Michelle A. Hart MD CCFP M.Sc.C.H
Sid Feldman MD CCFP FCFP
Baycrest Health Sciences, Toronto, ON
Department of Family and Community Medicine,
University of Toronto
Faculty/Presenter Disclosure
• Faculty: Dr. Michelle Hart
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
None
Disclosure of Commercial
Support
• This program has not received financial support.
• This program has not received in-kind support.
• Potential for conflict(s) of interest: None
Mitigating Potential Bias
None
Faculty/Presenter Disclosure
• Faculty: Dr. Sid Feldman
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
None
Disclosure of Commercial
Support
• This program has not received financial support.
• This program has not received in-kind support.
• Potential for conflict(s) of interest: None
Mitigating Potential Bias
None
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Dr. Daphna Grossman
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By the end of this hour you will be able to:
1. Utilize best methods for accurate diagnosis
of congestive heart failure
2. Apply current evidence for effective
management of congestive heart failure and
delay progression of heart failure
3. Employ resources in the community to
support patients with strategies for selfmanagement
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6.
Review on basics of heart failure
Diagnosing Heart Failure
Management of Heart Failure
Future Directions: What’s coming down the
pipeline for HF Management
Advanced Care Planning, Prognostication
and End-Of-Life
Summary of Heart Failure
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Definition of Heart Failure
Why is it important?
How does it happen?
Types of Heart Failure
Staging and Classes of Heart Failure
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Canadian Cardiovascular Society (CCS)
“Complex syndrome in which abnormal heart
function results in, or increases risk of clinical
symptoms and signs of low cardiac output
and/or pulmonary or systemic congestion”
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In North America, it is the fastest growing
cardiac diagnosis for individuals > 65 years
Average annual mortality rate of 10-35% in
Canada
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Myocardial injury or stress on heart initiates
the process of ventricular dysfunction
Cardiac remodelling worsens function
Progressive process
Declining function exacerbates remodelling
Neurohormonal activation: hemodynamic
stresses, cardiotoxicity, myocardial fibrosis –
ongoing remodelling and progression
Two Categories:
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Left ventricular systolic dysfunction with
Reduced Ejection Fraction (HF-REF)
HF with preserved ejection fraction (HF-PEF)
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½ the cases
More often in older, female patients
Often have hypertension, atrial fibrillation
Less coronary artery disease
Mortality less than for HF-REF
Morbidity similar
American Heart Association
 Treatment linked to objective criteria
 Uses risk factor and cardiac structure
New York Heart Association (NYHA) Functional
Classification
 Based on subjective clinical evaluation
 Changes with treatment response and disease
progression
 Complementary with AHA
Canadian Cardiovascular Society (CCS) uses NYHA
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Fatigue
Weakness
Ankle edema
Weight gain
Exertional dyspnea
Orthopnea
Paroxysmal Nocturnal Dyspnea
Cough
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Ascites/Abdominal Distension
Enlarged liver
Tachycardia
Displaced, sustained apex beat
3rd or 4th heart sound
Left parasternal heave
Murmurs of mitral and/or tricuspid regurgitation
Increased JVP
Pulmonary crackles
Pleural effusion
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Renal failure
Obesity
COPD
Depression/anxiety
Severe anemia
Pulmonary embolism
Atrial Fibrillation
Hypoalbuminemia
Dependent edema
Fluid retention 2˚ to calcium channel blocker or
non-steroidal anti-inflammatory drugs
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Class 1 Recommendation, Level C Evidence
Clinical history
Physical Exam
Initial lab investigations
Transthoracic Echocardiography
Radionuclide Angiography
Coronary Angiography
Cardiac Magnetic Resonance
Assessment of Functional Capacity: NYHA
Figure 1
New York Heart Association Classification
Canadian Journal of
Cardiology 2013; 29:168-181)
Copyright © 2013 Canadian
Cardiovascular Society
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CCS Updated 2012 Guidelines
Constellation of symptoms (eg, orthopnea
and shortness of breath on exertion) and
signs (eg, edema and respiratory crackles)
Physical examination evaluates systemic
perfusion and presence of congestion (cold or
warm, wet or dry)
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Laboratory testing
Electrocardiogram (ECG)
Chest x-ray
Echocardiogram
Taken from: The Radiology Assistant
http://www.radiologyassistant.nl/en/p4c132f36513d4
Taken from: The Radiology Assistant
http://www.radiologyassistant.nl/en/p4c132f36513d4
PCWP = Pulmonary
Capillary Wedge
Pressure
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A slight mild elevation of cardiac troponin is
not infrequently observed in acute
decompensation and not necessarily
indicative of myocardial infarction (MI).
