Ccc2012 Hf Wkshop

7/28/2019 Ccc2012 Hf Wkshop

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CCS HEART FAILURE WORKSHOP

THE PRACTICAL MANAGEMENT OF

HEART FAILURE2012 UPDATE


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WELCOME!


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Heart Failure Guidelines

Learning Objectives

At the conclusion of this workshop, participants will beable to:

1. Review changes and updates for optimal

management of chronic and acute heart failure;updating 2006 recommendations to 2012 context and

environment;

2. Discuss exercise for heart failure patients - where to

begin, what to do and where to end; and

3. Identify opportunities and challenges of surgery for

patients with an ischemic etiology for heart failure.


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Acute Heart Failure


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What is heart failure?

Chronic Heart Failure (CHF):

Heart failure is a complex syndrome in which

abnormal heart function results in, or increases

the subsequent risk of, clinical symptoms and

signs of low cardiac output and/or pulmonary or

systemic congestion.

Acute Heart Failure Syndrome (AHF):

gradual or rapid change in heart failure signs

and symptoms resulting in the need for urgenttherapy


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Classification of AHF

high BP, +/- preserved LV systolic fxn;increased sympathetic tone with HR,

vasoconstriction; may be euvolaemic

or only mildly hypervolemic, and

frequently with signs of pulmonary or

systemic congestion

Severe respiratory distress, RR,

orthopnea, rales. O2 sats


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Has care evolved?

1950 1974 2012

Morphine Morphine Morphine?

Sedation

Oxygen Oxygen?

Dietary sodium restriction Dietary sodium restriction Dietary sodium restriction?

Strict bed rest Early mobilization

Digitalis Inotropes Avoid inotropes

Mercurial diuretics Diuretics ?Diuretics

Venesection Vasodilators ?Vasodilators

Harrisons Principles of Internal Medicine 1st Edition (1950)

Ramirez A et al. N Engl J Med1974;290(9):499-501


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CASE 1

74 year old female

2 months worsening SOB/orthopnea

Presented to ED after Chinese food

Past Hx unclear, no meds

Physical exam

HR 98, BP 142/82, RR 28, temp 36.0C

JVP elevated, crackles, pulses 2+,

legs warm and LEE+


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CASE 1

74 year old female

CXR = pending

Labs = pending


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prepare to provide your answer!


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How confident are you that it is

AHF?

1. 80%


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How confident are you that it is

AHF?

1. 80%

No right answer


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AHF Dx Scoring systems

Baggish AL, et al.Am Heart J 2006; 151: 48-54].

Predictor Points Our Case

Elevated NT-proBNP 4 ?

Interstitial edema on

CXR2 ?

Orthopnea 2 -

Absence of fever 2 2Current loop diuretic

use1 -

Age > 75 years 1 -

Rales on lung

examination1 1

Absence of cough 1 1Interpretation 4

e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93


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CASE 1

74 year old female

CXR = increased pulmonary markings c/w

edema, no evidence of COPD Labs = troponin I 0.20

BNP 728 pg/ml

Creatinine 130


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AHF Dx Scoring systems

Baggish AL, et al.Am Heart J

2006; 151: 48-54].

Predictor Points Our Case

Elevated NT-proBNP 4 4

Interstitial edema on

CXR2 2

Orthopnea 2 -

Absence of fever 2 2Current loop diuretic

use1 -

Age > 75 years 1 -

Rales on lung

examination1 1

Absence of cough 1 1Interpretation 10

e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93


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CCS 2012

We recommend the use of a validated diagnostic

scoring system for patients in whom thediagnosis of AHF is being considered (Strong

Recommendation, Moderate Quality

Evidence).

e.g. PRIDE score, Boston criteria

This recommendation places a relatively high

value on evaluating the constellation of clinical

findings in a patient with suspected AHF andless value on an individual physical

examination finding, presenting symptom or

investigation.


