Heart Failure Guidelines ACCF/AHA 2013
ACCF/AHA Practice Guideline
2013 ACCF/AHA Guideline for the Management of Heart Failure A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American College of Chest Physicians, Heart Rhythm Society and International Society for Heart and Lung Transplantation Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation
WRITING COMMITTEE MEMBERS* Clyde W. Yancy, MD, MSc, FACC, FAHA, Chair†‡; Mariell Jessup, MD, FACC, FAHA, Vice Chair*†; Biykem Bozkurt, MD, PhD, FACC, FAHA†; Javed Butler, MBBS, FACC, FAHA*†; Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA§; Mark H. Drazner, MD, MSc, FACC, FAHA*†; Gregg C. Fonarow, MD, FACC, FAHA*†; Stephen A. Geraci, MD, FACC, FAHA, FCCP‖; Tamara Horwich, MD, FACC†; James L. Januzzi, MD, FACC*†; Maryl R. Johnson, MD, FACC, FAHA¶; Edward K. Kasper, MD, FACC, FAHA†; Wayne C. Levy, MD, FACC*†; Frederick A. Masoudi, MD, MSPH, FACC, FAHA†#; Patrick E. McBride, MD, MPH, FACC**; John J.V. McMurray, MD, FACC*†; Judith E. Mitchell, MD, FACC, FAHA†; Pamela N. Peterson, MD, MSPH, FACC, FAHA†; Barbara Riegel, DNSc, RN, FAHA†; Flora Sam, MD, FACC, FAHA†; Lynne W. Stevenson, MD, FACC*†; W.H. Wilson Tang, MD, FACC*†; Emily J. Tsai, MD, FACC†; Bruce L. Wilkoff, MD, FACC, FHRS*††
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. †ACCF/AHA representative. ‡ACCF/AHA Task Force on Practice Guidelines liaison. §American College of Physicians representative. ‖American College of Chest Physicians representative. ¶International Society for Heart and Lung Transplantation representative. #ACCF/AHA Task Force on Performance Measures liaison. **American Academy of Family Physicians representative. ††Heart Rhythm Society representative. ‡‡Former Task Force member during this writing effort. This document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in May 2013. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0b013e31829e8776/-/DC1. The online-only Comprehensive Relationships Table is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/ CIR.0b013e31829e8776/-/DC2. The American Heart Association requests that this document be cited as follows: Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327. This article has been copublished in the Journal of the American College of Cardiology. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Association (my.americanheart.org). A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail [email protected]. Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright- Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page. (Circulation. 2013;128:e240-e327.) © 2013 by the American College of Cardiology Foundation and the American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31829e8776 Downloaded from http://circ.ahajournals.org/e240 by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e241
ACCF/AHA TASK FORCE MEMBERS Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair‡‡; Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; Nancy M. Albert, PhD, CCNS, CCRN, FAHA; Biykem Bozkurt, MD, PhD, FACC, FAHA; Ralph G. Brindis, MD, MPH, MACC; Mark A. Creager, MD, FACC, FAHA‡‡; Lesley H. Curtis, PhD; David DeMets, PhD; Robert A. Guyton, MD, FACC; Judith S. Hochman, MD, FACC, FAHA; Richard J. Kovacs, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA‡‡; E. Magnus Ohman, MD, FACC; Susan J. Pressler, PhD, RN, FAAN, FAHA; Frank W. Sellke, MD, FACC, FAHA; Win-Kuang Shen, MD, FACC, FAHA; William G. Stevenson, MD, FACC, FAHA‡‡; Clyde W. Yancy, MD, MSc, FACC, FAHA‡‡
Table of Contents 5.5. Tachycardia-Induced Cardiomyopathy . . . .e251 5.6. Myocarditis and Cardiomyopathies Due to Preamble ...... e242 Inflammation ...... e251 1. Introduction ...... e245 5.6.1. Myocarditis ...... e251 1.1. Methodology and Evidence Review ...... e245 5.6.2. Acquired Immunodeficiency Syndrome .e252 1.2. Organization of the Writing Committee . . . . e245 5.6.3. Chagas Disease ...... e252 1.3. Document Review and Approval ...... e245 5.7. Inflammation-Induced Cardiomyopathy: 1.4. Scope of This Guideline With Reference to Noninfectious Causes ...... e252 Other Relevant Guidelines or Statements . . . e245 5.7.1. Hypersensitivity Myocarditis . . . . . e252 2. Definition of HF ...... e246 5.7.2. Rheumatological/Connective Tissue 2.1. HF With Reduced EF (HFrEF) ...... e247 Disorders ...... e252 2.2. HF With Preserved EF (HFpEF) ...... e247 5.8. Peripartum Cardiomyopathy ...... e252 3. HF Classifications ...... e247 5.9. Cardiomyopathy Caused By Iron Overload . . e252 4. Epidemiology ...... e248 5.10. Amyloidosis ...... e252 4.1. Mortality ...... e248 5.11. Cardiac Sarcoidosis ...... e253 4.2. Hospitalizations ...... e248 5.12. Stress (Takotsubo) Cardiomyopathy . . . . .e253 4.3. Asymptomatic LV Dysfunction ...... e248 6. Initial and Serial Evaluation of the HF Patient . . . e253 4.4. Health-Related Quality of Life and 6.1. Clinical Evaluation ...... e253 Functional Status ...... e249 6.1.1. History and Physical Examination: 4.5. Economic Burden of HF ...... e249 Recommendations ...... e253 4.6. Important Risk Factors for HF (Hypertension, 6.1.2. Risk Scoring: Recommendation . . . .e253 Diabetes Mellitus, Metabolic Syndrome, and 6.2. Diagnostic Tests: Recommendations . . . . .e253 Atherosclerotic Disease) ...... e249 6.3. Biomarkers: Recommendations ...... e255 5. Cardiac Structural Abnormalities and Other 6.3.1. Natriuretic Peptides: BNP or NT-proBNP . e256 Causes of HF ...... e249 6.3.2. Biomarkers of Myocardial Injury: 5.1. Dilated Cardiomyopathies ...... e249 Cardiac Troponin T or I ...... e256 5.1.1. Definition and Classification of Dilated 6.3.3. Other Emerging Biomarkers . . . . . e256 Cardiomyopathies ...... e249 6.4. Nonin vasive Cardiac Imaging: 5.1.2. Epidemiology and Natural History Recommendations ...... e256 of DCM ...... e250 6.5. Invasive Evaluation: Recommendations . . . e258 5.2. Familial Cardiomyopathies ...... e250 6.5.1. Right-Heart Catheterization ...... e259 5.3. Endocrine and Metabolic Causes of 6.5.2. Left-Heart Catheterization ...... e259 Cardiomyopathy ...... e250 6.5.3. Endomyocardial Biopsy ...... e260 5.3.1. Obesity ...... e250 7. Treatment of Stages A to D ...... e260 5.3.2. Diabetic Cardiomyopathy ...... e250 7.1. Stage A: Recommendations ...... e260 5.3.3. Thyroid Disease ...... e250 7.1.1. Recognition and Treatment of Elevated 5.3.4. Acromegaly and Growth Hormone Blood Pressure ...... e260 Deficiency ...... e250 7.1.2. Treatment of Dyslipidemia and 5.4. Toxic Cardiomyopathy ...... e251 Vascular Risk ...... e260 5.4.1. Alcoholic Cardiomyopathy ...... e251 7.1.3. Obesity and Diabetes Mellitus . . . . .e260 5.4.2. Cocaine Cardiomyopathy ...... e251 7.1.4. Recognition and Control of Other 5.4.3. Cardiotoxicity Related to Cancer Conditions That May Lead to HF . . . e260 Therapies ...... e251 7.2. Stage B: Recommendations ...... e261 5.4.4. Other Myocardial Toxins and Nutritional 7.2.1. Management Strategies for Stage B . . .e262 Causes of Cardiomyopathy ...... e251 7.3. Stage C ...... e262 Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e242 Circulation October 15, 2013
7.3.1. Nonpharmacological Interventions . . . e262 8.3. Maintenance of GDMT During Hospitalization: 7.3.1.1. Education: Recommendation . . e262 Recommendations ...... e286 7.3.1.2. Social Support ...... e263 8.4. Diuretics in Hospitalized Patients: 7.3.1.3. Sodium Restriction: Recommendations ...... e286 Recommendation ...... e263 8.5. Renal Replacement Therapy—Ultrafiltration: 7.3.1.4. Treatment of Sleep Disorders: Recommendations ...... e287 Recommendation ...... e263 8.6. P arenteral Therapy in Hospitalized HF: 7.3.1.5. Weight Loss ...... e263 Recommendation ...... e287 7.3.1.6. Activity, Exercise Prescription, 8.7. Venous Thromboembolism Prophylaxis in and Cardiac Rehabilitation: Hospitalized Patients: Recommendation . . . .e288 Recommendations ...... e264 8.8. Ar ginine Vasopressin Antagonists: 7.3.2. Pharmacological Treatment for Stage C Recommendation ...... e288 HFrEF: Recommendations ...... e264 8.9. Inpatient and Transitions of Care: 7.3.2.1. Diuretics: Recommendation . . .e265 Recommendations ...... e288 7.3.2.2. ACE Inhibitors: Recommendation e265 9. Important Comorbidities in HF ...... e290 7.3.2.3. ARBs: Recommendations . . . e267 9.1. Atrial Fibrillation ...... e290 7.3.2.4. Beta Blockers: Recommendation . e267 9.2. Anemia ...... e293 7.3.2.5. Aldosterone Receptor Antagonists: 9.3. Depression ...... e293 Recommendations ...... e268 9.4. Other Multiple Comorbidities ...... e293 7.3.2.6. Hydralazine and Isosorbide 10. Surgical/Percutaneous/Transcatheter Interventional Dinitrate: Recommendations . . e270 Treatments of HF: Recommendations ...... e293 7.3.2.7. Digoxin: Recommendation . . .e271 11. Coordinating Care for Patients With Chronic HF . .e295 7.3.2.8. Other Drug Treatment . . . . .e271 11.1. Coordinating Care for Patients With 7.3.2.8.1. Anticoagulation: Chronic HF: Recommendations ...... e295 Recommendations . . e271 11.2. Systems of Care to Promote Care Coordination 7.3.2.8.2. Statins: for Patients With Chronic HF ...... e296 Recommendation . . . . . e272 11.3. Palliative Care for Patients With HF . . . . e296 7.3.2.8.3. Ome ga-3 Fatty Acids: 12. Quality Metrics/Performance Measures: Recommendation . . . . . e272 Recommendations ...... e296 7.3.2.9. Drugs of Unproven Value 13. Evidence Gaps and Future Research Directions . . e299 or That May Worsen HF: References ...... e299 Recommendations ...... e273 Appendix 1. Author Relationships With Industry 7.3.2.9.1. Nutritional Supplements and Other Entities (Relevant) ...... e320 and Hormonal Appendix 2. Reviewer Relationships With Industry Therapies ...... e273 and Other Entities (Relevant) ...... e323 7.3.2.9.2. Antiarrh ythmic Agents e273 Appendix 3. Abbreviations ...... e327 7.3.2.9.3. Calcium Channel Blockers: Recommendation . . . . . e273 7.3.2.9.4. Nonsteroidal Anti- Preamble Inflammatory Drugs . e274 The medical profession should play a central role in evaluating 7.3.2.9.5. Thiazolidinediones . .e274 the evidence related to drugs, devices, and procedures for the 7.3.3. Pharmacological Treatment for Stage detection, management, and prevention of disease. When prop- C HFpEF: Recommendations . . . . . e274 erly applied, expert analysis of available data on the benefits 7.3.4. De vice Therapy for Stage C HFrEF: and risks of these therapies and procedures can improve the Recommendations ...... e274 quality of care, optimize patient outcomes, and favorably affect 7.3.4.1. Implantable Cardioverter- costs by focusing resources on the most effective strategies. An Defibrillator ...... e278 organized and directed approach to a thorough review of evi- 7.3.4.2. Cardiac Resynchronization dence has resulted in the production of clinical practice guide- Therapy ...... e279 lines that assist clinicians in selecting the best management 7.4. Stage D ...... e280 strategy for an individual patient. Moreover, clinical practice 7.4.1. Definition ofAdvanced HF ...... e280 guidelines can provide a foundation for other applications, 7.4.2. Important Considerations in Determining If the Patient Is Refractory ...... e280 such as performance measures, appropriate use criteria, and 7.4.3. Water Restriction: Recommendation . . .e280 both quality improvement and clinical decision support tools. 