Chronic Congestive Heart Failure: American Heart Association Sociedad Española de Cardiología

CHRONIC CONGESTIVE
HEART FAILURE
American Heart Association
in collaboration with
Sociedad Española de Cardiología
date posted: March, 2003

Chronic Congestive Heart Failure
Committee on Post Graduate Education,
Council on Clinical Cardiology,
American Heart Association
Developed in collaboration with the
Sociedad Española de Cardiología
Prepared by:
Ann F. Bolger, MD
José LópezSendón, MD
The content of these slides is current as of March 2003
Future revisions will be posted on the
American Heart Association website (www.americanheart.org).
The Problem (USA)
• 5,000,000 patients
• 6,500,000 hospital days / year
• 300,000 deaths / year
• 6% 10% of people > 65 years
• 5.4% of health care budget (38 billion)
• Incidence x 2 in last ten years
Gottdiener J et al. JACC 2000;35:1628
Haldeman GA et al. Am Heart J 1999;137:352
Kannel WB et al. Am Heart J 1991;121:951
O’Connell JB et al. J Heart Lung Transplant 1993;13:S107
Definition of heart failure
Clinical syndrome that can result from any
structural or functional cardiac disorder that
impairs the ability of the ventricle to fill with
or eject blood
AHA / ACC HF guidelines 2001
Clinical symptoms / signs secondary to
abnormal ventricular function
ESC HF guidelines 2001
Suspected Heart Failure
because of SYMPTOMS and/or SIGNS
Assess presence of CARDIAC DISEASE NORMAL
by ECG, XRay or BNP (if available) No Heart Failure
Tests abnormal
VENTRICULAR FUNCTION NORMAL
Imaging by ECHODoppler, No Heart Failure
Nuclear angiography or MRI if available
Tests abnormal
Heart Failure: Systolic / Diastolic
Identify etiology, evaluate severity, choose therapy
HF Risk Factors
No Heart disease A
No symptoms
Stages in the evolution
of Heart Failure
Heart disease
No symptoms B
Asymptomatic
LV dysfunction
C
Prior or current
HF Symptoms
D
Refractory
HF symptoms
Hypertension
Diabetes, Hyperchol.
Family Hx A
Cardiotoxins
Stages in the Evolution
of Heart Failure
Heart disease
B Clinical Characteristics
(any)
Asymptomatic
LV dysfunction
Systolic / Diastolic
C
Dyspnea, Fatigue
Reduced exercise
tolerance
D
Marked symptoms
at rest despite
max. therapy
Treat risk factors
Avoid toxics
ACEi in selected p.
A
Stages in the Evolution
of Heart Failure
ACEi
B Treatment
β blockers
In selected
patients
C
ACEi
β blockers
Diuretics / Digitalis
D
Palliative therapy
Mech. Assist device
Heart Transplant
Incidence
• n = 5888
• Age > 65 y
• Followup 5.5 y
• 4 different locations in the US
• INCIDENCE: 19.3 / 1000 personyears
The Cardiovascular Health Study
Gottdiener J et al. JACC 2000;35:1628
The Cardiovascular Health Study
JACC 2000;35:1628
Risk Factors
Coronary heart Disease
Direct Causes
1 Myocardial abnormalities (CHD!)
2 Hemodynamic overload
3 Ventricular filling abnormalities
4 Ventricular dyssynergy
Aggravating Factors
• Medications
• New heart disease
• Myocardial ischemia
• Pregnancy • Endocarditis
• Arrhythmias (AF) • Obesity
• Infections • Hypertension
• Thromboembolism • Physical activity
• Hyper/hypothyroidism • Dietary excess
Initial / Ongoing Evaluation
• Identify heart disease
• Assess functional capacity (NYHA, 6 min walk, …)
• Assess volume status: (edema, rales, jugular,
hepatomegaly, body weight)
• Lab assessment: routine: electrolytes, renal funct.
Repeat ECHO, RX only if significant changes in
functional status
• Assess prognosis
Prognosis
50 <30 Post MI
n=196
40
Cardiac
30
Mortality 3135
% 20
3645
10
4653
5460 >60
0
20 30 40 50 60 70 80
Brodie B. et al
Am J Cardiol 1992;69:1113
LVEF
Treatment Objectives
Survival
Morbidity
Exercise capacity
Quality of life
Neurohormonal changes
Progression of CHF
Symptoms
(Cost)
Treatment
• Prevention. Control of risk factors
• Life style
All • Treat etiologic cause / aggravating factors
• Drug therapy
• Personal care. Team work
• Revascularization if ischemia causes HF
Selected patients
• ICD (Implantable Cardiac Defibrillator)
• Ventricular resyncronization
• Ventricular assist devices
• Heart transplant
• Artificial heart
• Neoangiogenesis, Gene therapy
Failure
Chronic Congestive Heart
Treatment
Pharmacologic Therapy
• Diuretics
• ACE inhibitors
• Beta Blockers
• Digitalis
• Spironolactone
• Other
Diuretics
• Essential to control symptoms
secondary to fluid retention
• Prevent progression from HT to HF
• Spironolactone improves survival
• New research in progress
Diuretics
Thiazides
Cortex Inhibit active exchange of ClNa
in the cortical diluting segment of the
ascending loop of Henle
Ksparing
Inhibit reabsorption of Na in the
distal convoluted and collecting tubule
Loop diuretics
Medulla Inhibit exchange of ClNaK in
the thick segment of the ascending
loop of Henle
Loop of Henle
Collecting tubule
Diuretics. Indications
1. Symptomatic HF, with fluid retention
• Edema
• Dyspnea
• Lung Rales
• Jugular distension
• Hepatomegaly
• Pulmonary edema (Xray)
Loop Diuretics / Thiazides. Practical Use
• Start with variable dose. Titrate to achieve
dry weight
• Monitor serum K+ at “frequent intervals”
• Reduce dose when fluid retention is controlled
• Teach the patient when, how to change
dose
• Combine to overcome “resistance”
• Do not use alone
Loop diuretics. Dose (mg)

