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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
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)
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
Pneumococcal vaccination
Annual influenza vaccination
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]
Eplerenone: up to 50 g reduces
hospitalization and death in HF patients
(NYHA II, LVEF < 30%) (EMPASIS-HF Trial)
Digoxin
Relieves symptoms
Decreases hospitalizations
[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:
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
Beta-blockers
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
ARBs
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
Vasodilatators
Hydralazine 37.5 mg TID 75 mg TID
Isorbide dinitrate 20 mg TID 40 mg TID