2 I. Reduced EF (HFrEF)
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- Reynard French
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2 HF Classification EF Description 2 I. Reduced EF (HFrEF) 40% 1. Referred to as systolic HF. 2. Randomized trials mainly enrolled patients with HFrEF. 3. Efficacious therapies is shown only in these patients. II. Preserved EF (HFpEF) 50% 1. Referred to as diastolic HF. 2. Diagnosis by excluding noncardiac causes. 3. To date, efficacious therapies have not been identified. a. HFpEF, 41% to 49% 1. A borderline or intermediate group. Borderline 2. Characteristics, treatment, & outcomes are similar to HFpEF. b. HFpEF, >40% 1. Previously had HFrEF which improved. Improved 2. Clinically distinct from persistently preserved or reduced EF. 3. Research is needed to better characterize these patients. ACC/AHA Stages of HF NYHA Classification of HF A At high risk but without structural None heart disease or symptoms of HF. B Structural heart disease but without signs or symptoms of HF. I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. C D Structural heart disease with prior or current symptoms of HF. Refractory HF requiring specialized interventions. I II III IV No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. Risk Scores to Predict Outcomes in Heart Failure All patients with chronic HF Seattle Heart Failure Model Heart Failure Survival Score CHARM Risk Score CORONA Risk Score Specific to chronic HFpEF I PRESERVE Score Acutely Decompensated HF ADHERE Classification and Regression Tree (CART) Model American Heart Association Get With the Guidelines Score EFFECT Risk Score ESCAPE Risk Model and Discharge Score OPTIMIZE HF Risk Prediction Nomogram Biomarker, Application Setting COR LOE Natriuretic peptides Diagnosis or exclusion of HF Ambulatory, Acute I A Prognosis of HF Ambulatory, Acute I A Achieve guideline directed medical therapy (GDMT) Ambulatory 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
3 Classification of patients 3 presenting with acute decompensated HF with 2 minute bedside assessment of hemodynamic profile 1. 67% warm & wet 2. 28% cold & wet 3. 5% cold & dry 4. 1 year mortality/trasplantation is 2x for cold & wet as for warm & wet 5. Some patient are on border of warm & wet and cold & wet 6. For warm & dry, look for non HF causes of symptoms History and Physical Examination Recommendations COR LOE H&P: cardiac/noncardiac disorders or behaviors causing/worsening HF I C In idiopathic DCM: 3 generational family history to help diagnose familial DCM I C Vol. Status & VS at each encounter: wt, JVP, peripheral edema, orthopnea I B Validated multivariable risk score: for amb./hosp. prognosis assessment Diagnostic Tests recommendations COR LOE Initial labs: CBC, U/A, Lytes (+Ca, Mg), BUN, Cr, Glucose, FLP, LFTs, TSH I C Serial Lytes & renal funtion monitoring when indicated I C 12 ECG on all initial HF presentations I C Hemochromatosis & HIV screening in selected patients IIa C Rheum disease, amyloidosis, pheo testing if clinically suspected IIa C Noninvasive Imaging Recommendations COR LOE Patients with suspected, acute, or new onset HF should undergo a chest x ray I C A 2 D echo with Doppler should be performed for initial evaluation of HF I C Repeat EF for change in status, post Rx affecting EF, or device consideration I C Noninvasive imaging to detect ischemia & viability in HF and CAD IIa C Viability assessment is reasonable before revascularization in HF with CAD Radionuclide ventriculography or MRI can be useful to assess LVEF and volume IIa C MRI is reasonable when assessing myocardial infiltration or scar Routine repeat measurement of LVEF should not be performed III: N.B. B Invasive Evaluation Recommendations COR LOE PA cath: resp. distress & impaired perfusion if clinical assessment is inadequate I C Invasive monitoring: persistent symptoms +/ uncertain hemodynamics IIa C Coronary arteriography: when coronary ischemia may be contributing to HF IIa C Endomyocardial bx: if a specific diagnosis is suspected that would influence Rx IIa C Routine invasive hemodynamic monitoring: in normotensive patients with HF III: N.B. B Endomyocardial bx: in the routine evaluation of HF III: Harm C HFpEF Treatment Recommendations COR LOE Systolic and diastolic blood pressure control according to guidelines I B Diuretics should be used for relief of symptoms due to volume overload I C Revascularization with angina or demonstrable ischemia despite GDMT IIa C AF management according to guidelines to improve symptoms IIa C Use of, ACE inhibitors, and ARBs for hypertension IIa C ARBs might be considered to decrease hospitalizations IIb B Nutritional supplementation is not recommended III: N.B. C
