Congestive heart failure treatment of special populations

Jump to navigation Jump to search
Siren.gif

Resident
Survival
Guide
88px

Congestive Heart Failure Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure treatment of special populations On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Congestive heart failure treatment of special populations

CDC on Congestive heart failure treatment of special populations

Congestive heart failure treatment of special populations in the news

Blogs on Congestive heart failure treatment of special populations

Directions to Hospitals Treating Congestive heart failure treatment of special populations

Risk calculators and risk factors for Congestive heart failure treatment of special populations

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

There is unfortunately insufficient data in subgroups of patients to mandate a change to guidelines recommendations regarding the management of heart failure. Dosages should be altered as needed in the elderly or in those with altered metabolism. African american patients may respond to the addition of hydralazine and nitrates to the standard of care in the treatment of heart failure.

Women

Women may not drive the same benefit from angiotensin-converting enzyme inhibitors in meta-analysis (mortality HR = 0.80 (95% CI 0.68-0.93) for men but HR = 0.90 (95% CI 0.78-1.05) for women) [1], but women do appear to drive the same benefit from beta blockers as men (HRs for mortality 063 & 0.66 respectively).[1]

Race

ACE Inhibition

Blacks tend to have a poorer response to ACE inhibition, specifically in response to equivalent doses of enalapril (44% reduction in heart failure hospitalization among whites versus no benefit among black patients in SOLVD).[2] Similar results have been observed with respect blood pressure management. In the SOLVD study quoted above, there was a 5 mm Hg reduction in systolic blood pressure among white patients but no reduction in systolic blood pressure among black patients. Despite the lack of improvement in hospitalization or systolic blood pressure, blacks did experience a reduction in mortality that was similar to that of white patients. Thus, ACE inhibitors should continue to be used in black patients.

Beta Blockers

Randomized trials have shown mixed benefits for blacks with beta blockers. In the BEST trial, bucindolol (they beta blocker with partial beta agonist activity) was not associated with the benefit in blacks[3], however in the carvedilol trials blacks did sustain a benefit[4]. It has been speculated that there may be differences in the beta adrenergic system between blacks and whites that account for these differences.

Hydralazine Plus Nitrates

Black patients appeared to derive particular benefit from the combination of hydralazine plus nitrates.[5]

Diabetics

In general, the management of the diabetic patient with heart failure is similar to that of the non-diabetic patient. However, the thiazolidinediones (which can cause fluid retention) and metformin (which can cause lactic acidosis in the patient with congestive heart failure) are relatively contraindicated in the patient with congestive heart failure.

2009 and 2005 ACC/AHA Focused Update Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult and 2006 ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT) [6][7] [8]

Treatment of Special Populations (DO NOT EDIT) [6][7]

Class I
"1. The addition of a fixed dose of isosorbide dinitrate and hydralazine to a standard medical regimen for HF, including ACEIs and beta-blockers, is recommended in order to improve outcomes for patients self-described as African Americans, with NYHA functional class III or IV HF. Others may benefit similarly, but this has not yet been tested. (Level of Evidence: A)"
"2. Groups of patients including (a) high-risk ethnic minority groups (e.g., blacks), (b) groups underrepresented in clinical trials, and (c) any groups believed to be underserved should, in the absence of specific evidence to direct otherwise, have clinical screening and therapy in a manner identical to that applied to the broader population. (Level of Evidence: B) "
"3. It is recommended that evidence-based therapy for HF be used in the elderly patient, with individualized consideration of the elderly patient’s altered ability to metabolize or tolerate standard medications. (Level of Evidence: C) "

Left Ventricular Dysfunction Due to Prior Myocardial Infarction (DO NOT EDIT) [8]

