2016 Update to Heart Failure Clinical Practice Guidelines

2016 Update to Heart Failure Clinical Practice Guidelines

Tuesday August 2, 2016 1:00pm ? 2:00pm CST (60 minute webinar)

Presenters: Dr. Gregg Fonarow, MD, FACC, FAHA, FHFSA Dr. Clyde Yancy, MD, MSc, MACC, FAHA, MACP Dr. Paul Heidenreich, MD, MS, FACC

8/2/2016

Clyde W. Yancy, MD, MSc, MACC, FAHA, MACP

Vice Dean, Diversity & Inclusion Magerstadt Professor of Medicine Professor of Medical Social Sciences Chief, Division of Cardiology Northwestern University, Feinberg School of Medicine Associate Director, Bluhm Cardiovascular Institute

Gregg C. Fonarow, MD, FACC, FAHA

The Eliot Corday Professor of Cardiovascular Medicine and Science Co-Chief of Clinical Cardiology UCLA Division of Cardiology Director, Ahmanson-UCLA Cardiomyopathy Center Co-Director, UCLA Preventative Cardiology Program

Paul A Heidenreich, MD, MS,

FACC

Associate Professor of Medicine

Vice-Chair for Clinical, Quality and Analytics, Department of Medicine

Stanford University

?2013, American Heart Associa2tion

2016 Update to Heart Failure Clinical Practice Guidelines

? New Epidemiology ? New Therapies ? New Guidelines ? New Phenotype

From: A Contemporary Appraisal of the Heart Failure Epidemic in Olmsted County, Minnesota, 2000 to 2010 JAMA Intern Med. 2015;175(6):996-1004. doi:10.1001/jamainternmed.2015.0924

Figure Legend:

Temporal Trends in Heart Failure Incidence Rates Overall and by Reduced or Preserved Ejection Fraction Among Women and Men in Olmsted County, Minnesota, 2000 to 2010Yearly rates (smoothed using 3-year moving average) per 100 000 persons have been standardized by the direct method to the age distribution of the US population in 2010. HFpEF indicates heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.

Copyright ? 2016 American Medical

Date of download: 6/10/2016

Association. All rights reserved.

A Contemporary Appraisal of the HF Epidemic

? Age and sex-specific incidence of heart failure has declined ? 315/100,000 to 219/100,000

? Rate reduction of 37.5% ? Incidence decline was greater for HFrEF ? 45.1% vs. HFpEF -27.9% ? Risk for CV death was lower for HFpEF but the same for non-CV death ? Hospitalizations have increased 34% ? Most hospitalizations, 63%, were due to non-cardiovascular causes

? Thus today's epidemic of heart failure is defined by a marked increase in

hospitalizations, predominance of non-CV death rate, and persistence and

predominance of HFpEF

Roger VL et al. JAMA Intern Med. 2015; April 20. Epub ahead of print.

Stages, Phenotypes and Treatment of HF

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

STAGE C

Structural heart disease with prior or current symptoms of HF

Heart Failure

STAGE D

Refractory HF

e.g., Patients with: ? HTN ? Atherosclerotic disease ? DM ? Obesity ? Metabolic syndrome

or Patients ? Using cardiotoxins ? With family history of

cardiomyopathy

Structural heart disease

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

e.g., Patients with: ? Previous MI ? LV remodeling including

LVH and low EF ? Asymptomatic valvular

disease

Development of symptoms of HF

e.g., Patients with: ? Known structural heart disease and ? HF signs and symptoms

Refractory symptoms of HF at rest, despite GDMT

e.g., Patients with:

? Marked HF symptoms at

rest

? Recurrent hospitalizations

despite GDMT

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

HFpEF

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

HFrEF

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

THERAPY Goals ? Control symptoms ? Improve HRQOL ? Reduce hospital

readmissions ? Establish patient's 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

Yancy, C. Jessup M, Bozkurt B. et al. JACC 2013

Pharmacologic Treatment for Stage C HFrEF

HFrEF Stage C NYHA Class I ? IV

Treatment:

For all volume overload, NYHA class II-IV patients

Add

Class I, LOE C Loop Diuretics

Class I, LOE A ACEI or ARB AND

Beta Blocker

For persistently symptomatic African Americans, NYHA class III-IV

Add

For NYHA class II-IV patients. Provided estimated creatinine >30 mL/min and K+ ................
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