4 4 Stage A Recommendations COR LOE Control of HTN & Lipids according to guidelines to lower the risk of HF I A Control & avoidance of obesity, DM, tobacco use, and cardiotoxic agents I C Stage B Recommendations COR LOE With history of MI & reduced EF, ACE inhibitors or ARBs to prevent HF I A With MI & reduced EF, evidence based to prevent HF I B With MI, statins should be used to prevent HF I A BP should be controlled to prevent symptomatic HF I A ACEi should ldbe used in all patients with a reduced def to prevent HF I A should be used in all patients with a reduced EF to prevent HF I C ICD with asymptomatic ischemic CM; 40 d post MI, EF 30%, & on GDMT Nondihydropyridine CCBs may be harmful in patients with low LVEF III: Harm C Stage C Pharmacologic Recommendations COR LOE Diuretics are recommended in patients with HFrEF with fluid retention I C ACE inhibitors are recommended for all patients with HFrEF I A ARBs are recommended in patients with HFrEF who are ACE inhibitor intolerant I A ARBs are reasonable as alternatives to ACEi as first line therapy in HFrEF IIa A ARB may added in persistently symptomatic patients with HFrEF on GDMT IIb A Routine combination of ACEi, ARB & aldo antagonist is potentially harmful III: Harm C 1 of 3 proven to reduce mortality is recommended for all stable patients I A Aldosterone antagonists with NYHA class II IV HF & LVEF 35% I A Aldosterone antagonists post acute MI & EF 40% with symptoms of HF or DM I B Aldosterone antagonist & GFR < 30: Cr > 2, > 2.5 ; or K >5 III: Harm B Hydralazine/ISDN for African Americans, & NYHA class III IV HFrEF on GDMT I A Hydralazine/ISDN in HFrEF patients who cannot be given ACEi or ARBs Digoxin can be beneficial in patients with HFrEF Chronic CHF w/ AF + 1 CHADS2 risk: should receive chronic anticoagulation I A Selection of anticoagulant agent should be individualized I C Chronic CHF w/ AF: reasonable to receive chronic anticoagulation Anticoag in HFrEF without AF, thromboembolic event, cardioembolic source III: N.B. B Statins are not beneficial as adjunctive therapy when prescribed solely for HF III: N.B. A Omega 3 PUFA supplement as adjunctive therapy in HFrEF or HFpEF patients Nutritional supplements as treatment for HF are not recommended in HFrEF III: N.B. B Hormonal therapies other than to replete deficiencies III: N.B. C Drugs known to adversely affect the clinical status of patients with HFrEF III: Harm B Long term use of an infusion of a positive inotropic drug except as palliation III: Harm C CCB are not recommended as routine in HFrEF III: N.B. A Stage C Non Pharmacologic Recommendations COR LOE Patients with HF should receive specific education to facilitate HF self care I B Exercise training is safe & effective to improve functional status I A Sodium restriction in symptomatic HF to reduce congestive symptoms IIa C CPAP can increase EF & improve functional status in HF and sleep apnea Cardiac rehab hbto improve functional capacity, exercise duration, QOL,mortality
5 5 GDMT RRR Mortality NNT/Mortality Reduction (Standardized to 36 mo) RRR CHF Hospitalizations ACEi or ARB 17% 26 31% Beta blocker 34% 9 41% Aldo antagonist 30% 6 35% Hydralazine/nitrate 43% 7 33% Cardiac causes of elevated BNP Noncardiac causes of elevated BNP CHF/RV syndromes; ACS; LVH Valvular heart disease Advancing age; Anemia; Renal failure OSA, severe pneumonia, pulmonary hypertension Pericardial disease; Myocarditis Critical illness; Bacterial sepsis; Severe burns Afib; Cardioversion. Cardiac surgery Toxic metabolic: cancer chemo & envenomation ICD Recommendations for Primary Prevention of SCD COR LOE 3m post dx or revasc/40 d post MI; EF 35% & NYHA II III on GDMT; expected survival 1 yr I A 40 d post MI; EF 30%; NYHA I on GDMT; expected survival 1 yr I B High risk of nonsudden death (freq hosp, frailty, severe comorbidities) IIb B CRT Recommendations COR LOE EF 35%; SR, LBBB, QRS 150 ms. NYHA II (LOE: B); NYHA III IV (LOE: A) I B/A EF 35%; SR, non LBBB QRS 150 ms. NYHA III/ambulatory IV on GDMT IIa A EF 35%; SR, LBBB, QRS ms. NYHA