Optimizing Heart

Failure Management
2005
Bridging the CARE GAP

CME Needs of Family

Physicians re CHF

Early detection
Etiology
Prognosis
Diagnosis
Physical exam
Asymptomatic LV
dysfunction

How to use beta blockers

Which beta blocker
Better standardization of
therapy

Rx titration
Diuretics
Beta blockers

Post hospital interventions

Lifestyle
Patient education
Diet
Rx
Exercise Rx

Compliance
Multi-system disease
Renal disease

Measuring the Impact of HF

Currently, there are over 500,000 Canadians with

HF
Incidence 50,000 cases/year
One year mortality after diagnosis ranges between
25-40% (ICES Atlas)
1% of Canadians over age 65 and 4% of Canadians
over 70 have CHF
The age-adjusted mortality for CHF is 106/100,000

Measuring the Impact of HF

Median survival currently 1.7 years for males, 3.2
yrs for females
5-year age adjusted mortality rate of 45% based on
the time period 1990-1999
Commonest diagnosis that brings a patient to
hospital for medical admission.
Re-admission rates are 46% within 3 months of
discharge and 54% within 6 months.

Heart Failure Epidemiology

Heart failure associated with high morbidity and
mortality
Contemporary Canadian data to quantify the
burden of CHF is limited
In 2000/01:

Total of 106,130 discharges for 85,679 CHF patients

32.7% of discharges were readmissions
19.9% of patients were re-hospitalized once or more during 2000
Total in-hospital mortality was 15.8%.
CHF is associated with the second highest total number of hospital
days and third highest number of patients affected.
Can J Cardiol. 2003 Mar 31;19(4):436-8.
Contemporary burden of illness of congestive heart failure in Canada.
Tsuyuki RT, Shibata MC, Nilsson C, Hervas-Malo M.

Contemporary burden of illness of congestive heart

failure in Canada.
Tsuyuki RT, Shibata MC, Nilsson C, Hervas-Malo M.

These figures should signal a call to

action for researchers, administrators
and health care providers regarding
the need for more efficacious
therapies, better application of
already-proven therapies and patient
education.
Can J Cardiol. 2003 Mar 31;19(4):436-8.

Heart Failure is the Quintessential

Disorder of Cardiovascular Aging
Convergence of
Age related changes in cardiovascular
structure and function

Rising prevalence of
Hypertension
Coronary heart disease
Valvular heart disease

Chronic Congestive Heart Failure

Evolution of Clinical Stages
NORMAL
Asymptomatic
LV Dysfunction
Compensated
CHF
Decompensated
CHF
Refractory
CHF

No symptoms
Normal exercise
Normal LV fxn
No symptoms
Normal exercise
Abnormal LV fxn
No symptoms
Exercise
Abnormal LV fxn
Symptoms
Exercise
Abnormal LV fxn

Symptoms not controlled

with treatment

Ventricular Remodeling in CHF

Jessup, NEJM 2003

Symptoms of HF

Fatigue
Activity decrease
Cough (especially supine)
Edema
Shortness of breath

DIET Approach to the Patient

With Heart Failure
Diagnose
Etiology
Severity (LV
dysfunction)

Initiate
Diuretic/ACE inhibitor
-blocker
Spirololactone
Digoxin

Educate

Diet
Exercise
Lifestyle
CV Risk

Titrate
Optimize ACE
inhibitor
Optimize -blocker

Therapy of CHF
Clinical Approach to CHF:
Consider etiology
Identify triggers
Exclude ischaemia
General measures
Symptomatic therapy
Prognostic therapy
See Guide for HF Management Check-list

Guide for HF Management

Symptoms & Signs of HF:

Fatigue (low cardiac out-put)
SOB
JVP
Rales
S3
Edema
Radiologic congestion
Cardiomegaly
Obtain CXR to r/o non-cardiac causes e.g. interstitial lung
disease & PPH

BNP in the Diagnosis of HF

The role of natriuretic peptides
ANP-atrial natriuretic peptide
Produced in atria in response to wall stress

