GET WITH THE

GUIDELINES
MANAGEMENT OF THE HEART FAILURE PATIENT
Meg Treacy, DNP, ANP-C
Cardiac Nurse Practitioner/Heart Failure Coordinator
Englewood, CO
Outline
• Heart failure basics
• Discuss evidence-based medical management
of heart failure
• Discuss, in particular, evidence-based beta-
blocker therapy for left ventricular systolic
dysfunction
• Review ACCF/AHA guidelines on care transition
HEART FAILURE BASICS
What is heart failure (HF)?
• HF is a complex clinical syndrome (collection of
symptoms) that results from any structural or functional
impairment of ventricular filling or ejection of blood
• When the heart is not able to maintain adequate cardiac output to
perfuse organ systems adequately and meet the metabolic needs
of the body
• Symptoms caused by systemic and/or pulmonary congestion due
to low output
• Symptoms include: dyspnea, fatigue, poor exercise tolerance,
orthopnea, PND, abdominal fullness, cough, frothy sputum, nocturia
• Physical exam findings: peripheral edema, ascites, lung rales/crackles,
elevated JVP, S3 gallop, tachypnea, hepatomegaly, abdominal
distention, etc..
• Lab work and imaging: elevated BNP, NT pro-BNP, congestion on CXR
What is cardiomyopathy?
• Cardiomyopathy = “disease of heart muscle”
• “A heterogeneous group of diseases of the myocardium associated with mechanical
and/or electrical dysfunction that usually (but not invariably) exhibit inappropriate
ventricular hypertrophy or dilatation and are due to a variety of causes that
frequently are genetic. Cardiomyopathies either are confined to the heart or are a
part of generalized systemic disorders, often leading to cardiovascular death or
progressive heart failure-related disability.”

• Ischemic cardiomyopathy
• Most common cause of heart failure
• Heart muscle damage from prior infarct (scar) or ischemia

• Non-ischemic cardiomyopathy
• Hypertensive, due to valve disease, lung disease (right sided), arrhythmia
(tachycardia-induced), toxic (ETOH, cocaine), viral, HIV, sarcoid, due to congenital
anomaly, idiopathic dilated, myocarditis, chemotherapy-induced, restrictive,
hypertrophic, stress-induced (i.e. Takotsubo), pregnancy/post-partum
Types of heart failure
• Systolic heart failure
• Signs of clinical heart failure + left ventricular ejection fraction
(LVEF) less than 40%
• Diastolic heart failure
• Signs of clinical heart failure + LVEF is greater than 40%
• Right heart failure
• Isolated right-sided dysfunction, left heart systolic function normal

…Different types of heart failure are treated differently!

 HFrEF HFpEF Borderline HFpEF Improved
HFpEF
Definition LV systolic LV systolic Characteristics, Patients who
dysfunction function treatment patterns, previously had
preserved, a & outcomes EF <40%
filling problem appear similar to
those of patients
with HFpEF

