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Acc Aha Guidelines Chronic Heart Failure
Acc Aha Guidelines Chronic Heart Failure
Acc Aha Guidelines Chronic Heart Failure
Slide Deck
Based on the ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult January 2006
Heart Failure is a Major and Growing Public Health Problem in the U.S.
Approximately 5 million patients in this country have HF Over 550,000 patients are diagnosed with HF for the first time each year
Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year
In 2001, nearly 53,000 patients died of HF as a primary cause
More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare
Guideline Scope
Document focuses on :
Prevention of HF Diagnosis and management of chronic HF in the adult
HF is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
Because not all patients have volume overload at the time of initial or subsequent evaluation, the term heart failure is preferred over the older term congestive heart failure.
For a substantial proportion of patients, causes are: 1. 2. 3. Coronary artery disease Hypertension Dilated cardiomyopathy
Stage A
Patients at High Risk for Developing Heart Failure
Stage A Therapy
Recommended Therapies to Reduce Risk Include:
Treating known risk factors (hypertension, diabetes, etc.) with therapy consistent with contemporary guidelines Avoiding behaviors increasing risk (i.e., smoking excessive consumption of alcohol, illicit drug use) Periodic evaluation for signs and symptoms of HF Ventricular rate control or sinus rhythm restoration Noninvasive evaluation of LV function Drug therapy Angiotensin Converting Enzyme Inhibitors (ACEI) Angiotensin Receptor Blockers (ARBs)
Stage B
Patients with Asymptomatic LV Dysfunction
Stage B Therapy
Recommended Therapies:
General Measures as advised for Stage A Drug therapy for all patients ACEI or ARBs Beta-Blockers ICDs in appropriate patients Coronary revascularization in appropriate patients Valve replacement or repair in appropriate patients
Stage B Therapy
General Measures
All Class I recommendations for Stage A should apply to patients with cardiac structural abnormalities who have not developed HF. (Levels of Evidence: A, B, and C as appropriate)
Patients who have not developed HF symptoms should be treated according to contemporary guidelines after an acute MI.
ACEI should be used in patients with a reduced EF and no symptoms of HF, even if they have not experienced MI.
ACEI or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF.
Stage B Therapy
ARBs can be beneficial in patients with low EF and no symptoms of HF who are intolerant of ACEIs.
Stage B Therapy
Beta-Blockers
Beta-blockers and ACEIs should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF. Beta-blockers are indicated in all patients without a history of MI who have a reduced LVEF with no HF symptoms.
Stage B Therapy
Stage B Therapy
Coronary Revascularization
Coronary revascularization should be recommended in appropriate patients without symptoms of HF in accordance with contemporary guidelines (see ACC/AHA Guidelines for the Management of Patients With Chronic Stable Angina).
Stage B Therapy
Valve Replacement/Repair
Valve replacement or repair should be recommended for patients with hemodynamically significant valvular stenosis or regurgitation and no symptoms of HF in accordance with contemporary guidelines.
Stage B Therapy
Stage C
Stage C Therapy
(Reduced LVEF with Symptoms)
Recommended Therapies:
General measures as advised for Stages A and B Drug therapy for all patients Diuretics for fluid retention ACEI Beta-blockers Drug therapy for selected patients Aldosterone Antagonists ARBs Digitalis Hydralazine/nitrates ICDs in appropriate patients Cardiac resynchronization in appropriate patients Exercise Testing and Training
Stage C Therapy
(Reduced LVEF with Symptoms)
General Measures
Measures listed as Class I recommendations for patients in stages A and B are also appropriate for patients in Stage C. (Levels of Evidence: A, B, and C as appropriate)
Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs).
Stage C Therapy
(Reduced LVEF with Symptoms)
Diuretics
Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention.
Stage C Therapy
(Reduced LVEF with Symptoms)
Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.
Stage C Therapy
(Reduced LVEF with Symptoms)
ARBs are reasonable to use as alternatives to ACEIs as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications.
Stage C Therapy
(Reduced LVEF with Symptoms)
ARBs (contd)
The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy.
Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patientswith current or prior symptoms of HF and reduced LVEF.
Stage C Therapy
(Reduced LVEF with Symptoms)
Aldosterone Antagonists
Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be less than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should be less than 5.0 mEq/L. Under circumstances where monitoring for hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists.
Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.
Stage C Therapy
(Reduced LVEF with Symptoms)
Beta-Blockers
Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated.
Stage C Therapy
(Reduced LVEF with Symptoms)
Digitalis
Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF.
Stage C Therapy
(Reduced LVEF with Symptoms)
A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an ACEI or ARB because of drug intolerance, hypotension, or renal insufficiency.
Stage C Therapy
(Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
ICDs (contd)
ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with nonischemic cardiomyopathy who have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. Placement of an ICD is reasonable in patients with LVEF of 30% to 35% of any origin with NYHA functional class II or III symptoms who are taking chronic optimal medical therapy and who have reasonable expectation of survival with good functional status of more than 1 year.
Stage C Therapy
(Reduced LVEF with Symptoms)
Cardiac Resynchronization
Patients with LVEF less than or equal to 35%, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration greater than 120 ms, should receive cardiac resynchronization therapy unless contraindicated.
Stage C Therapy
(Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Diuretics
Physicians should use diuretics to control pulmonary congestion and peripheral edema in patients with HF and normal LVEF.
Stage C Therapy
(Normal LVEF with Symptoms)
Coronary Revascularization
Coronary revascularization is reasonable in patients with HF and normal LVEF and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function.
Stage C Therapy
(Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Beta-Blockers
The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF.
Stage C Therapy
(Normal LVEF with Symptoms)
Digitalis
The usefulness of digitalis to minimize symptoms of HF in patients with HF and normal LVEF is not well established.
Stage D
Patients with Refractory End-Stage HF
Stage D Therapy
Recommended Therapies Include:
Control of fluid retention Referral to a HF program for appropriate pts Discussion of options for end-of-life care Informing re: option to inactivate defibrillator Device use in appropriate patients Surgical therapy Cardiac transplantation Mitral valve repair or replacement Other Drug Therapy Positive inotrope infusion as palliation in appropriate patients
Stage D Therapy
Stage D Therapy
Stage D Therapy
Stage D Therapy
Surgical Therapy
Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF.
The effectiveness of mitral valve repair or replacement is not established for severe secondary mitral regurgitation in refractory end-stage HF.
Stage D Therapy
Device Use
Consideration of an LV assist device as permanentor destination therapy is reasonable in highly selected patients with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy.
Pulmonary artery catheter placement may be reasonable to guide therapy in patients with refractory end-stage HF and persistently severe symptoms.
Stage D Therapy
Medical Therapy
Continuous intravenous infusion of a positive inotropic agent may be considered for palliation of symptoms in patients with refractory end-stage HF.
Routine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF.
Stage D Therapy
Routine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF.