D.BASEM ELSAID ENANYLECTURER OF CARDIOLOGY

AINSHAMS UNIVERSITY

HF: treatment--I

--Goals:Relieve symptoms and signs (e.g. oedema)Prevent hospital admissionImprove survival

Treatments recommended inpotentially all patients with systolic

heartfailure

Angiotensin-converting enzyme inhibitors

--ACE inhibitors have a modest effect on LV remodelling whereas beta-blockers often lead to a substantial improvement in EF.--ACEI[Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS) and Studies of Left Ventricular Dysfunction (SOLVD)-Treatment]--SE worsening of renal function, hyperkalaemia, symptomatic hypotension, cough, and, rarely,angioedema. An ACE inhibitor should only be used in patients with adequate renal function (creatinine ≤2.5 mg/dL or eGFR ≥30 mL/min/1.73 m2) and a normal serum potassium level-patients should be rechallenged, because many will not redevelopa cough, suggesting the initial development of cough was coincidental and may have been related to heart failure

Beta-blockers

--BB [Cardiac Insufficiency Bisoprolol Study II (CIBIS II), Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS), and Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF), Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors With Heart Failure (SENIORS)]--Should usually be initiated in stable patients, and used only with caution in recently decompensated patients (and only initiated in hospital in these patients). Recently decompensated patients were, however, safely initiated on betablocker treatment in COPERNICUS--Temporary discontinuation is advised in shocked or severely hypoperfused patients. Re-institution of treatment should be attempted before discharge.- β-Blockers should be initiated at low doses, uptitrated gradually . achieve target doses in 8 to 12 weeks from initiation of therapy

- β-Blocker therapy should only be initiated when patients are euvolemic and hemodynamicallystable, are usually on a good maintenance dose of diuretics (if indicated), and receivingACE inhibitors or ARBs.- If patient symptoms worsen during initiation or dose titration, the dose of diuretics or otherconcomitant vasoactive medications should be adjusted, and titration to target dose shouldbe continued after the patient’s symptoms return to baseline.- If uptitration continues to be difficult, the titration interval can be prolonged, the target dosemay have to be reduced, or the patient should be referred to a heart failure specialist.- If an acute exacerbation of chronic heart failure occurs, therapy should be maintained ifpossible; the dose can be reduced if necessary, but abrupt discontinuation should be avoided.If the dose is reduced (or discontinued), the β-blocker (and prior dose) should be graduallyreinstated before discharge, if possible.

Mineralocoricoid Receptor Antagonist

--MRA [Randomized Aldactone Evaluation Study (RALES) trial, Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF), Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS)]--Spironolactone and eplerenone can cause hyperkalaemia and worsening renal function should only be used inpatients with adequate renal function and a normal serum potassium concentration; if either is used, serial monitoring of serum electrolytes and renal function is mandatory.--Spironolactone can also cause breast discomfort and enlargement in men (10% compared with 1% on placebo, in RALES); this side effect is infrequent with eplerenone.

-Hydralazine: start at 37.5 mg three times a day and increase to a goal of 75 mg three times a day.-Isosorbide dinitrate: start at 20 mg three times a day and increase to a goal of 40 mg threetimes a day.In:=Those who cannot take an ACE inhibitor or ARB because of renal insufficiency or hyperkalemia= Those who are hypertensive and/or symptomatic despite taking ACE inhibitor, ARB, andβ-blockers= The combination of hydralazine and nitrates is recommended to improve outcomes forpatients self-described as African Americans with moderate-severe symptoms on optimalmedical therapy with ACE inhibitors, β-blockers, and diuretics.

ARBs

--ARBs are no longer the first choice recommendation in patients with HF and an EF ≤40% who remain symptomatic despite optimal treatment with an ACE inhibitor and beta-blocker. This is because in EMPHASIS-HF, eplerenone led to a larger reduction in morbidity–mortality than seen in the ARB ‘add-on’ trials discussed below, and because in both the Randomized Aldactone Evaluation Study (RALES) and EMPHASIS-HF, MRA treatment reduced all-cause mortality, whereas ARB ‘add-on’ treatment did not.--[Valsartan Heart Failure Trial (Val-HeFT) and CHARM-Added]reduced the risk of HF hospitalization (RRR 24% in Val-HeFT and 17% in CHARM-Added) but not all-cause hospitalization.