7.4.4. Inotropic Support: Recommendations . . e281 The American College of Cardiology Foundation (ACCF) 7.4.5. Mechanical Circulatory Support: and the American Heart Association (AHA) have jointly pro- Recommendations ...... e282 duced guidelines in the area of cardiovascular disease since 7.4.6. Cardiac Transplantation: Recommendation .e283 1980. The ACCF/AHA Task Force on Practice Guidelines 8. The Hospitalized Patient ...... e284 (Task Force), charged with developing, updating, and revis- 8.1. Classification ofAcute Decompensated HF . . .e284 ing practice guidelines for cardiovascular diseases and proce- 8.2. Precipitating Causes of Decompensated HF: dures, directs and oversees this effort. Writing committees are Recommendations ...... e285 charged with regularly reviewing and evaluating all available Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e243
Table 1. Applying Classification of Recommendation and Level of Evidence
A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. evidence to develop balanced, patient-centric recommenda- In analyzing the data and developing recommendations and tions for clinical practice. supporting text, the writing committee uses evidence-based Experts in the subject under consideration are selected by methodologies developed by the Task Force.1 The Class of the ACCF and AHA to examine subject-specific data and write Recommendation (COR) is an estimate of the size of the treat- guidelines in partnership with representatives from other med- ment effect considering risks versus benefits in addition to evi- ical organizations and specialty groups. Writing committees dence and/or agreement that a given treatment or procedure is are asked to perform a literature review; weigh the strength or is not useful/effective or in some situations may cause harm. of evidence for or against particular tests, treatments, or pro- The Level of Evidence (LOE) is an estimate of the certainty cedures; and include estimates of expected outcomes where or precision of the treatment effect. The writing committee such data exist. Patient-specific modifiers, comorbidities, and reviews and ranks evidence supporting each recommenda- issues of patient preference that may influence the choice of tion with the weight of evidence ranked as LOE A, B, or C tests or therapies are considered. When available, information according to specific definitions that are included in Table 1. from studies on cost is considered, but data on efficacy and Studies are identified as observational, retrospective, prospec- outcomes constitute the primary basis for the recommenda- tive, or randomized where appropriate. For certain conditions tions contained herein. for which inadequate data are available, recommendations Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e244 Circulation October 15, 2013 are based on expert consensus and clinical experience and risks, benefits, and alternatives to a particular treatment and are ranked as LOE C. When recommendations at LOE C are be involved in shared decision making whenever feasible, supported by historical clinical data, appropriate references particularly for COR IIa and IIb, for which the benefit-to-risk (including clinical reviews) are cited if available. For issues ratio may be lower. for which sparse data are available, a survey of current prac- The Task Force makes every effort to avoid actual, potential, tice among the clinicians on the writing committee is the basis or perceived conflicts of interest that may arise as a result of for LOE C recommendations and no references are cited. The industry relationships or personal interests among the mem- schema for COR and LOE are summarized in Table 1, which bers of the writing committee. All writing committee members also provides suggested phrases for writing recommendations and peer reviewers of the guideline are required to disclose within each COR. A new addition to this methodology is sepa- all current healthcare-related relationships, including those ration of the Class III recommendations to delineate whether existing 12 months before initiation of the writing effort. In the recommendation is determined to be of “no benefit” or is December 2009, the ACCF and AHA implemented a new pol- associated with “harm” to the patient. In addition, in view of icy for relationship with industry and other entities (RWI) that the increasing number of comparative effectiveness studies, requires the writing committee chair plus a minimum of 50% comparator verbs and suggested phrases for writing recom- of the writing committee to have no relevant RWI (Appendix 1 mendations for the comparative effectiveness of one treatment includes the ACCF/AHA definition of relevance). These state- or strategy versus another have been added for COR I and IIa, ments are reviewed by the Task Force and all members during LOE A or B only. each conference call and/or meeting of the writing committee In view of the advances in medical therapy across the spec- and are updated as changes occur. All guideline recommen- trum of cardiovascular diseases, the Task Force has desig- dations require a confidential vote by the writing committee nated the term guideline-directed medical therapy (GDMT) and must be approved by a consensus of the voting members. to represent optimal medical therapy as defined by ACCF/ Members are not permitted to draft or vote on any text or rec- AHA guideline–recommended therapies (primarily Class I). ommendations pertaining to their RWI. Members who recused This new term, GDMT, will be used herein and throughout all themselves from voting are indicated in the list of writing future guidelines. committee members, and specific section recusals are noted Because the ACCF/AHA practice guidelines address patient in Appendix 1. Authors’ and peer reviewers’ RWI pertinent populations (and clinicians) residing in North America, drugs to this guideline are disclosed in Appendixes 1 and 2, respec- that are not currently available in North America are discussed tively. Additionally, to ensure complete transparency, writing in the text without a specific COR. For studies performed in committee members’ comprehensive disclosure information— large numbers of subjects outside North America, each writ- including RWI not pertinent to this document—is available ing committee reviews the potential influence of different as an online supplement. Comprehensive disclosure infor- practice patterns and patient populations on the treatment mation for the Task Force is also available online at http:// effect and relevance to the ACCF/AHA target population www.cardiosource.org/en/ACC/About-ACC/Who-We-Are/ to determine whether the findings should inform a specific Leadership/Guidelines-and-Documents-Task-Forces.aspx. recommendation. The work of writing committees is supported exclusively by The ACCF/AHA practice guidelines are intended to assist the ACCF and AHA without commercial support. Writing clinicians in clinical decision making by describing a range committee members volunteered their time for this activity. of generally acceptable approaches to the diagnosis, manage- In an effort to maintain relevance at the point of care for ment, and prevention of specific diseases or conditions. The practicing clinicians, the Task Force continues to oversee guidelines attempt to define practices that meet the needs of an ongoing process improvement initiative. As a result, in most patients in most circumstances. The ultimate judgment response to pilot projects, several changes to these guidelines regarding care of a particular patient must be made by the cli- will be apparent, including limited narrative text, a focus nician and patient in light of all the circumstances presented on summary and evidence tables (with references linked to by that patient. As a result, situations may arise for which abstracts in PubMed), and more liberal use of summary rec- deviations from these guidelines may be appropriate. Clinical ommendation tables (with references that support LOE) to decision making should involve consideration of the quality serve as a quick reference. and availability of expertise in the area where care is provided. In April 2011, the Institute of Medicine released 2 reports: When these guidelines are used as the basis for regulatory or Clinical Practice Guidelines We Can Trust and Finding What payer decisions, the goal should be improvement in quality of Works in Health Care: Standards for Systematic Reviews.2,3 care. The Task Force recognizes that situations arise in which It is noteworthy that the ACCF/AHA practice guidelines are additional data are needed to inform patient care more effec- cited as being compliant with many of the proposed standards. tively; these areas will be identified within each respective A thorough review of these reports and of our current meth- guideline when appropriate. odology is under way, with further enhancements anticipated. Prescribed courses of treatment in accordance with these The recommendations in this guideline are considered cur- recommendations are effective only if followed. Because lack rent until they are superseded by a focused update or the full- of patient understanding and adherence may adversely affect text guideline is revised. Guidelines are official policy of both outcomes, clinicians should make every effort to engage the the ACCF and AHA. patient’s active participation in prescribed medical regimens Jeffrey L. Anderson, MD, FACC, FAHA and lifestyles. In addition, patients should be informed of the Chair, ACCF/AHA Task Force on Practice Guidelines Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e245
