HF Gui 2012 SD EN

2012 CCS Heart Failure Management Guidelines Update
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McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181
19-07-26 Copyright © 2013, Canadian Cardiovascular Society 1

Canadian Cardiovascular Society Guidelines
2012 UPDATE
Heart Failure Management: Focus on Acute and
Chronic Heart Failure

Learning Objectives
At the conclusion of this workshop, participants will be
able 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.

Acute Heart Failure

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 urgent
therapy”

Classification of AHF
usually a hx of prog.
worsening of known chronic HF on
Rx, and evidence of
systemic/pulmonary congestion.
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 <90% RA
prior to O2
Clinical and lab evidence of an

ACS; ~15% of patients with an
ACS have signs and symptoms
of HF. Episodes of AHF are
frequently assoc w/ or Usually sys BP <90 mmHg or low output in absence of
precipitated by arrhythmia drop in MAP >30 mmHg and pulmonary congestion with
(bradycardia, AF, VT). absent/low urine output. Organ increased JVP, w/ or w/out
hypoperfusion and pulmonary HSM, and low LV filling
congestion develop rapidly pressures
McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181 ESC 2008
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
Harrison’s Principles of Internal Medicine 1st Edition (1950) Ramirez A et al. N Engl J Med 1974;290(9):499-501

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+

CASE 1

• CXR = pending
• Labs = pending

… prepare to provide your answer!

How confident are you that it is

AHF?
1. <20%
2. 21-40%
3. 41-60%
4. 61-80%
5. >80%

How confident are you that it is

AHF?
1. <20%
2. 21-40%
3. 41-60%
4. 61-80%
5. >80%
No right answer

AHF Dx Scoring systems

Predictor Points Our Case
Elevated NT-proBNP 4 ?
Interstitial edema on 2 ?
CXR
Orthopnea 2 -
Absence of fever 2 2
Current loop diuretic 1 -
use
Age > 75 years 1 -
Rales on lung 1 1
examination
Absence of cough 1 1
Interpretation 4
e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93
Baggish AL, et al. Am Heart J 2006; 151: 48-54].


CASE 1

• CXR = increased pulmonary markings c/w
edema, no evidence of COPD
• Labs = troponin I 0.20
– BNP 728 pg/ml
– Creatinine 130

AHF Dx Scoring systems

Predictor Points Our Case
Elevated NT-proBNP 4 4
Interstitial edema on 2 2
CXR
Orthopnea 2 -
Absence of fever 2 2
Current loop diuretic 1 -
use
Age > 75 years 1 -
Rales on lung 1 1
examination
Absence of cough 1 1
Interpretation 10
e.g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93
Baggish AL, et al. Am Heart J 2006; 151: 48-54].


CCS 2012
We recommend the use of a validated diagnostic scoring system
for patients in whom the diagnosis 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 and less value on an individual physical
examination finding, presenting symptom or investigation.

CCS 2012
• We recommend that in the clinical scenario when

the clinical diagnosis of AHF is of intermediate
pre-test probability, NP level be obtained to
rule-out (BNP <100 pg/ml; NT-proBNP <300
pg/ml) or rule-in (BNP >500 pg/ml; NT-proBNP
>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 Quality
Evidence)

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.

CCS 2012: Practical Tips

• A transthoracic echocardiogram should be
performed within 72 hours of presentation.
• For patients with a prior echocardiogram,

another is not required unless there has been
a 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.

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


Where on this table does this pt fit?
1 2
Dry and Warm Wet and Warm
Increasing
Perfusion/
Cardiac Output 3 4
Dry and Cold Wet and Cold
Increasing Congestion / PCWP
Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804

1. Dry and Warm

2. Wet and Warm
3. Dry and Cold
4. Wet and Cold

1 2
Dry and Warm Wet and Warm
Increasing
Perfusion/
Cardiac Output 3 4
Dry and Cold Wet and Cold
Increasing Congestion / PCWP
Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41:1797-804

Admit or discharge?


Treatment options?

CCS 2012: Oxygen

We recommend supplemental oxygen be considered for
patients 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 without
supportive data.

CCS 2012: CPAP/BIPAP
We recommend CPAP or BIPAP not be used

routinely (Strong Recommendation,
Moderate Quality Evidence).
Values and Preferences: This recommendation

places 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.

