ACC Heart Failure Guidelines Slide Deck

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ACC Heart Failure GuidelinesSlide Deck

• Based on the ACC/AHA 2005 Guideline Update
• for the Diagnosis and Management of
• Chronic Heart Failure in the Adult
• January 2006

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Supported by Medtronic, Inc. Medtronic, Inc. was
not involved in the development of this slide
deck and in no way influenced its contents.
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ACC/AHA 2005 Guideline Update for the Management
of Patients With Chronic Heart Failure in the
Adult Writing Committee Members
Sharon Ann Hunt, MD, FACC, FAHA, Chair
William T. Abraham, MD, FACC, FAHA Marshall H.
Chin, MD, MPH, FACP Arthur M. Feldman, MD, PhD,
FACC, FAHA Gary S. Francis, MD, FACC,
FAHA Theodore G. Ganiats, MD Mariell Jessup, MD,
FACC, FAHA Marvin A. Konstam, MD, FACC
Donna M. Mancini, MD Keith Michl, MD, FACP John
A. Oates, MD, FAHA Peter S. Rahko, MD, FACC,
FAHA Marc A. Silver, MD, FACC, FAHA Lynne Warner
Stevenson, MD, FACC, FAHA Clyde W. Yancy, MD,
FACC, FAHA
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Applying Classification of Recommendations and
Level of Evidence
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Applying Classification of Recommendations and
Level of Evidence
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Applying Classification of Recommendations and
Level of Evidence
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Applying Classification of Recommendations and
Level of Evidence
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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

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Heart Failure is Primarily a Condition of the
Elderly

• 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

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Guideline Scope

• Document focuses on
• Prevention of HF
• Diagnosis and management of
• chronic HF in the adult

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Definition of Heart Failure
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.
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Heart Failure vs. Congestive Heart Failure

• 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.

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Causes of HF in Western World

• For a substantial proportion of patients, causes
  are
• Coronary artery disease
• Hypertension
• Dilated cardiomyopathy

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Stages of Heart Failure

• 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

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Stages of Heart Failure

• Designed to emphasize preventability of HF
• Designed to recognize the progressive nature of
  LV dysfunction

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Stages of Heart Failure

• 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

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Stage A
Patients at High Risk for Developing Heart
Failure
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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)

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Stage A Therapy
Using Therapy Consistent with Contemporary
Guidelines

• In patients at high risk for developing HF,
• systolic and diastolic hypertension should be
• controlled in accordance with contemporary
• guidelines.
• In patients at high risk for developing HF, lipid
  
• disorders should be treated in accordance
• with contemporary guidelines.

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Stage A Therapy
Using Therapy Consistent with Contemporary
Guidelines

• In patients at high risk for developing HF who
• have known atherosclerotic vascular disease,
• healthcare providers should follow current
• guidelines for secondary prevention.
• For patients with diabetes mellitus (who are all
• at high risk for developing HF), blood sugar
• should be controlled in accordance with
• contemporary guidelines.

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Stage A Therapy
Using Therapy Consistent with Contemporary
Guidelines

• Thyroid disorders should be treated in
• accordance with contemporary guidelines in
• patients at high risk for developing HF.

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Stage A Therapy
Avoiding Behaviors That Increase Risk
Patients at high risk for developing HF should
be counseled to avoid behaviors that may
increase the risk of HF (e.g., smoking,
excessive alcohol consumption, and illicit drug
use).
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Stage A Therapy
Periodic Evaluation for Signs and Symptoms
Healthcare providers should perform periodic
evaluation for signs and symptoms of HF in
patients at high risk for developing HF.
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Stage A Therapy
Ventricular Rate Control or Sinus Rhythm
Restoration
Ventricular rate should be controlled or sinus
rhythm restored in patients with
supraventricular tachyarrhythmias who are at
high risk for developing HF.
I
IIa
IIa
IIb
IIb
III
III
I
IIa
IIa
IIb
IIb
III
III
I
IIa
IIa
IIb
IIb
III
III
IIa
IIa
IIb
IIb
III
III
I
IIa
IIb
III
I
IIa
IIb
III
I
IIa
IIb
III
IIa
IIb
III
I
I
I
B
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Stage A Therapy
Noninvasive Evaluation of LV Function
Healthcare providers should perform a
noninvasive evaluation of LV function
(i.e., LVEF) in patients with a strong family
history of cardiomyopathy or in those receiving
cardiotoxic interventions.
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Stage A Therapy
Angiotensin Converting Enzyme Inhibitors (ACEI)
ACEI can be useful to prevent HF in patients at
high risk for developing HF who have a history
of atherosclerotic vascular disease, diabetes
mellitus, or hypertension with associated
cardiovascular risk factors.
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Stage A Therapy
Angiotension Receptor Blockers (ARBs)
ARBs can be useful to prevent HF in patients at
high risk for developing HF who have a history
of atherosclerotic vascular disease, diabetes
mellitus, or hypertension with associated
cardiovascular risk factors.
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Stage A Therapy
Therapies NOT Recommended
Routine use of nutritional supplements solely to
prevent the development of structural heart
disease should not be recommended for patients
at high risk for developing HF.
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Stage B

Patients with Asymptomatic LV Dysfunction
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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

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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.