1. Introduction All information on reviewers’ RWI was distributed to the writ- ing committee and is published in this document (Appendix 2). 1.1. Methodology and Evidence Review This document was approved for publication by the govern- The recommendations listed in this document are, when- ing bodies of the ACCF and AHA and endorsed by the American ever possible, evidence based. An extensive evidence review Association of Cardiovascular and Pulmonary Rehabilitation, was conducted through October 2011 and includes selected American College of Chest Physicians, Heart Rhythm Society, other references through April 2013. Searches were extended and International Society for Heart and Lung Transplantation. to studies, reviews, and other evidence conducted in human subjects and that were published in English from PubMed, 1.4. Scope of This Guideline With Reference to EMBASE, Cochrane, Agency for Healthcare Research and Other Relevant Guidelines or Statements Quality Reports, and other selected databases relevant to this This guideline covers multiple management issues for the guideline. Key search words included but were not limited to adult patient with HF. Although there is an abundance of the following: heart failure, cardiomyopathy, quality of life, evidence addressing HF, for many important clinical consid- mortality, hospitalizations, prevention, biomarkers, hyperten- erations, this writing committee was unable to identify suf- sion, dyslipidemia, imaging, cardiac catheterization, endo- ficient data to properly inform a recommendation. The writing myocardial biopsy, angiotensin-converting enzyme inhibitors, committee actively worked to reduce the number of LOE “C” angiotensin-receptor antagonists/blockers, beta blockers, car- recommendations, especially for Class I−recommended thera- diac, cardiac resynchronization therapy, defibrillator, device- pies. Despite these limitations, it is apparent that much can based therapy, implantable cardioverter-defibrillator, device be done for HF. Adherence to the clinical practice guidelines implantation, medical therapy, acute decompensated heart herein reproduced should lead to improved patient outcomes. failure, preserved ejection fraction, terminal care and trans- Although of increasing importance, HF in children and con- plantation, quality measures, and performance measures. genital heart lesions in adults are not specifically addressed in Additionally, the committee reviewed documents related to this guideline. The reader is referred to publically available the subject matter previously published by the ACCF and resources to address questions in these areas. However, this AHA. References selected and published in this document are guideline does address HF with preserved ejection fraction (EF) representative and not all-inclusive. in more detail and similarly revisits hospitalized HF. Additional To provide clinicians with a representative evidence base, areas of renewed interest are in stage D HF, palliative care, tran- whenever deemed appropriate or when published, the absolute sition of care, and quality of care for HF. Certain management risk difference and number needed to treat or harm are provided strategies appropriate for the patient at risk for HF or already in the guideline (within tables), along with confidence intervals affected by HF are also reviewed in numerous relevant clinical and data related to the relative treatment effects such as odds practice guidelines and scientific statements published by the ratio, relative risk, hazard ratio, and incidence rate ratio. ACCF/AHA Task Force on Practice Guidelines, AHA, ACCF Task Force on Appropriate Use Criteria, European Society of 1.2. Organization of the Writing Committee Cardiology, Heart Failure Society of America, and the National The committee was composed of physicians and a nurse with Heart, Lung, and Blood Institute. The writing committee saw broad expertise in the evaluation, care, and management of no need to reiterate the recommendations contained in those patients with heart failure (HF). The authors included general guidelines and chose to harmonize recommendations when cardiologists, HF and transplant specialists, electrophysiolo- appropriate and eliminate discrepancies. This is especially the gists, general internists, and physicians with methodologi- case for device-based therapeutics, where complete alignment cal expertise. The committee included representatives from between the HF guideline and the device-based therapy guide- the ACCF, AHA, American Academy of Family Physicians, line was deemed imperative.4 Some recommendations from American College of Chest Physicians, American College of earlier guidelines have been updated as warranted by new evi- Physicians, Heart Rhythm Society, and International Society dence or a better understanding of earlier evidence, whereas for Heart and Lung Transplantation. others that were no longer accurate or relevant or which were overlapping were modified; recommendations from previous 1.3. Document Review and Approval guidelines that were similar or redundant were eliminated or This document was reviewed by 2 official reviewers each consolidated when possible. nominated by both the ACCF and the AHA, as well as 1 to The present document recommends a combination of life- 2 reviewers each from the American Academy of Family style modifications and medications that constitute GDMT. Physicians, American College of Chest Physicians, Heart GDMT is specifically referenced in the recommendations for Rhythm Society, and International Society for Heart and Lung the treatment of HF (Section 7.3.2). Both for GDMT and other Transplantation, as well as 32 individual content review- recommended drug treatment regimens, the reader is advised ers (including members of the ACCF Adult Congenital and to confirm dosages with product insert material and to evalu- Pediatric Cardiology Council, ACCF Cardiovascular Team ate carefully for contraindications and drug-drug interactions. Council, ACCF Council on Cardiovascular Care for Older Table 2 is a list of documents deemed pertinent to this effort Adults, ACCF Electrophysiology Committee, ACCF Heart and is intended for use as a resource; it obviates the need to Failure and Transplant Council, ACCF Imaging Council, repeat already extant guideline recommendations. Additional ACCF Prevention Committee, ACCF Surgeons’ Scientific other HF guideline statements are highlighted as well for the Council, and ACCF Task Force on Appropriate Use Criteria). purpose of comparison and completeness. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e246 Circulation October 15, 2013
Table 2. Associated Guidelines and Statements
Publication Year Title Organization (Reference) Guidelines Guidelines for the Management of Adults With Congenital Heart Disease ACCF/AHA 20085 Guidelines for the Management of Patients With Atrial Fibrillation ACCF/AHA/HRS 20116–8 Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults ACCF/AHA 20109 Guideline for Coronary Artery Bypass Graft Surgery ACCF/AHA 201110 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities ACCF/AHA/HRS 20134 Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy ACCF/AHA 201111 Guideline for Percutaneous Coronary Intervention ACCF/AHA/SCAI 201112 Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic AHA/ACCF 201113 Vascular Disease: 2011 Update Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease ACCF/AHA/ACP/AATS/PCNA/SCAI/STS 201214 Guideline for the Management of ST-Elevation Myocardial Infarction ACCF/AHA 201315 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction ACCF/AHA 201316 Guidelines for the Management of Patients With Valvular Heart Disease ACCF/AHA 200817 Comprehensive Heart Failure Practice Guideline HFSA 201018 Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure ESC 201219 Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care NICE 201020 Antithrombotic Therapy and Prevention of Thrombosis ACCP 201221 Guidelines for the Care of Heart Transplant Recipients ISHLT 201022 Statements Contemporary Definitions and Classification of the Cardiomyopathies AHA 200623 Genetics and Cardiovascular Disease AHA 201224 Appropriate Utilization of Cardiovascular Imaging in Heart Failure ACCF 201325 Appropriate Use Criteria for Coronary Revascularization Focused Update ACCF 201226 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of NHLBI 200327 High Blood Pressure Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel NHLBI 200228 III Guidelines Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical AHA/AACVPR 201129 Centers and Beyond Decision Making in Advanced Heart Failure AHA 201230 Recommendations for the Use of Mechanical Circulatory Support: Device Strategies and Patient Selection AHA 201231 Advanced Chronic Heart Failure ESC 200732 Oral Antithrombotic Agents for the Prevention of Stroke in Nonvalvular Atrial Fibrillation AHA/ASA 201233 Third Universal Definition of Myocardial Infarction ESC/ACCF/AHA/WHF 201234 AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AATS, American Association for Thoracic Surgery; ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians; ACP, American College of Physicians; AHA, American Heart Association; ASA, American Stroke Association; ESC, European Society of Cardiology; HFSA, Heart Failure Society of America; HRS, Heart Rhythm Society; ISHLT, International Society for Heart and Lung Transplantation; NHLBI, National Heart, Lung, and Blood Institute; NICE, National Institute for Health and Clinical Excellence; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; and WHF, World Heart Federation.