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CCS 2012

We recommend that in the clinical scenario whenthe clinical diagnosis of AHF is ofintermediate

pre-test probabi l i ty, NP level be obtained to

rule-out (BNP 900 pg/ml if age 50-75 years, NT-proBNP

>1800 if age >75 years) AHF as the cause for

the presenting symptoms suspicious of AHF

(Strong Recommendation, Moderate QualityEvidence)


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CCS 2012: Practical Tips

A precipitating cause for AHF should be sought.

An ECG and a chest x-ray should be performed

within 2 hours of initial presentation.

Initial blood tests should include: complete blood

count, creatinine, blood urea nitrogen, glucose,

sodium, potassium, and troponin.


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CCS 2012: Practical Tips

A transthoracic echocardiogram should beperformed within 72 hours of presentation.

For patients with a prior echocardiogram,

another is not required unless there has beena significant change in clinical status requiring

investigation, a lack of clinical response to

appropriate therapy and/or it is greater than

12 months since the prior echocardiogram.


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CASE 2

52 year old male with history of HF Presented to ED after the Edmonton Oilers won theStanley Cup

SOBOE, orthopnea

HR 98, BP 99/52, RR 24, temp 36.0c

JVP difficult to assess (thick neck)

crackles

pulses weak, legs cool and LEE

Trop 0.15


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Where on this table does this pt fit?

Adapted from Forrester, Am J Med 1978

Nohria et al. JACC 2003; 41:1797-804

Dry and Warm

Dry and Cold

Wet and Warm

Wet and Cold

Increasing Congestion / PCWP

IncreasingPerfusion/

Cardiac Output

1 2

3 4


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Where on this table does thispt fit?1. Dry and Warm

2. Wet and Warm

3. Dry and Cold

4. Wet and Cold

1 2 3 4

0% 0%0%0%


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Where on this table does this pt fit?

Adapted from Forrester, Am J Med 1978

Nohria et al. JACC 2003; 41:1797-804

Dry and Warm

Dry and Cold

Wet and Warm

Wet and Cold

Increasing Congestion / PCWP

IncreasingPerfusion/

Cardiac Output

1 2

3 4


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Admit or discharge?


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Treatment options?


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CCS 2012: Oxygen

We recommend supplemental oxygen be considered forpatients who are hypoxemic; titrated to an oxygen

saturation >90% (Strong Recommendation, Moderate

Quality Evidence).

Values and Preferences: This recommendation places

relatively higher value on the physiologic studies

demonstrating potential harm with the use of excess

oxygen in normoxic patients and less value on long-

term clinical usage of supplemental oxygen withoutsupportive data.


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CCS 2012: CPAP/BIPAP

We recommend CPAP or BIPAP not be usedroutinely (Strong Recommendation,

Moderate Quality Evidence).

Values and Preferences: This recommendationplaces high weight on RCT data with a

demonstrated lack of efficacy and with safety

concerns in routine use. Treatment with

BIPAP/CPAP may be appropriate for patients

with persistent hypoxia and pulmonary

edema.


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CASE 2

52 year old male with history of HF

Presented to ED after the Edmonton Oilers won the

Stanley Cup

SOBOE, orthopnea

HR 98, BP 99/52, RR 24, temp 36.0c

JVP difficult to assess (thick neck)

crackles

pulses weak, legs cool and LEE

Trop 0.15


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DOSE St d D i


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Acute Heart Failure (1 symptom AND 1 sign)


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Efficacy:

Patient Global Assessment by visual analog

scale over 72 hours using area under the curve

Safety:

Change in creatinine from baseline to 72 hours

DOSE: Co-Primary Endpoints


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DOSE: patient

global

assessment


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DOSE: Death, Rehosp, ER visit


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CCS 2012: Diuretics

We recommend intravenous diuretics be given as first

line therapy for patients with congestion (Strong

Recommendation, Moderate Quality Evidence).

We recommend for patients requiring intravenous

diuretic therapy, furosemide may be dosed

intermittently (e.g. twice daily) or as a continuous

infusion (Strong Recommendation, ModerateQuality Evidence).


