Workshop PIT 2013

Management of Heart Failure

Lr|ka Maharan|
Sard[lLo Ceneral PosplLal
?ogyakarLa
SympLoms LhaL may occur wlLh hearL fallure ...
Heart Failure

At Risk for Heart Failure

STAGE A
At high risk for HF but
without structural heart
disease or symptoms of HF
STAGE B
Structural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Prevent hospitalization
! Prevent mortality
Strategies
! Identification of comorbidities
Treatment
! Diuresis to relieve symptoms
of congestion
! Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
! Revascularization or valvular
surgery as appropriate
STAGE C
Structural heart disease
with prior or current
symptoms of HF
THERAPY
Goals
! Control symptoms
! Patient education
! Prevent hospitalization
! Prevent mortality
Drugs for routine use
! Diuretics for fluid retention
! ACEI or ARB
! Beta blockers
! Aldosterone antagonists
Drugs for use in selected patients
! Hydralazine/isosorbide dinitrate
! ACEI and ARB
! Digoxin
In selected patients
! CRT
! ICD
! Revascularization or valvular
surgery as appropriate
STAGE D
Refractory HF
THERAPY
Goals
! Prevent HF symptoms
! Prevent further cardiac
remodeling
Drugs
! ACEI or ARB as
appropriate
! Beta blockers as
appropriate
In selected patients
! ICD
! Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
! Known structural heart disease and
! HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
! Heart healthy lifestyle
! Prevent vascular,
coronary disease
! Prevent LV structural
abnormalities
Drugs
! ACEI or ARB in
appropriate patients for
vascular disease or DM
! Statins as appropriate
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Reduce hospital
readmissions
! Establish patients end-
of-life goals
Options
! Advanced care
measures
! Heart transplant
! Chronic inotropes
! Temporary or permanent
MCS
! Experimental surgery or
drugs
! Palliative care and
hospice
! ICD deactivation
Refractory
symptoms of HF
at rest, despite
GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
! Marked HF symptoms at
rest
! Recurrent hospitalizations
despite GDMT
e.g., Patients with:
! Previous MI
! LV remodeling including
LVH and low EF
! Asymptomatic valvular
disease
e.g., Patients with:
! HTN
! Atherosclerotic disease
! DM
! Obesity
! Metabolic syndrome
or
Patients
! Using cardiotoxins
! With family history of
cardiomyopathy
Development of
symptoms of HF
Structural heart
disease
STAGE A
At high risk for HF but
without structural heart
disease or symptoms of HF
STAGE B
Structural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Prevent hospitalization
! Prevent mortality
Strategies
! Identification of comorbidities
Treatment
! Diuresis to relieve symptoms
of congestion
! Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
! Revascularization or valvular
surgery as appropriate
STAGE C
Structural heart disease
with prior or current
symptoms of HF
THERAPY
Goals
! Control symptoms
! Patient education
! Prevent hospitalization
! Prevent mortality
Drugs for routine use
! Diuretics for fluid retention
! ACEI or ARB
! Beta blockers
! Aldosterone antagonists
Drugs for use in selected patients
! Hydralazine/isosorbide dinitrate
! ACEI and ARB
! Digoxin
In selected patients
! CRT
! ICD
! Revascularization or valvular
surgery as appropriate
STAGE D
Refractory HF
THERAPY
Goals
! Prevent HF symptoms
! Prevent further cardiac
remodeling
Drugs
! ACEI or ARB as
appropriate
! Beta blockers as
appropriate
In selected patients
! ICD
! Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
! Known structural heart disease and
! HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
! Heart healthy lifestyle
! Prevent vascular,
coronary disease
! Prevent LV structural
abnormalities
Drugs
! ACEI or ARB in
appropriate patients for
vascular disease or DM
! Statins as appropriate
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Reduce hospital
readmissions
! Establish patients end-
of-life goals
Options
! Advanced care
measures
! Heart transplant
! Chronic inotropes
! Temporary or permanent
MCS
! Experimental surgery or
drugs
! Palliative care and
hospice
! ICD deactivation
Refractory
symptoms of HF
at rest, despite
GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
! Marked HF symptoms at
rest
! Recurrent hospitalizations
despite GDMT
e.g., Patients with:
! Previous MI
! LV remodeling including
LVH and low EF
! Asymptomatic valvular
disease
e.g., Patients with:
! HTN
! Atherosclerotic disease
! DM
! Obesity
! Metabolic syndrome
or
Patients
! Using cardiotoxins
