DEFINITION of HEART FAILURE

Heart Failure is a pathophysiological state in which an abnormality of cardiac function to pump the blood at a rate commensurate with requirements of metabolizing tissue.

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1528

Epidemiology
Europe The prevalence of symptomatic HF range from 0.4-2%. 10 million HF pts in 900 million total population

USA

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

nearly 5 million HF pts. 500,000 pts are D/ HF for the 1st time each year. Last 10 years number of hospitalizations has increased. Nearly 300,000 patients die of HF each year.
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

Aims of treatment 1. Prevention

a) Prevention and/or controlling of diseases leading to cardiac dysfunction and heart failure b) Prevention of progression to heart failure once cardiac dysfunction is established

2. Morbidity
Maintenance or improvement in quality of life

3. Mortality
Increased duration of life
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Management outline
Establish that the patient has HF. Ascertain presenting features: pulmonary oedema, exertional breathlessness, fatigue, peripheral oedema Assess severity of symptoms Determine aetiology of heart failure Identify precipitating and exacerbating factors Identify concomitant diseases Estimate prognosis Anticipate complications Counsel patient and relatives Choose appropriate management Monitor progress and manage accordingly
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

New York Heart Association (NYHA) Classification of Heart Failure Class I Class II Class - III Class - IV
No limitation : ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations. Slight limitation of physical activity : comfortable at rest but ordinary activity results in fatigue, dyspnoea, or palpitation. Marked limitation of physical activity : comfortable at rest but less than ordinary activity results in symptoms.

Unable to carry out any physical activity without discomfort : symptoms of heart failure are present even at rest with increased discomfort with any physical activity.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1531

ACC/AHA A New Approach To The Classification of HF

Stage
A

Descriptions
Patient who is at high risk for developing HF but has no structural disorder of the heart. Patient with a structural disorder of the heart but who has never developed symptoms of HF. patient with past or current symptoms of HF associated with underlying structural heart disease. Patient with end-stage disease

Examples
Hypertension; CAD; DM; rheumatic fever; cardiomyopathy. LV hypertrophy or fibrosis; LV dilatation; asymptomatic VHD; MI. Dyspnea or fatigue ec LV systolic dysfunction; asymptomatic patients with HF. Frequently hospitalized pts ; pts awaiting heart transplantation etc

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

Algorithm for the Diagnosis of Heart Failure

Guidelines for the diagnosis and treatment of chronic heart failure

Suspected Heart Failure Because of symptoms and signs Assess presence of cardiac diseases by ECG, X-ray or Natriuretic peptide (where available) Test Abnormal Imaging by Echocardiography (Nuclear angiography or MRI Where available) Test Abnormal Assess etiology, degree, precipitating Factors and type of cardiac dysfunction Choose Therapy

European Heart Journal (2001) 22, 1530

Normal Heart Failure Unlickely

Normal Heart Failure Unlickely

Additonal diagnosis tests where appropriate (e.g. coronary angiography)

Stages in the evolution of HF and recommended therapy by stage

Stage A
Pts with : Hypertension CAD DM Cardiotoxins FHx CM

Stage B
Pts with : Previous MI LV systolic dysfunction Asymptomatic Valvular disease

Stage C
Pts with : Struct. HD

Stage D
Pts who have marked symptoms at rest despite maximal medical therapy.

Struct. Heart Disease

Develop Symp.of HF

Refract. Shortness of Symp.of breath and fatigue, HF at rest

reduce exercise tolerance

THERAPY Treat Hypertension Stop smoking Treat lipid disorders Encourage regular exercise Stop alcohol & drug use ACE inhibition

THERAPY All measures under stage A ACE inhibitor Beta-blockers

THERAPY All measures under stage A Drugs for routine use: diuretic ACE inhibitor Beta-blockers digitalis

THERAPY All measures under stage A,B and C Mechanical assist device Heart transplantation Continuous IV inotrphic infusions for palliation

ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2001

Treatment options
Non-pharmacological management General advice and measures Exercise and exercise training
Pharmacological therapy Angiotensin-converting enzyme (ACE) inhibitors Diuretics Beta-adrenoceptor antagonists Aldosterone receptor antagonists Angiotensin receptor antagonists Cardiac glycosides Vasodilator agents (nitrates/hydralazine) Positive inotropic agents Anticoagulation Antiarrhythmic agents Oxygen Devices and surgery Revascularization (catheter interventions and surgery), other forms of surgery Pacemakers Implantable cardioverter defibrillators (ICD) Heart transplantation, ventricular assist devices, artificial heart Ultrafiltration, haemodialysis
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Pharmacological therapy

Angiotensin-converting enzyme inhibitors

Recommended as first-line therapy.

