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Michelle A. Hart MD CCFP M.Sc.C.

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:

Disclosure of Commercial
• 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
Faculty/Presenter Disclosure
• Faculty: Dr. Sid Feldman
• Program: 51st Annual Scientific Assembly

• Relationships with commercial interests:

Disclosure of Commercial
• 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
 Dr. Daphna Grossman
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 self-
1. Review on basics of heart failure
2. Diagnosing Heart Failure
3. Management of Heart Failure
4. Future Directions: What’s coming down the
pipeline for HF Management
5. Advanced Care Planning, Prognostication
and End-Of-Life
6. Summary of Heart Failure
 Definition of Heart Failure
 Why is it important?
 How does it happen?
 Types of Heart Failure
 Staging and Classes of Heart Failure
 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”
 In North America, it is the fastest growing
cardiac diagnosis for individuals > 65 years
 Average annual mortality rate of 10-35% in
 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:

 Left ventricular systolic dysfunction with

Reduced Ejection Fraction (HF-REF)

 HF with preserved ejection fraction (HF-PEF)

◦ 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

 Based on subjective clinical evaluation
 Changes with treatment response and disease
 Complementary with AHA

Canadian Cardiovascular Society (CCS) uses NYHA

 Fatigue
 Weakness
 Ankle edema
 Weight gain
 Exertional dyspnea
 Orthopnea
 Paroxysmal Nocturnal Dyspnea
 Cough
 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
 Renal failure
 Obesity
 Depression/anxiety
 Severe anemia
 Pulmonary embolism
 Atrial Fibrillation
 Hypoalbuminemia
 Dependent edema
 Fluid retention 2˚ to calcium channel blocker or
non-steroidal anti-inflammatory drugs
 Class 1 Recommendation, Level C Evidence

1. Clinical history
2. Physical Exam
3. Initial lab investigations
4. Transthoracic Echocardiography
5. Radionuclide Angiography
6. Coronary Angiography
7. Cardiac Magnetic Resonance
8. 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
 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)
 Laboratory testing
 Electrocardiogram (ECG)
 Chest x-ray
 Echocardiogram
Taken from: The Radiology Assistant
Taken from: The Radiology Assistant PCWP = Pulmonary
Capillary Wedge
http://www.radiologyassistant.nl/en/p4c132f36513d4 Pressure
 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
 BNP and prohormone (NT-proBNP) are
synthesized and released from the heart in
response to end-diastolic volume and
 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
 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 Your patient's score

Age > 75 y 1
Orthopnea present 2
Lack of cough 1

Current loop diuretic use

(before presentation)

Rales on lung exam 1

Lack of fever 2
Elevated NT-proBNP 4
Interstitial edema on
chest x-ray
14 Total =

Likelihood of heart failure Low 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
 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
1) Risk factor management
2) Patient education
3) Treatment: Non-pharmacological
4) Treatment: Pharmacological
5) 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]
 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]

 Patient with vascular disease or diabetes with

end-organ damage, prescribe target-dose
 [Class IIa Evidence, Level B Recommendation]
 Critical for successful therapy
 Best way to maintain adherence/compliance
 Patient information/handouts
-Eg. Canadian Heart Failure Network (CHFN)
 Self-management, meds (when applicable)
 Action plan – what to do if symptoms worsen
 Multidisciplinary interventions appear
beneficial (studies from academic centres
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
[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:

 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

 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

 Pneumococcal vaccination
 Annual influenza vaccination

[Class I Recommendation, Level C Evidence]

 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
9. Common drug interactions (increase or decrease
concentration) and side effects
Drugs Aging (2013) 30:765–782
Heart Failure with Reduced Ejection Fraction
-ACEi (or ARB) and ß-blocker
-Aldosterone antagonists
-Omega-3 Polyunsaturated Fatty Acids
-What about ASA/Antiplatelets?
 Loop diuretic (eg. Furosemide) for congestive
 When symptoms clear, use lowest possible
dose [Class I, Level C]

 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

 All patients with HF and LVEF < 40% should

receive target-dose combination therapy with
an ACEi and ß-blocker
[Class I, Level A]

 Asymptomatic patients with LVEF < 35%

should receive an ACEi
[Class I, Level A]
ACEi (or ARB) and ß-blocker

 If cannot tolerate ACEi, substitute with ARB

[Class I, Level A]

 Monitor serum Creatinine

 Patients optimally treated with ACEi and ß-
blocker with persistent HF symptoms, ↑

