Heart Failure Ben Starnes MD FACC Interventional Cardiology Arkansas Cardiology Baptist Health Heart Institute

Heart FailureHeart Failure

Ben Starnes MD FACCBen Starnes MD FACCInterventional CardiologyInterventional Cardiology

Arkansas CardiologyArkansas Cardiology

Baptist Health Heart InstituteBaptist Health Heart Institute

Financial disclosuresFinancial disclosures

-None-None


Moving away from the term Congestive Moving away from the term Congestive Heart Failure Heart Failure

Heart Failure imposes a significantHeart Failure imposes a significantburden on the US healthcare systemburden on the US healthcare system

-Heart failure accounts for over 3.4 million visits to -Heart failure accounts for over 3.4 million visits to physician offices, hospital outpatient departments, and physician offices, hospital outpatient departments, and emergency departmentsemergency departments11

-More than 1,000,000 hospitalizations occur with the -More than 1,000,000 hospitalizations occur with the primary diagnosis of heart failureprimary diagnosis of heart failure22

-Over 6.5 million days are spent in US hospitals for heart -Over 6.5 million days are spent in US hospitals for heart failurefailure33

1 Vital Health Statistics 13. 2004;157:1-70.2 AHA Heart Disease and Stroke Statistics 2010 Update. Circulation. 2010;121:e46-215.3 European Heart Journal Supplements; V.7; Suppl B; 2005; pB8.

Heart Failure is a Clinical Heart Failure is a Clinical DiagnosisDiagnosis

Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. J Am Coll Cardiol. 2003;41:1797-1804.2003;41:1797-1804.


Beta BlockersBeta Blockers

Beta-blockers (using 1 of the 3 proven to reduceBeta-blockers (using 1 of the 3 proven to reduce

mortality, i.e., bisoprolol, carvedilol, and sustainedmortality, i.e., bisoprolol, carvedilol, and sustained

release metoprolol succinate) are recommended forrelease metoprolol succinate) are recommended for

all stable patients with current or prior symptoms of all stable patients with current or prior symptoms of

HF and reduced LVEF, unless contraindicated.HF and reduced LVEF, unless contraindicated.

Beta BlockersBeta BlockersACC GuidelinesACC Guidelines

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII


Ace Inhibitors in severe heart failureAce Inhibitors in severe heart failure

Ace Inhibitors in mild to moderate heart Ace Inhibitors in mild to moderate heart failurefailure

ACEIs are recommended for all patients withcurrent or prior symptoms of HF and reducedLVEF, unless contraindicated.


Ace InhibitorsACC Guidelines

Aldosterone AntagonistsAldosterone Antagonists



Addition of an aldosterone antagonist is recommended inselected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should beless than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should beless than 5.0 mEq/L. Under circumstances where monitoring for hyperkalemia or renal dysfunction is notanticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists.

Routine combined use of an ACEI, ARB, and aldosteroneantagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF.



Aldosterone AntagonistsACC guidelines

SCD-HeFTSCD-HeFT

SCD-HeFT ProtocolSCD-HeFT Protocol

Inclusion criteria

Placebo n=847 ICD implant n=829

40 months average follow- up

• Optimize: B, ACE-I, Diuretics

Bardy GH. Chapter Excerpt from Arrhythmia Treatment and Therapy. Woosley RL, Singh SN, editors. Marcel Dekker, 1st edition. 2000;323-42.SCD-HeFT Investigators Meeting, August 2001, data from most recent follow-up

Amiodarone n=845

ICD therapy is indicated in patients with LVEF less than ICD therapy is indicated in patients with LVEF less than 35% due to prior MI who are at least 40 days post-MI 35% due to prior MI who are at least 40 days post-MI and are in NYHA functional Class II or III. and are in NYHA functional Class II or III.

ICD therapy is indicated in patients with nonischemic ICD therapy is indicated in patients with nonischemic DCM who have an LVEF less than or equal to 35% and DCM who have an LVEF less than or equal to 35% and who are in NYHA functional Class II or III. who are in NYHA functional Class II or III.



All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

Implantable Cardioverter-DefibrillatorsImplantable Cardioverter-Defibrillators

Cardiac Resynchronization Therapy* in Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart FailurePatients With Severe Systolic Heart Failure

For patients who have left ventricular ejection fraction For patients who have left ventricular ejection fraction (LVEF) less than or equal to 35%, a QRS duration greater (LVEF) less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, cardiac than or equal to 0.12 seconds, and sinus rhythm, cardiac resynchronization therapy (CRT) with or without an ICD is resynchronization therapy (CRT) with or without an ICD is indicated for the treatment of New York Heart Association indicated for the treatment of New York Heart Association (NYHA) functional Class III or ambulatory Class IV heart (NYHA) functional Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical failure symptoms on optimal recommended medical therapy. therapy.


*All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

End Stage Heart FailureEnd Stage Heart FailureVentricular assist DeviceVentricular assist Device

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Cardiac TransplantationCardiac Transplantation

Palliative CarePalliative Care

Diastolic Heart FailureDiastolic Heart Failure

Heart failure with preserved LV systolic Heart failure with preserved LV systolic functionfunction

Generally due to hypertension Generally due to hypertension left left ventricular hypertrophy ventricular hypertrophy impaired LV impaired LV filling and decreased LV stroke volumefilling and decreased LV stroke volume

Diastolic Heart FailureDiastolic Heart FailureTreatment:Treatment:

-Diuretics to relieve congestion-Diuretics to relieve congestion

-Beta Blockers/Calcium channel blockers to -Beta Blockers/Calcium channel blockers to reduce heart rate and improve diastolic fillingreduce heart rate and improve diastolic filling

-Control blood pressure-Control blood pressure

-Maintain sinus rhythm -Maintain sinus rhythm

Atrial fibrillation leads to loss of atrial Atrial fibrillation leads to loss of atrial kick (20% of cardiac output)kick (20% of cardiac output)

Take Home PointsTake Home PointsMedical TherapyMedical Therapy

-Ace inhibitors/beta blockers-Ace inhibitors/beta blockers

-Aldosterone antogonist (LVEF <35)-Aldosterone antogonist (LVEF <35)

-Diuretics as needed-Diuretics as needed

-Digoxin last line-Digoxin last line

Device therapyDevice therapy-ICD-ICD

-Cardiac Resynchronization Therapy-Cardiac Resynchronization Therapy

End Stage Heart FailureEnd Stage Heart Failure-Ventricular Assist Device/Heart Transplant-Ventricular Assist Device/Heart Transplant

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Heart Failure Ben Starnes MD FACC Interventional Cardiology Arkansas Cardiology Baptist Health Heart Institute