Initial Maximum
Bumetanide 0.5 to 1.0 / 12-24h 10 /
day
Furosemide 20 to 40 / 12-24h 400 / day
Torsemide 10 to 20 / 12-24h 200 / day
Thiazides, Loop Diuretics. Adverse Effects
• K+, Mg+ (15 60%) (sudden death ???)
• Na+
• Stimulation of neurohormonal activity
• Hyperuricemia (15 40%)
• Hypotension. Ototoxicity. Gastrointestinal.
Alkalosis. Metabolic
Sharpe N. Heart failure. Martin Dunitz 2000;43
Kubo SH , et al. Am J Cardiol 1987;60:1322
MRFIT, JAMA 1982;248:1465
Pool Wilson. Heart failure. Churchill Livinston 1997;635
Diuretic Resistance
• Neurohormonal activation
• Rebound Na+ uptake after volume loss
• Hypertrophy of distal nephron
• Reduced tubular secretion (renal failure, NSAIDs)
• Decreased renal perfusion (low output)
• Altered absortion of diuretic
• Noncompliance with drugs
Brater NEJM 1998;339:387
Kramer et al. Am J Med 1999;106:90
Managing Resistance to Diuretics
• Restrict Na+/H2O intake (Monitor Natremia)
• Increase dose (individual dose, frequency, i.v.)
• Combine: furosemide + thiazide / spiro / metolazone
• Dopamine (increase cardiac output)
• Reduce dose of ACEi
• Ultrafiltration
Motwani et al Circulation 1992;86:439