 Add ARB  consult cardiologist/internist

 Addition of an ARB to ACE inhibitor and β-
blockade therapy modestly improves clinical
outcome predominantly by reducing HF
 Monitor BP, K+, Renal function: use with
 ONTARGET hypertension trial: 13% increased
risk of renal dysfunction [Level I-1 Evidence]
Aldosterone Antagonists/Mineralocorticoid
Receptor Antagonists (MRAs)

 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]
 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)
 Relieves symptoms
 Decreases hospitalizations

 In patients in sinus rhythm who have

moderate-severe symptoms despite optimal
medical therapy

[Class I, Level A Evidence]


 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

 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
 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.β-
blockers) to reduce hospitalizations and
deaths because of HF
 On basis that resting HR independently
predicts CV events, including HF
 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
 Treatment trials have been inconclusive,
limited evidence-based recommendations
 Best available data is for ACEi and ARB
 Combo therapy for most patients (add ARB)
[Class IIa, Level B]
 If HR is high, ß-blockers may be useful to
prolong diastolic filling time and relieve
pulmonary congestions
 Diuretics : for symptom control

 Once acute congestion cleared, use lowest

dose compatible with stable weight and

 [Class I, Level C]
 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]
 Emphasis on management of comorbidities:

◦ Atrial Fibrillation: 50% of patients

-ß-blocker or Digoxin to control ventricular rate
-Restoration of sinus rhythm
 Thiazolidinediones
 Nonsteroidal anti-inflammatory agents
 Cyclooxygenase-2 inhibitors
 Common arrhythmia in HF
 Associated with higher rates of adverse clinical
 Increased risk of thromboembolism including
 Manage and classify according to current AF
 General approach : control rate
 Limited data to support a specific upper heart
rate target
 Current CCS AF guidelines target rate < 100
 β-Blockers are preferred over digoxin for rate
 Rate-lowering CCBs are acceptable alternatives
in patients with HF-PEF
 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
 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
 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:
◦ Ischemia
◦ Hypertension
◦ Valvular disease
◦ Syncope
◦ Renal Dysfunction
◦ Other comorbidities
◦ Unknown etiology
◦ Treatment intolerance
◦ Poor compliance [Class I, Level C]
 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
 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
 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.
 Patient-centred decision making
 Open communication with patients and their
families: critical concepts in high quality care
 Description of underlying condition +
 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
 Likely to Benefit - reasonable likelihood that
life support will restore/maintain organ
function or likelihood of returning to pre-
arrest 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
 Admissions to acute care vs. care at home
and end-of-life planning
 When is the right time to have the discussion?
 Exploring end-of-life preferences,
 Quality of life as a valuable goal of therapy
 Treatment modality:
Improve symptom + prognosis
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
 No clear “transition point”
 When do you start PC?

 Costly and invasive therapies

 When do you say “no”?

 Sudden death (50%)

 Poor patient understanding of illness

Reviewed 38,702 consecutive patients with
first time admissions for heart failure
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 co-
morbidities 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

 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
 Pain (>70%!)
 Depression (60%)
 Myopathy
 Cachexia
 Cognitive impairment

Goodlin J Am Coll Cardiology (2009)

 Consensus panels advocate provision of
palliative care concurrent with efforts to
prolong life in heart failure

ACC/AHA Practice Guidelines

 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
 A clinical syndrome: impaired cardiac output
and/or volume overload, concurrent cardiac
 Progressive
 Associated with poor quality of life – frequent
hospitalizations, poor survival
 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
 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
 Delayed progression/prolong survival
through early diagnosis, optimized
pharmacotherapy, non-pharmacological
 Manage side-effects
 Adherence, self-management strategies
 Complex cases – manage with support of
cardiology consultation, specialty heart
failure clinics
 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
 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
 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 Start Dose Target Dose

ACE Inhibitors
Captopril 6.25-12.5 mg TID 25-50 mg TID
Enalapril 1.25-2.5 mg BID 10 mg BID
Lisinopril 2.5-5 mg OD 20-35 mg OD
Perindopril 2-4 mg OD 4-8 mg OD
Ramipril 1.25-2.5 mg BID 5 mg BID
Trandolapril 1-2 mg OD 4 mg OD

Bisoprolol 1.25 mg OD 10 mg OD
Carvedilol 3.125 mg BID 25 mg BID*
Metoprolol CR/XL** 12.5-25 mg OD 200 mg OD

* 50 mg BID if weight is >85 kg

** Not available in Canada
Drug Start Dose Target Dose

Candesartan 4 mg OD 32 mg OD
Valsartan 40 mg BID 160 mg BID

Aldosterone Antagonists
Spironolactone 12.5 mg OD 50 mg OD
Eplerenone 25 mg OD 50 mg OD

Hydralazine 37.5 mg TID 75 mg TID
Isorbide dinitrate 20 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.