Comprehensive Overview of Heart Failure Management: 2006 Guidelines and 2012 Update

1. Heart Failure 2006 CCS Guidelines & 2012/13 update Michelle Gibson http://www.ccsguidelineprograms.ca/index.php?option=com_content&view=article&id=185&Itemid=107

2. My Advice • Read the 2006 guidelines if you haven’t • Then, skim the 2012 update • Acute • Chronic • Updates 2007-2011 – interesting, not essential • 2013 – rehab and revascularization

3. Chronic HF

4. Source: Canadian Journal of Cardiology 2013; 29:168-181 (DOI:10.1016/j.cjca.2012.10.007 )

5. Chronic HF • Diagnosis is clinical, but… • Triad of edema, fatigue and dyspnea is not sensitive or specific • Atypical presentations in women, elderly, obese patients

6. CHF - diagnosis • H & P, BNP? • 12 lead ECG – rhythm, rate, QRS, etc. • Echo – to assess systolic and diastolic function, valves, LV, etc. • Angiography if angina present, if candidate for interventions • NYHA

7. CHF – preserved EF • 50% of patients in HF clinics • More prevalent in elderly, women, HTN • Less mortality (still high), but equal morbidity • This is easy: • No evidence for management. • Control risk factors, use diuretics judiciously, control rate (b-blockers and CCBs)

8. CHF – Non-pharm • Regular exercise – stable sxwith impaired EF • 3-5 times/week, 30-45 mins • Aerobic and resistance – moderate intensity • May need graded stress test first • Refer to cardiac rehab!

9. CHF – non-pharm • Sodium restriction! • 2-3 g of salt/day (less if severe) • Daily morning weights • Fluid restriction to 1.5 to 2 L/d ***in patients with fluid issues, not managed by diuretics • Read – not all patients! • Refer to CHF program if available

10. ACE inhibitor • For everyone post MI • For everyone with EF <35% (even if asymptomatic); <40% if symptomatic

11. ARB • If intolerant to ACE • Added to ACE with NYHA II-IV and EF <40% “if deemed at increased risk” • (NB – be CAREFUL!) • Consider if b-blockers are contraindicated or not tolerated

12. MRA • Mineralocorticoid receptor antagonists: • Spironolactone • Eplerenone • Complex recommendations - HUH? • >55 yrs, EF < 30% (or <35% with QRS > 130), and recent CV admission OR ^NP –(epl.) • Post MI, EF <30% and HF; or EF <30% with DM. (epl.) • *EF < 30%, NYHA IIIb-IV; otherwise optimized

13. Practical tips • Try to back off on diuretics when starting other meds • R/A need for vasodilators when stable • OK for Cr increase up to 30% • Check electrolytes (Na/K) • Keep K+ > 4 mmol/L • ACE/ARB combo – use with caution!

14. CHF – b blockers • All with EF <40% • Class IV, though – stabilize before adding BB • Start low, titrate up to target or max tolerated dose • Don’t start if symptomatic hypotension that you can’t fix; if bad RAD, symptomatic brady, AV block. • Stable COPD is OK.

15. Practical tip • May need to wait 6 -12 months before improvement after b-blocker initiated • Try not to stop abruptly – try to reduce dose, back off on other meds if possible

16. Diuretics • Most patients need loop diuretic (no kidding) • Use lowest dose possible – can often decrease • May need thiazide or low-dose metolazone • Monitor lytes, renal function, BP carefully

17. Digoxin • In NSR, with mod to severe sx despite optimal therapy • In A-fib – to rate control if b-blockers not enough, or contraindicated

18. ISDN and hydralazine • Use in addition to standard therapy in black patients • Consider in other patients unable to tolerate ANCE or ARB

19. Omega-3 • 1gm daily – consider – in HF and reduced EF

20. Platelet inhibition & anticoag • ASA – 81mg to 325mg – ONLY if needed otherwise for 2nd prevention • Recommend against routine use of anticoag in NSR patients • Consider anticoag if intra-cardiac thrombus or after large anterior MI

22. Miscellaneous • Cardiac resynchronization – check the list.

23. Avoid!

24. Avoid • NSAIDs • Cox II inhibitors • Glitazones • Negative inotrope CCBs and anti-arrhythmics

25. Quiz • Which drug classes have been shown to decrease mortality? • Morbidity? • Neither?

26. Acute HF • After your H & P, normally need: • Labs, ECG, CXR, Echo • Use a scoring system:

27. Acute HF • Role for BNP: • When the clinical diagnosis is uncertain • Key point in diagnosis: • “Evaluate the clinical constellation of findings .. vs. focus on individual findings, symptoms, or investigation”

28. AHF - treatment • O2 for hypoxemia; to keep sats >90% • No role for routine CPAP/BiPAP • IV diuretics for patients with congestion • Furosemide bid or continuous infusion • Vasodilators (but keep SBP>100), for relief of dyspnea in hemodynamically stable patients • e.g. nitroglycerine

29. AHF – treatment • Continue b-blockers unless hypotensive or bradycardic

30. My thoughts • Know the difference between normal EF and decreased EF • Know non-pharmacological mgt • Know drugs- morbidity & mortality.