modestly or delay the progressive
worsening of HRQOL in HF.
• CRT is only therapy known to improve HRQOL.
49. Management of Heart Failure
• A substantial genetic risk exists in some patients for development of
HF obtaining a three generation family history of HF is recommended.
• Many therapeutic agents especially anthracycline based
chemotherapeutic agents increases risk of HF. Use of advanced
echocardiographic technique & or biomarkers to identify HF risk is
needed.
50. Management of Heart Failure
(contd…)
• Elevated BP is a major risk factor for development of both
HFpEF & HFrEF, a risk that extends across all age groups.
• Long term treatment of both systolic and diastolic hypertension
reduces the risk of incident HF by 50%.
• Diuretic based antihypertensive therapy has been shown to
prevent HF in wide range of patients.
• Dysglycemia appears to be directly linked to the risk with
HbA1C concentration powerfully predicting incident HF. Those
with HbA1C > 10.5% had a nearly 4 fold increase risk of HF
compared to those with a value of < 6.5%.
51. Management of Heart Failure
(contd…)
• Data on dietary sodium restriction is conflicting. Observational data
suggests an association between dietary sodium intake with fluid
retention and risk for hospitalization.
• Other studies have signaled a worsening neurohormonal profile with
sodium restriction in HF.
• 3 RCT that assessed outcomes with sodium restriction have all shown
that lower sodium intake is associated with worse outcome in HFrEF
(AJC 2009: 103: 93-102, J. CARD Fail 2009: 15; 364)
52. Management of Heart Failure
(contd…)
• Sleep disorders are common in patients with HF. About 61% has
either central or obstructive sleep apnea. HF patients rarely report
daytime sleepiness. High degree of suspicious for sleep disorders
should be maintained for this patients.
• Obesity Paradox – A “U” shaped distribution curve has been
suggested in which mortality is greatest in Cachectic patients, lower in
normal, over weight & mildly obese patients and higher again in more
severely obese patients.
53. Management of Heart Failure
(contd…)
• Diuretics are only drugs used for the treatment of HF that can
adequately control the fluid retention in HF, however their effect on
morbidity and mortality are not known.
• ACEI can reduce risk of death & reduce hospitalization in HFrEF. The
benefits of ACEI are seen in asymptomatic, mild, moderate and severe
LV dysfunction and HF i& in patients with and without CAD.
• ACEI & ARB’s can prevent the development of other risk factor for HF
such as renal dysfunction.
54. Management of Heart Failure
(contd…)
• ACEI should be prescribed to all patients with HFrEF. Unless
contraindication, ACEI are used together with Beta blockers.
• Available data suggests that there are no difference among
available ACEI in their effects on symptom or survival.
• Abrupt withdrawal of treatment with ACEI can lead to clinical
deterioration and should be avoided.
55. Management of Heart Failure –
Guideline 2013
• Long term treatment with beta blockers can lessen the symptom
of HF, improves the clinical status and enhances the patients’
overall sense of well being. Beta blockers reduces the risk of
death.
• Benefits of beta blockers are seen in patients with or without
CAD, with or without DM as well as in women and blacks.
• Beta blockers should be prescribed to an patients with stable
HFrEF unless they have a contraindication to their use or are
intolerant of these drugs.
56. Management of Heart Failure –
Guideline 2013
• Patient need not take high dose of ACEI before initiation of beta
blocker therapy. In patients taking a low dose of ACEI, the
addition of a beta blocker produces a greater improvement in
symptom and reduction in the risk of death than does an
increase in the dose of ACEI even in target doses used in clincal
trials.
• Beta blockers can be safely started before discharge even in
patients hospitalized for HF, provided they do not require IV
Inotropic therapy for HF.
57. Management of Heart Failure –
Guideline 2013
• Three beta blockers (Bisoprolol, sustained release Metoprolol
(succinate) & Carvedilol) have been shown to be effective in
reducing the risk of death in patients with chronic HFrEF.
• There is no beta blocker class effect:
- Bucindolol lacks uniform effectiveness across different
population.
- Short acting Metoprolol tart rate less effective in HF clinical
trials.
- Nebivolol demonstrated modest reduction in primary end
points of mortality and hospitalization
58. Management of Heart Failure –
Guideline 2013
• Up to 30% of patients with CRT fail to experience clinical
improvement.
