![Definition of Heart Failure with
Terminologies
Classification Ejection
Fraction
Description
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
≤40% Symptoms ± signs
II. Heart Failure with
Preserved Ejection Fraction
(HFpEF)
≥50% Symptoms ± signs
Elevated levels of natriuretic peptides
At least one additional criteria:
1.Releavent structural heart disease[ LVH / or LAE]
2.LV DIASTOLIC DYSFUNCTION
III. Heart Failure with
mid range Ejection
Fraction (HFmrEF)
40-49% Symptoms ± signs
Elevated levels of natriuretic peptides
At least one additional criteria:
1.Releavent structural heart disease[ LVH / or LAE]
2.LV DIASTOLIC DYSFUNCTION
2016 ESC Guidelines](https://image.slidesharecdn.com/optimizingheartfailuremanagement-190918053431/85/Optimizing-heart-failure-management-4-320.jpg)
![Devices in Heart Failure
• Biventricular Pacing or Cardiac
Resynchronization therapy [CRT]
• Automatic Implantable Cardioverter
Defibrillator[AICD]](https://image.slidesharecdn.com/optimizingheartfailuremanagement-190918053431/85/Optimizing-heart-failure-management-22-320.jpg)
Optimizing heart failure management
- 2. Overview • Definition • Classification and Terminology • Evaluation and Diagnosis • Pharmacological Treatment for HF • Device therapy for HF • Non Pharmacological Treatment for HF
- 3. Definition of Heart Failure HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/ or elevated intracardiac pressures at rest or during stress.
- 4. Definition of Heart Failure with Terminologies Classification Ejection Fraction Description I. Heart Failure with Reduced Ejection Fraction (HFrEF) ≤40% Symptoms ± signs II. Heart Failure with Preserved Ejection Fraction (HFpEF) ≥50% Symptoms ± signs Elevated levels of natriuretic peptides At least one additional criteria: 1.Releavent structural heart disease[ LVH / or LAE] 2.LV DIASTOLIC DYSFUNCTION III. Heart Failure with mid range Ejection Fraction (HFmrEF) 40-49% Symptoms ± signs Elevated levels of natriuretic peptides At least one additional criteria: 1.Releavent structural heart disease[ LVH / or LAE] 2.LV DIASTOLIC DYSFUNCTION 2016 ESC Guidelines
- 5. Classification of Heart Failure ACCF/AHA Stages of HF NYHA Functional Classification A At high risk for HF but without structural heart disease or symptoms of HF. None B Structural heart disease but without signs or symptoms of HF. I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. C Structural heart disease with prior or current symptoms of HF. I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. D Refractory HF requiring specialized interventions.
- 6. Initial and Serial Evaluation of the HF Patient History and Physical Examination Diagnostic Tests Biomarkers (Ambulatory/Outpatient)
- 7. Biomarkers-BNP/NT Pro BNP • To support clinical decision making regarding the diagnosis of HF • Prognosis or disease severity in chronic HF. • BNP- or NT-proBNP guided HF therapy can be useful to achieve optimal dosing in select clinically euvolemic patients • Biomarkers of myocardial injury or fibrosis may be considered for additive risk stratification in patients with chronic HF.