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Stage B Therapy
Angiotensin Converting Enzyme Inhibitors (ACEI)

• 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.
• 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.

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Stage B Therapy
Angiotensin Receptor Blockers (ARBs)

• An ARB should be administered to post-MI patients
• without HF who are intolerant of ACEIs and have a
  
• low LVEF.
• ACEIs or ARBs can be beneficial in patients with
• hypertension and LVH and no symptoms of HF.
• ARBs can be beneficial in patients with low EF
  and
• no symptoms of HF who are intolerant of ACEIs.

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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.

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Stage B Therapy
Internal Cardioverter Defibrillator (ICD)

• Placement of an ICD is reasonable in patients
  with
• ischemic cardiomyopathy who are at least 40 days
• post-MI, have an LVEF of 30 or less, are NYHA
• functional class I on chronic optimal medical
  therapy,
• and have reasonable expectation of survival with
  a
• good functional status for more than 1 year.
• Placement of an ICD might be considered in
  patients
• without HF who have nonischemic cardiomyopathy
• and an LVEF less than or equal to 30 who are in
• NYHA functional class I with chronic optimal
  medical
• therapy and have a reasonable expectation of
  survival
• with good functional status for more than 1 year.

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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).

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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.

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Stage B Therapy
Therapies NOT Recommended

• Digoxin should not be used in patients with low
  EF,
• sinus rhythm, and no history of HF symptoms,
• because in this population, the risk of harm is
  not
• balanced by any known benefit.
• Use of nutritional supplements to treat
  structural
• heart disease or to prevent the development of
• symptoms of HF is not recommended.
• Calcium channel blockers with negative inotropic
• effects may be harmful in asymptomatic patients
• with low LVEF and no symptoms of HF after MI.

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Stage C

Patients with Past or Current Symptoms of Heart
Failure
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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

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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).

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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.

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Stage C Therapy (Reduced LVEF with Symptoms)
Angiotensin Enzyme Converting Inhibitors (ACEIs)

• ACEIs are recommended for all patients with
• current or prior symptoms of HF and reduced
• LVEF, unless contraindicated.
• 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.

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Stage C Therapy (Reduced LVEF with Symptoms)
Angiotensin Receptor Blockers (ARBs)

• ARBs approved for the treatment of HF are
• recommended in patients with current or prior
• symptoms of HF and reduced LVEF who are ACEI-
• intolerant (see full text guidelines for
  information
• regarding patients with angioedema).
• 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.

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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.

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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.

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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.
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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.
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Stage C Therapy (Reduced LVEF with Symptoms)
Hydralazine and Isosorbide Dinitrate
The addition of a combination of hydralazine and
a nitrate is reasonable for patients with reduced
LVEF who are already taking an ACEI and
beta- blocker for symptomatic HF and who have
persistent 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.
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Stage C Therapy (Reduced LVEF with Symptoms)
Implantable Cardioverter- Defibrillators (ICDs)
An ICD is recommended as secondary prevention to
prolong survival in patients with current or
prior symptoms of HF and reduced LVEF who have a
history of cardiac arrest, ventricular
fibrillation, or hemodynamically destabilizing
ventricular tachycardia. ICD therapy is
recommended for primary prevention to reduce
total mortality by a reduction in sudden cardiac
death in patients with ischemic heart disease
who are at least 40 days post-MI, have an LVEF
less than or equal to 30, with NYHA functional
class II or III symptoms while undergoing
chronic optimal medical therapy, and have
reasonable expectation of survival with a good
functional status for more than 1 year.
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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.
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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.
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Stage C Therapy (Reduced LVEF with Symptoms)
Exercise Testing and Training
Maximal exercise testing with or without
measurement of respiratory gas exchange is
recommended to facilitate prescription of an
appropriate exercise program for patients
presenting with HF. Exercise training is
beneficial as an adjunctive approach to improve
clinical status in ambulatory patients with
current or prior symptoms of HF and reduced
LVEF.
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Stage C Therapy (Reduced LVEF with Symptoms)
Unproven/Not Recommended Drugs and Interventions
for HF