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Diuretic dosing for ADHF

Creatinine

clearance*Patient

Initial

IV doseMaintenance

dose

Lowest diuretic dose

that allows for

clinical stability is

the ideal dose

60 mL/min/1.73m2 New-onset HF or no maintenance

diuretic therapy

Established HF or chronic oraldiuretic therapy

New-onset HF or no maintenance

diuretic therapy

Established HF or chronic oral

diuretic therapy

Furosemide 20-40 mg

2-3 times daily

Furosemide bolus equivalent

to oral dose

Furosemide 20-80 mg

2-3 times daily

Furosemide bolus equivalent

to oral dose

< 60 mL/min/1.73m2

*Creat inine clearance is calculated from th e Cockro ft-Gault or Modif ied Diet in Renal Disease form ula. See text for detai ls.

Intravenous continuous furosemide at doses of 5 to 20mg/h is also an option.

Practical Tips When Response to Diuretic is Suboptimal

Reevaluate the need for additional diuresis by assessing volume status

Restrict NA+/H2O intake (and exercise caution reducing oral intake below 500 ml per 24 hours).

Review diuretic dosing. Higher bolus doses will be more effective than more frequent lower doses. Diuretic infusions (eg, furosemide 20-40 mg bolusthen 5-20 mg/h) can be a useful strategy when other options are not available.

Add another type of diuretic with different site of action (thiazides, spironolactone). Thiazide diuretics (eg oral metolazone 2.5-5 mg OB/BID or

hydrochlorothiazide 25-50 mg) are often given at least 30 minutes before the loop diuretic to enhance diuresis, although this is not required to have

an adequate effect.

Consider hemodynamic assessment and/or positive inotropic agents if clinical evidence of poor perfusion coexists with diure tic resistance.

Refer for hemodialysis, ultrafiltration, or other renal replacement strategies if diuresis is impeded by renal insufficiency.


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For a persistently symptomatic

patient with HF, what is next

option?1. Higher dose lasix

2. Different diuretic

3. Add vasodilator4. Add inotropic agent

5. Patience.

6. Other choice


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CCS 2012: Vasodilators

We recommend the following intravenous vasodilators,titrated to systolic blood pressure (SBP) > 100 mmHg, for

relief of dyspnea in hemodynamically stable patients (SBP

> 100 mmHg):

a) Nitroglycerin (Strong Recommendation, Moderate QualityEvidence);

b) Nesiritide (Weak Recommendation, High Quality

Evidence);

c) Nitroprusside (Weak Recommendation, Low QualityEvidence).

AHA 2012: RELAX-AHF, CARRESS


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CCS 2012: Inotropes

We recommend hemodynamically stable patients do notroutinely receive inotropes like dobutamine, dopamine or

milrinone (Strong Recommendation, High Quality

Evidence).

Values and Preferences These recommendations for

inotropes place high value on the potential harm

demonstrated when systematically studied in clinical trials

and less value on potential short term hemodynamic effects

of inotropes.


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RESYNCHRONIZATION THERAPYand

DEVICES

Anique Ducharme, MD MSc FRCPC


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Anique Ducharme, Institut de Cardiologie de Montral, Universit de Montral

The speaker has received fees/honoraria from the following

sources:

Abbott vascular, Medtronic, Merck, Otsuka, Pfizer, Sorin &

St-Jude Medical

None of the drugs, devices, or treatment modalities mentioned

in this presentation are non approved indications.

Conflict Disclosures


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A Case of Mild Heart Failure

61 years old female,

previous MI,

stable NYHA II, LVEF 25%

On optimal dose of

lisinopril, eplerone andbisoprolol, occasional

diuretics

Has not been assessedfor device Rx

BP 99/67 mmHg, HR 76

bpm

K, 4.7 mEq/L; NT-proBNP

4500 pg/mL

EKG: old anterior MI, LBBBQRS 155 ms.


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You started treating this patient with mild symptoms

of HF and low ejection fraction with epleronone as

recommended. Dosage was increased up to 50 mgwithout side effects. What do you do next?