! With family history of
cardiomyopathy
Development of
symptoms of HF
Structural heart
disease
STAGE A
At high risk for HF but
without structural heart
disease or symptoms of HF
STAGE B
Structural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Prevent hospitalization
! Prevent mortality
Strategies
! Identification of comorbidities
Treatment
! Diuresis to relieve symptoms
of congestion
! Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
! Revascularization or valvular
surgery as appropriate
STAGE C
Structural heart disease
with prior or current
symptoms of HF
THERAPY
Goals
! Control symptoms
! Patient education
! Prevent hospitalization
! Prevent mortality
Drugs for routine use
! Diuretics for fluid retention
! ACEI or ARB
! Beta blockers
! Aldosterone antagonists
Drugs for use in selected patients
! Hydralazine/isosorbide dinitrate
! ACEI and ARB
! Digoxin
In selected patients
! CRT
! ICD
! Revascularization or valvular
surgery as appropriate
STAGE D
Refractory HF
THERAPY
Goals
! Prevent HF symptoms
! Prevent further cardiac
remodeling
Drugs
! ACEI or ARB as
appropriate
! Beta blockers as
appropriate
In selected patients
! ICD
! Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
! Known structural heart disease and
! HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
! Heart healthy lifestyle
! Prevent vascular,
coronary disease
! Prevent LV structural
abnormalities
Drugs
! ACEI or ARB in
appropriate patients for
vascular disease or DM
! Statins as appropriate
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Reduce hospital
readmissions
! Establish patients end-
of-life goals
Options
! Advanced care
measures
! Heart transplant
! Chronic inotropes
! Temporary or permanent
MCS
! Experimental surgery or
drugs
! Palliative care and
hospice
! ICD deactivation
Refractory
symptoms of HF
at rest, despite
GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
! Marked HF symptoms at
rest
! Recurrent hospitalizations
despite GDMT
e.g., Patients with:
! Previous MI
! LV remodeling including
LVH and low EF
! Asymptomatic valvular
disease
e.g., Patients with:
! HTN
! Atherosclerotic disease
! DM
! Obesity
! Metabolic syndrome
or
Patients
! Using cardiotoxins
! With family history of
cardiomyopathy
Development of
symptoms of HF
Structural heart
disease
STAGE A
At high risk for HF but
without structural heart
disease or symptoms of HF
STAGE B
Structural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Prevent hospitalization
! Prevent mortality
Strategies
! Identification of comorbidities
Treatment
! Diuresis to relieve symptoms
of congestion
! Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
! Revascularization or valvular
surgery as appropriate
STAGE C
Structural heart disease
with prior or current
symptoms of HF
THERAPY
Goals
! Control symptoms
! Patient education
! Prevent hospitalization
! Prevent mortality
Drugs for routine use
! Diuretics for fluid retention
! ACEI or ARB
! Beta blockers
! Aldosterone antagonists
Drugs for use in selected patients
! Hydralazine/isosorbide dinitrate
! ACEI and ARB
! Digoxin
In selected patients
! CRT
! ICD
! Revascularization or valvular
surgery as appropriate
STAGE D
Refractory HF
THERAPY
Goals
! Prevent HF symptoms
! Prevent further cardiac
remodeling
Drugs
! ACEI or ARB as
appropriate
! Beta blockers as
appropriate
In selected patients
! ICD
! Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
! Known structural heart disease and
! HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
! Heart healthy lifestyle
! Prevent vascular,
coronary disease
! Prevent LV structural
abnormalities
Drugs
! ACEI or ARB in
appropriate patients for
vascular disease or DM
! Statins as appropriate
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Reduce hospital
readmissions
! Establish patients end-
of-life goals
Options
! Advanced care
measures
! Heart transplant
! Chronic inotropes
! Temporary or permanent
MCS
! Experimental surgery or
drugs
! Palliative care and
hospice
! ICD deactivation
Refractory
symptoms of HF
at rest, despite
GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
! Marked HF symptoms at
rest
! Recurrent hospitalizations
despite GDMT
e.g., Patients with:
! Previous MI
! LV remodeling including
LVH and low EF
! Asymptomatic valvular
disease
e.g., Patients with:
! HTN
! Atherosclerotic disease
! DM
! Obesity
! Metabolic syndrome
or
Patients
! Using cardiotoxins
! With family history of
cardiomyopathy
Development of
symptoms of HF
Structural heart
disease