Ivabradine

--Ivabradine is a drug that inhibits the If channel in the sinus node. Its only known pharmacological effect is to slow the heart rate in patients in sinus rhythm (it does not slow the ventricular rate in AF).-- The Systolic Heart failure treatment with the If inhibitor ivabradine Trial (SHIFT) enrolled 6588 patients in NYHA functional class II–IV, sinus rhythm with a rate of ≥70 b.p.m., and an EF ≤35% randomized to ivabradine (up-titrated to a maximal dosage of 7.5 mg twice daily) or placebo, added to a diuretic (in 84%), digoxin (22%), an ACE inhibitor (79%), an ARB (14%), a beta-blocker (90%), and an MRA (60%). Only 26% of patients were, however, on full-dose beta-blocker the reduction in cardiovascular death (or all-cause death) was not significant, but the RRR in HF hospitalization was 26%-- Safety evidence for ivabradine comes from the MorBidity-mortality EvAlUaTion of the If inhibitor ivabradine in patients with coronary disease and left ventricULar dysfunction (BEAUTIFUL) trial, an RCT in which 10 917 patients with coronary heart disease and an EF ,40% were assigned to treatment with ivabradine 7.5 mg twice daily or placebo and followed for a median of 19 months. Although ivabradine did not reduce the primary outcome of cardiovascular death, myocardial infarction, or HF hospitalization, it was well tolerated

Digoxin

-Inhibitors of the Na-K . ATPase pump in the sarcolemic membrane of the myocyte and other cells This inhibition causes intracellular accumulation of Na, which makes the Na-Ca pump extrude less Ca,

causing Ca to accumulate inside the cell. Cardiac glycosides also enhance parasympathetic and reduce sympathetic outputs to the heart, through carotid sinus baroreflex sensitization.-Digoxin has a narrow safety margin (the difference in plasma drug concentrations betweentherapeutic and toxic levels is small). Patients with digoxin toxicity may manifest nausea,vomiting, anorexia, diarrhea, fatigue, generalized malaise, visual disturbances (green or yellowhalos around lights and objects), and arrhythmias. In the presence of hypokalemia, digoxintoxicity may occur within the therapeutic level. Digoxin dose should be reduced in elderlypatients, in patients with renal insufficiency (glomerular filtration rate [GFR] less than 60 ml/min)& Sinus bradycardia& Sinus arrest& First- and second-degree AV block& AV junctional escape& Paroxysmal atrial tachycardia with AV block & Bidirectional ventricular tachycardia& Premature ventricular beats& Bigeminy& Regularized atrial fibrillation or atrial fibrillation with slow ventricular response (common)

-Digoxin withdrawal is sufficient with only suggestive symptoms.-Activated charcoal may enhance the gastrointestinal (GI) clearance of digoxin if given within 6 hours of ingestion. Drugs that increased plasma digoxin levels (Quinidine, verapamil, amiodarone, propafenone, and quinine) should be discontinued (except amiodarone because of its long half-life). -Correction of hypokalemia is vital (intravenous [IV] replacement through a large vein is preferred with life-threatening arrhythmias).-Symptomatic AV block may respond to atropine or to phenytoin (100 mg IV every 5 minutes up to 1000 mg until response or side effects); if no response, use Digibind. The use of temporary transvenous pacing should be avoided. -Patients with severe bradycardia should be given Digibind, even if they respondto atropine. -Lidocaine and phenytoin may be used to treat ventricular arrhythmias, but forpotentially life-threatening bradyarrhythmias or tachyarrhythmias, Digibind should be used.-Dialysis has no role because of the high tissue binding of digoxin.Phenytoin:Loading Dose: 

14-18mg/kg IV direct

Maintenance Dose:5mg/kg/day (in divided doses every 8 hours)

Treatments not recommended(unproven benefit)

--Statins: Two recent trials(CORONA and GISSI-HF) studied statin treatment specifically in patients with chronic HF and did not demonstrate convincing evidence of benefit (although there was little evidence of harm).Despite the evidence in other areas of cardiovascular medicine, the evidence does not therefore support the initiation of statins in most patients with chronic HF.-- Direct renin inhibitor (aliskiren) is not presently recommended as an alternative to an ACE inhibitor or ARB.-- Other than in patients with AF (both HF-REF and HF-PEF), there is no evidence that an oral anticoagulant reduces mortality–morbidity compared with placebo or aspirin.-LV thrombus INR 2.0–3.0 for at least 3 monthsand up to 1 year

