The Failing Heart in Primary Care Hamid Ikram
How fares the Heart Failure Epidemic? 4357 patients, 57% women, mean age 74 years
HFSA 2010 Practice Guideline (3.1) Heart Failure Prevention A careful and thorough clinical assessment, with appropriate investigation for known or potential risk factors, is recommended in an effort to prevent development of LV remodeling, cardiac dysfunction, and HF. Strength of Evidence = A Adapted from:
HFSA 2010 Practice Guideline (3.2) HF Risk Factor Treatment Goals Risk Factor Goal Hypertension Generally < 130/80 Diabetes See ADA guidelines 1 Hyperlipidemia See NCEP guidelines 2 Inactivity Obesity 20-30 min. aerobic 3-5 x wk. Weight reduction < 30 BMI Alcohol Men 2 drinks/day, women 1 Smoking Dietary Sodium Cessation Maximum 2-3 g/day 1 Diabetes Care 2006; 29: S4-S42 2 JAMA 2001; 285:2486-97 Adapted from:
Treating Hypertension to Prevent HF Aggressive blood pressure control: Decreases risk of new HF by ~ 50% 56% in DM2 Aggressive BP control in patients with prior MI: Decreases risk of new HF by ~ 80% Lancet 1991;338:1281-5 (STOP-Hypertension JAMA 1997;278:212-6 (SHEP) UKPDS Group. UKPDS 38. BMJ 1998;317:703-713
HFSA 2010 Practice Guideline (3.3-3.4) Prevention ACEI and Beta Blockers ACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with: Coronary artery disease Peripheral vascular disease Stroke Diabetes and another major risk factor Strength of Evidence = A ACE inhibitors and beta blockers are recommended for all patients with prior MI. Strength of Evidence = A
HFSA 2010 Practice Guideline (4.8, 4.10) Heart Failure Patient Evaluation Recommended evaluation for patients with a diagnosis of HF: Assess clinical severity and functional limitation by history, physical examination, and determination of functional class* Assess cardiac structure and function Determine the etiology of HF Evaluate for coronary disease and myocardial ischemia Evaluate the risk of life threatening arrhythmia Identify any exacerbating factors for HF Identify co-morbidities which influence therapy Identify barriers to adherence and compliance Strength of Evidence = C *Metrics to consider include the 6-minute walk test and NYHA functional class Adapted from:
HFSA 2010 Practice Guideline (4.19) Evaluation Follow Up Assessments Recommended Components of Follow-Up Visits Signs and symptoms evaluated during initial visit Functional capacity and activity level Changes in body weight Patient understanding of and compliance with dietary sodium restriction and medical regimen History of arrhythmia, syncope, pre-syncope, palpitation, or ICD discharge Adherence and response to therapeutic interventions Exacerbating factors for HF, including worsening ischemic heart disease, hypertension, and new or worsening valvular disease Strength of Evidence = B
Natriuretic peptides
Causes of Elevated Cardiac Natriuretic PeptidesP
Small Trials and meta-analyses show an encouraging trend- a large scale randomized trial is needed- one on the way
HFSA 2010 Practice Guideline (7.1, 7.7) Pharmacologic Therapy: ACE Inhibitors ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF 40%. Strength of Evidence = A ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF 40%. Post MI Strength of Evidence = B Non Post-MI Strength of Evidence = C Adapted from:
HFSA 2010 Practice Guideline (7.3) Pharmacologic Therapy: Angiotensin Receptor Blockers ARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency. Strength of Evidence = A
HFSA 2010 Practice Guideline (7.9) Pharmacologic Therapy: Beta Blockers CONCOMITANT DISEASE Beta blocker therapy is recommended in the great majority of patients with HF and reduced LVEF even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease. Use with caution in patients with: Diabetes with recurrent hypoglycemia Asthma or resting limb ischemia. Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmhg). Not recommended in patients with asthma with active bronchospasm. Strength of Evidence = C
HFSA 2010 Practice Guideline (11.8, 15.2) Pharmacologic Therapy: Beta Blockers PRESERVED LVEF Beta blocker treatment is recommended in patients with HF and preserved LVEF who have: Prior MI Strength of Evidence = A Hypertension Strength of Evidence = B Atrial fib. requiring control of ventricular rate Strength of Evidence = B THE ELDERLY Beta-blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction. Strength of Evidence = B In the absence of contraindications, these therapies are also recommended in the very elderly (age > 80 years). Strength of Evidence = C
HFSA 2010 Practice Guideline Pharmacologic Therapy: Beta Blocker Overview* General considerations Initiate at low doses Up-titrate gradually, generally no sooner than at 2 week intervals Use target doses shown to be effective in clinical trials Aim to achieve target dose in 8-12 weeks If symptoms worsen or other side effects appear If up-titration continues to be difficult Maintain at maximum tolerated dose Adjust dose of diuretic or concomitant vasoactive med. Continue titration to target after symptoms return to baseline Prolong titration interval Reduce target dose Consider referral to a HF specialist *Consult language of specific recommendations Adapted from:
