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Heart Failure: ACC Heart Failure: ACC Guidelines for Dx and Guidelines for Dx and
ManagementManagement
Steven W. Harris MHS PACSteven W. Harris MHS PAC
EpidemiologyEpidemiology
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
EpidemiologyEpidemiology
The incidence of HF approaches 10 per 1000 population after age 65
HF is the most common Medicare diagnosis-related group
More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare
ACC GuidelinesACC Guidelines
Focus on : Prevention of HF Diagnosis and management of chronic HF
in the adult.
DefinitionDefinition
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.”
• Use terms: Compensated Heart Failure: euvolemic Decompensated Heart Failure: fluid overload
EtiologyEtiology
For a substantial proportion of patients, causes are:
Coronary artery disease Hypertension Dilated cardiomyopathy
Signs and SymptomsSigns and Symptoms
? ? ? ? ? ? ? ? ? ? ? ? ??
SymptomsSymptoms
Decreased Perfusion:Decreased Perfusion:• WeaknessWeakness• FatigueFatigue• ConfusionConfusion• RestlessnessRestlessness• AnxietyAnxiety• PalpitationsPalpitations• Cold ExtremitiesCold Extremities
SymptomsSymptoms
Increased LV preload:Increased LV preload:• DOEDOE• PNDPND• Cough: often positionalCough: often positional• WheezeWheeze• OrthopneaOrthopnea• Abdominal DistensionAbdominal Distension• edemaedema
SignsSigns
Increased Preload/Decreased perfusionIncreased Preload/Decreased perfusion Pedal edemaPedal edema Hepatic congestionHepatic congestion JVDJVD RalesRales WheezingWheezing S3 S3 TachycardiaTachycardia CyanosisCyanosis Cold extremitiesCold extremities
New York Heart Association New York Heart Association ClassesClasses
NYHA I: NYHA I: no symptomsno symptoms w/ physical activity, w/ physical activity, but known diseasebut known disease
NYHA II: NYHA II: slight limitationsslight limitations, symptoms w/ , symptoms w/ normal activities, but able to walk 3 blocksnormal activities, but able to walk 3 blocks
NYHA III: symptoms w. minimal activity and NYHA III: symptoms w. minimal activity and marked limitation of activitymarked limitation of activity
NYHA IV: symptoms NYHA IV: symptoms at restat rest and any activity and any activity
Stages of Heart FailureStages of Heart Failure
Designed to emphasize preventability of HF through treatment therapies.
Designed to recognize the progressive nature of LV dysfunction.
Stages of HFStages of HF
COMPLEMENT, DO NOT REPLACE NYHA CLASSES
NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)
Stages - progress in one direction due to cardiac remodeling
Stages of HFStages of HF
At Risk for Heart Failure: STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction Heart Failure: STAGE C Past or current symptoms of
HF STAGE D End-stage HF
Management of Patients with Known Atherosclerotic Disease But No HF
Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest.
Placebo
Ramipril
Placebo
Perindopril
20% rel. risk red. p = .0003
22% rel. risk red. p < .001
HOPE
EUROPA
NEJM 2000;342:145-53 (HOPE).
Lancet 2003;362:782-8 (EUROPA).
02468
10121416
0 1 2 3 4
Years
% MI,Stroke,
CV Death
0
3
6
9
12
15
0 1 2 3 4 5
Years
% MI,CV Death,
Cardiac Arrest
ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative
Val-HeFT
Valsartan
Placebo
p = 0.017
Months
Su
rviv
al %
CV
Dea
th o
r H
F H
osp
%
Placebo
Candesartan
CHARM-Alternative
HR 0.77, p = 0.0004
Months
Maggioni AP et al. JACC 2002;40:1422-4.Granger CB et al. Lancet 2003;362:772-6.
50
60
70
80
90
100
0 3 6 9 12 15 18 21 24 270
10
20
30
40
50
0 9 18 27 36 42
0000
2020
1010
% o
f P
atie
nts
Wit
h E
ven
t%
of
Pat
ien
ts W
ith
Eve
nt
22 44 66 88
Carvedilol
Placebo
HR = 0.67 (CI = 0.47HR = 0.67 (CI = 0.47--0.96)0.96)
Weeks After RandomizationWeeks After Randomization
3030
COPERNICUS: Death, Hospitalization, or Study Drug Withdrawal in High Risk Patients
Krum H et al. JAMA 2003;289:754-6.