2. Definition of HF signs or symptoms of volume overload, the term “heart HF is a complex clinical syndrome that results from any failure” is preferred over “congestive heart failure.” There structural or functional impairment of ventricular filling or is no single diagnostic test for HF because it is largely a ejection of blood. The cardinal manifestations of HF are clinical diagnosis based on a careful history and physical dyspnea and fatigue, which may limit exercise tolerance, examination. and fluid retention, which may lead to pulmonary and/ The clinical syndrome of HF may result from disorders or splanchnic congestion and/or peripheral edema. Some of the pericardium, myocardium, endocardium, heart valves, patients have exercise intolerance but little evidence of fluid or great vessels or from certain metabolic abnormalities, but retention, whereas others complain primarily of edema, most patients with HF have symptoms due to impaired left dyspnea, or fatigue. Because some patients present without ventricular (LV) myocardial function. It should be emphasized Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e247
Table 3. Definitions of HFrEF and HFpEF
Classification EF (%) Description I. Heart failure with reduced ≤40 Also referred to as systolic HF. Randomized controlled trials have mainly enrolled patients with HFrEF, and it is only in ejection fraction these patients that efficacious therapies have been demonstrated to date. (HFrEF) II. Heart failure with ≥50 Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF preserved ejection is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. fraction (HFpEF) To date, efficacious therapies have not been identified. a. HFpEF, borderline 41 to 49 These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patients with HFpEF. b. HFpEF, improved >40 It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients. EF indicates ejection fraction; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; and HFrEF, heart failure with reduced ejection fraction. that HF is not synonymous with either cardiomyopathy or LV HFpEF has been variably classified as EF >40%, >45%, dysfunction; these latter terms describe possible structural >50%, and ≥55%. Because some of these patients do not or functional reasons for the development of HF. HF may be have entirely normal EF but also do not have major reduc- associated with a wide spectrum of LV functional abnormali- tion in systolic function, the term preserved EF has been used. ties, which may range from patients with normal LV size and Patients with an EF in the range of 40% to 50% represent an preserved EF to those with severe dilatation and/or markedly intermediate group. These patients are often treated for under- reduced EF. In most patients, abnormalities of systolic and lying risk factors and comorbidities and with GDMT similar diastolic dysfunction coexist, irrespective of EF. EF is consid- to that used in patients with HFrEF. Several criteria have been ered important in classification of patients with HF because proposed to define the syndrome of HFpEF. These include a) of differing patient demographics, comorbid conditions, prog- clinical signs or symptoms of HF; b) evidence of preserved nosis, and response to therapies35 and because most clinical or normal LVEF; and c) evidence of abnormal LV diastolic trials selected patients based on EF. EF values are dependent dysfunction that can be determined by Doppler echocardiog- on the imaging technique used, method of analysis, and opera- raphy or cardiac catheterization.41 The diagnosis of HFpEF is tor. Because other techniques may indicate abnormalities in more challenging than the diagnosis of HFrEF because it is systolic function among patients with a preserved EF, it is largely one of excluding other potential noncardiac causes of preferable to use the terms preserved or reduced EF over pre- symptoms suggestive of HF. Studies have suggested that the served or reduced systolic function. For the remainder of this incidence of HFpEF is increasing and that a greater portion guideline, we will consistently refer to HF with preserved EF of patients hospitalized with HF have HFpEF. 42 In the gen- and HF with reduced EF as HFpEF and HFrEF, respectively eral population, patients with HFpEF are usually older women (Table 3). with a history of hypertension. Obesity, CAD, diabetes melli- tus, atrial fibrillation (AF), and hyperlipidemia are also highly 2.1. HF With Reduced EF (HFrEF) prevalent in HFpEF in population-based studies and regis- In approximately half of patients with HFrEF, variable tries.40,43 Despite these associated cardiovascular risk factors, degrees of LV enlargement may accompany HFrEF. 36,37 hypertension remains the most important cause of HFpEF, The definition of HFrEF has varied, with guidelines of left with a prevalence of 60% to 89% from large controlled tri- ventricular ejection fraction (LVEF) ≤35%, <40%, and als, epidemiological studies, and HF registries.44 It has been ≤40%.18,19,38 Randomized controlled trials (RCTs) in patients recognized that a subset of patients with HFpEF previously with HF have mainly enrolled patients with HFrEF with an had HFrEF. 45 These patients with improvement or recovery EF ≤35% or ≤40%, and it is only in these patients that effi- in EF may be clinically distinct from those with persistently cacious therapies have been demonstrated to date. For the preserved or reduced EF. Further research is needed to better present guideline, HFrEF is defined as the clinical diagnosis characterize these patients. of HF and EF ≤40%. Those with LV systolic dysfunction See Online Data Supplement 1 for additional data on commonly have elements of diastolic dysfunction as well.39 HFpEF. Although coronary artery disease (CAD) with antecedent myocardial infarction (MI) is a major cause of HFrEF, many 3. HF Classifications other risk factors (Section 4.6) may lead to LV enlargement Both the ACCF/AHA stages of HF38 and the New York Heart and HFrEF. Association (NYHA) functional classification38,46 provide use- ful and complementary information about the presence and 2.2. HF With Preserved EF (HFpEF) severity of HF. The ACCF/AHA stages of HF emphasize the In patients with clinical HF, studies estimate that the preva- development and progression of disease and can be used to lence of HFpEF is approximately 50% (range 40% to 71%).40 describe individuals and populations, whereas the NYHA These estimates vary largely because of the differing EF cut- classes focus on exercise capacity and the symptomatic status off criteria and challenges in diagnostic criteria for HFpEF. of the disease (Table 4). Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e248 Circulation October 15, 2013
Table 4. Comparison of ACCF/AHA Stages of HF and NYHA Functional Classifications
ACCF/AHA Stages of HF38 NYHA Functional Classification46 A At high risk for HF but without structural heart None disease or symptoms of HF B Structural heart disease but without signs or I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. symptoms of HF C Structural heart disease with prior or current I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. symptoms of HF II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. D Refractory HF requiring specialized interventions IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. ACCF indicates American College of Cardiology Foundation; AHA, American Heart Association; HF, heart failure; and NYHA, New York Heart Association.
The ACCF/AHA stages of HF recognize that both risk fac- having a greater 5-year mortality rate than whites.58 HF in tors and abnormalities of cardiac structure are associated with non-Hispanic black males and females has a prevalence of HF. The stages are progressive and inviolate; once a patient 4.5% and 3.8%, respectively, versus 2.7% and 1.8% in non- moves to a higher stage, regression to an earlier stage of HF Hispanic white males and females, respectively.51 is not observed. Progression in HF stages is associated with reduced 5-year survival and increased plasma natriuretic pep- 4.1. Mortality tide concentrations.47 Therapeutic interventions in each stage Although survival has improved, the absolute mortality rates aimed at modifying risk factors (stage A), treating structural for HF remain approximately 50% within 5 years of diagno- heart disease (stage B), and reducing morbidity and mortality sis.53,59 In the ARIC study, the 30-day, 1-year, and 5-year case (stages C and D) (covered in detail in Section 7) are reviewed fatality rates after hospitalization for HF were 10.4%, 22%, in this document. The NYHA functional classification gauges and 42.3%, respectively.58 In another population cohort study the severity of symptoms in those with structural heart dis- with 5-year mortality data, survival for stage A, B, C, and ease, primarily stages C and D. It is a subjective assessment D HF was 97%, 96%, 75%, and 20%, respectively.47 Thirty- by a clinician and can change frequently over short periods of day postadmission mortality rates decreased from 12.6% to time. Although reproducibility and validity may be problem- 10.8% from 1993 to 2005; however, this was due to lower atic,48 the NYHA functional classification is an independent in-hospital death rates. Postdischarge mortality actually predictor of mortality.49 It is widely used in clinical practice increased from 4.3% to 6.4% during the same time frame.60 and research and for determining the eligibility of patients for These observed temporal trends in HF survival are primar- certain healthcare services. ily restricted to patients with reduced EF and are not seen in See Online Data Supplement 2 for additional data on those with preserved EF.40 ACCF/AHA stages of HF and NYHA functional classifications. See Online Data Supplement 3 for additional data on mortality. 4. Epidemiology The lifetime risk of developing HF is 20% for Americans ≥40 4.2. Hospitalizations years of age.50 In the United States, HF incidence has largely HF is the primary diagnosis in >1 million hospitalizations annu- remained stable over the past several decades, with >650 000 ally.51 Patients hospitalized for HF are at high risk for all-cause new HF cases diagnosed annually.51–53 HF incidence increases rehospitalization, with a 1-month readmission rate of 25%.61 In with age, rising from approximately 20 per 1000 individuals 2013, physician office visits for HF cost $1.8 billion. The total 65 to 69 years of age to >80 per 1000 individuals among those cost of HF care in the United States exceeds $30 billion annu- ≥85 years of age.52 Approximately 5.1 million persons in the ally, with over half of these costs spent on hospitalizations.51 United States have clinically manifest HF, and the prevalence continues to rise.51 In the Medicare-eligible population, HF 4.3. Asymptomatic LV Dysfunction prevalence increased from 90 to 121 per 1000 beneficiaries The prevalence of asymptomatic LV systolic or diastolic dys- from 1994 to 2003.52 HFrEF and HFpEF each make up about function ranges from 6% to 21% and increases with age.62–64 half of the overall HF burden.54 One in 5 Americans will be In the Left Ventricular Dysfunction Prevention study, partici- >65 years of age by 2050.55 Because HF prevalence is highest pants with untreated asymptomatic LV dysfunction had a 10% in this group, the number of Americans with HF is expected to risk for developing HF symptoms and an 8% risk of death or significantly worsen in the future. Disparities in the epidemi- HF hospitalization annually.65 In a community-based popula- ology of HF have been identified. Blacks have the highest risk tion, asymptomatic mild LV diastolic dysfunction was seen in for HF.56 In the ARIC (Atherosclerosis Risk in Communities) 21% and moderate or severe diastolic dysfunction in 7%, and study, incidence rate per 1000 person-years was lowest among both were associated with an increased risk of symptomatic white women52,53 and highest among black men,57 with blacks HF and mortality.64 Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e249
