Chronic HF:
Outpatient Management and
Guidelines
Michael Blazing MD
DUMC
Outpatient CHF “MADE” easy
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Meds
Advice
Devices
Education
CHF “Made” easy - Meds
• Meds the 5 Ms
– Mortality reducing
– Morbidity reducing
– Maintaining weight
– Managing Blood pressure
– Mitigating non-adherence
CHF “Made” easy - Meds
• Mortality reduction – Systolic CHF
– ACE inhibitors - ALL
• ARB can be substituted but not a primary choice
• Best evidence for Candesartan (CHARM Lancet 2003) , Valsartan
(Val-HeFT NEJM 2001), Higher dose 150mg Losartan (HEAAL Lancet
2009)
– Beta-blocker – Only 3
• Carvediol (COPERNICUS NEJM 2001), metoprolol succinate
(MERIT-HF Lancet 1999), bisoprolol (CIBIS-II Lancet 1999) only
• More is better and reduces mortality
– Careful in COPD
– Careful in Right Heart Failure
• Metoprolol tartrate inferior to carvedilol (COMET Lancet 2003)
CHF “Made” easy - Meds
• Mortality reduction – Systolic CHF
– Aldosterone blockade
• Eplerenone – selective A1 blockade mortality reduction post MI
(EPHESES NEJM 2003) and in Class II chronic CHF (EMPHASIS HF
NEJM 2011)
• Spironolactone – non-selective blockade – Mortality reduction in
Class III-IV CHF (RALES NEJM 1999)
• Who to really watch for hyperkalemia
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Elderly
Women
Renal insufficiency
DM and sickle cell (type IV RTA)
– Nitrates and Hydralazine
• African Americans - (A HEFT NEJM 2004)
– Study utilized fixed combination pill
– Dosing is three times per day with short acting nitrate
CHF “Made” easy - Meds
• Morbidity – Systolic CHF
– ACE
• Titration reduces hospitalization (ATLAS Circ 1999)
• Target dose top dose of ACE/ARB
– Beta-blocker – titration reduces death
– Digoxin
• Level 0.5-1 reduces hospitalization (Dig Trial NEJM 1997)
• Level > 1 increased mortality
– Judicious diuretic use
CHF “Made” easy - Meds
Diastolic CHF
• Evidence based Mortality and Morbidity
CHF “mAde” easy - advice
• The malady is theirs to manage and can be
done with relative ease most of the time if a few
simple directions can be followed.
– Help the patient understand the disease and what can
be done to help with the symptoms
– Always emphasize taking the medications
– Dietary salt limitations
– Weigh daily
CHF “mAde” easy - advice
Systolic CHF
– Small engine in a big car
• Less horse power than is ideal and will burn out if
you do not care for it
» ACE - unloads
» Beta-blocker – governor on the engine
» Aldosterone and loop diuretics – keep water off
• Treat it like the little old lady treats her car and you
can last along time
• Treat it like a NASCAR driver and well . . .
CHF “mAde” easy - advice
Diastolic CHF - Body Builder vs gymnast
• Heart is muscle bound and can not accept blood
which backs up
– Blood should enter the heart like air enters a large paper
bag – big change in volume no change in pressure
– In diastolic CHF its like blowing air or water into a new
balloon – larger the balloon more pressure it takes.
Pressure backs up and cause edema and SOB
• Best management is careful fluid – daily weight
and treatments that help the heart remodel
– ACE, Beta-blocker, aldosterone antangonists, nitrates
CHF “maDe” easy - Devices
Devices
Diagnostic Testing
Defibrillators
Advanced therapies
Ventricular assist devices
Transplant
CHF “maDe” easy - Devices
• Diagnostic testing
– Figure out the etiology
• Ischemic or non-ischemic – Key to prevent
worsening
• Cath preferred but MRI, nuclear stress acceptable
if cath is not possible
– Baseline Echo
• EF
• LVIDS, LVIDD, Estimated RV pressure
• Valvular component
CHF “maDe” easy - Devices
• Diagnostic testing
– Additional Echo
• Change in symptoms
• Decision for ICD
• To follow valvular disease – yearly or so unless
symptoms change
• NO INDICATION FOR YEARLY ECHO IN
STABLE PATIENT
CHF “maDe” easy - Devices
• Diagnostic testing
– Role of CPX (cardiopulmonary testing)
• Some advocate testing everyone
• For patients who are progressing and candidates
for more advanced (VAD, transplant) therapy
• If the dyspnea is out of proportion to CHF on exam
– BNP
• Management by BNP alone has not been validated
• A marker along with volume, renal fxn, Class
CHF “maDe” easy - Devices
Defibrillators
• EF < 40%
• Life expectancy at least 1 year
• Not in refractory class IV CHF
– Unless as bridge to transplant
– Unless a also with wide QRS and candidate for BiV ICD
• At least 40 days post MI or revascularization
• Between 3 and 9 months out for new NICM
CHF “maDe” easy - Devices
Resynchronization therapy – BiV ICD
• EF < 35%
• QRS > 120 ms
– Better if LBBB or IVCD
– Less effective with RBBB
• Class III or IV CHF
• ? Utility in Class I and II CHF
– New studies may advocate this as a preventive approach
– MADIT-CRT (Moss et al, NEJM 2010)
» Reduced non-fatal CHF events but no change
mortality.
CHF “maDe” easy - Devices
Ventricular assist device/Transplant
• Improve quantity and quality of life
• Approaches are bridge or “destination”
• Referral to transplant cardiology for those with
– Refractory symptoms
– Progressive symptoms
• Earlier rather than later consultation helps with
management and options
CHF “madE” easy - Education
• Patient - Daily weight
• Loop diruetics (water pills) relieve the symptoms
but most likely worsen the disease
– Activate neuro-hormonal responses
– Increase electrolyte disturbances
– Challenge the kidneys
• Weight monitoring along with salt restriction will
lead to minimization of their use (until very late in
the disease)
• Get a calendar and write weight down daily
• Advocate using weight to titrate diuretics
– Allows holidays and personal management
CHF “madE” easy - Education
• Patient - Salt restriction
• 2 gram salt diet – “what the H… is 2 grams”
– No added salt
– No salty foods
» Minimal to nothing out of a box or can unless you read it
» Minimize eating out
» No processed meats/ foods (including frozen dinners)
• Vegetables, meats (counter or wrapped), fruits all ok
CHF “madE” easy - Education
• Physician – role is to teach and quiz
• Have the patient describe what is wrong with his
heart
• Reconnect the role of the medications in this disease
for temporizing the deterioration
• How is he going to manage it?
• What role does salt play?
• How can daily weights help with management of fluid
and fluid pills?