Stage A: at risk for HFStage A: at risk for HF
TherapyTherapy Treat Hypertension Treat Hypertension Encourage Smoking cessationEncourage Smoking cessation Treat lipid disordersTreat lipid disorders Encourage regular exerciseEncourage regular exercise Discourage ETOH, drugsDiscourage ETOH, drugs Control Metabolic SyndromeControl Metabolic Syndrome ACE or ARB in appropriate patents for vasc dz or ACE or ARB in appropriate patents for vasc dz or
diabetesdiabetes
Stage B: Structural disease/No SxStage B: Structural disease/No Sx
Therapy:Therapy: All measures under Stage AAll measures under Stage A ACE or ARB in appropriate patientsACE or ARB in appropriate patients Beta-blockers in appropriate patientsBeta-blockers in appropriate patients ICDs in appropriate patientsICDs in appropriate patients
Stage C: Structural Disease with Stage C: Structural Disease with current or prior sx current or prior sx
TherapyTherapy:: All measures under Stages A and BAll measures under Stages A and B Routine UseRoutine Use
• ACE, Beta-blockerACE, Beta-blocker• Diuretics for fluid retentionDiuretics for fluid retention
Selected PatientsSelected Patients• Aldosterone antagonistAldosterone antagonist• ARBARB• DigitalisDigitalis• Hydralazine/nitratesHydralazine/nitrates
Devices: BI-V, ICDDevices: BI-V, ICD
Stage D: refractory HFStage D: refractory HF
TherapyTherapy All measures from stages A, B, CAll measures from stages A, B, C Decision: Decision:
• Appropriate level of careAppropriate level of care• Compassionate end-of-life careCompassionate end-of-life care• TransplantTransplant• Chronic Inotropes: neo, epi, dopamine.Chronic Inotropes: neo, epi, dopamine.• Permanent Mechanical Support: LVADPermanent Mechanical Support: LVAD• Experimental surgery /drugs. Experimental surgery /drugs.
DevicesDevices
An implantable cardioverter-defibrillator An implantable cardioverter-defibrillator (ICD) for secondary prevention to prolong (ICD) for secondary prevention to prolong survival in patients with a history of cardiac survival in patients with a history of cardiac arrest, ventricular fibrillation, or arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular hemodynamically destabilizing ventricular tachycardia. tachycardia.
DevicesDevices
An ICD for primary prevention to reduce An ICD for primary prevention to reduce total mortality by preventing sudden cardiac total mortality by preventing sudden cardiac death (SCD) in patients with death (SCD) in patients with ischemic heart ischemic heart diseasedisease who meet the following criteria: at who meet the following criteria: at least least 40 days40 days post-myocardial infarction, an post-myocardial infarction, an LVEF 30 percentLVEF 30 percent, New York Heart , New York Heart Association functional class II or III Association functional class II or III symptoms despite optimal chronic medical symptoms despite optimal chronic medical therapy, and a reasonable expectation of therapy, and a reasonable expectation of survival with a good functional status for survival with a good functional status for more than one year.more than one year.
DevicesDevices
An ICD for primary prevention to reduce An ICD for primary prevention to reduce total mortality by preventing SCD in patients total mortality by preventing SCD in patients with with nonischemic cardiomyopathynonischemic cardiomyopathy who meet who meet the following criteria: an the following criteria: an LVEF less than 30LVEF less than 30 percent, New York Heart Association percent, New York Heart Association functional class II or III symptoms despite functional class II or III symptoms despite optimal chronic medical therapy, and a optimal chronic medical therapy, and a reasonable expectation of survival with a reasonable expectation of survival with a good functional status for more than one good functional status for more than one year. year.
DevicesDevices
Cardiac resynchronization therapy, Cardiac resynchronization therapy, unless contraindicated, in patients who unless contraindicated, in patients who meet the following criteria: cardiac meet the following criteria: cardiac dyssynchrony as defined by a dyssynchrony as defined by a QRS QRS duration >120duration >120 msec, msec, LVEF 35 percentLVEF 35 percent, , sinus rhythm, and New York Heart sinus rhythm, and New York Heart Association functional class III or Association functional class III or ambulatory class IV symptoms despite ambulatory class IV symptoms despite optimal chronic medical therapy. optimal chronic medical therapy.
Patient SurveilancePatient Surveilance
MAWDSMAWDS MedicineMedicine ActivityActivity WeightWeight DietDiet SymptomsSymptoms
CASE 1CASE 1
56 y/o female 56 y/o female DMDM BP 146/84BP 146/84 LDL 150LDL 150 Non-smokerNon-smoker Exercises dailyExercises daily
Case 2Case 2
63 y/o male63 y/o male AWMI 1 year agoAWMI 1 year ago EF 28%EF 28% DiabeticDiabetic BP 128/72BP 128/72 SmokerSmoker DOE with strenuous activityDOE with strenuous activity
Case 3Case 3
44 y/o male44 y/o male DMDM CHD, prior Inferior MICHD, prior Inferior MI EF 46%EF 46% BP 132/78BP 132/78 Walks daily. Unable to walk up inclines.Walks daily. Unable to walk up inclines. C/o LE edema and weight gain of 10 lbsC/o LE edema and weight gain of 10 lbs
Case 4Case 4
60 y/o female60 y/o female H/o BRCA treated with adriamycinH/o BRCA treated with adriamycin BP 110/68 on ACE, CoregBP 110/68 on ACE, Coreg EF 30%EF 30% Non-diabeticNon-diabetic Symptoms with minimal activitySymptoms with minimal activity LBBBLBBB
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