1. Angiotensin receptor blocker

2. ICD3. CRT

4. CRT + ICD (CRT-D)

CRT in Patients with Mild HF Symptoms:


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CRT in Patients with Mild HF Symptoms:

MADIT-CRT

Moss et al, NEJM 2009

1820 pts, mostly NYHA II, CRT+ICD vs ICD alone

Low risk population, annual mortality ~3%

40% reduction in HF events in CRT-ICD group


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RAFT: Death or HF hospitalization

Outcome ICD (N=904) ICD-CRT

(N=894)

Hazard ratio

(95% CI)

P

value

Primary outcome

Death or

hospitalization for HF

363 (40.3%) 297 (33.2%) 0.75 (0.64-

0.87)


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CRT: Mortality reduction

Al-Majed et al, Annals of Internal Medicine 2011


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CRT: HF Hosp reduction

Al-Majed et al, Annals of Internal Medicine 2011

Medical Therapy in Perspective


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ed ca e apy e spect e

Zannad et al, N Engl J Med, 2010Tang et al, N Engl J Med 2010

RAFT

1800 pts, 80% NYHA II

CRT-D vs ICD; median f/u 40months

25% reduction in mortality

EMPHASIS HF

2700+ patients, NYHA II

Eplerenone vs Placebo; median f/21mo

25% reduction in mortality


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Recommendation 2011 (Update)

We recommend the use of CRT in combination

with an ICD for HF patients on optimal medical

therapy with NYHA II HF symptoms, LVEF < 30%,

and QRS duration > 150 ms.

(Strong Recommendation, High Quality Evidence)


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Practical tips

QRS> 150 ms based on a subgroup analysis

of MADIT-CRT and RAFT studies

Most LBBB are >150 msec

The selection of patients should be

individualized and based on risk features


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CRT for Everyone?Maybe not

Not everyone will benefit

Non-response is ~30% depending on the def in i t ion o f:

Death

Hospitalization

Failure to improve 1 NYHA functional class

Failure to improve peak VO2 or 6 min walk distance

Absence of reverse remodelling (LVESV or EF) Absence of improvement in dyssynchrony

Consider Risks vs Benefits:Real World


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Krahn et al, Ont ICD Database Circulation 2011

Poole et al, REPLACE Registry Circulation 2010

N = 1081 ICD replacements N = 713 Upgrade Procedures

Importance of Patient Selection


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Much uncertainty persists:

Narrow QRS with mechanical dyssynchrony

LV dysfunction and chronic RV pacing

Atrial fibrillation and LBBB

Right bundle branch block

Asymptomatic patients

Class IV/Stage D patients

Importance of Patient Selection

Recommendation


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Recommendation

Routine CRT implantation is not currently

recommended for patients with heart failure and

narrow QRS (150ms, on average. Thebenefit in patients with QRS 120ms to 150ms is

less clear

Echocardiography derived parameters of

dyssynchrony cannot be recommended on aroutine basis since clinical utility has not been

established

Practical tips


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Practical tip

The use of CRT may prevent worsening in

patients with LV systolic dysfunction who

require permanent pacing and who are

expected to have a high burden of ventricular

pacing


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The ACEI-ARB-MRA Dilemma

Jonathan Howlett MD

Disclosures at www.hfcc.ca


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prepare to provide your answers!


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Case 1.

34 year old female with NYHA FC II HF with LVEF 29%BP 130/70, HR 63, Na 139, Creat 100, K+ 4.0

On BB, ACE, diuretic target doses.

Which drug should you start next?

A. ARB

B. Aldo Inhibitor

C. Neither

D. Does not matter, going for device anyway


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Case 2.

64 year old female with NYHA FC I HF with LVEF 29%BP 160/70, HR 63, Na 139, Creat 100, K+ 4.2

On BB, ACE, CCB, diuretic target doses.


A. ARB

B. Aldo Inhibitor

C. Neither

D. Both


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Case 3.

84 year old female with NYHA FC IIIb HF with LVEF 29%BP 100/70, HR 70, Na 139, Creat 160, K+ 4.7

On BB, ACE, Digoxin, diuretic optimal doses.