The utility of natriuretic peptide (NP) to
exclude (“rule out”) or confirm (“rule in”) the
diagnosis in the appropriate clinical scenario
is well established.
NPs are best used when the diagnosis is
uncertain
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BNP and prohormone (NT-proBNP) are
synthesized and released from the heart in
response to end-diastolic volume and
pressure
High negative predictive value
BNP <100 pg/mL rules out HF in patients
presenting with dyspnea in the acute care
setting [level I-1 Evidence]
BNP > 500 pg/mL confirms HF in patients
with dyspnea
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Several clinical scoring systems have been
derived and validated and combine commonly
used clinical features with NP values to
improve diagnosis and decision-making
The most commonly used clinical scoring
system was developed by Baggish et al.
Table 1. A clinical scoring system for diagnosis of AHF
Predictor
Possible score
Age > 75 y
1
Orthopnea present
2
Lack of cough
1
Current loop diuretic use
(before presentation)
1
Rales on lung exam
1
Lack of fever
2
Elevated NT-proBNP
4
Interstitial edema on
chest x-ray
2
14
Likelihood of heart failure Low
Your patient's score
Total =
0-5
Intermediate
6-8
High
9-14
Elevated NT-proBNP was defined as > 450 pg/mL if age < 50 years and >
900 pg/mL if age > 50 years
Source: CCS Guidelines 2012
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Age
Sex
Weight
Medications
Pulmonary Disease
Renal disease
Routine use of BNP in evaluation, diagnosis
and management of HF in primary care awaits
more research
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Risk factor management
Patient education
Treatment: Non-pharmacological
Treatment: Pharmacological
When to refer?
Cardiovascular risk factor targets
 National guidelines, lifestyle, pharmacologic
measures for patients with high risk of
developing HF and for those already
diagnosed with HF
[Class I Evidence, Level A Recommendation]
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Elderly Patients (>80 years) with sitting BP >
160/90 mmHg and standing systolic BP >
140 mmHg lower sitting BP to 150/80 mmHg
[Class I Evidence, Level A Recommendation]
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Patient with vascular disease or diabetes with
end-organ damage, prescribe target-dose
ACEi or ARB
[Class IIa Evidence, Level B Recommendation]
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Critical for successful therapy
Best way to maintain adherence/compliance
Patient information/handouts
-Eg. Canadian Heart Failure Network (CHFN)
http://www.chfn.ca/patient-education-tools
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Self-management, meds (when applicable)
Action plan – what to do if symptoms worsen
Multidisciplinary interventions appear
beneficial (studies from academic centres
only)
1) Physical activity and exercise training
2) Salt and fluid restriction & weight management
3) Reducing risk of serious respiratory infections
1) Physical activity and exercise training
- Earlier studies: reduction in mortality
- Cochrane review (2010) >3500 patients:
Risk of death (mild-mod HF) ↔ [Level I-1 Evidence)
Hospital Admissions ↓
- All studies: health-related quality of life ↑
- Exercise programs mainly aerobic
[Class IIa Recommendation, Level B Evidence]
1) Regular daily physical activity that does not
induce symptoms, for all patients with stable
HF symptoms and impaired LV systolic
function; to prevent muscle deconditioning
[Class IIa Recommendation, Level B Evidence]
2) All patients should have a graded exercise
stress test to assess functional capacity,
identify angina or ischemia, and determine