ACEi. Mechanism of Action
VASOCONSTRICTION VASODILATATION
ALDOSTERONE PROSTAGLANDINS
VASOPRESSIN Kininogen tPA
SYMPATHETIC Kallikrein
Angiotensinogen
RENIN
Angiotensin I
BRADYKININ
A.C.E. Inhibitor Kininase II
ANGIOTENSIN II Inactive Fragments
ACEI. Clinical Effects
• Improve symptoms
• Reduce remodelling / progression
• Reduce hospitalization
• Improve survival
Mortality Reduction with ACEi
Study ACEi Clinical Seting
CONSENSUS Enalapril CHF
SOLVD treatment Enalapril CHF
AIRE Ramipril CHF
VheftII Enalapril CHF
TRACE Trandolapril CHF / LVD
SAVE Captopril LVD
SMILE Zofenopril High risk
HOPE Ramipril High risk
ACEi
0.8
0.7
Placebo
0.6
Probabiility 0.5
p< 0.001
of 0.4 p< 0.002
Death 0.3
Enalapril
0.2
0.1
0
0 1 2 3 4 5 6 7 8 9 10 11 12
CONSENSUS
N Engl J Med 1987;316:1429
Months
ACEi
50
p = 0.0036
Placebo
40 n=1284
% 30
Mortality Enalapril
20 n=1285
n = 2589
CHF 10
NYHA IIIII
EF < 35
0
0 6 12 18 24 30 36 42 48
SOLVD (Treatment) Months
N Engl J M 1991;325:293
ACEi
30 Asymptomatic
ventricular Placebo
dysfunction post MI n=1116
20
Mortality, Captopril
n=1115
%
10
n = 2231
3 16 days post AMI
EF < 40 ² 19%
12.5 150 mg / day p=0.019
0
SAVE 0 1 2 3 4
N Engl J Med 1992;327:669 Years
ACEi
Placebo
30
20
Mortality Ramipril
%
10 10
p = 0.002
n = 2006
HF after AMI
0
0 6 12 18 24 30
AIRE Months
Lancet 1993;342:821
ACEi. Indications
• Symptomatic heart failure
• Asymptomatic ventricular dysfunction
LVEF < 35 40 %
• Selected high risk subgroups
ACEi. Practical Use
• Start with very low dose
• Increase dose if well tolerated
• Renal function & serum K+ after 12 w
• Avoid fluid retention / hypovolemia (diuretic
use)
• Dose NOT determined by symptoms
• Combine to overcome “resistance”
• Do not use alone
ACEi. Dose (mg)
Initial Maximum
Captopril 6.25 / 8h 50 / 8h
Enalapril 2.5 / 12 h 10 to 20 / 12h
Fosinopril 5 to 10 / day 40 / day
Lisinopril 2.5 to 5.0 / day 20 to 40 / day
Quinapril 10 / 12 h 40 / 12 h
Ramipril 1.25 to 2.5 / day 10 / day
ACEI. Adverse Effects
• Hypotension (1st dose effect)
• Worsening renal function
• Hyperkalemia
• Cough
• Angioedema
• Rash, ageusia, neutropenia, …
ACEI. Contraindications
• Intolerance (angioedema, anuric renal fail.)
• Bilateral renal artery stenosis
• Pregnancy
• Renal insufficiency (creatinine > 3 mg/dl)
• Hyperkalemia (> 5,5 mmol/l)
• Severe hypotension
ßAdrenergic Blockers
Mechanism of action
• Density of ß1 receptors
• Inhibit cardiotoxicity of catecholamines
• Neurohormonal activation
• HR
• Antiischemic
• Antihypertensive
• Antiarrhythmic

Clinical Effects
• Improve symptoms (only long term)
• Reduce remodelling / progression
• Reduce hospitalization
• Reduce sudden death
• Improve survival
1.0
Carvedilol
(n=696)
0.9
Survival p<0.001 Placebo

% 0.8 (n=398)
0.7 Risk reduction = 65%
III HF
0.6
0 50 100 150 200 250 300 350 400
Days
US Carvedilol HF
NEJM 1996; 334: 134955
1
Bisoprolol
0.9 11.8%
0.8
P< 0.00005
Survival
0.7 ICCC NYHA IIIIV Placebo
n=2647 17.3%
0.6
Annual Mortality: bisoprolol=8.2%; placebo=12%
Mean Followup 1.4 years
0.5
0 200 400 600 800
CIBISII Days
Lancet 1999;353:9
Placebo
15
p=0.0062
Mortality
Metoprolol
% 10
5 Risk
Reduction 34%
NYHA IIIV
N=3991 0
0 3 6 9 12 15 18 21
MERITHF Months
Lancet 1999; 353: 2001
100
90
80
Survival
Carvedilol
% 70
p=0.00014
35% RR
60
N = 2289 Placebo
IIIIV NYHA
50
0 4 8 12 16 20 24 28
COPERNICUS Months
NEJM 2001;344:1651