Stages of Heart Failure
STAGE A
At high risk for HF but
without structural heart
disease or symptoms of HF
STAGE B
Structural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Prevent hospitalization
! Prevent mortality
Strategies
! Identification of comorbidities
Treatment
! Diuresis to relieve symptoms
of congestion
! Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
! Revascularization or valvular
surgery as appropriate
STAGE C
Structural heart disease
with prior or current
symptoms of HF
THERAPY
Goals
! Control symptoms
! Patient education
! Prevent hospitalization
! Prevent mortality
Drugs for routine use
! Diuretics for fluid retention
! ACEI or ARB
! Beta blockers
! Aldosterone antagonists
Drugs for use in selected patients
! Hydralazine/isosorbide dinitrate
! ACEI and ARB
! Digoxin
In selected patients
! CRT
! ICD
! Revascularization or valvular
surgery as appropriate
STAGE D
Refractory HF
THERAPY
Goals
! Prevent HF symptoms
! Prevent further cardiac
remodeling
Drugs
! ACEI or ARB as
appropriate
! Beta blockers as
appropriate
In selected patients
! ICD
! Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
! Known structural heart disease and
! HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
! Heart healthy lifestyle
! Prevent vascular,
coronary disease
! Prevent LV structural
abnormalities
Drugs
! ACEI or ARB in
appropriate patients for
vascular disease or DM
! Statins as appropriate
THERAPY
Goals
! Control symptoms
! Improve HRQOL
! Reduce hospital
readmissions
! Establish patients end-
of-life goals
Options
! Advanced care
measures
! Heart transplant
! Chronic inotropes
! Temporary or permanent
MCS
! Experimental surgery or
drugs
! Palliative care and
hospice
! ICD deactivation
Refractory
symptoms of HF
at rest, despite
GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
! Marked HF symptoms at
rest
! Recurrent hospitalizations
despite GDMT
e.g., Patients with:
! Previous MI
! LV remodeling including
LVH and low EF
! Asymptomatic valvular
disease
e.g., Patients with:
! HTN
! Atherosclerotic disease
! DM
! Obesity
! Metabolic syndrome
or
Patients
! Using cardiotoxins
! With family history of
cardiomyopathy
Development of
symptoms of HF
Structural heart
disease

Stages, Phenotypes and Treatment of HF
PearL lallure wlLh
kLDUCLD
L[ecuon lracuon
(nI!LI)
Ll < 40
PearL lallure wlLh
kLSLkVLD
L[ecuon lracuon
(nI"LI)
Ll > 30
nI"LI
8orderllne
Ll 41 Lo 49
nI"LI
lmproved
Ll >40

Definition of Heart Failure
Clinical Evaluation
History and Physical Examination
Diagnostic Tests

Initial and Serial Evaluation
of the HF Patient

Diagnostic Tests
In|na| |aboratory eva|uanon: compleLe blood counL,
urlnalysls, serum elecLrolyLes, blood urea nlLrogen, serum
creaunlne, glucose, fasung llpld prole, llver funcuon LesLs,
and Lhyrold-sumulaung hormone.
A 12-|ead LCG
ulagnosuc LesLs for rheumaLologlc dlseases, amyloldosls, or
pheochromocyLoma
MeasuremenL of 8n or n-Lermlnal pro-8-Lype naLrlureuc
pepude (n1-pro8n)

Noninvasive Cardiac Imaging
ChesL x-ray
Lchocardlogram wlLh uoppler
lmaglng for myocardlal lschemla and vlablllLy
8adlonucllde venLrlculography or M8l
Recommendations for Invasive Evaluation
Recommendation COR LOE
Monitoring with a pulmonary artery catheter should be performed in
patients with respiratory distress or impaired systemic perfusion when
clinical assessment is inadequate
I C
Invasive hemodynamic monitoring can be useful for carefully selected
patients with acute HF with persistent symptoms and/or when
hemodynamics are uncertain
IIa C
When coronary ischemia may be contributing to HF, coronary
arteriography is reasonable
IIa C
Endomyocardial biopsy can be useful in patients with HF when a
specific diagnosis is suspected that would influence therapy
IIa C
Routine use of invasive hemodynamic monitoring is not recommended in
normotensive patients with acute HF
III: No
Benefit
B

Endomyocardial biopsy should not be performed in the routine
evaluation of HF
III: Harm C

Invasive Evaluation
Treatment of Stages A to D

Guideline for HF
PyperLenslon and llpld dlsorders should be conLrolled ln
accordance wlLh conLemporary guldellnes Lo lower Lhe rlsk of
Pl.