BNP-brain natriuretic peptides

Produced in ventricles in response to volume and pressure
overload

CNP-central nervous system and endothelium

Produced in response to endothelial stress

Produced as prohormones and cleaved to active molecule

(ANP/BNP)and inactive NT forms

BNP in the Diagnosis of HF

ANP/BNP elevated in

Heart failure
Systemic and pulmonary hypertension
Hypertrophic and restrictive cardiomyopathy
Pulmonary embolism
COPD
Cor pulmonale
AMI Cirrhosis
Renal Failure

BNP in the Diagnosis of HF

Higher levels of BNP correlate with
higher PCW pressures
in compensated and decompensated patients

larger LV volumes
lower ejection fractions
in symptomatic HF patients

BNP study (Circ 2002;106: 416-422)

BNP sensitivity 90% and specificity 73% for HF

BNP Diagnostic Cut Points for CHF

JACC 2001;37(2):379-85.
BNP > 400 pg/L acute CHF present
BNP 100 pg/L 400 pg/L
Diagnostic of CHF with

Sensitivity 90%
Specificity 76%
Predictive accuracy 83%
R/O pulmonary embolism, LV dysfunction without
acute CHF or cor pulmonale

BNP < 100 pg/L 98% negative predictive accuracy

Identify triggers
Acute-sudden onset
Ischaemia
Arrhythmia
Infection
Pulmonary
embolism
Acute valvular
pathology

Chronic-gradual onset
Anemia
Thyrotoxicosis
Non-compliance
Diet
Rx e.g. NSAIDs

Non-Invasive Evaluation of the Heart Failure

Patient-Implications of LV Ejection Fraction
To know where you
are going you must
know where you are
coming from
Evaluate LV function
clinical
echo
gated study

Ejection fraction
(obtain echo or LV gated study)
LVEF 40% = systolic dysfunction
LVEF 40-55% = mixed systolic and
diastolic dysfunction
LVEF 55% = diastolic dysfunction
identify triggers
treat underlying disorder
(HPT/ischaemia/pericardial
constriction/restrictive CM/infiltrative
disorders)

Echocardiographic Evaluation
of CHF
LV function (EF),chamber
size,wall motion
Segmental dysfunctioncoronary disease
MS-severity, valve area
AS- valve gradient, valve
area
AR/MR severity
TR- RV systolic pressure
= PA pressure

RV function
R/O IHSS, HCM
R/O Pericardial Disease
R/O rare causes e.g.
myxoma, infiltrative
disorders- restrictive
cardiomyopathy
Diastolic function
Hyperdynamic states

Diastolic Dysfunction
30-50% of elderly HF patients have
reserved LV systolic function
Diastolic dysfunction may induce dyspnea
on exertion
Frank congestion usually has identifiable
precipitant

Clinical Implications of LV
Dysfunction in Heart Failure
Calculated EF by echo
unreliable in remodeled
LV
Visual estimate of EF
semi-quantitative
(CCN LV function scale)

Grade I LV EF 50%
Grade 2 LVEF 35-49%
Grade 3 LVEF 20-34%
Grade 4 LVEF< 20%

LVEF Entry Criteria in ACE

inhibitor and
-blocker Trials
SOLVD treatment an
prevention 35%
SAVE (post MI) 40%
U.S. Carvedilol HF Trials
Program LVEF 35%
Merit-HF LVEF 40%
CIBIS II LVEF 40%

Consider etiology

Ischemic- Cardiomyopathy (CM)

HPT-CM
Valvular HD-CM (AS/AR/MR)
Metabolic:

/ thyroid/hemochromatosis/ pheochromocytoma

Toxins:

Anthracyclines/Etoh/cocaine/amphetamines

Viral CM
Idiopathic Dilated CM
Other:

Treatment
General Measures
General measures:
Correct triggers and
precipitants of acute
and chronic HF
Low sodium diet
Fluid restriction
Regular exercise/
Activity HR Rx

Treat ischemia
Control hypertension
D/C Smoking
Treat lipid
abnormalities
Treat and control
diabetes
Identify & Rx
depression

