Heart Failure ACC AHA Guidelines for the Evaluation and

Heart Failure ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult David Stagaman, MD, FACC Rockwood Clinic Cardiology Complex clinical syndrome that can result from any structural or functional cardiac disorder that can impair the ability of the ventricle to fill with or eject blood Heart Failure vs. Congestive Heart Failure Because not all patients have volume overload at time of evaluation Introduction-Characterization of Heart Failure as a Clinical Syndrome A. HF as a Symptomatic Disorder B. HF as a Progressive Disorder Pathophysiologic Mechanisms Cardiac abnormalities hypertrophy necrosis fibrosis apoptosis ischemia Functional Abnormalities Mitral regurgitation Ischemic or hibernating myocardium Atrial and ventricular arrythmias Altered ventricular interaction 1 Biologically active circulating substances Renin-angiotensin-aldosterone Sympathetic nervous system (norepinephrine) Natriuretic peptides Cytokines Vasopressin Vasodilators ( bradykinin, nitric oxide) Other Factors Genetics Environmental toxins ( alcohol, chemo,drugs) Coexisting conditions ( D.M., HTN, CAD, Renal, Anemia, vitamins, sleep apnea, depression) Ventricular Remodeling after Infarction (Panel A) and in Diastolic and Systolic Heart Failure (Panel B) Primary Targets of Treatment in Heart Failure Jessup, M. et al. N Engl J Med 2003;348:2007-2018 Jessup, M. et al. N Engl J Med 2003;348:2007-2018 Therapy A. Patients at High Risk of Developing Left Ventricular Dysfunction 1. Control of Risk 2. Early Detection of HF Therapy (cont.) C. B. Patients with Left Ventricular Dysfunction Who Have Not Developed Symptoms (Stage B 1. Prevention of Cardiovascular Events 2. Early Detection of HF Patients with Left Ventricular Dysfunction with Current or Prior Symptoms 1. General Measures 2. Drugs Recommended for Routine Use 3. Interventions to be Considered for Use in Selected Patients 4. Drugs and Interventions Under Active Investigation 5. Drugs and Interventions of Unproved Value and Not Recommended 2 Therapy (cont.) D. Device Therapy Prophylactic ICD Biventricular resynchronization pacing Patients with Refractory End Stage HF 1. Management of Fluid Status 2. Utilization of Neurohormonal Inhibitors 3. Intravenous Peripheral Vasodilators and Positive Inotropic Agents 4. Mechanical and Surgical Strategies Prophylactic ICD Placement In patients with and without CAD LVEF<35% NYHA II-III Not recommended in chronic severe refractory HF Evidence Four large trials (>1000 patients) Madit II Ischemic cardiomyopathy ( prior M.I.) Average duration 6.5 years EF 23% Mortality 19.8% placebo, 14.2% ICD, 31% decrease SCD-HEFT Ischemic and non- ischemic CM(not class IV) Average duration 2 years EF 25% Mortality 7.2% placebo, 5.5% ICD(23% decrease) Most effective in class II patients 3 CABG-PATCH EF<30% ICD no benefit DINAMIT M.I. 6-40 days EF<35% (average 28%) 2.5 year follow up No mortality benefit Biventricular Resynchronization Pacing For patients with sinus rhythm QRS > 120 msec EF <35%; LV dilated > 5.5 cm Persistent, moderate to severe HF(class III), despite optimal medical therapy Biventricular Pacing Selected class IV patients may be considered Response rate 60-75% CARE-HF Trial 800 patients Mortality decrease 30%-20% Mean follow up 29 months EF increase 3% AFIB excluded Differential Diagnosis in Patient with HF and Normal LVEF with Symptoms Incorrect diagnosis of HF Inaccurate measurement of LVEF Primary valvular disease Restrictive (infiltrative) cardiomyopathies Amyloidosis, sarcoidosis, hemochromatosis Pericardial constriction Episodic or reversible LV systolic dysfunction Severe hypertension, myocardial ischemia • • • • • • • HF associated with high metabolic demand (high-output states) Anemia, thyrotoxicosis, arteriovenous fistulae Chronic pulmonary disease with right HF Pulmonary hypertension associated with pulmonary vascular disorders Atrial myxoma Diastolic dysfunction of uncertain origin Obesity 4 BNP There is no diagnostic test for heart failure Useful in the diagnosis of acutely decompensated heart failure No physiologic range for BNP established ( women, renal factors, AFIB) BNP Serial measurements ? Other causes of LV stretch ( ischemia, arrythmia, HTN) ? Sensitive but not specific test Most useful when negative(like DDimer) Team Management The Nuts and Bolts of Congestive Heart Failure Patient’s Partner Patient Nurse M.D. Vitals - Diet - Exercise - Drugs - Diuretic Use - Identify Patient’s CHF Symptoms Drugs to Avoid Pletal Theophylline NSAID’s Calcium Blockers Antiarrhythmics Actos, Avandia 5 Dose Titration ACE Inhibitors Digoxin Aldactone Beta Blockers Diuretic Titration Nocebo Effect 6