- 9. Recommendations for Noninvasive and Invasive Imaging • Chest X Ray • ECHO with Doppler • Nuclear Imaging for ischemia / myocardial Viability • Nuclear Imaging or MRI for LV volume and EF • Cardiac MRI for myocardial infiltration and scar • Coronary Angiogram in suspected CAD • Endomyocardial Biopsy in select cases
- 10. Treatment of Stage A HF • Hypertension and lipid disorders should be controlled as per guideline • Obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents, should be controlled or avoided
- 11. Recommendations for Treatment of Stage B HF • Patients with reduced EF, ACE inhibitors or ARBs and betablockers should be used to prevent HF • Patients with MI, statins should be used to prevent HF • Nondihydropyridine calcium channel blockers may be harmful in patients with low LVEF
- 12. Treatment of Stage C HF Non-pharmacological Interventions • Patients with HF should receive specific education to facilitate HF self-care. • Exercise training (or regular physical activity) is recommended to improve functional status. • Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms. • Continuous positive airway pressure (CPAP) in HF with OSA to improve LVEF and functional status
- 13. Pharmacological Treatment Of Heart Failure With Reduced Ejection Fraction
- 14. Pharmacologic Treatment for Stage C HFrEF HFrEF Stage C NYHA Class I – IV Treatment: For NYHA class II-IV patients. Provided estimated creatinine >30 mL/min and K+ <5.0 mEq/dL For persistently symptomatic African Americans, NYHA class III-IV Class I, LOE A ACEI or ARB AND Beta Blocker Class I, LOE C Loop Diuretics Class I, LOE A Hydral-Nitrates Class I, LOE A Aldosterone Antagonist AddAdd Add For all volume overload, NYHA class II-IV patients
- 15. Medical Therapy for Stage C HFrEF: Magnitude of Benefit Demonstrated in RCTs GDMT RR Reduction in Mortality NNT for Mortality Reduction (Standardized to 36 mo) RR Reduction in HF Hospitalizations ACE inhibitor or ARB 17% 26 31% Beta blocker 34% 9 41% Aldosterone antagonist 30% 6 35% Hydralazine/nitrate 43% 7 33%
- 16. Other Medications • If-channel inhibitor: Ivabradine reduced the combined endpoint of mortality and hospitalization for HF in patients with symptomatic HFrEF and LVEF ≤35%, in sinus rhythm and with a heart rate ≥70 beats per minute (bpm) • Digoxin may be considered in patients in sinus rhythm with symptomatic HFrEF to reduce the risk of hospitalization (both all-cause and HF hospitalizations) and patients with Af with FVR
- 17. Newer Drug for HF-ARNI • In ARNI, an ARB is combined with an inhibitor of neprilysin, an enzyme that degrades natriuretic peptides, bradykinin, adrenomedullin, and other vasoactive peptides. • In an RCT that compared the first approved ARNI, valsartan/sacubitril, with enalapril in symptomatic patients with HFrEF tolerating an adequate dose of either ACE inhibitor or ARB, the ARNI reduced the composite endpoint of cardiovascular death or HF hospitalization significantly, by 20%. • Side effects: hypotension and renal insufficiency and may lead to angioedema, as well. • Patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality .
- 18. Limitations of Standard Treatment • Lack of compliance • Refractory heart failure despite optimal medical treatment • Intolerant to medical therapy • High risk of Sudden Cardiac Arrest
- 19. Heart Failure-Optimizing Outcomes with Device Therapies
- 20. Heart Failure Clinical Challenges 1 Lloyd-Jones D, et al. Circulation. 2010;121:e46-215. 2 Setoguchi S, et al. Am Heart J. 2007;154:260-266. Each year, more than one million hospitalizations occur with the primary diagnosis of heart failure1 Repeated heart failure hospitalizations are associated with increased mortality2 sudden death occurs at four times the rate of the general population
- 21. CHF Patients Survival Results 1. Framingham Heart Study (1948 – 1988) in Atlas of Heart Diseases. 2. American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Dallas, Tex.