HF Management Algorithm
Is it Heart Failure?
Symptoms & Signs

YES
Diagnostic Tests:
CXR/ECG/BNP
Additional Tests
Specific Tx
Cath
CABG
Valve Sx

YES
Echo/RNA/MRI:
Etiology/Severity
Systolic HF:
MedicalSx/Device

Life Style +
Patient Education
HF Clinics F/U

Diastolic HF:
Rx causeReferral

Primary Targets of Treatments

in CHF

Jessup, NEJM 2003

Symptoms

Prognosis & Symptoms

Assess LV Function (echo, gated RNA)

EF < 40%-systolic dysfunction
EF 40-55%-systolic/diastolic dysfunction
EF >55%-diastolic dysfunction

Assess Volume Status

Signs and Symptoms of

Fluid Retention
Loop Diuretic
+/- Thiazide
(titrate to euvolemic state)

Add Digoxin for

symptom control

No Signs and Symptoms

of Fluid Retention

ACE inhibitor/ARB if ACE intolerant

Combination Rx if HF, hospitalization or -blocker intolerant

-blocker (NYHA II-IV)

Spironolactone
(NYHA Class III-IV CHF/EF<35%/Cr<200/K<5)

Heart Failure Therapeutic Goal

Mild-Moderate Heart Failure
Primary goal = Reduce mortality
-blockers + ACE inhibitors
Prevent progression to symptoms
Prevent progressive LV dysfunction

Heart Failure Therapeutic Goal

Moderate-Severe Heart Failure
Primary goal = Reduce symptoms
Improve quality of life (QOL)
Reduce hospitalizations
Prevent sudden death

General Rx Strategies in HF
Asymptomatic

Mild/Mod

Severe

Refractory

Inotropes, mitral repair, VAD, Tx

Correct Cause:
Arrhythmias
Ischemia
Pressure Load

Tailored Rx
Digoxin
Diuretics (Spironolactone)
Carvedilol/ -Blockers

Angiotensin Converting Enzyme Inhibitors

No Added Salt
Activity as Tolerated
Modified from Warner-Stevenson, ACC HF Summit

2 gm Na
Customized Ex Training

Symptomatic therapy
Diuretics (see How to Adjust Your Diuretic)
Titrate to euvolemic state
Maintain Ideal Body Weight
(dry weight = JVP normal / trace pedal edema)

Furosemide 20 mg. 80 mg OD-BID

HCT/Zaroxolyn for refractory congestion
Digoxin
For persisting symptoms in NSR (systolic dysfunction)
or symptoms and rate control in Afib.
Dose: 0.125 mg 0.25 mg
(Lower dose in elderly: 0.0625 mg)

The Effect of Digoxin on Mortality and

Morbidity in Patients with Heart Failure

NEJM Volume 336:525-533 February 20, 1997 Number 8

DIG Trial

DIG Trial

ACE Inhibitors are the Cornerstone

of Rx in CHF
CCS 2003 Consensus HF Update (draft)
ACE I Rx ASAP post MI
Continue indefinitely if EF < 40% or clinical
HF
Rx for all asymptomatic patients with LVEF
35%
Rx for all symptomatic patients with LVEF
35%
Target dose use in clinical trials or max
tolerated dose

ACE Inhibitors in CHF

ACE Inhibitors Post MI

Overview of Long Term ACE Inhibitor

Trials Showing Mortality Benefit
Study
SOLVD

Number Criteria RRR % ARR %

NNT

Lives
saved/1000

2569

LVEF
35%

16

4.5

22

50

SAVE

2231

19

4.2

24

45

AIRE

2006

LVEF
40%
Clinical
CHF

27

5.7

18

60

TRACE

1749

LVEF
35%

22

7.6

13

90

Treatment

Whats New in Ace inhibition in HF

Long Term Follow-up

SOLVD

X-SOLVD

Optimal Dosing of
ACE Inhibitors
General Guideline:
Start low and titrate to
the target dose used in
the clinical trials or the
MAXIMUM
TOLERATED DOSE
(ATLAS trial)