A. ARB

B. Aldo Inhibitor

C. Neither- I will use nitrates preferentially

D. Both

When to Use ARBs as Add-on Therapy?


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When to Use ARBs as Add on Therapy?

Pfeffer MA et al. Lancet2003;363:759-66. Cohn JN et al. N Engl J Med2001;345:1667-75.

In patients with persistent HF symptoms, and whoare at increased risk of HF hospitalization, despite

optimal treatment with ACE inhibitors and beta-blockers (Class I, Level A)

CHARM Proportion of patients with

CV death or hospital admission for CHF

Val-HeFTProbability of freedom from combined endpoint(All-cause mortality, cardiac arrest with resuscitation, hospitalization for

worsening HF, or therapy with intravenous inotropes or vasodilators)

Arnold JMO et al. Can J Cardiol2006;22(1):23-45.

CHARM-Added


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Permanent study drug discontinuations

Placebo

Candesartan

0

5

10

15

20

25

Percent of patients

p=0.0003 p=0.079 p=0.0001 p


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2006 Recommendation

Patients with LVEF 30% and severesymptoms despite optimized other

therapies

(Class I, Level B)

Or with AHF with an LVEF less than 30%

following acute myocardial infarction

(Class IIa, level B)

69

EMPHASIS: BaselineCh t i ti


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Characteristics

Characteristic Eplerenone (N=1364) Placebo (N=1373)Mean age yr 68.7 (7.7) 68.6 (7.6)

Female sex % 22.7% 21.9%

Ischemic heart disease % 70 68

Blood pressure mm Hg 124

17/75

10 124

17/75

10

Atrial fibrillation or flutter % 30 32

Diabetes mellitus no. (%) 34 29

Serum Creatinine mg/dl 1.14 (0.30) 1.16 (0.31)

Estimated GFR ml/min/1.73 m2

71.2 (21.9) 70.4 (21.7)

< 60 ml/min/1.73 m2 no. (%) 32 35

Serum Potassium mmol/liter 4.3 (0.4) 4.3 (0.4)

Zannad, NEJM2011; 364:11-21

EMPHASIS: Primary Endpoint


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0

10

20

30

40

50

0 1 2 3

Primar

yEndpoint:

CumulativeK-MR

ate(%)

Years from Randomizati on

Eplerenone

HR [95% CI] = 0.63 [0.54, 0.74] P < 0.0001

Placebo

No. atRisk

Placebo 1373 848 512 199Eplerenone 1364 925 562 232

356 (25.9)

249 (18.3)

0

10

20

30

40

0 1 2 3

HeartFailure

Hospitalization:

Cumulative

K-MR

ate(%)

Years from Randomization

Eplerenone

HR [95% CI] = 0.58 [0.47, 0.70] P < 0.0001

Placebo

No. at Risk

Placebo 1373 848 512 199

Epl erenone 1364 925 562 232

253 (18.4)

164 (12.0)

71

213 (15.5)

171 (12.5)

*Unadjusted HR, 0.78; 0.64, 0.95; p=0.01

Patient Follow up and Dosing


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Patient Follow-up and Dosing

Eplerenone Placebo

Discontinuations in surviving patients (%) 16.3% 16.6%

Discontinuations for AE n (%) 188 (13.8%) 222 (16.2%)*

Mean dose at month 5 (mg/day) 39.113.8 40.812.9

* p = 0.09

Recommendation 2011


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Recommendation 2011

We recommend that an aldosterone receptor

blocking agent such as eplerenone beconsidered for patients with mild to moderate

(NYHA II) HF, aged > 55 years with LV systolic

dysfunction (LVEF < 30%, or if LVEF is 30% and

35% with QRS duration >130 ms), and recenthospitalization for CVD or elevated BNP/NT-pro-

BNP levels, who are on standard HF therapy

(Strong Recommendation, High-Quality Evidence)

Combination RAAS Blockade- Options


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Add an ARB

Mean BP reduction 5-7 / 3-5 mmHg

Mean in creatinine < 30 umol/L Mean in potasssium 0.3 Mmol/L

Reduction in CHF/CV Death in Mild/mod HF

Evidence with triple therapy

Combination RAAS BlockadeAdd Spironolactone

Mean BP reduction -1 to +5/ _1+3 mmHg

Mean in creatinine < 50 umol/L

Mean in potasssium 0.5- 0.9 Mmol/L

Trials stopped early in enhanced moderate HF

No evidence in triple therapy


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But we vote with our feet!