optimal target HR for exercise training
3) Exercise training should be considered when
symptoms have stabilized and patient is
euvolemic
[Class IIa Recommendation, Level B Evidence]
4) Referral to cardiac rehabilitation program
should be considered for all stable NYHA I to II
HF patients
5) Moderate-intensity aerobic (30-45 mins)
and resistance training, 3-5 x/wk for NYHA II
to III, with LVEF < 40% can be considered
2) Salt and fluid restriction & weight management
Symptomatic patients: No-salt-added diet (total
2-3g daily)
Patients with fluid retention: low-salt diet (1-2 g
total daily)
[Class I Recommendation, Level C Evidence]
2) Salt and fluid restriction & weight management
Significant renal dysfunction/fluid retention not
easily controlled with diuretics:
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Monitor daily morning weight
Fluid restriction 1.5-2 L per day
[Class I Recommendation, Level C Evidence)
2) Salt and fluid restriction & weight management
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Patients with recurrent fluid retention who are
able to follow instructions can be taught to
adjust their diuretic dose based on symptoms
and changes in daily body weight
3) Reducing risk of serious respiratory infections
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Pneumococcal vaccination
Annual influenza vaccination
[Class I Recommendation, Level C Evidence]
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Some differences between how to
(pharmacologically) manage HF with reduced
EF vs. preserved EF
Treat probable HF
◦ Eg. Echocardiography results unavailable
◦ Use diuretic and nitrates for symptoms relief
◦ Consider ACEi and ß-blocker in the long-term
1. Type of heart failure: systolic or diastolic or mixed HF
2. NYHA class of symptoms
3. Renal function
4. Co-morbidities (e.g., COPD, anemia)
5. Life expectancy
6. Time needed to produce an effect
7. Goals of care or target symptom improvement including
patient preferences
8. Goals of pulse and blood pressure reduction with HF
medications
9. Common drug interactions (increase or decrease
concentration) and side effects
Drugs Aging (2013) 30:765–782
Heart Failure with Reduced Ejection Fraction
(HF-REF)
-Diuretic
-ACEi (or ARB) and ß-blocker
-Aldosterone antagonists
-Digoxin
-Nitrates/Vasodilators
-Omega-3 Polyunsaturated Fatty Acids
-Ivabradine
-What about ASA/Antiplatelets?
Diuretic
 Loop diuretic (eg. Furosemide) for congestive
symptoms
 When symptoms clear, use lowest possible
dose
[Class I, Level C]
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If volume overload persists, despite
optimisation of dose: add a second diuretic
(eg. Metolazone or a Thiazide diuretic)
[Class IIb, Level B]
ACEi (or ARB) and ß-blocker
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All patients with HF and LVEF < 40% should
receive target-dose combination therapy with
an ACEi and ß-blocker
[Class I, Level A]
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Asymptomatic patients with LVEF < 35%
should receive an ACEi
[Class I, Level A]
ACEi (or ARB) and ß-blocker
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If cannot tolerate ACEi, substitute with ARB
[Class I, Level A]
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Monitor serum Creatinine
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Patients optimally treated with ACEi and ßblocker with persistent HF symptoms, ↑
hospitalization
Add ARB  consult cardiologist/internist
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Addition of an ARB to ACE inhibitor and βblockade therapy modestly improves clinical
outcome predominantly by reducing HF
hospitalizations
Monitor BP, K+, Renal function: use with
caution!