Captopril 6.25-12.5 mg
50 mg BID-TID
(SAVE)
Enalapril 2.5 mg BID
20 mg BID (SOLVD/X)
Ramipril 2.5 mg BID 5
mg BID (AIRE/EX)
Lisinopril 10 mg OD
30-40 mg OD (GISSI 3)
Trandolapril 1mg 4 mg
(TRACE)

Summary ARBs in CHF

# pts.

ELITE II

Val-HeFT

VALIANT

CHARM

ARB vs ACEI

ARB vs
placebo
( ACEI BB)

Captopril,
Valsartan or
Combination

ARB vs placebo ( ACEI)

3,152

5,010

4909/4909/4885

7,601

Population

Heart failure

Heart failure

Post MI with
clinical or radiologic
HF

Symptomatic HF Class II-III/

LV function/preserved LVF
(added+alternative/preserved)

Endpoints

1o All-cause
mortality,
sudden death
or resuscitated
cardiac arrest:
NS

1o All-cause
mortality: NS
1o Combined
M/M:
ACEI+ARB =
-13.2%
ACE intolerant:
-33% all
cause mortality

1o All-cause
mortality: NS
2o CV Death, MI, or
HF:NS

1o All-cause mortality: NS
2o CV death or HF
hospitalization:
CHARM Added:
ACEI+ARB = -15%
CHARM Alternative:
ARB = -30%
CHARM Preserved: NS

Valsartan noninferior to Captopril

Combined Morbidity/Mortality in
Subgroups: Val-HeFT
All
Demographics
< 65
65
Male
Female

Favors valsartan

No. patients
5010

Favors placebo

2660
2350
4007
1003

Etiology/Co-morbidity
IHD (yes)
2865
IHD (no)
2145
Diabetes (yes)
1276
Diabetes (no)
3734
Disease Severity
NYHA II
NYHA III/IV
EF 27
EF < 27
LVIDD < 3.57
LVIDD 3.57

3095
1910
2623
2385
2505
2505

0.4
Cohn JN, et al: Val-HeFT NEJM December 2001

0.6

0.8

1.0

1.2

1.4

Mortality in SAVE,
TRACE, AIRE, and VALIANT
Hazard Ratio for Mortality

SAVE
TRACE

Valsartan preserves
99.6% of mortality
benefit of captopril,
representing a 25% RR

AIRE
Combined
VALIANT
(imputed placebo)
0.5

Favors
Active Drug

Pfeffer M et al. N Engl J Med 2003;349:1893-906

Favors
Placebo

CHARM Programme
Mortality and morbidity
All Cause Mortality

0.77

Alternative

p=0.0004
0.85

Added

p=0.011
0.89

Preserved
Overall

CV Death or
CHF Hospitalisation

0.91

p=0.055

0.7 0.8 0.9 1.0 1.1 1.2

Hazard ratio

p heterogeneity=0.37

0.84

p=0.118
p<0.0001

0.6 0.7 0.8 0.9 1.0 1.1 1.2

Hazard ratio

p heterogeneity=0.43

Evidence for Various ARBs

Diovan
(valsartan)

Avapro
(irbesartan)

Cozaar
(losartan)

-45%

-6%

-35%

-30%

N/a

N/a

Heart failure
hospitalizations

-27.5%
(ValHeFT)

N/a

-8.1%
(ELITE II)

-17%
(CHARM)

N/a

N/a

CV outcome in
CHF-treated
patients

-13.3%
(ValHeFT)

N/a

+7%
(ELITE II)

-15%
(CHARM)

N/a

N/a

Positive CV
outcomes in
CHF

Yes

N/a

No

Yes

N/a

N/a

Equivalent
Efficacy to ACEi
post MI

Yes

N/a

No

N/a

N/a

N/a

Reduction in
microalbuminuria with
starting dose

Atacand
Micardis
(candesartan (telmisartan)
cilexetil)

Teveten
(eprosartan)

