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