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Fonarow, Circulation 2011.; p 1601-10

CHF Clinics Increased use of EBM versusCommunity- the First 1933 Patients


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Community- the First 1933 Patients

EB Therapy

First visit from

Community

(n= 1155)

Previously seen in

clinic

(n= 778)

P value

Age (SD) 62 (16) 63 (14) ns

LVEF (SD) 30 (14) 31 (14) ns

ACE inhibitor (%) 79 81 ns

ACE inhibitor

(% at target)25 60 0.01

Diuretic (%) 49 66 0.01

Beta Blocker (%) 49 58 0.01

Aldo Antagonist

(%)15 30 0.01

J Card Fail, Volume 7, Issue 3 Suppl 2, p.90 (2001)

Impact of HF Clinic Care on LVEF in Canadianswith HF


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Heart Failure GuidelinesEur Heart J 2011;32 (suppl 1)

Measurement Baseline

Assessment (SD)

Year 1 follow

up (SD)

Year 2 follow

up (SD)

P value baseline

to 2 years (SD)

LVEF 32 (14) 38 (15) 38 (14) p< 0.001

Improve by > 20% baseline 30 (14) 31 (14) p< 0.001

Improve by >10% ACE inhibitor (%) 79 81 p< 0.001

ACE use 54% 69% 69% p< 0.001

ACE or ARB 70% 93% 95% p< 0.001

Beta blocker use 63% 85% 85% p< 0.001

Aldo Antagonist 21% 35% 45% P< 0.001

with HF 21 Clinics with data from 1999-2010

599 patients with LVEF data at 0, 1,2 years

74% male, 63% ischemic etiology

Management of Patients with HF and


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Acute Intercurrent Medical Illness

HF patients with an acute dehydrating

illness of any kind should undergo promptevaluation (electrolytes, BUN, Crcl).

If diarrhea or vomiting occurs, the

aldosterone blocker should be stoppeduntil resolution.

Caution is also necessary when there are

other potential causes of dehydration,

including increase in diuretic dose.

Canadian Cardiovascular Society Consensus Conference recommendations update 2007

American College of Cardiology Foundation/American Heart Association practice

guidelines 2009

79

Suggested addition.


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Most of the time, the Aldosterone Antagonist is

the way to go

Monitoring is the most important aspect of Rx

Triple therapy is discouraged outside special

circumstances

Role for ARBs if:

Very high BP

Difficulty with K+ high

Cannot tolerate AA due to side effects

Osteoarthritis?


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Should all patients with HF

exercise and how?

Eileen OMeara, M.D.


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EXERCISE TRAINING IN CHRONIC HEART FAILURE


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QUESTION 1. TRUE OR FALSE?

All patients with stable New York Heart Association

(NYHA) class I-III should be considered for

enrolment in a tailored exercise training program,

in orderto improve exercise tolerance andquality of life.

A. True

B. False

The benefits of rehabilitation in HF


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The benefits of rehabilitation in HF

It is now well recognized that exercise-based cardiac

rehabilitation programs for patients with HF improveexercise capacity, skeletal and respiratory muscle function,

quality of life, autonomic function, biomarkers, and reduce

depressive symptoms as well as cardiovascular risk

factors. Piepoli MF et al. Eur J Heart Fail 2011; 13(4): 347357.Vanhees L et al. Eur J Cardiovasc Prev Rehabil 2011.