• There is poor correlation between mechanical & electrical
Dyssynchrony. No leading markers such as QRS width, echo
parameters assessing Dyssynchrony, scar or lead location has
been shown to be fool proof.
• Electrical Dyssynchrony measured by QRS width remains
strongest predictor of response to CRT.
• QRS narrowing after CRT is not seen in all responders and
patients with RBBB do not respond to CRT compared to
patients with LBBB.
59. Heart Failure Guidelines 2013
• Clinical practice guidelines are systemically developed
statements that aim to help Physicians & patients reach the
best healthcare decision.
• Guidelines are not lists of instructions, algorithms or protocols
to be followed verbatim.
• It is not a substitute for astute and conscientious clinical
judgment. There is always an element of interpretation and
judgment that needs to be exercised when adopting any of the
contents into clinical practice.
60. Heart Failure Guidelines 2013
(contd…)
• Major strength being well supported hitherto by good basic science
and pathophysiological research, large RCT & meta analysis.
• Major weakness – Inherent problem in guidelines for translation of
research into clinical practice.
- Generalizability of trial data
- Heterogeneity of response to treatment
- Population versus individuals
- No evidence of benefit or evidence of no benefit ?
70. (B) Subgroup Analysis of the MERIT-HF study suggesting that compared to the
placebo group, the effects of metoprolol were similar amongst patients who received
< 100 and > 100 mg once daily of metoprolol succinate. (C) Comparison of mortality
on metoprolol tartrate and Carvedilol.
71. Device Therapy for Stage C HFrEF:
Recommendations
Class I
1. ICD therapy is recommended for primary prevention of SCD to reduce total
mortality in selected patients with nonischemic DCM or ischemic heart disease
at least 40 days post-MI with LVEF of 35% or less, and NYHA class II or III
symptoms on chronic GDMT, who have reasonable expectation of meaningful
survival for more than 1 year (Level of Evidence: A)
2. CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left
bundle-branch block (LBBB) with a QRS duration of 150 ms or greater, and
NYHA class II, III, or ambulatory IV symptoms on GDMT (Level of Evidence: A for
NYHA Class III / IV; Level of Evidence: B for NYHA class II).
3. ICD therapy is recommended for primary prevention of SCD to reduce total
mortality in selected patients at least 40 days post-MI with LVEF of 30% or
less and NYHA class I symptoms while receiving GDMT, who have
reasonable expectation of meaningful survival for more than 1 year (Level of
Evidence B).
72. Device Therapy for Stage C HFrEF:
Recommendations
(Contd…)
Class IIa
1. CRT can be useful for patients who have LVEF of 35% or less,
sinus rhythm, a non-LBBB pattern with a QRS duration of 150
ms or greater, and NYHA class III/ambulatory class IV
symptoms on GDMT (Level of Evidence: A).
2. CRT can be useful for patients who have LVEF of 35% or less,
sinus rhythm, LBBB with a QRS duration of 120 to 149 ms, and
NYHA class II, III, or ambulatory IV symptoms on GDMT (Level of
Evidence B).
73. Device Therapy for Stage C HFrEF:
Recommendations
(Contd…)
Class IIa
3. CRT can be useful in patients with AF and LVEF of 35% or less
on GDMT if a) the patient requires ventricular pacing or
otherwise meets CRT criteria and b) atrioventricular nodal
ablation or pharmacological rate control will allow near 100%
ventricular pacing with CRT (Level of Evidence: B).
4. CRT can be useful for patients on GDMT who have LVEF of 35%
or less, and are undergoing placement of a new or replacement
device implantation with anticipated requirement for significant
(>40%) ventricular pacing (Level of Evidence: C).
74. Device Therapy for Stage C HFrEF:
Recommendations
(Contd…)
Class IIb
1. The usefulness of implantation of an ICD is of uncertain benefit to
prolong meaningful survival in patients with a high risk of non
sudden death as predicted by frequent hospitalizations, advanced
frailty, or co-morbidities such as systemic malignancy or severe
renal dysfunction (Level of Evidence: B).
2. CRT may be considered for patients who have LVEF of 35% or
less , sinus rhythm, a non-LBBB pattern with a QRS duration of
120 to 149 ms, and NYHA class III / ambulatory class IV on
GDMT (Level of Evidence B).