1
HR 0.77 (0.60 0.98) p<0.031
0.95
0.9 Carvedilol
Survival 116 / 975 (12%)
0.85
0.8
LVD / HF 0.75 Placebo

Post AMI 151 / 984 (15%)
0.7
0 0.5 1 1.5 2 2.5
CAPRICORN Years
Lancet 2001;357:1385
Indications
• Symptomatic heart failure
• Asymptomatic ventricular dysfunction
LVEF < 35 40 %
• After AMI
When to start
• Patient stable
• No physical evidence of fluid retention
• No need for i.v. inotropic drugs
• Start ACEI / diuretic first
• No contraindications
• In hospital or not
Dose (mg)
Initial Target
Bisoprolol 1.25 / 24h 10 / 24h
Carvedilol 3.125 / 12h 25 / 12h
Metoprolol tartrate 6.25 / 12h 75 / 12h
Metoprolol succinnate 12,525 / 24h 200 / 24h
• Start Low, Increase Slowly
• Increase the dose every 2 4 weeks
Adverse Effects
• Hypotension
• Fluid retention / worsening heart failure
• Fatigue
• Bradycardia / heart block
• Review treatment (+/diuretics, other drugs)
• Reduce dose
• Consider cardiac pacing
• Discontinue beta blocker only in severe cases
Contraindications
• Asthma (reactive airway disease)
• AV block (unless pacemaker)
• Symptomatic hypotension / Bradycardia
• Diabetes is NOT a contraindication
Digitalis

NaK ATPase NaCa Exchange
Na +
K +
Na+ Ca++
Myofilaments Ca++
K+ Na+
CONTRACTILITY
Digitalis. Mechanism of Action
Blocks Na+ / K+ ATPase => Ca+ +
• Inotropic effect
• Natriuresis
• Neurohormonal control
Plasma Noradrenaline
Peripheral nervous system activity
RAAS activity
Vagal tone
Normalizes arterial baroreceptors
NEJM 1988;318:358
Digitalis. Clinical Effects
• Improve symptoms
• Modest reduction in hospitalization
• Does not improve survival

Digitalis
50
40
Mortality
% 30
Placebo
20 n=3403 p = 0.8
N=6800
NYHA IIIII 10 Digoxin
n=3397
0
DIG 0 12 24 36 48
N Engl J Med 1997;336:525 Months
Digitalis. Indications
• When no adequate response to
ACEi + diuretics + betablockers
AHA / ACC Guidelines 2001
• In combination with ACEi + diuretics
if persisting symptoms
ESC Guidelines 2001
• AF, to slow AV conduction
Dose 0.125 to 0.250 mg / day
Digoxin. Contraindications
• Digoxin toxicity
• Advanced AV block without pacemaker
• Bradycardia or sick sinus without PM
• PVC’s and VT
• Marked hypokalemia
• WPW with atrial fibrillation

Aldosterone Inhibitors
Spironolactone ALDOSTERONE
Competitive antagonist of the
aldosterone receptor
(myocardium, arterial walls, kidney)
• Retention Na+ • Collagen
Edema
• Retention H2O deposition
Fibrosis
• Excretion K +
Arrhythmias myocardium
• Excretion Mg2+ vessels
Spironolactone 1.0
Annual Mortality
Aldactone 18%; Placebo 23%
0.9
Survival 0.8
0.7 Aldactone
N = 1663 0.6
NYHA IIIIV p < 0.0001
Mean followup 2 y
0.5
RALES months Placebo

