Professional Documents
Culture Documents
09/27/2013
Presenter: Clyde Yancy
9/27/2013
9/27/2013
Clyde Yancy
M.D., MSc, FACC, FAHA, MACP
9/27/2013
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal
information.
ACCF/AHA Representative. ACCF/AHA Task Force on Practice Guidelines Liaison. American College of Physicians Representative. American College of Chest Physicians
Representative. International Society for Heart and Lung Transplantation Representative. #ACCF/AHA Task Force on Performance Measures Liaison. **American Academy of Family
Physicians Representative. Heart Rhythm Society Representative.
Myocardial
infarction
Arrhythmia
Loss of
muscle
Sudden
death
Myocardial ischemia
CAD
Atherosclerosis
LVH
Remodeling
(due to
neurohormonal
activation)
Risk factors
Hyperlipidemia
Hypertension
Diabetes
Insulin resistance
Ventricular
dilation
Heart
failure
Death
c
D
The baseline process measure conformity was significantly lower among patients who died
compared with those who survived for 5 of 7 individual measures.
Fonarow GC, et al. Circulation. 2011;123(15):1601-1610.
+20% to -68%
P=0.1566
-43% to -91%
P<0.0001
-70% to -96%
P<0.0001
Odds Ratio
(95% confidence interval)
2 therapies
0.63 (0.47-0.85)
(p=0.0026)
3 therapies
0.38 (0.29-0.51)
(p<0.0001)
4 therapies
0.30 (0.23-0.41)
(p<0.0001)
5, 6, or 7 therapies
0.31 (0.23-0.42)
(p<0.0001)
0
0.5
1.5
Clinical Evaluation
Ejection
Fraction
40%
Description
Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
50%
a. HFpEF, Borderline
41% to 49%
b. HFpEF, Improved
>40%
ACCF/AHA Stages of HF
At high risk for HF but without structural
heart disease or symptoms of HF.
Structural heart disease but without signs
or symptoms of HF.
Structural heart disease with prior or
current symptoms of HF.
II
III
IV
D
Guideline for HF
Risk Scoring
Risk Scoring
I IIa IIb III
Chronic HF
All patients with chronic HF
Seattle Heart Failure Model
(204) / http://SeattleHeartFailureModel.org
(200) / http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc37354.shtml
(207)
(208)
(202)
Acutely Decompensated HF
ADHERE Classification and Regression
Tree (CART) Model
American Heart Association Get With the
Guidelines Score
(201)
(203) / http://www.ccort.ca/Research/CHFRiskModel.aspx
(215)
(216)
(206) /
http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidel
inesHFStroke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-TheGuidelines-Heart-Failure-Home- %20Page_UCM_306087_SubHomePage.jsp
Diagnostic Tests
Diagnostic Tests
I IIa IIb III
Biomarkers
Ambulatory/Outpatient
Ambulatory/Outpatient
I IIa IIb III
Ambulatory/Outpatient (cont.)
I IIa IIb III
The usefulness of serial measurement of BNP or NTproBNP to reduce hospitalization or mortality in patients
with HF is not well established.
I IIa IIb III
Biomarkers
Hospitalized/Acute
Hospitalized/Acute
I IIa IIb III
Hospitalized/Acute (cont.)
I IIa IIb III
Setting
COR
LOE
Diagnosis or exclusion of HF
Ambulatory,
Acute
Prognosis of HF
Ambulatory,
Acute
Ambulatory
IIa
Acute
IIb
Acute,
Ambulatory
IIb
IIb
Natriuretic peptides
Achieve GDMT
Guidance of acutely decompensated
HF therapy
Biomarkers of myocardial injury
Additive risk stratification
Biomarkers of myocardial fibrosis
Ambulatory
Additive risk stratification
Acute
Noncardiac
Advancing age
Anemia
Renal failure
Pulmonary causes: obstructive
sleep apnea, severe pneumonia,
pulmonary hypertension
Critical illness
Bacterial sepsis
Severe burns
Toxic-metabolic insults, including
cancer chemotherapy and
envenomation
(cont.)
No Benefit
COR
LOE
IIa
IIa
IIa
IIa
III: No
Benefit
Invasive Evaluation
Invasive Evaluation
Invasive hemodynamic monitoring with a pulmonary artery
catheter should be performed to guide therapy in patients who
have respiratory distress or clinical evidence of impaired perfusion
in whom the adequacy or excess of intracardiac filling pressures
cannot be determined from clinical assessment.