LVEF <40% >50% 41-49% >40%

Therapies BB + BP, HR control, BP, HR control, Typically
ACEi/ARB + treat symptoms treat symptoms remain on BB
aldosterone with diuresis with diuresis and ACEi/ARB
antagonist if
EF is less
than 35%
MEDICAL MANAGEMENT
OF HEART FAILURE
2013 ACCF/AHA Guideline for the Management of Heart Failure
Classification of Recommendation and Level of Evidence
MANAGEMENT OF SYSTOLIC
HEART FAILURE
Systolic heart failure
• Also referred to as “HF with reduced ejection fraction”
(HFrEF)
• Clinical diagnosis of heart failure + LVEF less than or
equal to 40%
• Commonly due to coronary artery disease, often with
history of prior MI
• Other common causes
• Toxic cardiomyopathy 2/2 ETOH use, cocaine, chemo
• Viral/myocarditis -> dilated cardiomyopathy
• Stress cardiomyopathy (physical or emotional stressor)
• Tachycardia-induced cardiomyopathy
Only in HFrEF patients have medical therapies been
proven to be efficacious
Treatment of systolic heart failure
• Evidence-based beta-blocker
• Class I: Use of 1 of the 3 beta blockers proven to reduce mortality
(e.g., bisoprolol, carvedilol, and sustained-release metoprolol
succinate) is recommended for all patients with current or prior
symptoms of HFrEF, unless contraindicated, to reduce morbidity
and mortality (Level of Evidence: A)
• ACE inhibitor or angiotensin receptor blocker
• Class I: ACE inhibitors are recommended in patients with HFrEF
and current or prior symptoms, unless contraindicated, to reduce
morbidity and mortality (Level of Evidence: A)
• Class I: ARBs are recommended in patients with HFrEF with
current or prior symptoms who are ACE inhibitor intolerant, unless
contraindicated, to reduce morbidity and mortality (Level of
Evidence: A)
Treatment of systolic heart failure
• Aldosterone antagonist for LVEF <35%
• Class I: Aldosterone receptor antagonists (or mineralocorticoid receptor
antagonists) are recommended in patients with NYHA class II–IV HF and
who have LVEF of 35% or less, unless contraindicated, to reduce morbidity
and mortality. Patients with NYHA class II HF should have a history of prior
cardiovascular hospitalization or elevated plasma natriuretic peptide levels
to be considered for aldosterone receptor antagonists.
• Creatinine should be 2.5 mg/dL or less in men or 2.0 mg/dL or less in
women (or estimated GFR >30), and potassium should be less than 5.0
mEq/L. Careful monitoring of potassium, renal function, and diuretic dosing
should be performed at initiation and closely followed thereafter to
minimize risk of hyperkalemia and renal insufficiency (Level of Evidence:
A)
• Class I: Aldosterone receptor antagonists are recommended to reduce
morbidity and mortality following an acute MI in patients who have LVEF of
40% or less who develop symptoms of HF or who have a history of
diabetes mellitus, unless contraindicated (Level of Evidence: B)
Why these medications?
BETA-BLOCKERS IN
SYSTOLIC HEART FAILURE
 Evidence-based beta-blockers
Initial daily dose Max dose Mean dose
achieved in
clinical trial
Bisoprolol 1.25 mg daily 10 mg daily 8.6 mg/day
Carvedilol 3.125 mg BID 50 mg BID 37 mg/day
(Coreg)
Carvedilol CR 10 mg daily 80 mg daily n/a
Metoprolol 12.5 mg-25 mg daily 200 mg daily 159 mg/day
succinate
(Toprol XL)

What’s missing…..?
Metoprolol tartrate (Lopressor)!
Which is the BID version of metoprolol
Why Toprol XL but not Lopressor?
• MERIT-HF trial (1999)
• Purpose was “to determine if metoprolol succinate decreases
mortality in patients with symptomatic HF with reduced ejection
fraction”
• Study demonstrated a 34% reduction in all cause mortality with
treatment with metoprolol succinate (versus placebo) and led to its
approval by the FDA – metoprolol tartrate was NOT approval
• Mortality benefit consistent with that seen with carvedilol in
CAPRICORN and bisoprolol in CIBIS-II
Why Toprol XL but not Lopressor?
• COMET trial (2003)
• Purpose was “to compare the effects of carvedilol and metoprolol
tartrate on morbidity and mortality in patients with mild to severe
chronic heat failure and reduced LV ejection fraction”
• The only major direct comparison study of beta-blockers and
demonstrated a 17% reduced in relative risk of death with
treatment with carvedilol over metoprolol tartrate (short acting
metoprolol) in patients with NYHA class II-IV and LVEF <35%
• Comment: metoprolol succinate (long acting, i.e. Toprol XL) was
not commercially available when this trial started
Additional comments about beta-
blockers…
But….