4.4. Health-Related Quality of Life and and women have a substantially greater risk for developing Functional Status HF than normotensive men and women.91 Elevated levels of HF significantly decreases health-related quality of life diastolic and especially systolic blood pressure are major risk (HRQOL), especially in the areas of physical functioning and factors for the development of HF.91,92 The incidence of HF is vitality.66,67 Lack of improvement in HRQOL after discharge greater with higher levels of blood pressure, older age, and from the hospital is a powerful predictor of rehospitalization longer duration of hypertension. Long-term treatment of both and mortality.68,69 Women with HF have consistently been systolic and diastolic hypertension reduces the risk of HF by found to have poorer HRQOL than men.67,70 Ethnic differences approximately 50%.93–96 With nearly a quarter of the American also have been found, with Mexican Hispanics reporting better population afflicted by hypertension and the lifetime risk of HRQOL than other ethnic groups in the United States.71 Other developing hypertension at >75% in the United States,97 strat- determinants of poor HRQOL include depression, younger egies to control hypertension are a vital part of any public age, higher body mass index (BMI), greater symptom burden, health effort to prevent HF. lower systolic blood pressure, sleep apnea, low perceived con- Diabetes Mellitus trol, and uncertainty about prognosis.70,72–76 Memory problems Obesity and insulin resistance are important risk factors for may also contribute to poor HRQOL.76 the development of HF.98,99 The presence of clinical diabetes Pharmacological therapy is not a consistent determinant of mellitus markedly increases the likelihood of developing HF HRQOL; therapies such as angiotensin-converting enzyme in patients without structural heart disease100 and adversely (ACE) inhibitors and angiotensin-receptor blockers (ARBs) affects the outcomes of patients with established HF.101,102 improve HRQOL only modestly or delay the progressive worsening of HRQOL in HF.77 At present, the only therapies Metabolic Syndrome shown to improve HRQOL are cardiac resynchronization The metabolic syndrome includes any 3 of the following: therapy (CRT)78 and certain disease management and edu- abdominal adiposity, hypertriglyceridemia, low high-den- cational approaches.79–82 Self-care and exercise may improve sity lipoprotein, hypertension, and fasting hyperglycemia. HRQOL, but the results of studies evaluating these interven- The prevalence of metabolic syndrome in the United States tions are mixed.83–86 Throughout this guideline we refer to exceeds 20% of persons ≥20 years of age and 40% of those meaningful survival as a state in which HRQOL is satisfac- >40 years of age.103 The appropriate treatment of hyperten- tory to the patient. sion, diabetes mellitus, and dyslipidemia104 can significantly See Online Data Supplement 4 for additional data on reduce the development of HF. HRQOL and functional capacity. Atherosclerotic Disease Patients with known atherosclerotic disease (eg, of the cor- 4.5. Economic Burden of HF onary, cerebral, or peripheral blood vessels) are likely to In 1 in 9 deaths in the United States, HF is mentioned on the develop HF, and clinicians should seek to control vascular risk death certificate. The number of deaths with any mention of factors in such patients according to guidelines.13 HF was as high in 2006 as it was in 1995.51 Approximately 7% of all cardiovascular deaths are due to HF. As previously noted, in 2013, HF costs in the United States 5. Cardiac Structural Abnormalities exceeded $30 billion.51 This total includes the cost of health- and Other Causes of HF care services, medications, and lost productivity. The mean 5.1. Dilated Cardiomyopathies cost of HF-related hospitalizations was $23 077 per patient 5.1.1. Definition and Classification of Dilated and was higher when HF was a secondary rather than the pri- Cardiomyopathies mary diagnosis. Among patients with HF in 1 large population Dilated cardiomyopathy (DCM) refers to a large group of study, hospitalizations were common after HF diagnosis, with heterogeneous myocardial disorders that are characterized by 83% of patients hospitalized at least once and 43% hospital- ventricular dilation and depressed myocardial contractility in ized at least 4 times. More than half of the hospitalizations the absence of abnormal loading conditions such as hyperten- were related to noncardiovascular causes.87–89 sion or valvular disease. In clinical practice and multicenter HF trials, the etiology of HF has often been categorized into 4.6. Important Risk Factors for HF (Hypertension, ischemic or nonischemic cardiomyopathy, with the term DCM Diabetes Mellitus, Metabolic Syndrome, and used interchangeably with nonischemic cardiomyopathy. This Atherosclerotic Disease) approach fails to recognize that “nonischemic cardiomyopa- Many conditions or comorbidities are associated with an thy” may include cardiomyopathies due to volume or pres- increased propensity for structural heart disease. The expedi- sure overload, such as hypertension or valvular heart disease, ent identification and treatment of these comorbid conditions which are not conventionally accepted as DCM.105 With the may forestall the onset of HF.14,27,90 A list of the important doc- identification of genetic defects in several forms of cardiomy- uments that codify treatment for these concomitant conditions opathies, a new classification scheme based on genomics was appears in Table 2. proposed in 2006.23 We recognize that classification of car- Hypertension diomyopathies is challenging, mixing anatomic designations Hypertension may be the single most important modifiable (ie, hypertrophic and dilated) with functional designations (ie, risk factor for HF in the United States. Hypertensive men restrictive), and is unlikely to satisfy all users. The aim of the Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e250 Circulation October 15, 2013 present guideline is to target appropriate diagnostic and treat- persistent increase in cardiac output, cardiac work, and ment strategies for preventing the development and progres- systemic blood pressure124 along with lipotoxicity-induced sion of HF in patients with cardiomyopathies; we do not wish cardiac myocyte injury and myocardial lipid accumulation to redefine new classification strategies for cardiomyopathies. have been implicated as potential mechanisms.125,126A study with participants from the Framingham Heart Study reported 5.1.2. Epidemiology and Natural History of DCM that after adjustment for established risk factors, obesity was The age-adjusted prevalence of DCM in the United States aver- associated with significant future risk of development of ages 36 cases per 100 000 population, and DCM accounts for HF. 99 There are no large-scale studies of the safety or effi- 10 000 deaths annually.106 In most multicenter RCTs and reg- cacy of weight loss with diet, exercise, or bariatric surgery in istries in HF, approximately 30% to 40% of enrolled patients obese patients with HF. have DCM.107–109 Compared with whites, African Americans have almost a 3-fold increased risk for developing DCM, irre- 5.3.2. Diabetic Cardiomyopathy spective of comorbidities or socioeconomic factors.108–110 Sex- Diabetes mellitus is now well recognized as a risk factor for related differences in the incidence and prognosis of DCM the development of HF independent of age, hypertension, obe- are conflicting and may be confounded by differing etiolo- sity, hypercholesterolemia, or CAD. The association between gies.108,109,111 The prognosis in patients with symptomatic HF mortality and hemoglobin A1c (HbA1c) in patients with and DCM is relatively poor, with 25% mortality at 1 year and diabetes mellitus and HF appears U-shaped, with the lowest 50% mortality at 5 years.112 Approximately 25% of patients risk of death in those patients with modest glucose control with DCM with recent onset of HF symptoms will improve (7.1%
Table 5. Screening of Family Members and Genetic Testing in Patients With Idiopathic or Familial DCM
Condition Screening of Family Members Genetic Testing Familial DCM • First-degree relatives not known to be affected should undergo periodic, • Genetic testing may be considered in conjunction with genetic serial echocardiographic screening with assessment of LV function and size. counseling.118,121–123 • Frequency of screening is uncertain, but every 3–5 y is reasonable.118 Idiopathic DCM • Patients should inform first-degree relatives of their diagnosis. • The utility of genetic testing in this setting remains uncertain. • Relatives should update their clinicians and discuss whether they should • Yield of genetic testing may be higher in patients with undergo screening by echocardiography. significant cardiac conduction disease and/or a family history of premature sudden cardiac death.118,121–123 DCM indicates dilated cardiomyopathy; and LV, left ventricular. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e251