CLher condluons LhaL may lead Lo or conLrlbuLe Lo Pl, such as
obeslLy, dlabeLes melllLus, Lobacco use, and known cardloLoxlc
agenLs, should be conLrolled or avolded.
I IIa IIb III
I IIa IIb III

Stages A

Stages B
ln all pauenLs wlLh a recenL or remoLe h|story of MI or ACS and
reduced LI, ACL |nh|b|tors should be used Lo prevenL
sympLomauc Pl and reduce morLallLy. ln pauenLs lnLoleranL of
ACL lnhlblLors, A88s are approprlaLe unless conLralndlcaLed.

ln all pauenLs wlLh a recenL or remoLe hlsLory of Ml or ACS and
reduced Ll, evldence-based beta b|ockers should be used Lo
reduce morLallLy.

ln all pauenLs wlLh a recenL or remoLe hlsLory of Ml or ACS,
stanns should be used Lo prevenL sympLomauc Pl and
cardlovascular evenLs.
I IIa IIb III
I IIa IIb III
I IIa IIb III

Stages B
ln pauenLs wlLh sLrucLural cardlac abnormallues, lncludlng Lv
hyperLrophy, ln Lhe absence of a hlsLory of Ml or ACS, b|ood
pressure shou|d be contro||ed ln accordance wlLh cllnlcal
pracuce guldellnes for hyperLenslon Lo prevenL sympLomauc Pl

ACL |nh|b|tors should be used ln all pauenLs wlLh a reduced Ll
Lo prevenL sympLomauc Pl, even |f they do not have a h|story
of MI

8eta b|ockers should be used ln all pauenLs wlLh a reduced Ll
Lo prevenL sympLomauc Pl, even |f they do not have a h|story
of MI
I IIa IIb III
I IIa IIb III
I IIa IIb III

Stages B
1o prevenL sudden deaLh, placemenL of an ICD |s reasonab|e ln
pauenLs wlLh asympLomauc lschemlc cardlomyopaLhy who are
aL leasL 40 days posL-Ml, have an LVLI of 30 or |ess, are on
approprlaLe medlcal Lherapy and have reasonable expecLauon
of survlval wlLh a good funcuonal sLaLus for more Lhan 1 year.

Nond|hydropyr|d|ne ca|c|um channe| b|ockers w|th neganve
|notrop|c eects may be harmful ln asympLomauc pauenLs wlLh
low LvLl and no sympLoms of Pl aer Ml.

I IIa IIb III
I IIa IIb III
Harm

Stages B

Stages C
auenLs wlLh Pl should recelve speclc educauon Lo
faclllLaLe nI se|f-care


Lxerc|se tra|n|ng (or regu|ar phys|ca| acnv|ty) ls
recommended as safe and eecuve for pauenLs wlLh Pl who
are able Lo paruclpaLe Lo lmprove funcuonal sLaLus


Sod|um restr|cnon ls reasonable for pauenLs wlLh
sympLomauc Pl Lo reduce congesuve sympLoms

I IIa IIb III
I IIa IIb III
I IIa IIb III
Stages C
Non Pharmacological Interventions
Stages C
Non Pharmacological Interventions
Connnuous pos|nve a|rway pressure (CA) can be
beneclal Lo lncrease LvLl and lmprove funcuonal sLaLus ln
pauenLs wlLh Pl and sleep apnea.