- 22. Devices in Heart Failure • Biventricular Pacing or Cardiac Resynchronization therapy [CRT] • Automatic Implantable Cardioverter Defibrillator[AICD]
- 23. Benefits of Cardiac Devices In Heart Failure • Improvement in HF symptoms • Reduces Hospitalization • Improvement in Quality of Life • Prevention of Sudden Cardiac Arrest
- 24. Mortality Reduction in Heart Failure
- 26. Prevalence of BBB in Heart Failure Left Bundle Branch Block More Prevalent with Impaired LV Systolic Function 38% 24% 8% Moderate/Severe HF (2) Impaired LVSF (1) Preserved LVSF (1) 1. Masoudi, et al. JACC 2003;41:217-23 2. Aaronson, et al. Circ 1997;95:2660-7
- 27. Overview of Device Therapy 27 Ventricular Dyssynchrony • Abnormal ventricular conduction resulting in a mechanical delay – Wide QRS (IVCD); typically LBBB morphology – Poor systolic function – Impaired diastolic function ECG depicting interventricular conduction delay
- 30. CRT-BIVENTRICULAR PACING RAO VIEW LAO VIEW
- 31. Cardiac Resynchronization Cardiac Resynchronization Improved Intraventricular Synchrony Improved Atrioventricular Synchrony Improved Interventricular Synchrony
- 32. CRT- LV Reverse Remodeling
- 33. CRT Is Highly Beneficial Treatment for Heart Failure1-8 1 Cleland J, et al. N Engl J Med. 2005;352:1539-1549. 2 Cleland J, et al. Eur Heart J. 2006;27:1928-1932. 3 Bristow MR, et al. J Card Fail. 2000;6:276-285. 4 Abraham W, et al. N Engl J Med. 2002;346:1845-1853. 5 Young J, et al. JAMA. 2003;289:2685-2694. 6 Linde C, et al. J Am Coll Cardiol. 2008;52:1834-1843. 7 Tang A, et al. N Engl J Med. 2010;363:2385-2395. 8 Moss A, et al. N Engl J Med. 2009;361:1329-1338. • Extends survival1-3,7,8 • Reduces heart failure hospitalizations1-3,6-8 • Improves cardiac function1,2,4,6,8 • Improves functional capacity or quality of life4,5 2000 2010 > 7,000 patients studied CARE-HF1,2 COMPANION3 MIRACLE4 MIRACLE ICD5 REVERSE6 RAFT7 MADIT CRT8 CRT is an effective treatment for those heart failure patients with systolic dysfunction and ventricular electrical conduction delays
- 34. CRT Reduces Heart Failure Admissions 1,2 CRT is proven to reduce heart failure admissions across all CRT-indicated patient populations 53% Reduction in Heart Failure Admissions1 52% Reduction in Heart Failure Admissions2 REVERSE CRT-D Clinical Trial CARE-HF CRT Clinical Trial 1 Year after Implant 1 Linde C, et al. J Am Coll Cardiol. 2008;52:1834-1843. 2 Cleland J, et al. N Engl J Med. 2005;352:1539-1549. CRT-Indicated Class II CRT-Indicated Class III/IV
- 35. Patient Selection based on Evidence
- 36. 2012 ACCF/AHA/HRS Guidelines for CRT Class I Recommendations CRT is indicated for patients who have* • LVEF ≤ 35% • Sinus rhythm • Left Bundle Branch Block (LBBB) • QRS duration ≥ 150 ms • NYHA class II, III, or ambulatory Class IV symptoms • Guideline-Directed Medical Therapy (Level of Evidence: A for NYHA class III/IV; Level of Evidence: B for NYHA class II) Class IIa Recommendations CRT can be useful for patients who have: • LVEF ≤ 35% • Sinus rhythm • LBBB • QRS duration 120 to 149 ms • NYHA class II, III, or ambulatory Class IV symptoms • Guideline-Directed Medical Therapy (Level of Evidence: B) CRT can be useful for patients who have: • LVEF ≤ 35% • Sinus rhythm • Non-LBBB pattern • QRS duration ≥ 150 ms • NYHA class III, or ambulatory Class IV symptoms • Guideline-Directed Medical Therapy (Level of Evidence: A) CRT can be useful for patients who have: • Atrial fibrillation • LVEF ≤ 35% • Guideline-Directed Medical Therapy If a) the patient requires ventricular pacing or otherwise meets CRT criteria, and b) AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT. (Level of Evidence: B) CRT can be useful for patients who have: • LVEF ≤ 35% • Guideline-Directed Medical Therapy • Anticipated requirement for significant (> 40%) ventricular pacing (Level of Evidence: C) * Assuming patient are on chronic, optimal medical therapy and have a reasonable expectation of survival with good functional status for > 1 year. Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol. October 2, 2012;60(14):1297-1313.