NEJM 1999;341:709 0 6 12 18 24 30 36
Spironolactone. Indications
• Recent or current symptoms despite
ACEi, diuretics, dig. and β blockers
• Recommended in advanced heart failure
(IIIIV), in addition to ACEi and diuretics
• Hypokalemia
Spironolactone. Practical use
• Do not use if hyperkalemia, renal insuf.
• Monitor serum K+ at “frequent intervals”
• Start ACEi first
• Start with 25 mg / 24h
• If K+ >5.5 mmol/L, reduce to 25 mg / 48h
• If K+ is low or stable consider 50 mg / day
New studies in progress
Other Drugs. (only in selected patients)
• Inotropics: refractory HF
• Nitrates: ischemia, angina, pulmonary congestion
• ARB: Contraindications to ACEi
• Antiarrhythmics: (only amiodarone) H risk arrhyth.
• Anticoagulants: High risk of embolysm
• Ca channel blockers: (only amlodipine) ischemia

Angiotensin II Receptor Blockers (ARB)
RENIN
Angiotensinogen Angiotensin I
ACE
Other pathways ANGIOTENSIN II
AT1
Receptor
Blockers
RECEPTORS
AT1 AT2

Vasoconstriction Proliferative Vasodilatation Antiproliferative

Action Action
• Candesartan, Eprosartan, Irbesartan
Losartan, Telmisartan, Valsartan
• Efficacy not equal / superior to ACEI
• Not indicated with beta blockers
• Indicated in patients intolerant to ACEI
1.0
Valsartan

0.9

Survival
Placebo

0.8
P = 0.8
0.7

0 3 6 9 12 15 18 21 24 27
ValHeFT
AHA 2000 Months

Vasodilators
VENOUS Venous
Vasodilatation
Nitrates
Molsidomine
MIXED
Calcium antagonists
αadrenergic Blockers
ACEI, ARBs
K+ channel activators
Nitroprusside
Arterial ARTERIAL
Vasodilatation Minoxidil
Hydralazine

NITRATES
HEMODYNAMIC EFFECTS
1 VENOUS VASODILATATION
Pulmonary congestion
Ventricular size
Preload Vent. Wall stress
MVO2
2 Coronary vasodilatation
Myocardial perfusion
3 Arterial vasodilatation • Cardiac output
• Blood pressure
Afterload

Nitrates
0.7
Placebo (273)
0.6 Prazosin (183)
Hz + ISDN (186)
0.5
Probability
0.4
of
0.3
Death
0.2
0.1
0
VHefT1 0 6 12 18 24 30 36 42
N Engl J Med 1986;314:1547 Months
Nitrate + Hydralazine
0.75
n = 804
HZ + ISDN
0,54
Probability 0.50
p = 0.016
0.47
of
0,48
0.36 0.42
death
0.25 0.31 Enalapril
0.25
0.13 0.18
0.09 p = 0.08
0
0 12 24 36 48 60
VHeFT II
N Engl J Med 1991; 325:303 Months
Nitrates. Clinical Use
• CHF with myocardial ischemia
• Orthopnea and paroxysmal nocturnal dyspnea
• In acute CHF and pulmonary edema:NTG sl / iv
• Nitrates + Hydralazine in intolerance
to ACEI (hypotension, renal insufficiency)
Positive Inotropes
• Digitalis
• Sympathomimetics
• Catecholamines
• Badrenergic agonists
• Phosphodiesterase inhibitors
• Amrinone, Milrinone, Enoximone
• Calcium sensitizers
• Levosimendan, Pimobendan
Positive Inotropic Therapy
•May increase mortality
Exception: Digoxin, Levosimendan
•Use only in refractory CHF
•NOT for use as chronic therapy
Drugs to Avoid (may increase symptoms, mortality)
• Inotropes, long term / intermittent
• Antiarrhythmics (except amiodarone)
• Calcium antagonists (except amlodipine)
• Nonsteroidal antiinflammatory drugs (NSAIDS)
• Tricyclic antidepressants
• Corticosteroids
• Lithium
NEW DRUGS (ongoing research)
1.
1. New neurohormonal modulators
2. New inotropics
3. Gene therapy
4. Myocyte transplant and mitosis
5. Neoangiogenesis / Growth factors
New Drugs (ongoing research)
1.
1. New neurohormonal modulators
• Betablockers
• Aldosterone receptor antagonists
• Angiotensin II receptor antagonists
• Endothelin inhibitors
• Vasopresin inhibitors
• Natriuretic Peptides
• Endopeptidase inhibitors
• Vasopeptidase inhibitors
Other Drugs (ongoing research)