Card|ac rehab|||tanon can be useful ln cllnlcally sLable
pauenLs wlLh Pl Lo lmprove funcuonal capaclLy, exerclse
durauon, P8CCL, and morLallLy
I IIa IIb III
I IIa IIb III
Stages C
Pharmacological Interventions
Measures llsLed as Class l recommendauons for pauenLs ln
sLages A and 8 are recommended where approprlaLe for
pauenLs ln sLage C. (Levels of Lvldence: A, 8, and C as
approprlaLe)



CuM1 (guldellne-dlrecLed medlcal Lherapy) as deplcLed ln
llgure 1 should be Lhe malnsLay of pharmacologlcal Lherapy
for Pl!Ll
I IIa IIb III
I IIa IIb III
See
recommendations
for stages A, B,
and C LOE for
LOE
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
Add Add Add
For all volume overload,
NYHA class II-IV patients
ACC/AHA 2013
D|urencs are recommended ln pauenLs wlLh Pl!Ll who have
evldence of u|d retennon, unless conLralndlcaLed, Lo lmprove
sympLoms.

ACL |nh|b|tors are recommended ln pauenLs wlLh Pl!Ll and
currenL or prlor sympLoms, unless conLralndlcaLed, Lo reduce
morbldlLy and morLallLy.

Ak8s are recommended ln pauenLs wlLh Pl!Ll wlLh currenL or
prlor sympLoms who are ACL |nh|b|tor-|nto|erant, unless
conLralndlcaLed, Lo reduce morbldlLy and morLallLy.
I IIa IIb III
I IIa IIb III
I IIa IIb III
Stages C
Pharmacological Interventions
Stages C
Pharmacological Interventions
8ouune "#$%&'() use of an ACL lnhlblLor, A88, and
aldosLerone anLagonlsL ls poLenually harmful for pauenLs
wlLh Pl!Ll.


use of 1 of Lhe 3 beLa blockers proven Lo reduce morLallLy
(l.e., b|sopro|o|, carved||o|, and susta|ned-re|ease
metopro|o| succ|nate) ls recommended for all pauenLs wlLh
currenL or prlor sympLoms of Pl!Ll, unless conLralndlcaLed,
Lo reduce morbldlLy and morLallLy.

I IIa IIb III
I IIa IIb III
Harm
Stages C
Pharmacological Interventions
AldosLerone recepLor anLagonlsLs are recommended Lo reduce
morbldlLy and morLallLy followlng an acuLe Ml ln pauenLs who
have LvLl of 40 or less who develop sympLoms of Pl or who
have a hlsLory of dlabeLes melllLus, unless conLralndlcaLed

lnapproprlaLe use of aldosLerone recepLor anLagonlsLs ls
poLenually harmful because of llfe-LhreaLenlng hyperkalemla or
renal lnsumclency when serum creaunlne greaLer Lhan 2.3 mg/
dL ln men or greaLer Lhan 2.0 mg/dL ln women (or esnmated
g|omeru|ar h|tranon rate <30 mL]m|n]1.73m2), and/or
potass|um above S.0 mLq]L
I IIa IIb III
I IIa IIb III
Harm
kecommendanons CCk LCL
#$%&'$(
ulgoxln can be beneclal ln pauenLs wlLh PlrLl lla 8
)(*+&,%-.,*&(
auenLs wlLh chronlc Pl wlLh permanenL/perslsLenL/paroxysmal Al and an
addluonal rlsk facLor for cardloembollc sLroke should recelve chronlc
anucoagulanL Lherapy*
l A
1he selecuon of an anucoagulanL agenL should be lndlvlduallzed l C
Chronlc anucoagulauon ls reasonable for pauenLs wlLh chronlc Pl who have
permanenL/perslsLenL/paroxysmal Al buL wlLhouL an addluonal rlsk facLor for
cardloembollc sLroke*
lla 8
Anucoagulauon ls noL recommended ln pauenLs wlLh chronlc PlrLl wlLhouL
Al, prlor Lhromboembollc evenL, or a cardloembollc source
lll: no 8eneL 8
01,*(2
SLauns are noL beneclal as ad[uncuve Lherapy when prescrlbed solely for Pl
lll: no 8eneL A
345%,67 8,9: )+$;2
Cmega-3 ulA supplemenLauon ls reasonable Lo use as ad[uncuve Lherapy ln
PlrLl or PlpLl pauenLs
lla 8
Stages C
Pharmacological Interventions
kecommendanons COR LOE
31<5! #!-%2
nuLrluonal supplemenLs as LreaLmenL for Pl are noL
recommended ln PlrLl
III: No
Benefit
B
Pormonal Lheraples oLher Lhan Lo repleLe declencles are noL
recommended ln PlrLl
III: No
Benefit
C
urugs known Lo adversely aecL Lhe cllnlcal sLaLus of pauenLs wlLh
PlrLl are poLenually harmful and should be avolded or
wlLhdrawn
III: Harm B
Long-Lerm use of an lnfuslon of a posluve lnoLroplc drug ls noL
recommended and may be harmful excepL as palllauon
III: Harm C
=,.+$-4 =<,((5. >.&+?5!2
Calclum channel blocklng drugs are noL recommended as rouune
ln PlrLl
III: No
Benefit
A
Stages C
Pharmacological Interventions
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%
Drug In|na| Da||y Dose(s) Max|mum Doses(s)
Mean Doses Ach|eved |n
C||n|ca| 1r|a|s
)=@ A(<$B$1&!2
CapLoprll 6.23 mg 3 umes 30 mg 3 umes 122.7 mg/d (421)
Lnalaprll 2.3 mg Lwlce 10 Lo 20 mg Lwlce 16.6 mg/d