5.4. Toxic Cardiomyopathy Ephedra, which has been used for athletic performance enhancement and weight loss, was ultimately banned by the 5.4.1. Alcoholic Cardiomyopathy US Food and Drug Administration for its high rate of adverse Chronic alcoholism is one of the most important causes of cardiovascular outcomes, including LV systolic dysfunction, DCM.136 The clinical diagnosis is suspected when biven- development of HF, and sudden cardiac death (SCD).151 tricular dysfunction and dilatation are persistently observed Primary and secondary nutritional deficiencies may lead in a heavy drinker in the absence of other known causes for to cardiomyopathy. Chronic alcoholism, anorexia nervosa, myocardial disease. Alcoholic cardiomyopathy most com- AIDS, and pregnancy can account for other rare causes of monly occurs in men 30 to 55 years of age who have been thiamine deficiency–related cardiomyopathy in the western heavy consumers of alcohol for >10 years.137 Women repre- world.152 Deficiency in l-carnitine, a necessary cofactor for sent approximately 14% of the alcoholic cardiomyopathy fatty acid oxidation, may be associated with a syndrome of cases but may be more vulnerable with less lifetime alcohol progressive skeletal myopathy and cardiomyopathy.153 consumption.136,138 The risk of asymptomatic alcoholic cardio- myopathy is increased in those consuming >90 g of alcohol 5.5. Tachycardia-Induced Cardiomyopathy per day (approximately 7 to 8 standard drinks per day) for >5 Tachycardia-induced cardiomyopathy is a reversible cause of years.137 Interestingly, in the general population, mild to mod- HF characterized by LV myocardial dysfunction caused by erate alcohol consumption has been reported to be protective increased ventricular rate. The degree of dysfunction correlates against development of HF.139,140 These paradoxical findings with the duration and rate of the tachyarrhythmia. Virtually any suggest that duration of exposure and individual genetic sus- supraventricular tachycardia with a rapid ventricular response ceptibility play an important role in pathogenesis. Recovery of may induce cardiomyopathy. Ventricular arrhythmias, includ- LV function after cessation of drinking has been reported.141 ing frequent premature ventricular complexes, may also induce Even if LV dysfunction persists, the symptoms and signs of cardiomyopathy. Maintenance of sinus rhythm or control of HF improve after abstinence.141 ventricular rate is critical to treating patients with tachycardia- 5.4.2. Cocaine Cardiomyopathy induced cardiomyopathy.154 Reversibility of the cardiomyopa- Long-term abuse of cocaine may result in DCM even with- thy with treatment of the arrhythmia is the rule, although this out CAD, vasculitis, or MI. Depressed LV function has been may not be complete in all cases. The underlying mechanisms reported in 4% to 18% of asymptomatic cocaine abusers.142–144 for this are not well understood. The safety and efficacy of beta blockers for chronic HF due to Ventricular pacing at high rates may cause cardiomyopathy. cocaine use are unknown.145 Additionally, right ventricular pacing alone may exacerbate HF symptoms, increase hospitalization for HF, and increase 5.4.3. Cardiotoxicity Related to Cancer Therapies mortality.155,156 Use of CRT in patients with a conduction delay Several cytotoxic antineoplastic drugs, especially the anthra- due to pacing may result in improved LV function and func- cyclines, are cardiotoxic and can lead to long-term cardiac tional capacity. morbidity. Iron-chelating agents that prevent generation of oxygen free radicals, such as dexrazoxane, are cardioprotec- 5.6. Myocarditis and Cardiomyopathies Due to tive,146,147 and reduce the occurrence and severity of anthracy- Inflammation cline-induced cardiotoxicity and development of HF. Other antineoplastic chemotherapies with cardiac toxicity 5.6.1. Myocarditis are the monoclonal antibody trastuzumab (Herceptin), high- Inflammation of the heart may cause HF in about 10% of cases 105,157 dose cyclophosphamide, taxoids, mitomycin-C, 5-fluoroura- of initially unexplained cardiomyopathy. A variety of infec- cil, and the interferons.148 In contrast to anthracycline-induced tious organisms, as well as toxins and medications, most often cardiac toxicity, trastuzumab-related cardiac dysfunction postviral in origin, may cause myocarditis. In addition, myocar- does not appear to increase with cumulative dose, nor is it ditis is also seen as part of other systemic diseases such as sys- associated with ultrastructural changes in the myocardium. temic lupus erythematosus and other myocardial muscle diseases However, concomitant anthracycline therapy significantly such as HIV cardiomyopathy and possibly peripartum cardiomy- increases the risk for cardiotoxicity during trastuzumab treat- opathy. Presentation may be acute, with a distinct onset, severe ment. The cardiac dysfunction associated with trastuzumab hemodynamic compromise, and severe LV dysfunction as seen is most often reversible on discontinuation of treatment and in acute fulminant myocarditis, or it may be subacute, with an indistinct onset and better-tolerated LV dysfunction.158 Prognosis initiation of standard medical therapy for HF.149 The true inci- varies, with spontaneous complete resolution (paradoxically dence and reversibility of chemotherapy-related cardiotoxic- most often seen with acute fulminant myocarditis)158 to the devel- ity are not well documented, and meaningful interventions to opment of DCM despite immunosuppressive therapy.159 The role prevent injury have not yet been elucidated. of immunosuppressive therapy is controversial.159 Targeting such 5.4.4. Other Myocardial Toxins and Nutritional Causes of therapy to specific individuals based on the presence or absence Cardiomyopathy of viral genome in myocardial biopsy samples may improve In addition to the classic toxins described above, a number of response to immunosuppressive therapy.160 other toxic agents may lead to LV dysfunction and HF, includ- Giant cell myocarditis is a rare form of myocardial inflam- ing ephedra, cobalt, anabolic steroids, chloroquine, clozap- mation characterized by fulminant HF, often associated with ine, amphetamine, methylphenidate, and catecholamines.150 refractory ventricular arrhythmias and a poor prognosis.161,162 Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e252 Circulation October 15, 2013
Histologic findings include diffuse myocardial necrosis with microcirculatory disturbances. Myocardial disease in rheuma- numerous multinucleated giant cells without granuloma for- toid arthritis can occur in the absence of clinical symptoms or mation. Consideration for advanced HF therapies, including abnormalities of the electrocardiogram (ECG).173 immunosuppression, mechanical circulatory support (MCS), and transplantation, is warranted. 5.8. Peripartum Cardiomyopathy Peripartum cardiomyopathy is a disease of unknown cause 5.6.2. Acquired Immunodeficiency Syndrome in which LV dysfunction occurs during the last trimester of The extent of immunodeficiency influences the incidence of pregnancy or the early puerperium. It is reported in 1:1300 to HIV-associated DCM.163–165 In long-term echocardiographic 1:4000 live births.174 Risk factors for peripartum cardiomy- follow-up,166 8% of initially asymptomatic HIV-positive opathy include advanced maternal age, multiparity, African patients were diagnosed with DCM during the 5-year follow- descent, and long-term tocolysis. Although its etiology remains up. Whether early treatment with ACE inhibitors and/or beta unknown, most theories have focused on hemodynamic and blockers will prevent or delay disease progression in these immunologic causes.174 The prognosis of peripartum cardio- patients is unknown at this time. myopathy is related to the recovery of ventricular function. 5.6.3. Chagas Disease Significant improvement in myocardial function is seen in 30% Although Chagas disease is a relatively uncommon cause of to 50% of patients in the first 6 months after presentation.174 DCM in North America, it remains an important cause of death However, for those patients who do not recover to normal or in Central and South America.167 Symptomatic chronic Chagas near-normal function, the prognosis is similar to other forms disease develops in an estimated 10% to 30% of infected per- of DCM.175 Cardiomegaly that persists for >4 to 6 months after sons, years or even decades after the Trypanosoma cruzi infec- diagnosis indicates a poor prognosis, with a 50% mortality rate tion. Cardiac changes may include biventricular enlargement, at 6 years. Subsequent pregnancy in women with a history of thinning or thickening of ventricular walls, apical aneurysms, peripartum cardiomyopathy may be associated with a further and mural thrombi. The conduction system is often affected, decrease in LV function and can result in clinical deterioration, typically resulting in right bundle-branch block, left anterior including death. However, if ventricular function has normal- fascicular block, or complete atrioventricular block. ized in women with a history of peripartum cardiomyopathy, the risk may be less.174 There is an increased risk of venous 5.7. Inflammation-Induced Cardiomyopathy: thromboembolism, and anticoagulation is recommended, espe- Noninfectious Causes cially if ventricular dysfunction is persistent. 5.7.1. Hypersensitivity Myocarditis 5.9. Cardiomyopathy Caused By Iron Overload Hypersensitivity to a variety of agents may result in aller- Iron overload cardiomyopathy manifests itself as systolic or gic reactions that involve the myocardium, characterized by diastolic dysfunction secondary to increased deposition of peripheral eosinophilia and a perivascular infiltration of the iron in the heart and occurs with common genetic disorders myocardium by eosinophils, lymphocytes, and histiocytes. A such as primary hemochromatosis or with lifetime transfusion variety of drugs, most commonly the sulfonamides, penicil- requirements as seen in beta-thalassemia major.176 Hereditary lins, methyldopa, and other agents such as amphotericin B, hemochromatosis, an autosomal recessive disorder, is the streptomycin, phenytoin, isoniazid, tetanus toxoid, hydro- most common hereditary disease of Northern Europeans, with chlorothiazide, dobutamine, and chlorthalidone, have been a prevalence of approximately 5 per 1000. The actuarial sur- reported to cause allergic hypersensitivity myocarditis.168 vival rates of persons who are homozygous for the mutation Most patients are not clinically ill but may die suddenly, pre- of the hemochromatosis gene C282Y have been reported to be sumably secondary to an arrhythmia. 95%, 93%, and 66%, at 5, 10, and 20 years, respectively.177 Similarly, in patients with thalassemia major, cardiac failure 5.7.2. Rheumatological/Connective Tissue Disorders is one of the most frequent causes of death. Chelation therapy, Along with a number of cardiac abnormalities (eg, pericar- including newer forms of oral chelators, such as deferoxamine, ditis, pericardial effusion, conduction system abnormali- and phlebotomy, have dramatically improved the outcome of ties, including complete atrioventricular heart block), DCM hemochromatosis, and the roles of gene therapy, hepcidin, and can be a rare manifestation of systemic lupus erythematosus calcium channel blockers are being actively investigated.178 and usually correlates with disease activity.169 Studies sug- gest that echocardiographic evidence of abnormal LV filling 5.10. Amyloidosis may reflect the presence of myocardial fibrosis and could be Cardiac amyloidosis involves the deposition of insoluble a marker of subclinical myocardial involvement in systemic proteins as fibrils in the heart, resulting in HF. Primary or lupus erythematosus patients.170 AL amyloidosis (monoclonal kappa or lambda light chains), Scleroderma is a rare cause of DCM. One echocardio- secondary amyloidosis (protein A), familial TTR amyloidosis graphic study showed that despite normal LV dimensions or (mutant transthyretin), dialysis-associated amyloidosis (beta- fractional shortening, subclinical systolic impairment was 2-microglobulin), or senile TTR amyloidosis (wild-type present in the majority of patients with scleroderma.171 Cardiac transthyretin) can affect the heart, but cardiac involvement involvement in rheumatoid arthritis generally is in the form is primarily encountered in AL and TTR amyloidosis.179 The of myocarditis and/or pericarditis, and development of DCM disease can be rapidly progressive, and in patients with ven- is rare.172 Myocardial involvement in rheumatoid arthritis is tricular septum thickness >15 mm, LVEF <40%, and symp- thought to be secondary to microvasculitis and subsequent toms of HF, median survival may be <6 months.180 Cardiac Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e253 biomarkers (eg, B-type natriuretic peptide [BNP], cardiac history and physical examination remain the cornerstones troponin) have been reported to predict response and progres- in the assessment of patients with HF. The components of sion of disease and survival.181 Three percent to 4% of