Based on the results of prior studies of exercise training, the

Canadian Cardiovascular Society has adopted recommendations

that physical activity be considered for stable patients with systolicdysfunction. Canadian Cardiovascular Society consensus conference

recommendations on heart failure 2006: diagnosis and

management. Can J Cardiol 2006;22(1):2345.

The HF-ACTION trial


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OConnor CM et al. JAMA 2009; 301: 14391450.

Flynn KE et al. JAMA 2009; 301: 14511459.

The HF-ACTION trial demonstrated no significant reduction

in the combined endpoint of all-cause mortality or

hospitalization (hazard ratio, 0.93; 95% confidence interval,

0.841.02; P=0.13).

After adjusting for 4 covariables associated with an increase

in the primary endpoint and for HF etiology, exercise

training was found to reduce the incidence of all-cause

mortality or all-cause hospitalization by 11% (HR, 0.89; 95%

CI, 0.810.99; P= 0.03).

exercise training conferred modest but statistically

significant improvements in self-reported health status.

The case of Madame T


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2007: 42 y.o. patient presents with EF 38% and

sustained VT. No significant CAD on angio.

Diagnosis: Familial cardiomyopathy

2007 - A defibrillator is implanted i.e. secondary

prevention and medical therapy is optimized

2008: EF increased to 45% 2010: EF is 50% on echocardiogram

2010 Amiodarone is stopped since patient fears the

side effects and EF is now normalized

She undergoes a treadmill test prior to exercisetraining in November 2010

The case of Madame T


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Sinustachycardia then

multiple PVCs

then VT


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Question 2. Select the best answer?

A She had ischemia and this sho ld ha e been


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A. She had ischemia and this should have been

investigated by another test

B. The adrenaline surge during the test lead to

ventricular tachycardia and the defibrillator

shocks were appropriate

C. The treadmill test should have been stopped

before her heart rate reached the programmed VT

zone so she would not receive shocks

D. She should not be allowed to reach this level of

exercise even if she did not have a defibrillator

anyway

E. She should have been on amiodarone or a higher

dose of beta-blockers


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Madame T: Actions and Reactions


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She complained to the hospital authorities and had to receive the

help of a psychologist to cope with the fear of defibrillator shocks.

The technician was unaware of how to prepare a patient with a

defibrillator for a treadmill test and the attending physician should

have supervised more closely in preparation for the test.

A written protocol was made to ensure that this would not happen

again. The patient was satisfied with the procedure.

She began training again about 1 year later and still sees her

cardiologist in that same hospital.

Current EF is 45% (July 2012 echocardiogram)

Treadmill test protocol for patients

ith d fib ill t


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with defibrillators

The indication for the treadmill test should be clearly

described and the patient must be flagged as having adefibrillator

Defibrillator programmation will be verified immediately

prior to the treadmill test

Maximal HR will be the programmed HR for VT therapyminus 20 beats per minute. The test should be stopped

immediately as that HR is reached.

All pharmacological treatments should be continued

(especially beta-blockers and antiarrhythmics) No adjustment to the defibrillator programmation should

be made in view of the treadmill test

Exercise Training in Stable HF is SAFE


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g

A stepwise approach to exercise training in stable HF is

suggested, including:

Cardiopulmonary/exercise testing is used for safety

assessment and exercise prescription.

Initial supervision ensures safety of the prescribed

program and may help patients understand their limits.

For patients who prefer home-based exercise, after a

minimum of 6-8 supervised sessions, exercise training

may continue with a home-based program.

Aerobic Exercise Training Prescription


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Moderate-intensity continuous aerobic exercise training at

rate of perceived exertion (RPE) 3-5 (Figure), 65-85%

maximum heart rate, and 50-75% peak V02 isrecommended in HF patients

Exercise program schedule in stable patients should begin

with aerobic exercise training, 10-15 minutes in duration,2-3 days per week frequency, before gradually increasing

training to a target of 30 minutes, 5 days per week.

Walking, treadmill, and stationary cycling can be chosen as

primary training modes. Moderate-intensity aerobic intervaltraining may be incorporated into the ET program in selected,

stable HF patients.


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Ccc2012 Hf Wkshop