II ambulatory IV on GDMT AF; EF 35% on GDMT if a) CRT criteria i met or b)avn ablation or rate control will cause 100% v pacing EF 35%; on GDMT; anticipated > 40% v pacing IIa C EF 35%; SR, non LBBB QRS ms. NYHA III/amb. IV on GDMT IIb B EF 35%; SR, non LBBB QRS 150 ms. NYHA II on GDMT IIb B EF 30%, ischemic; SR, LBBB QRS 150 ms. NYHA I on GDMT IIb C NYHA I or II, non LBBB QRS <150 ms III: N.B. B Comorbidities and/or frailty limit survival to <1 yr III: N.B. C Stage D Recommendations COR LOE Fluid restriction (1.5 to 2 L/d) esp. with hyponatremia, to reduce congestion IIa C IV inotropes in cardiogenic shock until definitive Rx (revascularize, Mechanical Circ. Support [MCS], transplant) or resolution of acute precipitating problem I C Continuous IV inotropes as bridge therapy for MCS or cardiac transplantation Short term IV inotropes in hospitalized patients with known severely low EF, hypotension, low CO, to maintain systemic perfusion & end organ performance IIb B Continuous IV inotropes as palliative end therapy for symptom control IIb B Inotropes, without a specific indication, or for palliative care III: Harm B Inotropes for inpatients without severely low EF, hypotension, or impaired perfusion, and evidence of sig. low cardiac output, with or without congestion III: Harm B MCS in selected patients with stage D HFrEF in whom definitive management (e.g., cardiac transplantation) or cardiac recovery is anticipated or planned Nondurable MCS (percutaneous/extracorporeal VADs) as bridge to recovery or bridge to decision in HFrEF with acute, profoud, hemodynamic compromise Durable MCS to prolong survival for carefully selected patients Transplant eval for selected Stage D patients on GDMT, device, & surgical Rx I C
6 6 Hospitalized Patient Recommendations COR LOE For fluid overload, treat with IV diuretics I B Loop diuretic initial IV PO daily dose; then should be serially adjusted I B Continue GDMT unless hemodynamic instability or contraindications I B Low dose after volume optimized & stopping IV agents I B Thrombosis/thromboembolism prophylaxis I B Lytes, BUN/Cr measurement during med titration, including diuretics I C When diuresis is inadequate: a) Give higher doses of IV loop diuretics; or b) Add a second diuretic (e.g., thiazide) IIa B B Low dose dopamine infusion with loop diuretics to improve diuresis IIb B Ultrafiltration may be considered for obvious volume overload IIb B Ultrafiltration may be considered for refractory congestion IIb C IV nitro, nipride or nesiritide may be considered for stable HF patients IIb B For vol. overload & severely low Na, consider vasopressin antagonists IIb B Hospital Discharge Recommendation or Indication COR LOE Performance improvement systems in hospital & early postdischarge for GDMT I B Pre discharge, at first & subsequent postdischarge visits, address the following: a) Initiate GDMT if not done or contraindicated. Optimize chronic oral Rx; b) causes of HF, barriers to care, and limitations in support; c) Assess vol. status & BP; adjust HF Rx. Assess renal function & electrolytes; I B f) manage comorbid conditions; g) HF education, self care, emergency plans, & adherence; h) palliative or hospice care. Multidisciplinary disease management program for patients high risk for readmit I B F/U in 7 14 days &/or telephone f/u within 3 days of discharge is reasonable Use of clinical risk prediction tools &/or biomarkers to identify high risk patients Surgical/Percutaneous/Transcatheter Rx Recommendation COR LOE CABG or PCI for angina on GDMT; esp. LM/LM equivalent stenosis I C CABG, to improve survival, with mild mod low EF & sig. multivessel CAD or prox. LAD stenosis, when viable myocardium is present CABG or medical Rx to improve M&M with EF <35%, HF & sig. CAD Surgical AVR for critical AS, & predicted surgical mortality 10% TAVR for critical AS in patients who are deemed inoperable CABG for ischemic HD, severely low EF, suitable anatomy, w/ or w/o viability IIb B Transcath MV repair or MV surgery for functional MR; uncertain benefit IIb B LV aneurysmectomy for intractable HF & ventricular arrhythmias IIb B 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 increase diuretics to maintain vol. status, using lasix > 160 mg/d +/ metolazone Progressive decline in serum sodium, usually to <133 meq/l Frequent ICD shocks
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