(412)
loslnoprll 3 Lo 10 mg once 40 mg once ---------
Llslnoprll 2.3 Lo 3 mg once 20 Lo 40 mg once 32.3 Lo 33.0 mg/d (444)
erlndoprll 2 mg once 8 Lo 16 mg once ---------
Culnaprll 3 mg Lwlce 20 mg Lwlce ---------
8amlprll 1.23 Lo 2.3 mg once 10 mg once ---------
1randolaprll 1 mg once 4 mg once ---------
)C>2
CandesarLan 4 Lo 8 mg once 32 mg once 24 mg/d (419)
LosarLan 23 Lo 30 mg once 30 Lo 130 mg once 129 mg/d (420)
valsarLan 20 Lo 40 mg Lwlce 160 mg Lwlce 234 mg/d (109)
).;&215!&(5 )(1,%&($212
SplronolacLone 12.3 Lo 23 mg once 23 mg once or Lwlce 26 mg/d (424)
Lplerenone 23 mg once 30 mg once 42.6 mg/d (443)
Stages C
Drugs Commonly Used for HFrEF
Recommendations COR LOE
Systolic and diastolic blood pressure should be controlled
according to published clinical practice guidelines
I B
Diuretics should be used for relief of symptoms due to
volume overload
I C
Coronary revascularization for patients with CAD in
whom angina or demonstrable myocardial ischemia is
present despite GDMT
IIa

C
Management of AF according to published clinical
practice guidelines for HFpEF to improve symptomatic
HF
IIa C
Use of beta-blocking agents, ACE inhibitors, and ARBs
for hypertension in HFpEF
IIa C
ARBs might be considered to decrease hospitalizations in
HFpEF
IIb B
Nutritional supplementation is not recommended in
HFpEF
III: No
Benefit
C
Stages C
Drugs Commonly Used for HFpEF
ApproxlmaLely half of Lhe deaLhs ln pauenLs wlLh
Pl, especlally ln Lhose wlLh mllder sympLoms, occur
suddenly and unexpecLedly, and many, lf noL mosL,
of Lhese are relaLed Lo venLrlcular arrhyLhmlas
European Society of Cardiology 2012
uebrlllauon 1herapy
The Two Lower Chambers Of The Heart Do Not Beat At The

Same Time

Ventr|cu|ar Dysynchrony
Card|ac kesyncron|zanon 1herapy - Ck1
rov|des 8|ventr|cu|ar pac|ng
Composed of:
ulse generaLor
8A paclng and senslng lead
8v paclng lead
Lv paclng lead
ICD therapy ls recommended for pr|mary prevennon of SCu Lo
reduce LoLal morLallLy ln selecLed pauenLs wlLh nonlschemlc
uCM or lschemlc hearL dlsease aL leasL 40 days posL-Ml wlLh
LVLI of 3S or |ess, and n?PA class ll or lll sympLoms on
chronlc CuM1, who have reasonable expecLauon of meanlngful
survlval for more Lhan 1 year.