• Metoprolol tartrate is • No head-to-head

dosed BID but duration is comparison has been done
between carvedilol and
variable and dose related metoprolol succinate but…
• 50% reduction in maximum • MADIT-CRT (2009)
heart rate after single doses
• Study on benefit from cardiac
of 20, 50, and 100 mg resynchronization therapy
occurred at 3.3, 5, and 6.4 • Recent retrospective analysis
hours, respectively demonstrated a 30%
reduction in hospitalized for
heart failure or death in
patients treated with carvedilol
over metoprolol
MANAGEMENT OF DIASTOLIC
HEART FAILURE
Diastolic heart failure
• Also referred to as “HF with preserved ejection fraction”
(HFpEF)
• Clinical diagnosis of heart failure + LVEF greater than or
equal to 50%
• Commonly due to hypertension
• Patients often are older and female
• High prevalence of obesity, diabetes, atrial fibrillation
Treatment of diastolic heart failure
• We don’t know!
• Blood pressure control
• Class I:Systolic and diastolic blood pressure should be controlled in
patients with HFpEF in accordance with published clinical practice
guidelines to prevent morbidity (Level of Evidence: B)
• Treat the symptoms with diuresis
• Class I: Diuretics should be used for relief of symptoms due to volume
overload in patients with HFpEF. (Level of Evidence: C)
CARE TRANSITION FOR THE
HEART FAILURE PATIENT
Care transition for the HF patient
• “For patients with HF, the transition from inpatient to
outpatient care can be an especially vulnerable period
because of the progressive nature of the disease state,
complex medical regimens, the large number of comorbid
conditions, and the multiple clinicians who may be
involved” (ACCF/AHA, 2013)
• “Early post-discharge follow-up may help minimize gaps
in understanding of changes to the care plan or
knowledge of test results and has been associated with a
lower risk of subsequent re-hospitalization” (ACCF/AHA,
2013)
Cost of heart failure admissions
• HF is the primary diagnosis in >1 million hospitalizations
annually
• Patients hospitalized for HF are at high risk for all-cause
re-hospitalization, with a 1-month readmission rate of 25%
• In 2013, physician office visits for HF cost $1.8 billion
• The total cost of HF care in the United States exceeds
$30 billion annually, with over half of these costs spent on
hospitalizations
• The mean cost of HF-related hospitalizations was
$23,077 per patient and was higher when HF was a
secondary rather than the primary diagnosis
ACCF/AHA Recommendation
• Class I Recommendations
• 1. The use of performance improvement systems and/or evidence-based
systems of care is recommended in the hospital and early post-discharge
outpatient setting to identify appropriate HF patients for GDMT, provide
clinicians with useful reminders to advance GDMT, and assess the clinical
response (Level of Evidence: B)
• 2. Throughout the hospitalization as appropriate, before hospital discharge, at
the first post-discharge visit, and in subsequent follow-up visits, the following
should be addressed (Level of Evidence: B)
• initiation of GDMT if not previously established and not contraindicated
• precipitant causes of HF, barriers to optimal care transitions, and limitations in post-
discharge support
• assessment of volume status and supine/upright hypotension with adjustment of HF
therapy as appropriate
• titration and optimization of chronic oral HF therapy
• assessment of renal function and electrolytes where appropriate
• assessment and management of comorbid conditions
• reinforcement of HF education, self-care, emergency plans, and need for adherence
• consideration for palliative care or hospice care in selected patients
ACCF/AHA Recommendation
• Class IIa
• 1. Scheduling an early follow-up visit (within 7 to 14 days) and early
telephone follow-up (within 3 days) of hospital discharge are
reasonable (Level of Evidence: B)
• 2. Use of clinical risk-prediction tools and/or biomarkers to identify
patients at higher risk for post-discharge clinical events are
reasonable (Level of Evidence: B)
Goals of follow-up appointment
• Medication reconciliation
• Initiation of guideline derived medical therapy if indicated
• Follow-up lab work if needed
• Physical exam/volume assessment
• Review hospital stay with patient and provider
• Re-educate, re-educate, re-educate
• Prevent re-admission!
Our hospital’s example
• Our Heart Failure Team makes an appointment with
primary care provider within 7 days of hospital discharge
• Important to acknowledge day and time preferences of the
patient/family
• If no PCP, we make appointment with a family medicine
resident to establish care
• When cardiology is consulted, attempt is made to follow-
up with cardiology within 7 days of hospital discharge
• Appointment date and time is communicated to patient
personally and added to discharge instructions
• At this time, we do not have an outpatient heart failure
clinic which is a major limitation for us
THANK YOU!
Questions?
Megan.Treacy@healthonecares.com
References
• ACCF/AHA. (2013). 2013 ACCF/AHA guideline for the
management of heart failure. Circulation, 62, e240-e327.
• Go, A.S., Mozaffarian, D., Roger, V.L., et al. (2013) Heart
disease and stroke statistics–2013 update: a report from the
American Heart Association. Circulation,127, e6–245.
• MERIT Investigators. (1999). Effect of metoprolol CR/XL in
chronic heart failure: metoprolol CR/XL Randomised
Intervention Trial in Congestive Heart Failure (MERIT-HF.
Lancet, 353, 201–207.
• Poole-Wilson, P., Swedberg, K., Cleland, J.G.F, et al. (2003).
Comparison of carvedilol and metoprolol on clinical outcomes
in patients with chronic heart failure in the carvedilol or
metoprolol european trial (COMET): Randomised controlled
trial. Lancet, 362, 7-13.
Contact Information