ONTARGET hypertension trial: 13% increased
risk of renal dysfunction [Level I-1 Evidence]
Aldosterone Antagonists/Mineralocorticoid
Receptor Antagonists (MRAs)
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Spironolactone for patients with LVEF < 30%
and severe HF symptoms HF symptoms
despite optimal medical therapy
Monitor renal function and electrolyte status
[Class I, Level B]
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Aldosterone Antagonists/Mineralocorticoid
Receptor Antagonists (MRAs)
Eplerenone: up to 50 g reduces
hospitalization and death in HF patients
(NYHA II, LVEF < 30%)
(EMPASIS-HF Trial)
Digoxin
 Relieves symptoms
 Decreases hospitalizations
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In patients in sinus rhythm who have
moderate-severe symptoms despite optimal
medical therapy
[Class I, Level A Evidence]
Nitrates/Vasodilators
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Isosorbide Dinitrate plus Hydralazine added
to standard therapy for African-American
patients who have HF with reduced EF
A-HeFT (African-American Heart Failure Trial)
[Class IIa, Level A]
Consider this combination for other HF
patients who cannot tolerate recommended
standard therapy [Class IIb, Level B]
Source: Canadian Journal of Cardiology 2013; 29:168-181
(DOI:10.1016/j.cjca.2012.10.007 )
Copyright © 2013 Canadian Cardiovascular Society
Omega-3 Polyunsaturated Fatty Acids
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Recent study in patients with NYHA class II-IV
symptoms and ejection fraction (EF) ≤ 40%
Use of omega-3 polyunsaturated fatty acids
(1 g daily)
Modest reduction in cardiovascular mortality
and hospitalization
Ivabradine
 Inhibits the If channel
 Not yet approved
 Might be considered in patients who remain
symptomatic with a heart rate > 70 bpm
(despite optimal medical therapy eg.βblockers) to reduce hospitalizations and
deaths because of HF
 On basis that resting HR independently
predicts CV events, including HF
hospitalization
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Antiplatelet agents such as aspirin should be
administered ONLY to patients with HF who
have a documented history of coronary artery
disease and stroke or who are deemed high
risk for CV events
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Treatment trials have been inconclusive,
limited evidence-based recommendations
Best available data is for ACEi and ARB
therapy.
Combo therapy for most patients (add ARB)
[Class IIa, Level B]
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If HR is high, ß-blockers may be useful to
prolong diastolic filling time and relieve
pulmonary congestions
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Diuretics : for symptom control
Once acute congestion cleared, use lowest
dose compatible with stable weight and
symptoms
[Class I, Level C]
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Emphasis on management of comorbidities
◦ Diabetes
◦ Hypertension : Control diastolic and systolic as per
Hypertension guidelines
[Class I, Level A]
◦ Coronary Revascularization: CABG for patients
whose ischemia affects cardiac function
[Class IIa, Level C]
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Emphasis on management of comorbidities:
◦ Atrial Fibrillation: 50% of patients
-ß-blocker or Digoxin to control ventricular rate
-Restoration of sinus rhythm
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Thiazolidinediones
Nonsteroidal anti-inflammatory agents
Cyclooxygenase-2 inhibitors
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Common arrhythmia in HF
Associated with higher rates of adverse clinical
events
Increased risk of thromboembolism including
stroke
Manage and classify according to current AF
guidelines
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General approach : control rate
Limited data to support a specific upper heart
rate target
Current CCS AF guidelines target rate < 100
bpm
β-Blockers are preferred over digoxin for rate
control
Rate-lowering CCBs are acceptable alternatives
in patients with HF-PEF
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Combination of β-blocker and digoxin is
more effective than β-blocker alone
When rhythm control is required because of
symptoms, Amiodarone is preferred
Unless contraindicated, oral anticoagulants
should be initiated in patients deemed high
risk for stroke as per current AF guidelines
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Primary Implantable Cardioverter-Defibrillator
(ICD) therapy improves survival in patients
with NYHA II-III ischemic and non-ischemic
HF with EF ≤ 35% and in patients with a
previous MI with EF ≤ 30%.91
ICD therapy does not provide any survival
benefit early after an MI
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Cardiac Resynchronisation Therapy (CRT)
Devices (aka Biventricular pacing)
In combination with Implantable
Cardioverter-Defibrillator (ICD) in less
symptomatic HF patients [Level I-1 Evidence]
CCS recommends combination for HF patients
on optimal therapy with:
NYHA II symptoms
LVEF < 30%
QRS duration > 150 msec [Level I, Class A]
CCS recommendation:
 At initial HF diagnosis
 After HF hospitalization
 HF associated with any of the following:
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Ischemia
Hypertension
Valvular disease
Syncope
Renal Dysfunction
Other comorbidities
Unknown etiology
Treatment intolerance
Poor compliance
[Class I, Level C]
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Vasopressin Antagonists: improve volume
overload and hyponatremia
Eg. Tolvapatan is approved by the US FDA
for hospitalized hypervolemic and
euvolemic hyponatremia in HF
Adenosine A1 Receptor Antagonists: arteriolar
vasodilatation, improved renal function,
natriuresis without activation of
tubuloglomerular feedback Eg. Rolofylline
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Selective Phosphodiesterase Type 5
Inhibitors: vascular smooth muscle dilatation,
role in the reversal of ventricular hypertrophy
(inhibiting downstream hypertrophy signaling
and improving ventricular function)
Eg. Sildenafil
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Patients with HF-REF: Ryanodine receptor
stabilizers, Sarcoplasmic Reticulum Calcium
ATPase isoform (SERCA) activators, blockers of
the RAAS (direct renin inhibitors, aldosterone
synthase inhibitors)
Patients with HF-PEF: strategies target specific
structural and functional abnormalities that lead
to increased myocardial stiffness.
