Congestive heart failure treatment of special populations

Heart failure
ICD-10	I50.0
ICD-9	428.0
DiseasesDB	16209
MedlinePlus	000158
MeSH	D006333

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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) .

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)

Treatment of Special Populations (DO NOT EDIT)

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)

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

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• 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

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

References

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