• Erythropoietin
• Ranolazine
• Matrix metalloproteinases
• Growth Hormone
• L-Thyroxine
• Inhibitors of carnitine palmitoyltransferse-I
• Dopamine-β -hyydroxylase inhibitors
• Antithrombotics
Refractory EndStage HF
• Review etiology, treatment & aggrav. factors
• Control fluid retention
• Resistance to diuretics
• Ultrafiltration ?
• iv inotropics / vasodilators during
decompensation
• Consider resynchronization
• Consider mechanical assist devices
• Consider heart transplantation
Heart Transplant. Indications
• Refractory cardiogenic shock
• Documented dependence on IV inotropic support
to maintain adequate organ perfusion
• Peak VO2 < 10 ml / kg / min
• Severe symptoms of ischemia not amenable to
revascularization
• Recurrent symptomatic ventricular arrhythmias
refractory to all therapeutic modalities
Contraindications: age, severe comorbidity
Heart Failure and Myocardial Ischemia
• Coronary HD is the cause of 2/3 of HF
• Segmental wall motion abnormalities are not
specific if ischemia
• Angina coronary angio and revascularization
• No angina
• Search for ischemia and viability in all ?
• Coronary angiography in all ?
Supraventricular Arrhythmias
• Risk of embolization (AF)
• Anticoagulation in AF
• Systolic & diastolic dysfunction
• Digoxin, beta blockers
• Amiodarone if bblocker ineffective/ contraind.
• Conversion to sinus rhythm in all ?
ongoing research
Ventricular Arrhythmias / Sudden Death
• Antiarrhythmics ineffective (may increase mortality)
Amiodarone do not improve survival
• β blockers reduce all cause mortality and SD
• Control ischemia
• Control electrolyte disturbances
• ICD (Implantable Cardiac Defibrillator)
• In secondary prevention of SD
• In sustained, hemodynamic destabilizing VT
• Ongoing research will establish new indications
Diastolic Heart Failure
• Incorrect diagnosis of HF
• Inaccurate measurement of LVEF
• Primary valvular disease
• Restrictive (infiltrative) cardiomyopathies (Amyloidosis…)
• Pericardial constriction
• Episodic or reversible LV systolic dysfunction
• Severe hypertension, ischemia
• High output states: Anemia, thyrotoxicosis, etc
• Chronic pulmonary disease with right HF
• Pulmonary hypertension
• Atrial myxoma
• LV Hypertrophy
• Diastolic dysfunction of uncertain origin
Diastolic Heart Failure
• Treat as HF with low LVEF
• Control:
• Hypertension
• Tachycardia
• Fluid retention
• Myocardial ischemia
• Ongoing research
HEART FAILURE MODELS
CONGESTIVE Digoxin, Diurétics
HEMODYNAMIC Vasodilators
NEUROHUMORAL ACE inhibitors,
β Blockers, Spironolactone
IMMUNOLOGICAL Cytokine inhibitors
TREATMENT STRATEGIES
Diuretics Vasodilators Symptom
Inotropics relief
Neurohumoral activation
ACEis, β blockers Prevention
Spironolatone of disease
progression
ARBs?, ANP?
ET1?
Gene Antiremodeling Reversal
therapy? strategies of HF
Mann. Circulation 1999; 100: 9991008
AHA / ACC
Recommendations for the Evaluation of Patients
Class I
1. Thorough history and physical examination
2. Patient’s ability to perform desired activities
3. Volume status (fluid retention, edema)
4. Lab: blood count, electrolytes, creatinine, glucose, …
5. Initial 12lead ECG and chest radiograph
7. Initial 2D ECHO or radionuclide ventriculography
to assess left ventricular systolic function
8. Coronary arteriography in patients with angina
http://www.americanheart.org/presenter.jhtml?identifier=11841
AHA / ACC
Recommendations for the Evaluation of Patients
Class III
1. Routine endomyocardial biopsy
2. Routine Holter monitoring
or signalaveraged electrocardiography.
3. Repeat coronary arteriography or noninvasive testing
for ischemia in patients with already excluded
coronary artery disease
4. Routine measurement of norepinephrine or endothelin
ACC
mmendations for Patients at High Risk of Developing H
e A)
I
trol of systolic and diastolic hypertension
atment of lipid disorders