-Blocker Saves Lives

in Heart Failure?
blocker is the most important progress in
Heart Failure Rx in the last 5 years

HF Trials Modulating receptors

Trial
US
US Carvedilol
Carvedilol

Aus-NZ
CIBIS II
MERIT
COPERNICUS
COPERNICUS

HF Pts
II-III
II
EF<35%
EF<40%
EF<25%

N
Rx
RR
1,094 Carvedilol 0.35
415 Carvedilol 0.74
2,647 Bisoprolol 0.66
3,991 Metopr-CR 0.66
2,289 Carvedilol 0.65

Background Rx = ACEi + Diuretics +/- Digoxin

Number Need to Rx in HF
TRIAL

Therapy

Enalapril
vs. Plac
Metoprolol
MERIT
vs. Plac
Bisoprolol
CIBIS-2
vs. Plac
COPERN Carvedilol
ICUS
vs. Plac
Spiro vs.
RALES
Placebo
SOLVD

Lee, Liu, Packer

Annual
Annual
Absolute NNRx/year
Mortality- Mortality- Risk
to Save
Placebo Treatment Reducn One Life

12.5%

11.2%

1.3%

77

11.0%

7.2%

3.8%

26

13.2%

8.8%

4.4%

23

18.5%

11.4%

7.1%

14

22.5%

15.8%

6.7%

15

-adrenergic Blocking Agents

Titrate to target dose
Bisoprolol 1.25 -10 mg OD
Carvedilol 3.125 - 25 mg BID
Metoprolol 12.5 - 50 to75 mg /BID

If unable to tolerate high dose -blocker

maintain highest tolerated dose
Continue indefinitely

Patient Selection for Successful

- Blocker Initiation

Stable symptoms
Stable background heart failure medications
No recent CV hospitalization
Stable CV status (no hypotension or
bradycardia)
Euvolemic status
Start low and titrate slowly

Patients With Heart Failure Who

Should Not Be Started on -blockers
General Contraindications
Bronchospastic pulmonary disease
Severe bradycardia, high degree AV block,
sick sinus syndrome

Heart Failure Considerations

Congestive symptoms at rest (NYHA Class IV)
Patients who require intravenous therapy for HF
Unstable symptoms or recent changes in
background medications
Hospitalized patients (especially for worsening HF)

RALES Trial
Spironolactone 12.5-25 mg OD added to
ACE-inhibitor/diuretic/+/- digoxin in stable
Class III-IV CHF/LVEF
35%/CR<220/K<5.0
30% RRR in death from progressive HF and
sudden cardiac death
35% reduction in hospitalization for
worsening HF

NEJM Volume 341:709-717 Number 10

RALES Caveats
With aldosterone antagonist follow K/Cr in 3-7 days
furosemide to avoid azotemia

Inadequate follow-up can lead to increased rates of

hospitalization for hyperkalemia and associated mortality
NEJM Volume 351:543-551 Number 6

Caution:

Diabetics
Renal disease
Elderly
NSAIDS
COX-2 inhibitors

Severity of Heart Failure

Modes of Death
NYHA II
12%
24%
64%

NYHA III

CHF

CHF

Other

26%

Sudden
Death

59%
15%

n = 103

Other
Sudden
Death
n = 103

NYHA IV
33%
11%

56%

CHF
Other
Sudden
Death
n = 27

MERIT-HF Study Group. LANCET

1999;353:2001-07.

Therapies Provided by Todays

Dual-Chamber ICDs

Atrium
AT/AF tachyarrhythmia detection
Antitachycardia pacing
Cardioversion

Ventricle

Atrium &
Ventricle

VT/ VF detection

Bradycardia sensing

Antitachycardia pacing

Bradycardia pacing

Cardioversion
Defibrillation

Evaluate for Implantable Devices

Consider EPS Referral
VT:
Symptomatic sustained or non-sustained ventricular arrhythmia
(LVEF 30-40%)

AICD:

Prior MI/CAD (LVEF 30% with IVCD 0.12 sec: MADIT II)
or both CRT/AICD(NYHA III-IV;QRS 0.12:COMPANION).
CHF: (NYHA II-III & LVEF < 35% SCD-HeFT)

Cardiac Resynchronization Therapy (CRT):

(NYHA Class III-IV with reduced ejection fractions; LVEF <
35%
QRS duration 0.13 with IVCD or LBBB: MIRACLE /
MUSTIC)

Sudden Cardiac Death-Heart Failure

SCD-HeFT
Hypothesis and Primary Endpoint
To determine, by intention-to-treat analysis, if
amiodarone or a conservatively programmed
shock-only single lead ICD reduces all-cause
mortality compared to placebo* in patients with
either ischemic or non-ischemic NYHA Class II
and III CHF and EF < 35%.
Good background Therapy
ACE or ARB 87%
-blocker 78%
Bardy G et al.

NEJM 2005; 352:3

Sudden Cardiac Death

SCD-HeFT
Trial

Heart Failure

*Double-blind for drug therapy

Enrollment Scheme
DCM + CAD and CHF
EF < 35%
NYHA Class II or III
6 minute walk, Holter
R
Bardy G et al.
NEJM 2005; 352:3
Sudden Cardiac Death

SCD-HeFT
Trial

Heart Failure

Placebo Amiodarone

ICD

Kaplan-Meier Estimates of Death

from Any Cause

Sudden Cardiac Death

SCD-HeFT
Trial

Heart Failure

Bardy G et al.
NEJM 2005; 352:3

Kaplan-Meier Estimates of Death

from Any Cause:
Ischemic CHF

Sudden Cardiac Death

SCD-HeFT
Trial

Heart Failure

Non-Ischemic CHF

Bardy G et al.
NEJM 2005; 352:3

Hazard Ratios for the Comparison of

Amiodarone and ICD Therapy with Placebo

Sudden Cardiac Death

SCD-HeFT
Trial

Heart Failure

Bardy G et al. NEJM 2005; 352:3

SCD-HeFT: Primary Conclusions

1. In class II or III CHF patients with EF < 35% on
good background drug therapy, the mortality rate
for placebo-controlled patients is 7.2% per year over
5 years
2. Simple, single lead, shock-only ICDs decrease
mortality by 23%
3. Amiodarone, when used as a primary preventative
agent, does not improve survival
Sudden Cardiac Death

SCD-HeFT
Trial

Heart Failure

Bardy G et al.
NEJM 2005; 352:3

Cardiac Resynchronization
Therapy (CRT)
Atrial-biventricular
stimulation
Electrical
synchronization
narrower QRS
Mechanical
synchronization
reverse remodeling

Resynchronization/Defibrillati
on for Advanced Heart Failure
Trial

RAFT
Hypothesis:
In patients with LV Dysfunction (EF
30%) and QRS duration 120 ms with
moderate to severe CHF symptoms, the
addition of Cardiac Resynchronization
Therapy (CRT) to Implantable
Cardioverter Defibrillator (ICD) and
optimal medical therapy reduces the
combined end point of mortality and CHF
hospitalization.

RAFT - Design
Randomized Controlled Trial:
ICD vs CRT/ICD

Blinding
Patient, HF Care (Blinded)
Device care (Un-blinded)

Patients randomized to a 1:1 proportion to:

ICD (Single or Dual) or
CRT/ICD

Stratified for: Center & AF & Single/Dual ICD indication

RAFT Inclusion Criteria

NYHA Class II or III
QRS duration 120 ms or Paced QRS 200 ms
LVEF 30% by MUGA or LVEF 30% and LVEDD > 60mm by
echocardiogram within 6 months of randomization
ICD indication: 1 or 2 prevention
Optimal Heart Failure Pharmacotherapy
Normal sinus rhythm or
Chronic persistent atrial tachyarrhythmia with resting ventricular Heart
Rate of 60 bpm and ventricular rate 90 bpm during a 6 minute hall
walk or
Chronic persistent atrial tachyarrhythmia with resting ventricular Heart
Rate of >60 bpm and ventricular rate > 90 bpm during a 6 minute hall
walk and booked for an AV junction ablation
*NYHA Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical
activity results in fatigue or dyspnea
** NYHA Class III: Marked limitation of physcial activity. Comfortable at rest, but less than
ordinary activity causes fatigue or dyspnea.