Diuretics

--No mortality or morbidity effect studied,,, symptomatic.-- Loop diuretics produce a more intense and shorter diuresis than thiazides, which cause a more gentle and prolonged diuresis.Thiazides may be less effective in patients with reduced kidney function.-- Do not use thiazides if estimated glomerular filtration rate <30 mL/min, except when prescribed synergistically with loop diuretics.-- Self-adjust of diuretic dose, based on monitoring of symptoms/signs of congestion and daily weight measurements.-- † If a potassium-losing diuretic is used with the combination of anACE inhibitor and an MRA (or ARB), potassium replacement isusually not required.† Serious hyperkalaemia may occur if potassium-sparing diureticsor supplements are taken in addition to the combination of anACE inhibitor (or ARB) and MRA.

-New recommendationfrom 2009 Focused Update states that for hospitalized heart failure patients, if diuresis isinadequate to relieve congestion, higher doses of loop diuretics should be used, addition of seconddiuretic should be made or continuous infusion of a loop diuretic should be considered.

Heart failure with ‘preserved’ ejection fraction (diastolic heart failure)

-- Diuretics are used to control sodium and water retention and relieve breathlessness and oedema-- Adequate treatment of hypertension and myocardial ischaemia.-- The drugs that should be avoided in HF-REF should also be avoided in HF-PEF, with the exception of CCBs.-- (CHARM)-Preserved Trial, Perindopril for Elderly People with Chronic Heart failure trial (PEP-CHF), Irbesartan in heart failure with preserved systolic function trial (I-Preserve) no reduction in the primary composite endpoint of death or HF hospitalization

=Control of systolic and diastolic hypertension as per published hypertension guidelines= Control of ventricular rate in atrial fibrillation= Diuretics to control pulmonary congestion and peripheral edema= Consider revascularization in patients with significant coronary artery disease and symptomsand/or demonstrable ischemia, where ischemia may be regarded as a contributor to abnormalcardiac function= Restoration and maintenance of sinus rhythm in certain patients with atrial fibrillation maybe useful to control symptoms= β-blockers can be considered for HFpEF with:○ Prior myocardial infarction○ Hypertension○ Atrial fibrillation= ACE inhibitors or ARBs can be considered for HFpEF with:○ Hypertension○ Diabetes○ Atherosclerotic vascular disease= Calcium channel blockers can be considered for HFpEF with:○ Atrial fibrillation requiring control of ventricular rate in patients for whom blockers haveproven inadequate: consider diltiazem or verapamil○ Symptom-limiting angina○ Hypertension: consider amlodipine= Digitalis may be considered for rate control in atrial fibrillation if not responsive to otheragents listed above.

Non-surgical device treatment of systolic heartfailure: I- ICD

II- CRT

Uncertain

HF+AF

-- The most common arrhythmia in HF.-- Identification of correctable causes (e.g. hyperthyroidism, electrolyte disorders, uncontrolled hypertension, mitral valve disease).--Identification of potential precipitating factors (e.g. recent surgery, chest infection or exacerbation of chronic pulmonary disease/asthma, acute myocardial ischaemia, alcohol binge) as this may determine whether a rhythm-control strategy is preferred to a rate-control strategy.--Assessment for thromboembolism prophylaxis.--Rhythm control is probably best reserved for patients with a reversible secondary cause of AF (e.g. hyperthyroidism) or an obvious precipitant (e.g. recent pneumonia) and in patients who cannot tolerate AF after optimization of rate control and HF therapy. --Amiodarone is the only antiarrhythmic that should be used in patients with systolic HF.--CHA2DS2-VASc vs HASBLED

Symptomatic bradycardia, atrioventricular block

--Before implanting a conventional pacemaker in a patient withHF-REF, consider whether there is an indication for an ICD,CRT-P, or CRT-D.--Because right ventricular pacing may induce dyssynchrony andworsen symptoms, CRT should be considered instead of conventionalpacing in patients with HF-REF.--Physiological pacing to maintain an adequate chronotropic responseand maintain atrial–ventricular coordination with a DDD system is preferable to VVI pacing in patients with both HF-REF and HF-PEF.--Pacing solely in order to permit initiation or titration of betablockertherapy in the absence of a conventional indication is not recommended.

Thank you