African a focused history and physical examination for the patient Americans carry an amyloidogenic allele of the human serum with HF are listed in Table 6. The history provides clues protein transthyretin (TTR V122I), which appears to increase to the etiology of the cardiomyopathy, including the diag- risk for cardiac amyloid deposition after 65 years of age.182 nosis of familial cardiomyopathy (defined as≥ 2 relatives with idiopathic DCM). Familial syndromes are now rec- 5.11. Cardiac Sarcoidosis ognized to occur in 20% to 35% of patients with appar- Cardiac sarcoidosis is an underdiagnosed disease that may ent idiopathic DCM118; thus, a 3-generation family history affect as many as 25% of patients with systemic sarcoidosis. should be obtained. The history also provides information Although most commonly recognized in patients with other about the severity of the disease and the patient’s prognosis manifestations of sarcoidosis, cardiac involvement may occur and identifies opportunities for therapeutic interventions. in isolation and go undetected. Cardiac sarcoidosis may pres- The physical examination provides information about the ent as asymptomatic LV dysfunction, HF, atrioventricular severity of illness and allows assessment of volume status block, atrial or ventricular arrhythmia, and SCD.183 Although and adequacy of perfusion. In advanced HFrEF, orthopnea untested in clinical trials, early use of high-dose steroid ther- and jugular venous pressure are useful findings to detect apy may halt or reverse cardiac damage.184 Cardiac magnetic elevated LV filling pressures.187,189,190 resonance and cardiac positron emission tomographic scan- See Online Data Supplements 5, 6, and 7 for additional ning can identify cardiac involvement with patchy areas of data on stress testing and clinical evaluation. myocardial inflammation and fibrosis. In the setting of ven- tricular tachyarrhythmia, patients may require placement of 6.1.2. Risk Scoring: Recommendation an implantable cardioverter-defibrillator (ICD) for primary Class IIa 185 prevention of SCD. 1. Validated multivariable risk scores can be useful to estimate subsequent risk of mortality in ambula- 5.12. Stress (Takotsubo) Cardiomyopathy tory or hospitalized patients with HF.199–207 (Level of Stress cardiomyopathy is characterized by acute reversible Evidence: B) LV dysfunction in the absence of significant CAD, triggered In the course of standard evaluation, clinicians should rou- 23 by acute emotional or physical stress. This phenomenon is tinely assess the patient’s potential for adverse outcome, identified by a distinctive pattern of “apical ballooning,” first because accurate risk stratification may help guide thera- described in Japan as takotsubo, and often affects postmeno- peutic decision making, including a more rapid transition to 186 pausal women. A majority of patients have a clinical presen- advanced HF therapies. A number of methods objectively tation similar to that of acute coronary syndrome (ACS) and assess risk, including biomarker testing (Section 6.3), as well may have transiently elevated cardiac enzymes. as a variety of multivariable clinical risk scores (Table 7); these risk scores are for use in ambulatory199,203,205,206,208 and 6. Initial and Serial Evaluation hospitalized patients.200,202,204,205,209 Risk models specifically for 201 of the HF Patient patients with HFpEF have also been described. One well-validated risk score, the Seattle Heart Failure 6.1. Clinical Evaluation Model, is available in an interactive application on the Internet210 and provides robust information about risk of mor- 6.1.1. History and Physical Examination: Recommendations tality in ambulatory patients with HF. For patients hospital- ized with acutely decompensated HF, the model developed Class I by ADHERE (Acute Decompensated Heart Failure National Registry) incorporates 3 routinely measured variables on 1. A thorough history and physical examination should hospital admission (ie, systolic blood pressure, blood urea be obtained/performed in patients presenting with nitrogen, and serum creatinine) and stratifies subjects into HF to identify cardiac and noncardiac disorders or categories with a 10-fold range of crude in-hospital mortal- behaviors that might cause or accelerate the develop- ity (from 2.1% to 21.9%).200 Notably, clinical risk scores have ment or progression of HF. (Level of Evidence: C) not performed as well in estimating risk of hospital readmis- 2. In patients with idiopathic DCM, a 3-generational sion.211 For this purpose, biomarkers such as natriuretic pep- family history should be obtained to aid in establishing tides hold considerable promise212,213 (Section 6.3). the diagnosis of familial DCM. (Level of Evidence: C) See Online Data Supplement 8 for additional data on clini- 3. Volume status and vital signs should be assessed at each patient encounter. This includes serial assess- cal evaluation risk scoring. ment of weight, as well as estimates of jugular venous 6.2. Diagnostic Tests: Recommendations pressure and the presence of peripheral edema or orthopnea.187–190 (Level of Evidence: B) Class I
Despite advances in imaging technology and increas- 1. Initial laboratory evaluation of patients present- ing availability of diagnostic laboratory testing, a careful ing with HF should include complete blood count, Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e254 Circulation October 15, 2013
Table 6. History and Physical Examination in HF
Comments History Potential clues suggesting etiology of HF A careful family history may identify an underlying familial cardiomyopathy in patients with idiopathic DCM.118 Other etiologies outlined in Section 5 should be considered as well. Duration of illness A patient with recent-onset systolic HF may recover over time.113 Severity and triggers of dyspnea and fatigue, presence of chest pain, To determine NYHA class; identify potential symptoms of coronary ischemia. exercise capacity, physical activity, sexual activity Anorexia and early satiety, weight loss Gastrointestinal symptoms are common in patients with HF. Cardiac cachexia is associated with adverse prognosis.191 Weight gain Rapid weight gain suggests volume overload. Palpitations, (pre)syncope, ICD shocks Palpitations may be indications of paroxysmal AF or ventricular tachycardia. ICD shocks are associated with adverse prognosis.192 Symptoms suggesting transient ischemic attack or thromboembolism Affects consideration of the need for anticoagulation. Development of peripheral edema or ascites Suggests volume overload. Disordered breathing at night, sleep problems Treatment for sleep apnea may improve cardiac function and decrease pulmonary hypertension.193 Recent or frequent prior hospitalizations for HF Associated with adverse prognosis.194 History of discontinuation of medications for HF Determine whether lack of GDMT in patients with HFrEF reflects intolerance, an adverse event, or perceived contraindication to use. Withdrawal of these medications has been associated with adverse prognosis.195,196 Medications that may exacerbate HF Removal of such medications may represent a therapeutic opportunity. Diet Awareness and restriction of sodium and fluid intake should be assessed. Adherence to medical regimen Access to medications; family support; access to follow-up; cultural sensitivity Physical Examination BMI and evidence of weight loss Obesity may be a contributing cause of HF; cachexia may correspond with poor prognosis. Blood pressure (supine and upright) Assess for hypertension or hypotension. Width of pulse pressure may reflect adequacy of cardiac output. Response of blood pressure to Valsalva maneuver may reflect LV filling pressures.197 Pulse Manual palpation will reveal strength and regularity of pulse rate. Examination for orthostatic changes in blood pressure and heart rate Consistent with volume depletion or excess vasodilation from medications. Jugular venous pressure at rest and following abdominal Most useful finding on physical examination to identify congestion.187–190,198 compression (http://wn.com/jugular_venous_distension_example)
188 Presence of extra heart sounds and murmurs S3 is associated with adverse prognosis in HFrEF. Murmurs may be suggestive of valvular heart disease. Size and location of point of maximal impulse Enlarged and displaced point of maximal impulse suggests ventricular enlargement. Presence of right ventricular heave Suggests significant right ventricular dysfunction and/or pulmonary hypertension. Pulmonary status: respiratory rate, rales, pleural effusion In advanced chronic HF, rales are often absent despite major pulmonary congestion. Hepatomegaly and/or ascites Usually markers of volume overload. Peripheral edema Many patients, particularly those who are young, may be not edematous despite intravascular volume overload. In obese patients and elderly patients, edema may reflect peripheral rather than cardiac causes. Temperature of lower extremities Cool lower extremities may reflect inadequate cardiac output. AF indicates atrial fibrillation; BMI, body mass index; DCM, dilated cardiomyopathy; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; LV, left ventricular; and NYHA, New York Heart Association.
urinalysis, serum electrolytes (including calcium and Class IIa magnesium), blood urea nitrogen, serum creatinine, glucose, fasting lipid profile, liver function tests, and 1. Screening for hemochromatosis or HIV is reasonable thyroid-stimulating hormone. (Level of Evidence: C) in selected patients who present with HF.216 (Level of 2. Serial monitoring, when indicated, should include Evidence: C) serum electrolytes and renal function. (Level of 2. Diagnostic tests for rheumatologic diseases, amy- Evidence: C) loidosis, or pheochromocytoma are reasonable in 3. A 12-lead ECG should be performed initially on all patients presenting with HF in whom there is a clini- patients presenting with HF. (Level of Evidence: C) cal suspicion of these diseases. (Level of Evidence: C) Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e255
Table 7. Selected Multivariable Risk Scores to Predict Outcome in HF
Risk Score Reference/Link Chronic HF All patients with chronic HF Seattle Heart Failure Model 203/http://SeattleHeartFailureModel.org Heart Failure Survival Score 199/http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc-37354.shtml CHARM Risk Score 206 CORONA Risk Score 207 Specific to chronic HFpEF I-PRESERVE Score 201
Acutely decompensated HF ADHERE Classification and Regression Tree (CART) Model 200 American Heart Association Get With The Guidelines Score 205/http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidelinesHFStroke/ GetWithTheGuidelinesHeartFailureHomePage/Get-With-The-Guidelines-Heart-Failure-Home-%20 Page_UCM_306087_SubHomePage.jsp EFFECT Risk Score 202/http://www.ccort.ca/Research/CHFRiskModel.aspx ESCAPE Risk Model and Discharge Score 214 OPTIMIZE HF Risk-Prediction Nomogram 215 ADHERE indicates Acute Decompensated Heart Failure National Registry; CHARM, Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity; CORONA, Controlled Rosuvastatin Multinational Trial in Heart Failure; EFFECT, Enhanced Feedback for Effective Cardiac Treatment; ESCAPE, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; I-PRESERVE, Irbesartan in Heart Failure with Preserved Ejection Fraction Study; and OPTIMIZE, Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure.