Ck1 ls lndlcaLed for pauenLs who have LVLI of 3S or |ess,
slnus rhyLhm, le bundle-branch block (L888) wlLh a C8S
durauon of 130 ms or greaLer, and n?PA class ll, lll, or
ambulaLory lv sympLoms on CuM1.
I IIa IIb III
I IIa IIb III
NYHA Class III/IV
I IIa IIb III
NYHA Class II

Device Therapy for Stage C HFrEF
Indications for CRT Therapy
Patient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or
with implantation of pacing or defibrillation device for special indications
LVEF <35%
Evaluate general health status
Comorbidities and/or frailty
limit survival with good
functional capacity to <1 y
Continue GDMT without
implanted device
Acceptable noncardiac health
Evaluate NYHA clinical status
NYHA class I
! LVEF !30%
! QRS "150 ms
! LBBB pattern
! Ischemic
cardiomyopathy
! QRS !150 ms
! Non-LBBB pattern
NYHA class II
! LVEF !35%
! QRS 120-149 ms
! LBBB pattern
! Sinus rhythm
! QRS !150 ms
! Non-LBBB pattern
! LVEF !35%
! QRS "150 ms
! LBBB pattern
! Sinus rhythm
! LVEF !35%
! QRS "150 ms
! Non-LBBB pattern
! Sinus rhythm
Colors correspond to the class of recommendations in the ACCF/AHA Table 1.
Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along
with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D
unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and
personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival.
NYHA class III &
Ambulatory class IV
! LVEF !35%
! QRS 120-149 ms
! LBBB pattern
! Sinus rhythm
! LVEF !35%
! QRS 120-149 ms
! Non-LBBB pattern
! Sinus rhythm
! LVEF !35%
! QRS "150 ms
! LBBB pattern
! Sinus rhythm
! LVEF!35%
! QRS "150 ms
! Non-LBBB pattern
! Sinus rhythm
! Anticipated to require
frequent ventricular
pacing (>40%)
! Atrial fibrillation, if
ventricular pacing is
required and rate
control will result in
near 100%
ventricular pacing
with CRT
Special CRT
Indications

Stage D
Clinical Events and Findings Useful for
Identifying Patients With Advanced HF
8epeaLed (>2) hosplLallzauons or Lu vlslLs for Pl ln Lhe pasL year
rogresslve deLerlorauon ln renal funcuon (e.g., rlse ln 8un and creaunlne)
WelghL loss wlLhouL oLher cause (e.g., cardlac cachexla)
lnLolerance Lo ACL lnhlblLors due Lo hypoLenslon and/or worsenlng renal funcuon
lnLolerance Lo beLa blockers due Lo worsenlng Pl or hypoLenslon
lrequenL sysLollc blood pressure <90 mm Pg
erslsLenL dyspnea wlLh dresslng or baLhlng requlrlng resL
lnablllLy Lo walk 1 block on Lhe level ground due Lo dyspnea or faugue
8ecenL need Lo escalaLe dlureucs Lo malnLaln volume sLaLus, oen reachlng dally
furosemlde equlvalenL dose >160 mg/d and/or use of supplemenLal meLolazone
Lherapy
rogresslve decllne ln serum sodlum, usually Lo <133 mLq/L
lrequenL lCu shocks
AdapLed from 8ussell eL al. CongesL PearL lall. 2008,14:316-21.
Stage D
Water Restriction

lluld resLrlcuon (1.3 Lo 2 L/d) ls reasonable ln sLage
u, especlally ln pauenLs wlLh hyponaLremla, Lo
reduce congesuve sympLoms.




I IIa IIb III
unul denluve Lherapy (e.g., coronary revascularlzauon, MCS,
hearL LransplanLauon) or resoluuon of Lhe acuLe preclplLaung
problem, pauenLs wlLh cardlogenlc shock should recelve
Lemporary lnLravenous lnoLroplc supporL Lo malnLaln sysLemlc
perfuslon and preserve end-organ performance.

Conunuous lnLravenous lnoLroplc supporL ls reasonable as
brldge Lherapy ln pauenLs wlLh sLage u refracLory Lo CuM1
and devlce Lherapy who are ellglble for and awalung MCS or
cardlac LransplanLauon.



I IIa IIb III
I IIa IIb III
Stage D
Inotropic Support
Lvaluauon for cardlac LransplanLauon ls lndlcaLed for
carefully selecLed pauenLs wlLh sLage u Pl desplLe
CuM1, devlce, and surglcal managemenL.
I IIa IIb III
Stage D
Cardiac Transplantation