Invasive hemodynamic monitoring can be useful for carefully
selected patients with acute HF who have persistent symptoms
despite empiric adjustment of standard therapies and
a. whose fluid status, perfusion, or systemic or pulmonary
vascular resistance is uncertain;
b. whose systolic pressure remains low, or is associated with
symptoms, despite initial therapy;
c. whose renal function is worsening with therapy;
d. who require parenteral vasoactive agents; or
e. who may need consideration for MCS or transplantation.
No Benefit
Harm
COR
LOE
IIa
IIa
IIa
III: No
Benefit
III: Harm
Guideline for HF
Treatment of Stages A to D
Treatment of Stages A to D
Stage A
Stage A
I IIa IIb III
Treatment of Stages A to D
Stage B
Stage B
I IIa IIb III
Stage B (cont.)
I IIa IIb III
Stage B (cont.)
I IIa IIb III
Harm
COR
LOE
IIa
III: Harm
Treatment of Stages A to D
Stage C
Treatment of Stages A to D
Nonpharmacological
Interventions
Stage C: Nonpharmacological
Interventions
I IIa IIb III
Stage C: Nonpharmacological
Interventions (cont.)
I IIa IIb III
Treatment of Stages A to D
See
recommendations
for stages A, B,
and C LOE for
LOE
ACE Inhibitors
Captopril
6.25 mg 3 times
Enalapril
2.5 mg twice
Fosinopril
5 to 10 mg once
Lisinopril
2.5 to 5 mg once
Perindopril
2 mg once
Quinapril
5 mg twice
Ramipril
1.25 to 2.5 mg once
Trandolapril
1 mg once
ARBs
Candesartan
4 to 8 mg once
Losartan
25 to 50 mg once
Valsartan
20 to 40 mg twice
Aldosterone Antagonists
Spironolactone
12.5 to 25 mg once
Eplerenone
25 mg once
Maximum Doses(s)
50 mg 3 times
10 to 20 mg twice
40 mg once
20 to 40 mg once
8 to 16 mg once
20 mg twice
10 mg once
4 mg once
32 mg once
50 to 150 mg once
160 mg twice
24 mg/d (419)
129 mg/d (420)
254 mg/d (109)
25 mg once or twice
50 mg once
26 mg/d (424)
42.6 mg/d (445)
Beta Blockers
Bisoprolol
1.25 mg once
Carvedilol
3.125 mg twice
Carvedilol CR
10 mg once
Metoprolol succinate
extended release
12.5 to 25 mg once
(metoprolol CR/XL)
Hydralazine & Isosorbide Dinitrate
37.5 mg hydralazine/
Fixed dose combination
20 mg isosorbide
(423)
dinitrate 3 times daily
Hydralazine and
Hydralazine: 25 to 50
isosorbide dinitrate (448)
mg, 3 or 4 times daily
and isorsorbide
dinitrate:
20 to 30 mg
3 or 4 times daily
Maximum Doses(s)
10 mg once
50 mg twice
80 mg once
200 mg once
75 mg hydralazine/
40 mg isosorbide
dinitrate 3 times daily
Hydralazine: 300 mg
daily in divided doses
and isosorbide dinitrate
120 mg daily in
divided doses
~175 mg hydralazine/90 mg
isosorbide dinitrate daily
---------
Harm
I IIa IIb III
Harm
No Benefit
I IIa IIb III
No Benefit
I IIa IIb III
No Benefit
I IIa IIb III
No Benefit
I IIa IIb III
Harm
Harm
No Benefit
COR
LOE
IIa
IIb
III: Harm
COR
LOE
III:
Harm
IIa
COR
LOE
IIa
IIa
III: No
Benefit
III: No
Benefit
IIa
COR
III: No
Benefit
III: No
Benefit
LOE
B
C
III: Harm
III: Harm
III: No
Benefit
RR Reduction
in Mortality
(Standardized to 36 mo)
RR Reduction
in HF
Hospitalizations
ACE inhibitor or
ARB
Beta blocker
Aldosterone
antagonist
17%
26
31%
34%
41%
30%
35%
Hydralazine/nitrate
43%
33%
Thank You!
9/27/2013
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