HFSA 2010 Practice Guideline (7.14-7.15) Pharmacologic Therapy: Aldosterone Antagonists An aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have: NYHA class IV HF (or class III, previously class IV) HF from reduced LVEF ( 35%) One should be considered in patients post-mi with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor (or ARB) and a beta blocker. Strength of Evidence = A Adapted from:
HFSA 2010 Practice Guideline (7.16-7.18) Aldosterone Antagonists and Renal Function Aldosterone antagonists are not recommended when: Creatinine > 2.5mg/dL (or clearance < 30 ml/min) Serum potassium> 5.0 mmol/l Therapy includes other potassium-sparing diuretics Strength of Evidence = A It is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 months Strength of Evidence = A Supplemental potassium is not recommended unless potassium is < 4.0 mmol/l Strength of Evidence = A Adapted from:
HFSA 2010 Practice Guideline (7.23) Pharmacologic Therapy: Diuretics Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by: Congestive symptoms Signs of elevated filling pressures Strength of Evidence = A Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF. Strength of Evidence = B
HFSA 2010 Practice Guideline (7.24) Pharmacologic Therapy: Diuretics Restoration of normal volume status may require multiple adjustments. Once a diuretic effect is achieved with short-acting loop diuretics, increase frequency to 2-3 times a day if necessary, rather than increasing a single dose. Strength of Evidence = B Oral torsemide may be considered in patients exhibiting poor absorption of oral medication or erratic diuretic effect. Strength of Evidence = C IV administration of diuretics may be necessary. Strength of Evidence = A Diuretic refractoriness may represent patient nonadherence, a direct effect of diuretic use on the kidney, or progression of underlying dysfunction. Adapted from:
The Digitalis Investigation Group study Reanalyses of the trial s findings have raised new questions about the role of digoxin in heart failure treatment. These new analyses showed that low serum digoxin concentrations used in patients with more severe disease offered the most benefit. Digoxin use in women was associated with increased mortality risk.
CRT Improves Quality of Life and NYHA Functional Class Average Change in Score (MLWHF) NYHA: Proportion Improving by 1 or More Class 0-5 -10-15 (%) 80 60 40 * * * -20 MIRACLE * * MUSTIC SR CONTAK CD * MIRACLE ICD * 20 0 MIRACLE CONTAK CD MIRACLE ICD Control CRT *P<.05 Control CRT Abraham WT et al. Circulation 2003;108:2596-603
HFSA 2010 Practice Guideline (11.1-11.2) HF with Preserved LVEF Diagnosis Careful attention to differential diagnosis is recommended in patients with HF and preserved LVEF. Treatments may differ based on cardiac disorder. Evaluation for ischemic disease and inducible myocardial ischemia should be included. Recommended diagnostic tools: Echocardiography Electrocardiography Stress imaging (via exercise or pharmacologic means, using myocardial perfusion or echocardiographic imaging) Cardiac catheterization Strength of Evidence = C Adapted from:
HFSA 2010 Practice Guideline (8.1) Heart Failure Patient Education It is recommended that patients with HF and their family members or caregivers receive individualized education and counseling that emphasizes self-care. This education and counseling should be delivered by providers using a team approach. Teaching should include skill building and target behaviors. Strength of Evidence = B Adapted from:
The Potential Impact of Effective Education on Patient Compliance Nonadherence rate when patients... Recall MD advice Don t recall advice Medications 8.7% 66.7% Diet 23.6% 55.8% Activity 76.4% 84.5% Smoking 60.0% 90.4% Alcohol 60.0% 81.8% Kravitz et al. Arch Int Med 1993;153:1869-78
HFSA 2010 Practice Guideline (8.7) Heart Failure Disease Management Patients recently hospitalized for HF and other patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care. Strength of Evidence = A Adapted from:
HF Disease Management and the Risk of Readmission 1.1 Ekman Risk Ratio 1 0.9 0.8 0.7 Cline Jaarsma Rich Stewart Rauh Lasater Venner 0.6 0.5 Naylor Fonarow Summary RR = 0.76 (95% CI.68-.87) Summary RR for randomized only = 0.75 (CI =.60-.95)
Advanced CHF has a worse Prognosis than many serious malignant diseases
HFSA 2010 Practice Guideline (8.13) End-of-Life Care in Heart Failure End-of-life care should be considered in patients who have advanced, persistent HF with symptoms at rest despite repeated attempts to optimize pharmacologic, device, and other therapies, as evidenced by one or more of the following: HF hospitalization Strength of Evidence = C Chronic poor quality of life with inability to accomplish activities of daily living Strength of Evidence = C Need for continuous IV inotropic therapy support Strength of Evidence = C
Uptitrate Medication in small increments Certain patients e.g. elderly and renal failure may require more frequent visits Monitor vital signs closely BP esp postural change, HR and Rhythm,JVP Alternate up-titration of different classes of drugs Monitor Renal function and Electrolyte Status Patients may complain of weakness and fatigue with dose changes- reassure them these are temporary and will improve Discourage sudden discontinuation of Rx by patient or other clinicians without prior discussion. Carefully review all medications during up-titration Consider temporary dose reduction of HF meds during acute non-cardiac illnesses Educate patients, relatives and other clinicians on benefits of GDMT