• Nutritional Supplements
• Hormonal Therapies
• Intermittent Intravenous
• Positive Inotropic Therapy

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Stage C Therapy (Reduced LVEF with Symptoms)
Unproven/Not Recommended Drugs and Interventions
Long-term use of an infusion of a positive
inotropic drug may be harmful and is not
recommended for patients with current or prior
symptoms of HF and reduced LVEF, except as
palliation for patients with end-stage disease
who cannot be stabilized with standard medical
treatment (see recommendations for Stage D).
Use of nutritional supplements as treatment for
HF is not indicated in patients with current or
prior symptoms of HF and reduced LVEF.
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Stage C Therapy (Reduced LVEF with Symptoms)
Unproven/Not Recommended Drugs and Interventions
Calcium channel blocking drugs are not indicated
as routine treatment for HF in patients with
current or prior symptoms of HF and reduced
LVEF. Hormonal therapies other than to replete
deficiencies are not recommended and may be
harmful to patients with current or prior
symptoms of HF and reduced LVEF. Routine
combined use of an ACEI, ARB, and aldosterone
antagonist is not recommended for patientswith
current or prior symptoms of HF and reduced
LVEF.
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Stage C Therapy (Normal LVEF with Symptoms)

• Recommended Therapies for Routine Use
• Treating known risk factor (hypertension) with
  therapy
• consistent with contemporary guidelines
• Ventricular rate control for all patients
• Drugs for all patients -
• Diuretics
• Drugs for appropriate patients
• ACEI
• ARBs
• Beta-Blockers
• Digitalis
• Coronary revascularization in selected patients
• Restoration/maintenance of sinus rhythm in
• appropriate patients

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Differential Diagnosis in Patient with HF and
Normal LVEF with Symptoms

• Incorrect diagnosis of HF
• Inaccurate measurement of LVEF
• Primary valvular disease
• Restrictive (infiltrative) cardiomyopathies
• Amyloidosis, sarcoidosis, hemochromatosis
• Pericardial constriction
• Episodic or reversible LV systolic dysfunction
• Severe hypertension, myocardial ischemia

• HF associated with high metabolic demand
  (high-output states)
• Anemia, thyrotoxicosis, arteriovenous fistulae
• Chronic pulmonary disease with right HF
• Pulmonary hypertension associated with pulmonary
  vascular disorders
• Atrial myxoma
• Diastolic dysfunction of uncertain origin
• Obesity

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Stage C Therapy (Normal LVEF with Symptoms)
Treating known risk factors - Hypertension
Physicians should control systolic and diastolic
hypertension in patients with HF and normal
LVEF, in accordance with published guidelines.
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Stage C Therapy (Normal LVEF with Symptoms)
Ventricular Rate Control
Physicians should control ventricular rate in
patients with HF and normal LVEF and
atrial fibrillation.
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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.

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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.

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Stage C Therapy (Normal LVEF with Symptoms)
Restoration/Maintenance of Sinus Rhythm

• Restoration and maintenance of sinus rhythm
• in patients with atrial fibrillation and HF and
• normal LVEF might be useful to improve
• symptoms.

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Stage C Therapy (Normal LVEF with Symptoms)
Angiotensin Enzyme Converting Inhibitors (ACEIs)

• 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.

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Stage C Therapy (Normal LVEF with Symptoms)
Angiotensin Receptor Blockers (ARBs)

• 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.

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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.
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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.
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Stage D

Patients with Refractory End-Stage HF
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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

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Stage D Therapy
Control of Fluid Retention
Meticulous identification and control of fluid
retention is recommended in patients with
refractory end-stage HF.
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Stage D Therapy
Referral to an HF Program
Referral of patients with refractory end-stage
HF to an HF program with expertise in the
management of refractory HF is useful.
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Stage D Therapy
Discussion of Options for End-of-Life Care
Options for end-of-life care should be discussed
with the patient and family when severe symptoms
in patients with refractory end-stage HF persist
despite application of all recommended
therapies.
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Stage D Therapy
Inform on option to inactivate defibrillation
Patients with refractory end-stage HF
and implantable defibrillators should receive
information about the option to inactivate
defibrillation.
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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.
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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.
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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.
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Stage D Therapy
Therapies NOT Recommended
Partial left ventriculectomy is not recommended
inpatients with nonischemic cardiomyopathy and
refractory end-stage HF. Routine intermittent
infusions of positive inotropic agents are not
recommended for patients with refractory
end-stage HF.