Should be uptitrated to the dosages shown to be effective in the large, controlled trials, and not titrated based on symptomatic improvement. Moderate renal insufficiency and a relatively low blood pressure (serum creatinine < 250 mol.l-1 and systolic BP > 90 mmHg) are not contraindications.
Absolute contraindications: bilateral renal artery stenosis and angioedema.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Diuretics

Essential for symptomatic treatment when

fluid overload is present and manifest.

Always be administered in combination

with ACE inhibitors if possible.

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Aldosterone receptor antagonists - spironolactone

Recommended in advanced HF (NYHA III-IV), in addition to ACE inhibition and diuretics to improve survival and morbidity

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Aldosterone receptor antagonists - spironolactone

The RALES mortality trial Low dose spironolactone (12.550 mg) on top of an ACE inhibitor and a loop diuretic improved survival of patients in advanced heart failure (NYHA class III or IV).

Beta-adrenoceptor antagonists

Recommended for the treatment of all pts with stable, mild, moderate and severe heart failure on standard treatment, unless there is a contraindication.

Patients with LV systolic dysfunction, with or without symptomatic HF, following an AMI long-term betablockade is recommended in addition to ACE inhibitor.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Survival 1.0 0.9 0.8 0.7 0.6 0.5

US Carvedilol Study
Carvedilol (n=696)

-Blockers in CHF All-cause Mortality

Placebo (n=398)

Risk reduction = 65%

P<0.001

0 50 100 150 200 250 300 350 400 Survival 1.0 Mortality % 20 Days Packer et al (1996)

CIBIS-II
Bisoprolol

MERIT-HF
Placebo

15 Metoprolol CR/XL

0.8 10

Risk reduction = 34%

0.6 P<0.0001 0

Placebo 5

Risk reduction = 34%

P=0.0062

0 0 200 400 Time after inclusion (days) 600 800 Lancet (1999) 0 3 6 9 12 15 Months of follow-up 18 21

The MERIT-HF Study Group (1999)

COPERNICUS
All-cause mortality
100
90

% Survival

80 70 60 0

Carvedilol Placebo

P=0.00013

Months

12

15

18

21

Beta-adrenoceptor antagonists CIBIS II, MERIT HF, US CARVEDILOL AND COPERNICUS study Reduction in total mortality, cardiovascular mortality, sudden death and death due to progression of heart failure in patients in func. class II-IV. reduces hospitalizations improves the functional class and leads to less worsening of heart failure.

Angiotensin II receptor antagonists ARBs could be considered in patients who do not tolerate ACE inhibitors for symptomatic treatment.

It is unclear whether ARBs are as effective as ACE inhibitors for mortality reduction. In combination with ACE inhibition, ARBs may improve heart failure symptoms and reduce hospitalizations for worsening heart failure.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560

Angiotensin II receptor antagonists

VAL-H
Patients were randomized to placebo or valsartan on top of standard therapy.
The results showed no difference in overall mortality, but a reduction in the combined endpoint all-cause mortality or morbidity expressed as hospitalization because of worsening heart failure.

Cardiac glycosides indicated in atrial fibrillation and any degree of symptomatic heart failure. A combination of digoxin and beta-blockade appears superior than either agent alone. In sinus rhythm, digoxin is recommended to improve the clinical status of patients with persisting heart failure despite ACE inhibitor and diuretic treatment.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Cardiac glycosides

DIG trial
Long-term digoxin did not improve survival. The primary benefit and indication for digoxin in heart failure is to reduce symptoms and improve clinical status decrease the risk of hospitalization for heart failure without an impact on survival.

Vasodilator agents in chronic heart failure

No specific role for vasodilators in the treatment of HF Used as adjunctive therapy for angina or concomitant hypertension. In case of intolerance to ACE inhibitors ARBs are preferred to the combination hydralazinenitrates.
HYDRALAZINE-ISOSORBIDE DINITRATE Hydralazine (up to 300 mg) in combination with ISDN (up to 160 mg) without ACE inhibition may have some beneficial effect on mortality, but not on hospitalization for HF. Nitrates may be used for the treatment of concomitant angina or relief of acute dyspnoea.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Positive inotropic therapy

Commonly used to limit severe episodes of HF or as a bridge to heart transplantation in end-stage HF. Repeated or prolonged treatment with oral inotropic agents increases mortality. Currently, insuffcient data are available to recommend dopaminergic agents for heart failure treatment.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560

Positive inotropic therapy

POSITIVE INOTROPHIC AGENTS Dobutamin Milrinone Levosimendan

DOPAMINERGIC AGENTS Ibopamine is not recommended for the treatment of chronic HF due to systolic LV dysfunction. Intravenous dopamine is used for the sort-term correction of haemodynamic disturbances of severe episodes of worsening HF.
Guidelines for the diagnosis and treatment of chronic heart failure
European Heart Journal (2001) 22, 1527-1560

Antiarrhythmics
No indication for the use of antiarrhythmic agents in HF

Indications for antiarrhythmic drug therapy include AF (rarely flutter), non-sustained or sustained VT.
CLASS I ANTIARRHYTHMICS

should be avoided
CLASS II ANTIARRHYTHMICS

Beta-blockers reduce sudden death in heart failure

CLASS III ANTIARRHYTHMICS

Amiodarone is the only antiarrhythmic drug without clinically relevant negative inotropic effects.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Anticoagulation Recommendation 1. All pts with HF and AF should be treated with warfarin unless contraindicated. 2. Patients with LVEF 35% or less.