Class I
" 1. Aggressive attempts should be made to treat HF that may be present in some patients with LV dysfunction due to prior MI and ventricular tachyarrhythmias. (Level of Evidence: C)"
" 2. Aggressive attempts should be made to treat myocardial ischemia that may be present in some patients with ventricular tachyarrhythmias. (Level of Evidence: C)"
" 3. Coronary revascularization is indicated to reduce the risk of SCD in patients with VF when direct, clear evidence of acute myocardial ischemia is documented to immediately precede the onset of VF. (Level of Evidence: B)"
" 4. If coronary revascularization cannot be carried out and there is evidence of prior MI and significant LV dysfunction, the primary therapy of patients resuscitated from VF should be the ICD] in patients who are receiving chronic optimal medical therapy and those who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: A)"
" 5. ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in SCD in patients with LV dysfunction due to prior MI who are at least 40 d post-MI, have an LVEF less than or equal to 30% to 40%, are NYHA functional class II or III, are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: A)"
" 6. The ICD is effective therapy to reduce mortality by a reduction in SCD in patients with LV dysfunction due to prior MI who present with hemodynamically unstable sustained VT, are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: A)"
Class III
" 1. Prophylactic antiarrhythmic drug therapy is not indicated to reduce mortality in patients with asymptomatic nonsustained ventricular arrhythmias. (Level of Evidence: B)"
" 2. Class IC antiarrhythmic drugs in patients with a past history of MI should not be used. (Level of Evidence: A)"
Class IIa
" 1. Implantation of an ICD is reasonable in patients with LV dysfunction due to prior MI who are at least 40 d post-MI, have an LVEF of less than or equal to 30% to 35%, are NYHA functional class I on chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: B) "
" 2. Amiodarone, often in combination with beta blockers, can be useful for patients with LV dysfunction due to prior MI and symptoms due to VT unresponsive to beta-adrenergic– blocking agents. (Level of Evidence: B)"
" 3. Sotalol is reasonable therapy to reduce symptoms resulting from VT for patients with LV dysfunction due to prior MI unresponsive to beta blocking agents. (Level of Evidence: C)"
" 4. Adjunctive therapies to the ICD, including catheter ablation or surgical resection, and pharmacological therapy with agents such as amiodarone or sotalol are reasonable to improve symptoms due to frequent episodes of sustained VT or VF in patients with LV dysfunction due to prior MI. (Level of Evidence: C)"
" 5. Amiodarone is reasonable therapy to reduce symptoms due to recurrent hemodynamically stable VT for patients with LV dysfunction due to prior MI who cannot or refuse to have an ICD implanted. (Level of Evidence: C)"
" 6. Implantation is reasonable for treatment of recurrent ventricular tachycardia in patients post-MI with normal or near normal ventricular function who are receiving chronic optimal medical therapy and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C)"
Class IIb
" 1. Curative catheter ablation or amiodarone may be considered in lieu of ICD therapy to improve symptoms in patients with LV dysfunction due to prior MI and recurrent hemodynamically stable VT whose LVEF is greater than 40%. (Level of Evidence: B)"
" 2. Amiodarone may be reasonable therapy for patients with LV dysfunction due to prior MI with an ICD indication, as defined above, in patients who cannot or refuse to have an ICD implanted. (Level of Evidence: C)"

Vote on and Suggest Revisions to the Current Guidelines

Sources

References

  1. 1.0 1.1 Shekelle PG, Rich MW, Morton SC, Atkinson CS, Tu W, Maglione M, Rhodes S, Barrett M, Fonarow GC, Greenberg B, Heidenreich PA, Knabel T, Konstam MA, Steimle A, Warner Stevenson L (2003). "Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status: a meta-analysis of major clinical trials". Journal of the American College of Cardiology. 41 (9): 1529–38. PMID 12742294. Retrieved 2013-04-25. Unknown parameter |month= ignored (help)
  2. Exner DV, Dries DL, Domanski MJ, Cohn JN (2001). "Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction". The New England Journal of Medicine. 344 (18): 1351–7. doi:10.1056/NEJM200105033441802. PMID 11333991. Retrieved 2013-04-25. Unknown parameter |month= ignored (help)
  3. "A trial of the beta-blocker bucindolol in patients with advanced chronic heart failure". The New England Journal of Medicine. 344 (22): 1659–67. 2001. doi:10.1056/NEJM200105313442202. PMID 11386264. Retrieved 2013-04-25. Unknown parameter |month= ignored (help)
  4. Yancy CW, Fowler MB, Colucci WS, Gilbert EM, Bristow MR, Cohn JN, Lukas MA, Young ST, Packer M (2001). "Race and the response to adrenergic blockade with carvedilol in patients with chronic heart failure". The New England Journal of Medicine. 344 (18): 1358–65. doi:10.1056/NEJM200105033441803. PMID 11333992. Retrieved 2013-04-25. Unknown parameter |month= ignored (help)
  5. Carson P, Ziesche S, Johnson G, Cohn JN (1999). "Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. Vasodilator-Heart Failure Trial Study Group". Journal of Cardiac Failure. 5 (3): 178–87. PMID 10496190. Retrieved 2013-04-25. Unknown parameter |month= ignored (help)
  6. 6.0 6.1 6.2 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235. DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202
  7. 7.0 7.1 7.2 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
  8. 8.0 8.1 Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.

Template:WikiDoc Sources