3. CRT may be considered for patients who have LVEF of 35% or
less, sinus rhythm, a non-LBBB pattern with a QRS duration of
150 ms or greater and NYHA class II symptoms on GDMT (Level
of Evidence B)
75. Device Therapy for Stage C HFrEF:
Recommendations
(Contd…)
Class IIb
4. CRT may be considered for patients who have LVEF
of 30% or less, ischemic etiology of HF, sinus rhythm,
LBBB with a QRS duration of 150 ms or greater, and
NYHA class I symptoms on GDMT (Level of Evidence C).
76. Device Therapy for Stage C HFrEF:
Recommendations
(Contd…)
Class III: No benefit
1. CRT is not recommended for patients with NYHA class I or II
symptoms and non-LBBB pattern with QRS duration less than
150 ms (Level of Evidence: B)
2. CRT is not recommended for patients whose co-morbidities and
/ or frailty limit survival with good functional capacity to less than
1 year (Level of Evidence: C)
77. 1. Severe symptoms of HF with dyspnea and / or fatigue at rest or
with minimal exertion (NYHA class III or IV)
2. Episodes of fluid retention (pulmonary and / or systemic
congestion, peripheral edema) and / or reduced cardiac output at
rest (peripheral hypoperfusion)
3. Objective evidence of severe cardiac dysfunction shown by at
least 1 of the following:
a) LVEF < 30%
b) Pseudonormal or restrictive mitral inflow pattern
c) Mean PCWP > 16 mm Hg and / or RAP > 12 mm Hg by PA
catheterization
d) High BNP or NT-proBNP plasma levels in the absence of non-
cardiac causes.
ESC Definition of Advanced HF
78. 4. Severe impairment of functional capacity shown by 1 of the
following:
a) Inability to exercise
b) 6-Minute walk distance < 300 m
c) Peak Vo2 < 12 to 14 mL/kg/min
5. History of > 1 HF hospitalization in past 6 months
6. Presence of all the previous features despite “attempts to optimize”
therapy, including diuretics and GDMT, unless these are poorly
tolerated or contraindicated, and CRT when indicated.
ESC Definition of Advanced HF
(contd…)
83. OMEGA-3 Fatty Acid in Heart Failure
• Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of n-3 poly-
unsaturated fatty acids in patients with chronic heart failure (the
GISSI-HF trial): a radomized, double-blind, placebo-controlled
trial. Lancet 2008: 372: 1223 – 30.
• Lavie CJ, Milani RV, Mehra MR, et al. Omega-3
polyunsaturated fatty acids and cardiovascular diseases. J Am
Coll Cardiol 2009: 54: 585-94
84. OMEGA-3 Fatty Acid in Heart Failure
(contd…)
• Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto
mio-cardico. Dietary supplementation with n-3 polyunsaturated
fatty acids and Vitamin E after myocardial infarction: results of
the GISSI-Prevenzione trial. Lancet 1999; 354:447-55.
• Nodari S, Triggiani M, Campia U, et al. Effects of n-3
polyunsaturated fatty acids on left ventricular function and
functional capacity in patients with dilated cardiomyopathy. J
Am Coll Cardiol 2011; 57: 870-9.
85. Statins in Heart Failure
• Kjekshus J. Apetrei E. Barrios V, et al. Rosuvastatin in older
patients with systolic heart failure. N Engl J Med 2007: 357:
2248 – 61.
• Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of
rosuvastatin in patients with chronic heart failure (the GISSI –
HF trial): a randomized, double-blind, placebo-controlled trial.
Lancet 2008: 372: 1231 – 9.