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


How much diuretic will you give

and how?
1. IV lasix 20 mg bid
4. IV lasix 10 mg/hour infusion
5. Other choice

DOSE: Study Design
Acute Heart Failure (1 symptom AND 1 sign)
<24 hours after admission
2x2 factorial randomization

High Dose (2.5 x
Low Dose (1 x oral) Low Dose (1x oral) High Dose (2.5 x oral)
Q12 IV bolus Continuous oral) Continuous infusion
infusion Q12 IV bolus
e.g. 48 hours
Home dose = 40 mg BID 1) Change to oral diuretics
Bolus = 80 (low) 200 (high) 2) continue current strategy
3) 50% increase in dose
72 hours
Co-primary endpoints
60 days
Clinical endpoints Felker, NEJM 2011

DOSE: Co-Primary Endpoints
• 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: patient
global
assessment

DOSE: Death, Rehosp, ER visit

DOSE-AHF Conclusions
• There was no statistically significant

difference in global symptom relief or
change in renal function at 72 hours for
either:
• bolus vs. infusion or low vs. high
• No clinical differences…but
– High was associated with favorable trends:
– Symptom relief (global assessment and dyspnea)
– Weight loss and net volume loss
– Proportion free from signs of congestion
– Reduction in NT-proBNP

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, Moderate
Quality Evidence).

Diuretic dosing for ADHF
Creatinin Initial Maintenanc

Patient
e IV dose† e
clearance dose
*
≥ 60 mL/min/1.73m 2
New-onset HF or no Furosemide 20-40 mg Lowest diuretic dose
maintenance diuretic 2-3 times daily that allows for
therapy
Furosemide bolus clinical stability is
Established HF or chronic equivalent the ideal dose
oral to oral dose
diuretic therapy
< 60 mL/min/1.73m2
Furosemide 20-80 mg
New-onset HF or no 2-3 times daily
maintenance diuretic
therapy Furosemide bolus
equivalent
*Creatinine clearance is calculated from
Established HFthe
or Cockroft-Gault
chronic or ModifiedtoDiet
oralin dose
Renal Disease formula. See text for details.
† Intravenous continuousoral
furosemide at doses of 5 to 20mg/h is also an option.
diuretic therapy
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
bolus
then 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 diuretic resistance.
• Refer for hemodialysis, ultrafiltration, or other renal replacement strategies if diuresis is impeded by renal insufficiency.


For a persistently symptomatic

patient with HF, what is next
option?
1. Higher dose lasix
2. Different diuretic
3. Add vasodilator
4. Add inotropic agent
5. Patience….
6. Other choice

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 Quality
Evidence);
b) Nesiritide (Weak Recommendation, High Quality
Evidence);
c) Nitroprusside (Weak Recommendation, Low Quality
Evidence).
AHA 2012: RELAX-AHF, CARRESS

CCS 2012: Inotropes
• We recommend hemodynamically stable patients do not

routinely 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.

Do I stop the beta-blockers on

admission?
• Cohorts suggest continuing beta-blockers advantageous
• RCT: B-CONVINCED
– Keep vs. Stop strategy in known HF pts on beta-blockers
– Keep was non-inferior to Stop.
– Does not delay clinical improvement
– Predicts staying on BB in the longer term
Eur Heart J 2009; 30:2186-92


RESYNCHRONIZATION THERAPY and DEVICES
Anique Ducharme, MD MSc FRCPC

Conflict Disclosures
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.
Anique Ducharme, Institut de Cardiologie de Montréal, Université de Montréal

• 61 years old female, • BP 99/67 mmHg, HR 76

previous MI, bpm
• stable NYHA II, LVEF 25% • K, 4.7 mEq/L; NT-proBNP
• On optimal dose of 4500 pg/mL
lisinopril, eplerone and • EKG: old anterior MI, LBBB
bisoprolol, occasional QRS 155 ms.
diuretics
• Has not been assessed
for device Rx


You started treating this patient with mild symptoms

of HF and low ejection fraction with epleronone as
recommended. Dosage was increased up to 50 mg
without side effects. What do you do next?
1.Angiotensin receptor blocker

2.ICD
3.CRT
4.CRT + ICD (CRT-D)

CRT in Patients with Mild HF Symptoms:

MADIT-CRT
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 Moss et al, NEJM 2009

RAFT: Death or HF hospitalization

Outcome ICD (N=904) ICD-CRT Hazard ratio P
(N=894) (95% CI) value
Primary outcome
Death or 363 (40.3%) 297 (33.2%) 0.75 (0.64- <0.001
hospitalization for HF 0.87)
Secondary outcomes
Death from any cause 236 (26.1%) 186 (20.8%) 0.75 (0.62- 0.003
0.91)
Hospitalization for HF 236 (26.1%) 174 (19.5%) 0.68 (0.56- <0.001
0.83)
1800 pts, 80% NYHA II