- 37. Role of AICD in HF • Prevention of sudden death is an important goal in HF. • Approximately half of the deaths in patients with HF, especially in those with milder symptoms, occur suddenly and unexpectedly, • Many, if not most, of these are related to ventricular arrhythmias
- 38. Severity of Heart Failure Modes of Death MERIT-HF Study Group. Lancet.1999;353:2001-2007. 12% 24% 64% CHF Other Sudden Death (N = 103) NYHA II 26% 15% 59% CHF Other Sudden Death (N = 103) NYHA III 56% 11% 33% CHF Other Sudden Death (N = 27) NYHA IV SCA Pump Failure NYHA Class II 64% 12% NYHA Class III 59% 26% NYHA Class IV 33% 56%
- 39. “Reduced left ventricular ejection fraction (LVEF) remains the single most important risk factor for overall mortality and sudden cardiac death.”1 1Prior SG, Aliot E, Blonstrom-Lundqvist C, et al. Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J, Vol. 22; 16; August 2001.
- 40. SCA Risk Factors Well Documented Clinical Factor Risk Description Low Left Ventricular Ejection Fraction (LVEF) About 45% of all SCA victims have LVEF < 30%1 Heart Failure (HF) 25% overall death in 2.5 years; and 50% die of SCA2 Prior Myocardial Infarction (MI) and HF SCD occurs at four times the rate of the general population3 Prior Ventricular Tachycardia (VT), Ventricular Fibrillation (VF) or SCA Risk of arrhythmic death is 18% after three years of a prior event4 Note: Any combination of these factors increases the risk of SCA. 1 de Vreede-Swagemakers JJ, et al. J Am Coll Cardiol. 1997;30:1500-1505. 2 Sweeney MO. PACE. 2001;24:871-888. 3 Adabag AS, et al. JAMA. 2008;300:2022-2029. 4 Pratt CM. Circulation. 1998;98(suppl 1):1494-1495.
- 41. Recommendation for AICD in HF • Secondary Prevention – Survivor of SCA or documented VT irrespective of LVEF • Primary Prevention – LVEF<35% and class II-III Symptoms despite 3 months optimal medical therapy – Post MI LVEF <35% after 40 days – Post CABG/PCI <35% after 3 months
- 42. AICD
- 43. Benefit of ICD therapy
- 45. Advancement in Device Therapy- Adaptive LV pacing
- 46. AdaptivCRT • Adaptiv CRT Reduced 30-Day HF Readmissions by 47% as compared to patients receiving echo-optimized BiV pacing • AdaptivCRT Reduced AF Risk by 46% • Reduced risk of HF hospitalization or death with Adaptiv CRT
- 47. Advancement in Device Therapy- Multipoint LV Pacing
- 48. Device therapy in HFrEF- Summary • Heart failure with severe LV dysfunction patients should be evaluated for appropriate device therapy. • CRT –P/CRT-D device therapy reduces mortality and hospitalization and improves the quality of life. • AICD implantation should be considered in severe LV dysfunction patients without IVCD
- 49. Clinical Events and Findings Useful for Identifying Patients With Advanced HF Repeated (≥2) hospitalizations or ED visits for HF in the past year Progressive deterioration in renal function (e.g., rise in BUN and creatinine) Weight loss without other cause (e.g., cardiac cachexia) Intolerance to ACE inhibitors due to hypotension and/or worsening renal function Intolerance to beta blockers due to worsening HF or hypotension Frequent systolic blood pressure <90 mm Hg Persistent dyspnea with dressing or bathing requiring rest Inability to walk 1 block on the level ground due to dyspnea or fatigue Recent need to escalate diuretics to maintain volume status, often reaching daily furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone therapy Progressive decline in serum sodium, usually to <133 mEq/L Frequent ICD shocks Adapted from Russell et al. Congest Heart Fail. 2008;14:316-21.
- 50. Treatment of Stage D HF • Fluid restriction (1.5 to 2 L/d) especially in patients with hyponatremia, to reduce congestive symptoms. • Inotropic support • Mechanical Circulatory Support • Cardiac transplantation
- 51. Surgical/Percutaneous/Transcatheter Interventional Treatment of HF • CABG or percutaneous intervention is indicated for HF in critical coronary lesions • Surgical or Trans catheter aortic valve replacement in critical Aortic Stenosis • Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency • Surgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF for specific indications including intractable HF and ventricular arrhythmias
- 52. Summary