◦ Eg. Dicarbonyl-breaking compounds reverse advanced
glycation-induced cross-linking of collagen and improve
the compliance of aged and/or diabetic myocardium.
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Patient-centred decision making
Open communication with patients and their
families: critical concepts in high quality care
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Description of underlying condition +
prognosis
Exploration patient’s values, needs, goals
+ expectations of treatment.
Discussion must take into account the
psychosocial, cultural and spiritual and/or
informational needs by patient or proxy
Options for treatment and expected
outcome - benefit vs. harm
Explanation of conclusion of holding or
withdrawing treatment
Explain that patient will not be abandoned palliative care
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Likely to Benefit - reasonable likelihood that
life support will restore/maintain organ
function or likelihood of returning to prearrest status is moderate
Unlikely to Benefit - there is almost certainly
no chance that the person will benefit from
CPR either because the underlying illness
makes recovery or improvement
unprecedented. Person unlikely to
experience permanent benefit.
Good End of Life care includes ongoing
communication between the health care
providers and the patient/POA
What are we addressing?
 Code status
 Aggressiveness of management “along the
way”
 Admissions to acute care vs. care at home
and end-of-life planning
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When is the right time to have the discussion?
Exploring end-of-life preferences,
expectations
Quality of life as a valuable goal of therapy
Treatment modality:
Improve symptom + prognosis
vs.
Symptom relief (at expense of survival)
Brunner-La Rocca et al (2012) “End-of-Life
preferences of elderly patients with chronic
heart failure”
 ~75% not willing to trade survival time for
excellent health
 25%: equal groups willing to trade up to 6
months, >6 mo-1yr, >1yr
 Patients ≥ 75 slightly more willing to trade
than younger patients
 During follow-up, patients willing to trade
any survival time decreased
Brunner-La Rocca et al (2012) continued:
Who were the patients willing to trade survival
time for symptom-free living?
 Older
 More females
 Lived alone
 Not married
 More signs and symptoms of CHF and poorer
quality of life
The next slides have some tools that may help
with prognostication, and informing your
discussions with patients and families
Medical Care of the Dying 2006
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No clear “transition point”
 When do you start PC?
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Costly and invasive therapies
 When do you say “no”?
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Sudden death (50%)
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Poor patient understanding of illness
Reviewed 38,702 consecutive patients with
first time admissions for heart failure
Overall:
30 day fatality rate – 12%
1 year fatality rate – 33%
If >75 y.o. and co-morbidities:
30 day fatality rate – 24%
1 year fatality rate – 60%
Jong et al Arch Int Med (2002)
EFFECT Score (http://www.ccort.ca/CHFriskmodel.aspx)
 Prediction score to stratify the risk of death in
heart failure patients
 Enter age in years, RR and Systolic BP at hospital
presentation, BUN, Sodium and list of comorbidities including: CVA, Dementia, COPD,
Cirrhosis, Cancer and Anemia.
 Calculate
EFFECT Score: http://www.ccort.ca/CHFriskmodel.aspx
Mortality risk at 30 days:
30-Day Score
30-Day Mortality Rate (%)
< 60
0.4
61-90
3.4
91-120
12.2
121-150
32.7
> 150
59.0
Mortality risk at one year:
One-Year Score
One-Year Mortality Rate
(%)
< 60
7.8
61-90
12.9
91-120
32.5
121-150
59.3
> 150
78.8
http://depts.washington.edu/shfm/index.php
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Insert age, gender, weight, EF, systolic BP,
NYHA class level, medications and lab data
Graph will appear showing mortality risk over
1,2, and 5 years
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SOB
Pain (>70%!)