CRT-D vs ICD
Median follow-up 40 months
ang AS, et al. N Engl J Med 2010

CRT: Mortality reduction
Al-Majed et al, Annals of Internal Medicine 2011


CRT: HF Hosp reduction
Al-Majed et al, Annals of Internal Medicine 2011


Medical Therapy in Perspective

RAFT EMPHASIS HF
1800 pts, 80% NYHA II 2700+ patients, NYHA II
CRT-D vs ICD; median f/u 40 Eplerenone vs Placebo; median
months f/u 21mo
25% reduction in 25% reduction in mortality

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

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)

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

CRT for Everyone?…Maybe not

• Not everyone will benefit
“Non-response” is ~30% depending on the definition of:
• 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
N = 1081 ICD replacements N = 713 Upgrade Procedures
Krahn et al, Ont ICD Database Circulation 2011 Poole et al, REPLACE Registry Circulation 2010

Importance of Patient Selection
• Much uncertainty persists:
– Narrow QRS with mechanical dyssynchrony ti o n

u l a
Po p
t
– LV dysfunction and chronic RV pacing
t ie n
P a
– Atrial fibrillation and LBBB
o r l
– Right bundle
d
W
branch block
a l
Re – Asymptomatic patients
– Class IV/Stage D patients

Recommendation
• Routine CRT implantation is not currently recommended for
patients with heart failure and narrow QRS (<120 ms)
• Patients enrolled in CRT studies who show benefit have a QRS

Practical tips
duration >150ms, on average. The benefit in patients with QRS
120ms to 150ms is less clear
• Echocardiography derived parameters of dyssynchrony cannot
be recommended on a routine basis since clinical utility has not
been established

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

The ACEI-ARB-MRA Dilemma
Jonathan Howlett MD
Disclosures at www.hfcc.ca

… prepare to provide your answers!

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

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

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?

• In patients with persistent HF symptoms, and who
are at increased risk of HF hospitalization, despite
optimal treatment with ACE inhibitors and beta-
blockers (Class I, Level A)
CHARM – Proportion of patients with Val-HeFT – Probability of freedom from combined endpoint
CV death or hospital admission for CHF (All-cause mortality, cardiac arrest with resuscitation, hospitalization for
worsening HF, or therapy with intravenous inotropes or vasodilators)
Pfeffer MA et al. Lancet 2003;363:759-66. Cohn JN et al. N Engl J Med 2001;345:1667-75.
Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.


CHARM-Added
Permanent study drug discontinuations
Percent of patients Placebo
25 24.2 Candesartan
20 What are the effects of Spiro?

18.3
15
10
7.8
5 4.5 4.1
3.1 3.4
0.7
0
AE/ Hypo- Increased Increased
lab. abnorm. tension creatinine potassium
p=0.0003 p=0.079 p=0.0001 p<0.0001

2006 Recommendation
• Patients with LVEF  30% and severe

symptoms 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: Baseline 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, NEJM 2011; 364:11-21


EMPHASIS: Primary Endpoint
356 (25.9) 253 (18.4)

249 (18.3)
164 (12.0)
213 (15.5)
171 (12.5)
*Unadjusted HR, 0.78; 0.64, 0.95; p=0.01

71
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) 39.1 ±13.8 40.8 ±12.9
* p = 0.09

Recommendation 2011
• We recommend that an aldosterone receptor

blocking agent such as eplerenone be
considered 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 recent
hospitalization for CVD or elevated BNP/NT-pro-
BNP levels, who are on standard HF therapy
•
(Strong Recommendation, High-Quality Evidence)

Combination RAAS Blockade- Options

Add an ARB
• Mean BP reduction 5-7 / 3-5 mmHg
• Mean Δ in creatinine < 30 umol/L
• Mean Δ in potasssium 0.3 Mmol/L
• Reduction in CHF/CV Death in Mild/mod HF
• Evidence with triple therapy
Combination RAAS Blockade
Add Spironolactone
 Mean BP reduction -1 to +5/ _1+3 mmHg
 Mean Δ in creatinine < 50 umol/L
 Mean Δ in potasssium 0.5- 0.9 Mmol/L
 Trials stopped early in ‘enhanced moderate HF’
 No evidence in triple therapy

But we vote with our feet!