HFSA Guidelines for Management of Patients With Heart Failure Caused by Left Ventricular Systolic Dysfunction - Pharmacological Approaches 2000

Antiplatelet Drugs Recommendation There is insufficient evidence concerning the potential negative therapeutic interaction between ASA and ACE inhibitors. Antiplatelet agent for pts with HF who have underlying CAD.

HFSA Guidelines for Management of Patients With Heart Failure Caused by Left Ventricular Systolic Dysfunction - Pharmacological Approaches 2000

Chronic heart failure choice of pharmacological therapy

ACE inhibitor Diuretic Beta-blocker Aldosterone Antagonist Not indicated

LV systolic dysfunction Asymptomatic LV dysfunction

Indicated

Not indicated

Post MI

Symptomatic HF (NYHA II)

Indicated

Indicated if Fluid retention Indicated comb. diuretic Indicated comb. diuretic

Indicated

Not indicated

Worsening HF (NYHA III-IV)

Indicated

Indicated

Indicated

End-stage HF (NYHA IV)

Indicated

Indicated

Indicated

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Chronic heart failure choice of pharmacological therapy

Angiotensin II receptor antagonists Not indicated Vasodilator (hydralazine/ Potassium -sparing Cardiac glycosides isosorbide diuretic dinitrate) With AF Not indicated Not indicated If persisting hypokalaemia

LV systolic dysfunction Asymptomatic LV dysfunction

Symptomatic HF (NYHA II)

Worsening HF (NYHA III-IV)

End-stage HF (NYHA IV)

(a) when AF If ACE inhibitors If ACE inhibitors and angiotensin are not tolerated (b) when improved from more severe II antagonists and not on betaare not HF in sinus blockade tolerated rhythm If ACE inhibitors If ACE inhibitors and angiotensin are not tolerated indicated II antagonists and not on betaare not blockade tolerated If ACE inhibitors If ACE inhibitors and angiotensin are not tolerated indicated II antagonists and not on betaare not blockade tolerated

If persisting hypokalaemia

If persisting hypokalaemia

Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Intervention

Surgical

Revascularization
Non Surgical

Pts with heart failure of ischaemic origin revascularization

symtomatic improvement.
A strong negative correlation of operative mortality and LVEF, a low LVEF (<25%) was associated with increased

operative mortality. Advance HF symptoms (NYHA IV)

resulted in a greater mortality rate. Off pump coronary revascularization may lower the surgical risk for HF. Heart Transplantation is an accepted mode of treatment for end-stage HF.
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Care and Follow-up

Recommended components of programs

use a team approach vigilant follow-up, first follow-up within 10 days of discharge discharge planning increased access to health care optimizing medical therapy with guidelines intense education and counselling inpatient and outpatient strategies address barriers to compliance early attention to signs and symptoms flexible diuretic regimen
Guidelines for the diagnosis and treatment of chronic heart failure European Heart Journal (2001) 22, 1527-1560

Resume
Pharmacological Treatment : I. II. Asymptomatic Systolic LV dysfunction :
ACE Inhibitor -Blocker (in CAD)

Symptomatic Systolic LV dysfunction

A. No fluid retention
ACE Inhibitor -Blocker If ischaemia (+) nitrate / revascularization

B.

Fluid retention
Diuretic ACE Inhibitor (ARBs if not tolerated) -Blocker Digitalis

Resume
III. Worsening HF
Standard treatment : ACE Inhibitor, -Blocker Diuretic : doses + loop diuretic Low dose spironolactone Digitalis Consider : Revascularization Valve surgery Heart transplant

IV.

End-stage HF
Intermittent inotrophic support Circulatory support (IABP, Ventr.Assist Devices) Haemofiltration on dialysis briddging to heart transplantation

Conclusion
Management of HF must be starting from the earlier stage (AHA/ACC stage A). Treatment at each stage can reduce morbidity and mortality. Before initiating therapy :
Established the correct diagnose. Consider management outline.

Conclusion
Non pharmacolgical intervention are helpfull in :
improving quality of life reducing readmission lowering cost.

Organize multi-disciplinary care :

HF clinic, HF nurse specialist, pts telemonitoring. Health care system.

To optimize HF management
Treatment should be according to the Guidelines, intensive education, and behavioral change efforts.

Thank YoU