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Optimization of Heart Failure TreatmentsSeptember 12, 2018
Thomas Lewandowski, MD, FACCThedaCare Cardiovascular Care
Framingham system for diagnosis of heart failureEither: Two major criteria or One major and two minor criteria
Minor criteria accepted only if no other attributable medical condition
Major Criteria• Paroxysmal nocturnal dyspnea• Weight loss of 4.5 kg (9.9 lb) in 5 days
in response to treatment • JVD• Hepatojugular reflux• S3 • Cardiomegaly• CVP > 16 cm H20• Acute pulmonary edema (HFrEF)• Rales (HFrEF)• Pulmonary edema (HFrEF), visceral
congestion or cardiomegaly at autopsy
Minor Criteria• Nocturnal Cough• Dyspnea on ordinary exertion• Decrease in vital capacity by
1/3 max• Pleural effusion• Tachycardia > 120• Hepatomegaly• Bilateral ankle edema
Source: Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol. 1993 Oct:22(4 suppl A):6A-13A
Diagnostic Criteria
LVH
Source: Yancy et al. 2017 Pathways for Optimization of Heart Failure Treatment. https://doi.org/10.1016/j.jack.2017.11.025
Testing and Medication Titration:
Source: Yancy et al. 2017 Pathways for Optimization of Heart Failure Treatment. https://doi.org/10.1016/j.jack.2017.11.025
Biomarkers Indications for Use
*Other biomarkers of injury or fibrosis include soluble ST2 receptor, galectin-3, and high-sensitivity troponin.ACC indicates American College of Cardiology; AHA, American Heart Association; ADHF, acute decompensated heart failure; BNP, B-type natriuretic peptide; COR, Class of Recommendation; ED, emergency department; HF, heart failure; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; and pts, patients.
Source: Yancy et al. 2017 Pathways for Optimization of Heart Failure Treatment. https://doi.org/10.1016/j.jack.2017.11.025
Heart Failure Medication Target Doses (HFrEF)
Source: Yancy et al. 2017 Pathways for Optimization of Heart Failure Treatment. https://doi.org/10.1016/j.jack.2017.11.025
Heart Failure Medication Target Doses (HFrEF)
Source: Yancy et al. 2017 Pathways for Optimization of Heart Failure Treatment. https://doi.org/10.1016/j.jack.2017.11.025
ACEiStop 36 hours
Before Starting
ARBMay Replace
Next Dose
To Make a Change
Heart Failure HFpEF Medication:
May Be Beneficial:Statins
Likely Beneficial:SpironolactoneChlorthalidone
No Benefit:ACEiARB
Not Recommended:NitratesPDE5iDigoxinB-Blocker – unless another
indication is present
Other Therapies (HFpEF):Cardiac Rehab- Exercise training
Improves Quality of life and Exercise CapacitySodium RestrictionPneumonia Vaccination and Annual Influenza VaccineRhythm control preferred over Rate control
Cardiac Resynchronization Therapy (CRT)• Class I Indications: (Recommended)
– NYHA Class II-IV– EF < 35%– LBBB, QRS > 150 msec
• Class IIa Indication: (is reasonable)– NYHA Class II-IV– LVEF < 35%– LBBB, QRS 120-149 msec, – non-LBBB QRS > 150 msec
• Class IIa Indication: (is reasonable)– Atrial fibrillation patients with EF < 35%– Near 100% ventricular pacing– Regardless of CHF Class
• Class IIa Indication: (is reasonable)– EF < 35% with Pacemaker – Expected Ventricular pacing > 40%
• Class IIb Indication: (may be considered)– NYHA Class III or IV– Non-LBBB QRS 120-149 msec– LV EF < 35%
• Class IIb Indication: (may be considered)– NYHA Class I– Ischemic etiology with EF < 30%– LBBB, QRS > 150 msec
• Class III Indication: (not Recommended)– NYHA Class I-II– EF < 35%– Non-LBBB QRS < 150 msec– Survival for cardiac, non-cardiac or frailty
< 1 year
Source: Adapted from http://professional.heart.org/professional/ScienceNews/UCM_444136_Major-Guideline-Changes-for-CRT-in-the-2012-ACCFAHAHRS-Focused-Update.jsp
Guidelines are just recommendations
Treat your patient-Not the guideline measures
Referrals for Advanced Heart Failure: Dos and Don’ts
• Do:
– Discuss and consider advanced HF therapies when class II
• Hyponatremia (NA <136)
• BUN >45, Crt >2.5
• BNP >4x upper normal limit
• Diuretic dose >2.0 mg/kg/dl
• Inability to take ACE/ARB/BB
– Consider if frequent arrhythmia
– Have a low threshold RHC
• Don’t:
– Wait for progressive renal dysfunction
– Wait for multiple pressers
– Wait for cardiac cachexia
– Necessarily assume PA pressures contraindicate right heart cath
Source: Yancy et al. 2017 Pathways for Optimization of Heart Failure Treatment. https://doi.org/10.1016/j.jack.2017.11.025
Source: Yancy et al. 2017 Pathways for Optimization of Heart Failure Treatment. https://doi.org/10.1016/j.jack.2017.11.025
“It’s Not Nice to Fool Mother Nature!”
Looks Like CHF – But it’s Not!
Non-Cardiac Pulmonary Edema: Pulmonary edema with PCWP < 18 mmHg
• ARDS (especially with sepsis, peritonitis, pancreatitis)• Other lung diseases- Often confused with ARDS• Diffuse alveolar hemorrhage • Cancers – lymphoma, Acute Leukemia, and cancer-associated DIC• Acute toxicity (mitomycin-C, methotrexate)
• High altitude and neurogenic pulmonary edema• Less common• Opioid overdose• Pulmonary embolism• Eclampsia• Transfusion-related acute lung injury
“The Forgotten Chamber”
Right Heart FailureSymptoms are related to systemic venous congestion and low cardiac output
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