Fonarow, Circulation 2011.; p 1601-10


CHF Clinics Increased use of EBM versus Community- the First

1933 Patients
First visit from Previously seen in
EB Therapy Community clinic P value
(n= 1155) (n= 778)
Age (SD) 62 (16) 63 (14) ns
LVEF (SD) 30 (14) 31 (14) ns
ACE inhibitor (%) 79 81 ns
ACE inhibitor
25 60 0.01
(% at target)
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 Canadians with HF

• 21 Clinics with data from 1999-2010
• 599 patients with LVEF data at 0, 1,2 years
• 74% male, 63% ischemic etiology
Measurement Baseline Year 1 follow Year 2 follow P value baseline

Assessment (SD) up (SD) up (SD) 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

Eur Heart J 2011;32 (suppl 1)
Management of Patients with HF and

Acute Intercurrent Medical Illness
• HF patients with an acute dehydrating illness of
any kind should undergo prompt evaluation
(electrolytes, BUN, Crcl).
• If diarrhea or vomiting occurs, the aldosterone

blocker should be stopped until 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…….
• 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?

Should all patients with HF

exercise and how?
Eileen O’Meara, M.D.


EXERCISE TRAINING IN CHRONIC HEART FAILURE

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
order to improve exercise tolerance and quality
of life.
A.True
B.False

The benefits of rehabilitation in HF

It is now well recognized that exercise-based cardiac
rehabilitation programs for patients with HF improve
exercise 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): 347–357.
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 systolic
dysfunction. Canadian Cardiovascular Society consensus conference
recommendations on heart failure 2006: diagnosis and
management. Can J Cardiol 2006;22(1):23–45.

The HF-ACTION trial

 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,
0.84–1.02; 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, 0.81–
0.99; P = 0.03).
 exercise training conferred modest but statistically
significant improvements in self-reported health status.
O’Connor CM et al. JAMA 2009; 301: 1439–1450.
Flynn KE et al. JAMA 2009; 301: 1451–1459.

The case of Madame T…

• 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 exercise
training in November 2010…

Sinus
tachycardia
then multiple
PVCs then VT


Question 2. Select the best answer?

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

PATIENT EVALUATION
PRIOR TO AN EXERCISE PROGRAM
The following should be obtained prior to a tailored exercise
training program:
An assessment of clinical status by a clinician experienced in the

management of heart failure patients should be completed
Establish if the patient has an ICD and if yes, verify if previous shocks
have been delivered and note the programmed VT zone
 Exercise test (evaluate ischemia, arrhythmias, rate responses of

patients with pacemakers, and determine training heart rate ranges)
 Non-cardiac causes of dyspnea or musculoskeletal disorders may limit

exercise tolerance and should be evaluated

Madame T: Actions and Reactions

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

with defibrillators
 The indication for the treadmill test should be clearly
described and the patient must be flagged as having a
defibrillator
 Defibrillator programmation will be verified immediately
prior to the treadmill test
 Maximal HR will be the programmed HR for VT therapy
minus 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
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

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 is
recommended 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 interval
training may be incorporated into the ET program in selected,
stable HF patients.

Thank you and questions

HF Gui 2012 SD EN

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2012 CCS Heart Failure Management Guidelines Update

The Canadian Cardiovascular Society (CCS) welcomes reuse of our

If your reuse request qualifies as medical institution internal education, you

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Canadian Cardiovascular Society Guidelines

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1.Review changes and updates for optimal management

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Acute Heart Failure

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What is heart failure?

• Chronic Heart Failure (CHF):

• Acute Heart Failure Syndrome (AHF):

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Severe respiratory distress, ↑RR,

Clinical and lab evidence of an

Has care evolved?

1950 1974 2012

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• 74 year old female

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• 74 year old female

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… prepare to provide your answer!

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How confident are you that it is

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How confident are you that it is

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AHF Dx Scoring systems

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

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• 74 year old female

McKelvie RS, Moe GW et al., Can J Cardiol 2013 Feb;29(2): 168-181

19-07-26 Copyright © 2013, Canadian Cardiovascular Society 14

AHF Dx Scoring systems

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

19-07-26 Copyright © 2013, Canadian Cardiovascular Society 15

This recommendation places a relatively high value on

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• We recommend that in the clinical scenario when

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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

• Initial blood tests should include: complete blood

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CCS 2012: Practical Tips

• For patients with a prior echocardiogram,

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