RAFT Exclusion Criteria

In-hospital patients who have an acute cardiac or noncardiac illness
that requires intensive care
Intra-venous inotropic agent 4 days prior to randomization
Expected to undergo cardiac transplantation within one year (status I)
Coronary revascularization (CABG or PCI) < 1month
Acute coronary syndrome(including MI) < 4 weeks
Patients with an existing ICD (Patients with an existing pacemaker
may be included if the patient satisfies all other inclusion/exclusion
criteria)
Uncorrected or uncorrectable primary valvular disease
Restrictive, hypertrophic or reversible form of cardiomyopathy

RAFT Exclusion criteria

contd
Patients with a life expectancy of less than one year from noncardiac cause.
Patients included in other clinical trial that will affect the
objectives of this study
Unable or unwilling to provide informed consent
History of noncompliance of medical therapy
Severe primary pulmonary disease such as cor pulmonale
Tricuspid prosthetic valve

Heart Failure Management Issues

High Mortality
High re-admission rates
Poor understanding of disease
Poor Rx adherence
On-going symptoms
Reduced Quality of Life
Dose Adjustments in the Elderly

Adherence Gap

Cost of medications
Complacency-patient and physician
Side effects
Lack of understanding
Infrequent monitoring intervals
Lack of reinforcement
Lack of feedback

Adherence Strategies

Patient education materials

Medication monitoring strategies
Pharmacy patient surveillance
Follow-up protocols
Role of Public Health nurses
Patient Awareness Initiatives
Out-patient Heart Failure Education Programs

CHF Implementation Targets

Heart Failure Specialists
General Cardiologists
Academic/Community

Internists
Academic/Community

Family Physicians
Hospital Nursing staff
Public Health Nurse
Residents & Housestaff
General Public

How can we amplify the impact

of HF therapy?
Inotropes,Devices
Transplant

Specialist/Cardiologist
HF Clinic

2 & 3

Dosing Optimization- Family

MD & Specialist

1 & 2

Recognition-Initial TherapyFamily MD

Primary Care Physician

Community Based
Awareness/Understanding

HF Awareness Program/PHN

Heart Failure Network

Apically connected tertiary centres

Vertically integrated local networks
Laterally integrated at all levels
Regional centres linked to local specialist
Hubs of resources dissemination
Shared resources/minimize duplication
Common denominator is primary care
physician/patient base

Heart Failure Networks

Lateral Integration

Role of Heart Failure Clinics

4 and 3 Heart Failure Clinics

Pre-transplant work-up
Out-patient parenteral inotropic therapy
Patient education
High risk rehabilitation programs
Regional hubs- national Heart Failure Network
Co-ordinating centre-Heart Failure Network
data-base

Role of Heart Failure Clinics

2 hospital based and community based Heart
Failure Clinics/Disease Management Programs

Patient identification and risk assessment

Patient education
Rx titration and fluid status monitoring
Low risk and intermediate risk exercise programs
Primary care liaison, education
Long term follow-up

Role of Primary Care Physician

Patient identification
Assess etiology
Assess LV Function
Initial stabilization of
acute HF
Rx initiation and
titration
(diuretics/ACEinhibitor/digoxin)

Optimize ACE
inhibitors
Rx -blocker if
comfortable with Rx
Patient education
Treatment integration
Long term follow-up

Role of Public Health Nurse

Patient education
Patient monitoring
Adherence
Follow-up

Role of the Public

Awareness
Initiate contact
Understanding
Lifestyle & diet modification
Compliance

Goals & Outcomes

Improve symptoms
Improve quality of life
Prevent progression of
LV dysfunction
Reduce hospitalization
and morbidity
Reduce mortality
Progression of HF
Sudden death