Depression (60%)
Myopathy
Cachexia
Cognitive impairment
Goodlin J Am Coll Cardiology (2009)
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Consensus panels advocate provision of
palliative care concurrent with efforts to
prolong life in heart failure
ACC/AHA Practice Guidelines
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Sudden death
Arrhythmia
Progressive Heart Failure
Importance of communication with patient
early in the disease: prognosis, advanced
medical directives (living will), resuscitation
wishes, identifying a substitute decision
maker/power of attorney
1.
2.
3.
4.
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A clinical syndrome: impaired cardiac output
and/or volume overload, concurrent cardiac
dysfunction
Progressive
Associated with poor quality of life – frequent
hospitalizations, poor survival
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Educate patients: communication,
communication, communication!
Teach patients to:
-weigh themselves daily
-recognize worsening symptoms
-adjust diuretic dose, in appropriate patients
-monitor salt and fluid intake
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Monitor clinical status of all patients with HF
Monitor renal function, electrolytes
Monitor BP, HR
Perform medication reviews
-q6months (minimum)
-If status change, qfew days-2 weeks
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Delayed progression/prolong survival
through early diagnosis, optimized
pharmacotherapy, non-pharmacological
treatments
Manage side-effects
Adherence, self-management strategies
Complex cases – manage with support of
cardiology consultation, specialty heart
failure clinics
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Titrate doses slowly
-ß-blocker increases slowly – double the
dose every 2-4 weeks
-ACEi increases slowly – double the dose
every 1-2 weeks
Optimize ß-blocker and ACEi
-Decrease doses of diuretics, nitrates and
other antihypertensives
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Refer to an interprofessional HF clinic for
patient education and management
Refer to a cardiac rehab program for
individualized exercise training for all stable
NYHA I to III HF patients
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Advanced care planning is an important part
of patient care
Disease trajectory difficult to follow
Prognostication tools can be helpful
Quality of life and exploration of patient
preferences and expectations important part
of high quality care
Drug
ACE Inhibitors
Captopril
Enalapril
Lisinopril
Perindopril
Ramipril
Trandolapril
Beta-blockers
Bisoprolol
Carvedilol
Metoprolol CR/XL**
Start Dose
Target Dose
6.25-12.5 mg TID
1.25-2.5 mg BID
2.5-5 mg OD
2-4 mg OD
1.25-2.5 mg BID
1-2 mg OD
25-50 mg TID
10 mg BID
20-35 mg OD
4-8 mg OD
5 mg BID
4 mg OD
1.25 mg OD
3.125 mg BID
12.5-25 mg OD
10 mg OD
25 mg BID*
200 mg OD
* 50 mg BID if weight is >85 kg
** Not available in Canada
Drug
ARBs
Candesartan
Valsartan
Start Dose
4 mg OD
40 mg BID
Aldosterone Antagonists
Spironolactone
Eplerenone
Vasodilatators
Hydralazine
Isorbide dinitrate
Target Dose
32 mg OD
160 mg BID
12.5 mg OD
25 mg OD
50 mg OD
50 mg OD
37.5 mg TID
20 mg TID
75 mg TID
40 mg TID
* 50 mg BID if weight is >85 kg
** Not available in Canada
Class and Definition
I
Evidence or general agreement that a given
procedure or treatment is beneficial, useful and effective
II
Conflicting evidence or a divergence of opinion about the
usefulness or efficacy of the procedure or treatment
IIa
Weight of evidence is in favour of usefulness or efficacy
IIb
Usefulness or efficacy is less well established by evidence or opinion
III
Evidence or general agreement that the procedure or treatment is not
useful or effective and in some cases may be harmful.
Level and Definition
A
Data derived from multiple randomized
clinical trials or meta-analysis
B
Data derived from a single randomized
clinical trial or non-randomized studies
C
Consensus of opinion or experts and/or
small studies.