86. Omega-3 Fatty Acids: Recommendation
Class IIa
Omega-3 polyunsaturated fatty acid (PUFA) supplementation is
reasonable to use as adjunctive therapy in patients with NYHA
class II-IV symptoms and HFrEF or HFpEF, unless
contraindicated, to reduce mortality and cardiovascular
hospitalizations (Level of Evidence: B)
87. Statins: Recommendation
Class III: No benefit
Statins are not beneficial as adjunctive therapy when
prescribed solely for the diagnosis of HF in the
absence of other indications for their use (Level of
Evidence: A)
88. Anticoagulation : Recommendation
Class I
1. Patients with chronic HF with permanent / persistent /
paroxysmal AF and an additional risk factor for cardioembolic
stroke (history of hypertension, diabetes mellitus, previous stroke
or transient ischemic attack, or > 75 years of age) should receive
chronic anticoagulant therapy (Level of Evidence: A)
2. The selection of an anticoagulant agent (warfarin, dabigatran,
apixaban, or rivaroxaban) for permanent / persistent / paroxysmal
AF should be individualized on the basis of risk factors, cost,
tolerability, patient preference, potential for drug interactions, and
other clinical characteristics, including time in the international
normalized ratio therapeutic range if the patient has been taking
warfarin (Level of Evidence: C)
89. Anticoagulation : Recommendation
(Contd…)
Class IIa
Chronic anticoagulation is reasonable for patients with chronic
HF who have permanent / persistent / paroxysmal AF but are
without an additional risk factor for cardioembolic stroke (Level
of Evidence: B)
Class III: No benefit
Anticoagulation is not recommended in patients with chronic
HFrEF without AF, a prior thromboembolic event, or a
cardioembolic source (Level of Evidence: B)
90. Class I
A patient admitted to the hospital with de-compensated
HF should receive venous thromboembolism
prophylaxis with an anticoagulant medication if the risk-
benefit ratio is favourable (Level of Evidence: B).
Venous Thrombo embolism Prophylaxis in
Hospitalized Patients: Recommendation
91. Treatment of Sleep Disorders:
Recommendation
Class IIa
Continuous positive airway pressure
can be beneficial to increase LVEF and
improve functional status in patients
with HF and sleep apnea
(Level of Evidence: B)
92. Stages, Phenotypes and Treatment of HF
STAGE A
At high risk for HF but
without structural heart
disease or symptoms of HF
STAGE B
Structural heart disease
but without signs or
symptoms 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 valvular
surgery as appropriate
STAGE C
Structural heart disease
with prior or current
symptoms of HF
THERAPY
Goals
· 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 D
Refractory 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 as
appropriate
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPY
Goals
· 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
Refractory
symptoms of HF
at rest, despite
GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Development of
symptoms of HF
Structural heart
disease
98. Pharmacological Treatment for
Stage C HFrEF (cont.)
Aldosterone receptor antagonists [or mineralocorticoid
receptor antagonists (MRA)] are recommended in
patients with 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 prior cardiovascular hospitalization or elevated
plasma natriuretic peptide levels to be considered for
aldosterone receptor antagonists. Creatinine should be
2.5 mg/dL or less in men or 2.0 mg/dL or less in women
(or estimated glomerular filtration rate >30
mL/min/1.73m2) and potassium should be less than 5.0
mEq/L. Careful monitoring of potassium, renal function,
and diuretic dosing should be performed at initiation and
closely followed thereafter to minimize risk of
hyperkalemia and renal insufficiency.
I IIa IIb III
99. Pharmacological Treatment for
Stage C HFrEF (cont.)
Aldosterone receptor antagonists are recommended
to reduce morbidity and mortality following an acute
MI in patients who have LVEF of 40% or less who
develop symptoms of HF or who have a history of
diabetes mellitus, unless contraindicated.
Inappropriate use of aldosterone receptor antagonists
is potentially harmful because of life-threatening
hyperkalemia or renal insufficiency when serum
creatinine greater than 2.5 mg/dL in men or greater
than 2.0 mg/dL in women (or estimated glomerular
filtration rate <30 mL/min/1.73m2), and/or potassium
above 5.0 mEq/L.
I IIa IIb III
I IIa IIb III
Harm
100. Pharmacological Treatment for
Stage C HFrEF (cont.)
The combination of hydralazine and isosorbide
dinitrate is recommended to reduce morbidity and
mortality for patients self-described as African
Americans with NYHA class III–IV HFrEF receiving
optimal therapy with ACE inhibitors and beta blockers,
unless contraindicated.
A combination of hydralazine and isosorbide dinitrate
can be useful to reduce morbidity or mortality in
patients with current or prior symptomatic HFrEF who
cannot be given an ACE inhibitor or ARB because of
drug intolerance, hypotension, or renal insufficiency,
unless contraindicated.