trol other risk factors (e.g., smoking, alcohol, drugs)
E inhibition in patients with a history of atheroscleroti
scular disease, diabetes mellitus, or hypertension
trol of ventricular rate in supraventricular arrhythmia
atment of thyroid disorders
iodic evaluation for signs and symptoms of HF
AHA / ACC
Recommendations for Patients at High Risk of Developing HF
(Stage A)
Class IIa
1. Noninvasive evaluation of left ventricular function in
patients with a strong family history of cardiomyopathy
or in those receiving cardiotoxic interventions
Class III
1. Exercise to prevent the development of HF
2. Reduction of dietary salt beyond that which is prudent
3. Routine testing to detect left ventricular dysfunction
4. Routine use of nutritional supplements
AHA / ACC
Recommendations for Patients With Asymptomatic
Left Ventricular Systolic Dysfunction (Stage B)
Class I
5. ACE inhibition in patients with previous AMI
6. ACE inhibition in patients with a reduced LVEF
7. Betablockade in patients with a recent AMI
8. Betablockade in patients with a reduced LVEF
9. Valve repair for significant valvular stenosis / regurgitation
10. Regular evaluation for signs and symptoms of HF
11. Also Class I recommendations for patients in Stage A
AHA / ACC
Recommendations for Patients With Asymptomatic
Left Ventricular Systolic Dysfunction (Stage B)
Class IIb
1. Systemic vasodilators in severe aortic regurgitation
Class III
1. Digoxin in patients in sinus rhythm
2. Reduction of dietary salt beyond that which is prudent
3. Exercise to prevent the development of HF
AHA / ACC
Recommendations for Treatment of Symptomatic Left
Ventricular Systolic Dysfunction (Stage C)
Class I
1. Diuretics in patients with fluid retention.
2. ACE inhibition in all patients
3. Betablockers in all stable patients
4. Digitalis for the treatment of symptoms of HF
5. Withdrawal of drugs adversely affecting clin. status
(most antiarrhythmics, most calcium channel
blockers, nonsteroidal antiinflammatory drugs, …)
AHA / ACC
Class IIa
1. Spironolactone in patients with recent or current
Class IV symptoms
2. Exercise training to improve clinical status
3. Angiotensin receptor blockade in patients who
cannot be given ACEI because of cough or angioedema
4. Hydralazine and a nitrate in patients who cannot be given
ACEi because of hypotension or renal insufficiency
AHA / ACC
Class IIb
1. Addition of angiotensin receptor blocker to ACEi
2. Addition of a nitrate to ACEI in patients
Class III
1. Longterm intermittent use inotropics infusion
2. Use of angiotensin blocker instead of ACEi
3. Use of angiotensin blocker before a betablocker
4. Use of Ca channel blocker for HF
AHA / ACC
Recommendations for Patients With Refractory
EndStage HF (Stage D)
Class I
1. Meticulous identification and control of fluid retention
2. Referral for cardiac transplantation in eligible patients
3. Referral to an HF program
4. Other class I recommendations for Stages A, B, and C
AHA / ACC
Recommendations for Patients With Refractory
EndStage HF (Stage D)
Class IIb
1. Pulmonary artery catheter to guide therapy
2. Mitral valve repair for severe secondary mitral regurg.
3. Continuous infusion of inotropics for symptoms
Class III
1. Partial left ventriculectomy
2. Routine intermittent infusions of inotropics

Chronic Congestive Heart Failure: American Heart Association Sociedad Española de Cardiología

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Chronic Congestive Heart Failure: American Heart Association Sociedad Española de Cardiología

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CHRONIC CONGESTIVE

date posted: March, 2003

Loop diuretics. Dose (mg)

A.C.E. Inhibitor Kininase II

Survival p<0.001 Placebo

LVD / HF 0.75 Placebo

RALES months Placebo

Vasoconstriction Proliferative Vasodilatation Antiproliferative

Other Drugs (ongoing research)

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