I IIa IIb III
I IIa IIb III
101. Pharmacological Treatment for
Stage C HFrEF (cont.)
Digoxin can be beneficial in patients with HFrEF,
unless contraindicated, to decrease hospitalizations
for HF.
Patients with chronic HF with permanent/persistent/
paroxysmal AF and an additional risk factor for
cardioembolic stroke (history of hypertension,
diabetes mellitus, previous stroke or transient
ischemic attack, or ≥75 years of age) should receive
chronic anticoagulant therapy (in the absence of
contraindications to anticoagulation).
I IIa IIb III
I IIa IIb III
102. Pharmacological Treatment for
Stage C HFrEF (cont.)
The selection of an anticoagulant agent (warfarin,
dabigatran, apixaban, or rivaroxaban) for
permanent/persistent/paroxysmal AF should be
individualized on the basis of risk factors, cost,
tolerability, patient preference, potential for drug
interactions, and other clinical characteristics,
including time in the international normalized rate
therapeutic ration if the patient has been taking
warfarin.
Chronic anticoagulation is reasonable for patients
with chronic HF who have
permanent/persistent/paroxysmal AF but are without
an additional risk factor for cardioembolic stroke (in
the absence of contraindications to anticoagulation).
I IIa IIb III
I IIa IIb III
103. Pharmacological Treatment for
Stage C HFrEF (cont.)
Anticoagulation is not recommended in patients with
chronic HFrEF without AF, a prior thromboembolic
event, or a cardioembolic source.
Statins are not beneficial as adjunctive therapy when
prescribed solely for the diagnosis of HF in the
absence of other indications for their use.
Omega-3 polyunsaturated fatty acid (PUFA)
supplementation is reasonable to use as adjunctive
therapy in patients with NYHA class II-IV symptoms
and HFrEF or HFpEF, unless contraindicated, to
reduce mortality and cardiovascular hospitalizations.
I IIa IIb III
No Benefit
I IIa IIb III
No Benefit
I IIa IIb III
104. Pharmacological Treatment for
Stage C HFrEF (cont.)
Nutritional supplements as treatment for HF are not
recommended in patients with current or prior
symptoms of HFrEF.
Hormonal therapies other than to correct deficiencies
are not recommended for patients with current or prior
symptoms of HFrEF.
Drugs known to adversely affect the clinical status of
patients with current or prior symptoms of HFrEF are
potentially harmful and should be avoided or
withdrawn whenever possible (e.g., most
antiarrhythmic drugs, most calcium channel blocking
drugs (except amlodipine), NSAIDs, or TZDs).
No Benefit
I IIa IIb III
I IIa IIb III
I IIa IIb III
No Benefit
Harm
105. Pharmacological Treatment for
Stage C HFrEF (cont.)
Long-term use of infused positive inotropic drugs is
potentially harmful for patients with HFrEF, except as
palliation for patients with end-stage disease who
cannot be stabilized with standard medical treatment
(see recommendations for stage D).
Calcium channel blocking drugs are not
recommended as routine treatment for patients with
HFrEF.
Harm
I IIa IIb III
I IIa IIb III
No Benefit
106. Arginine Vasopressin Antagonists
In patients hospitalized with volume overload,
including HF, who have persistent severe
hyponatremia and are at risk for or having
active cognitive symptoms despite water
restriction and maximization of GDMT,
vasopressin antagonists may be considered
in the short term to improve serum sodium
concentration in hypervolemic, hyponatremic
states with either a V2 receptor selective or a
nonselective vasopressin antagonist.
I IIa IIb III
107. 2013 Guidelines for cardiac resynchronization therapy in
patients with systolic heart failure
Recommendations Selection Criteria
Class I EF < 35%, QRS > 120
ms, optimal medical
management
SR NYHA class III – IV
Class II a Same AF or frequent
VP
Same
Class II b Same SR, AF,
Frequent VP
NYHA class I – II
Class III (cardiac
resynchronization
therapy not
recommended)
Asymptomatic patients with reduced EF in the absence of
other indications for pacing or in patients whose life
expectancy and functional status are limited by non-cardiac
conditions
Editor's Notes
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Recommendations for Inotropic Support, MCS, and Cardiac Transplantation
Recommendations for Inotropic Support, MCS, and Cardiac Transplantation