6.3. Biomarkers: Recommendations B. Hospitalized/Acute A. Ambulatory/Outpatient Class I
Class I 1. Measurement of BNP or NT-proBNP is useful to sup- port clinical judgment for the diagnosis of acutely 1. In ambulatory patients with dyspnea, measure- decompensated HF, especially in the setting of uncer- ment of BNP or N-terminal pro-B-type natriuretic tainty for the diagnosis.212,245–250 (Level of Evidence: A) peptide (NT-proBNP) is useful to support clinical 2. Measurement of BNP or NT-proBNP and/or cardiac decision making regarding the diagnosis of HF, troponin is useful for establishing prognosis or dis- 217–223 especially in the setting of clinical uncertainty. ease severity in acutely decompensated HF.248,251–258 (Level of Evidence: A) (Level of Evidence: A) 2. Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic Class IIb HF. 222,224–229 (Level of Evidence: A) 1. The usefulness of BNP- or NT-proBNP–guided ther- Class IIa apy for acutely decompensated HF is not well estab- lished.259,260 (Level of Evidence: C) 1. BNP- or NT-proBNP–guided HF therapy can be 2. Measurement of other clinically available tests such useful to achieve optimal dosing of GDMT in select as biomarkers of myocardial injury or fibrosis may be clinically euvolemic patients followed in a well- considered for additive risk stratification in patients 230–237 structured HF disease management program. with acutely decompensated HF.248,253,256,257,261–267 (Level (Level of Evidence: B) of Evidence: A) Class IIb In addition to routine clinical laboratory tests, other bio- 1. The usefulness of serial measurement of BNP or markers are gaining greater attention for their utility in HF NT-proBNP to reduce hospitalization or mortality in management. These biomarkers may reflect various patho- patients with HF is not well established.230–237 (Level physiological aspects of HF, including myocardial wall of Evidence: B) stress, hemodynamic abnormalities, inflammation, myocyte 2. Measurement of other clinically available tests injury, neurohormonal upregulation, and myocardial remod- such as biomarkers of myocardial injury or fibro- eling, as well as extracellular matrix turnover. Thus, these sis may be considered for additive risk stratifica- biomarkers are potentially powerful adjuncts to current stan- tion in patients with chronic HF.238–244 (Level of dards for the diagnosis, prognosis, and treatment of acute Evidence: B) and chronic HF. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e256 Circulation October 15, 2013
6.3.1. Natriuretic Peptides: BNP or NT-proBNP those with HFrEF. In addition, a lower natriuretic peptide BNP or its amino-terminal cleavage equivalent (NT-proBNP) goal and/or a substantial reduction in natriuretic peptides is derived from a common 108-amino acid precursor peptide during treatment are consistently present in the positive 275 (proBNP108) that is generated by cardiomyocytes in the con- “guided” therapy trials. Although most trials examining text of numerous triggers, most notably myocardial stretch. the strategy of biomarker “guided” HF management were Following several steps of processing, BNP and NT-proBNP small and underpowered, 2 comprehensive meta-analyses are released from the cardiomyocyte, along with variable concluded that BNP-guided therapy reduces all-cause mor- amounts of proBNP108, the latter of which is detected by all tality in patients with chronic HF compared with usual clin- assays that measure either “BNP” or “NT-proBNP.” ical care,231,232 especially in patients <75 years of age. This Assays for BNP and NT-proBNP have been increasingly survival benefit may be attributed to increased achieve- used to establish the presence and severity of HF. In general, ment of GDMT. In some cases, BNP or NT-proBNP levels BNP and NT-proBNP values are reasonably correlated, and may not be easily modifiable. If the BNP or NT-proBNP either can be used in patient care settings as long as their value does not fall after aggressive HF care, risk for death respective absolute values and cut points are not used inter- or hospitalization for HF is significant. On the other hand, changeably. BNP and NT-proBNP are useful to support clin- some patients with advanced HF have normal BNP or ical judgment for the diagnosis or exclusion of HF, in the NT-proBNP levels or have falsely low BNP levels because setting of chronic ambulatory HF217–223 or acute decompen- of obesity and HFpEF. All of these patients should still sated HF245–250; the value of natriuretic peptide testing is par- receive appropriate GDMT. ticularly significant when the etiology of dyspnea is unclear. Although lower values of BNP or NT-proBNP exclude 6.3.2. Biomarkers of Myocardial Injury: Cardiac Troponin the presence of HF and higher values have reasonably high T or I positive predictive value to diagnose HF, clinicians should be Abnormal concentrations of circulating cardiac troponin are aware that elevated plasma levels for both natriuretic peptides found in patients with HF, often without obvious myocardial have been associated with a wide variety of cardiac and non- ischemia and frequently in those without underlying CAD. cardiac causes (Table 8).268–271 This suggests ongoing myocyte injury or necrosis in these 238–241,276 BNP and NT-proBNP levels improve with treatment of patients. In chronic HF, elaboration of cardiac tropo- 238 chronic HF,225,272–274 with lowering of levels over time in gen- nins is associated with impaired hemodynamics, progres- 239 238–241,276 eral, correlating with improved clinical outcomes.248,251,254,260 sive LV dysfunction, and increased mortality rates. Thus, BNP or NT-proBNP “guided” therapy has been studied Similarly, in patients with acute decompensated HF, elevated against standard care without natriuretic peptide measure- cardiac troponin levels are associated with worse clinical out- 253,257,263 ment to determine whether guided therapy renders superior comes and mortality ; decrease in troponin levels over achievement of GDMT in patients with HF. However, RCTs time with treatment is associated with a better prognosis than 239 277 have yielded inconsistent results. persistent elevation in patients with chronic or acute HF. The positive and negative natriuretic peptide–guided Given the tight association with ACS and troponin elevation therapy trials differ primarily in their study populations, as well as the link between MI and the development of acute 278 with successful trials enrolling younger patients and only HF, the measurement of troponin I or T should be rou- tine in patients presenting with acutely decompensated HF syndromes. Table 8. Selected Causes of Elevated Natriuretic Peptide Concentrations 6.3.3. Other Emerging Biomarkers Cardiac Besides natriuretic peptides or troponins, multiple other bio- • Heart failure, including RV syndromes markers, including those reflecting inflammation, oxidative • Acute coronary syndrome stress, neurohormonal disarray, and myocardial and matrix • Heart muscle disease, including LVH remodeling, have been widely examined for their prognostic • Valvular heart disease value in HF. Biomarkers of myocardial fibrosis, soluble ST2 and • Pericardial disease galectin-3 are not only predictive of hospitalization and death in • Atrial fibrillation patients with HF but also additive to natriuretic peptide levels in • Myocarditis • Cardiac surgery their prognostic value. Markers of renal injury may also offer • Cardioversion additional prognostic value because renal function or injury may Noncardiac be involved in the pathogenesis, progression, decompensation, or complications in chronic or acute decompensated HF.242– • Advancing age 244,264,265,279 • Anemia Strategies that combine multiple biomarkers may • Renal failure ultimately prove beneficial in guiding HF therapy in the future. • Pulmonary: obstructive sleep apnea, severe pneumonia, pulmonary See Table 9 for a summary of recommendations from this hypertension section. • Critical illness • Bacterial sepsis 6.4. Noninvasive Cardiac Imaging: • Severe burns Recommendations • Toxic-metabolic insults, including cancer chemotherapy and envenomation See Table 10 for a summary of recommendations from this LVH indicates left ventricular hypertrophy; and RV, right ventricular. section. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e257
Table 9. Recommendations for Biomarkers in HF
Biomarker, Application Setting COR LOE References Natriuretic peptides Diagnosis or exclusion of HF Ambulatory, Acute I A 212, 217–223, 245–250 Prognosis of HF Ambulatory, Acute I A 222, 224–229, 248, 251–258 Achieve GDMT Ambulatory IIa B 230–237 Guidance for acutely Acute IIb C 259, 260 decompensated HF therapy Biomarkers of myocardial injury Additive risk stratification Acute, Ambulatory I A 238–241, 248, 253, 256–267 Biomarkers of myocardial fibrosis Additive risk stratification Ambulatory IIb B 242–244 Acute IIb A 248, 253, 256, 258–260, 262, 264–267 COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; and LOE, Level of Evidence.
Class I Class IIa
1. Patients with suspected or new-onset HF, or those 1. Noninvasive imaging to detect myocardial ischemia presenting with acute decompensated HF, should and viability is reasonable in patients presenting with undergo a chest x-ray to assess heart size and pul- de novo HF, who have known CAD and no angina, monary congestion and to detect alternative car- unless the patient is not eligible for revascularization diac, pulmonary, and other diseases that may cause of any kind. (Level of Evidence: C) or contribute to the patient’s symptoms. (Level of 2. Viability assessment is reasonable in select situations Evidence: C) when planning revascularization in HF patients with 2. A 2-dimensional echocardiogram with Doppler should CAD.281–285 (Level of Evidence: B) be performed during initial evaluation of patients pre- 3. Radionuclide ventriculography or magnetic resonance senting with HF to assess ventricular function, size, imaging can be useful to assess LVEF and volume when wall thickness, wall motion, and valve function. (Level echocardiography is inadequate. (Level of Evidence: C) of Evidence: C) 4. Magnetic resonance imaging is reasonable when 3. Repeat measurement of EF and measurement of the assessing myocardial infiltrative processes or scar severity of structural remodeling are useful to pro- burden.286–288 (Level of Evidence: B) vide information in patients with HF who have had a significant change in clinical status; who have experi- Class III: No Benefit enced or recovered from a clinical event; or who have received treatment, including GDMT, that might 1. Routine repeat measurement of LV function assess- have had a significant effect on cardiac function; or ment in the absence of clinical status change or treat- who may be candidates for device therapy. (Level of ment interventions should not be performed.289,290 Evidence: C) (Level of Evidence: B)
Table 10. Recommendations for Noninvasive Cardiac Imaging
Recommendations COR LOE Patients with suspected, acute, or new-onset HF should undergo a chest x-ray I C A 2-dimensional echocardiogram with Doppler should be performed for initial evaluation of HF I C Repeat measurement of EF is useful in patients with HF who have had a significant change in I C clinical status or received treatment that might affect cardiac function or for consideration of device therapy Noninvasive imaging to detect myocardial ischemia and viability is reasonable in HF and CAD IIa C Viability assessment is reasonable before revascularization in HF patients with CAD IIa B281–285 Radionuclide ventriculography or MRI can be useful to assess LVEF and volume IIa C MRI is reasonable when assessing myocardial infiltration or scar IIa B286–288 Routine repeat measurement of LV function assessment should not be performed III: No Benefit B289,290 CAD indicates coronary artery disease; COR, Class of Recommendation; EF, ejection fraction; HF, heart failure; LOE, Level of Evidence; LV, left ventricular; LVEF, left ventricular ejection fraction; and MRI, magnetic resonance imaging. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e258 Circulation October 15, 2013
The chest x-ray is important for the evaluation of patients pre- echocardiography. However, additional information about senting with signs and symptoms of HF because it assesses myocardial perfusion, viability, and fibrosis from mag- cardiomegaly and pulmonary congestion and may reveal alter- netic resonance imaging can help identify HF etiology and native causes, cardiopulmonary or otherwise, of the patient’s assess prognosis.298 Magnetic resonance imaging provides symptoms. Apart from congestion, however, other findings on high anatomical resolution of all aspects of the heart and chest x-ray are associated with HF only in the context of clini- surrounding structure, leading to its recommended use in cal presentation. Cardiomegaly may be absent in HF. A chest known or suspected congenital heart diseases.5 Cardiac x-ray may also show other cardiac chamber enlargement, computed tomography can also provide accurate assess- increased pulmonary venous pressure, interstitial or alveolar ment of cardiac structure and function, including the edema, valvular or pericardial calcification, or coexisting tho- coronary arteries.299 An advantage of cardiac computed racic diseases. Considering its low sensitivity and specificity, tomography over echocardiography may be its ability to the chest x-ray should not be the sole determinant of the spe- characterize the myocardium, but studies have yet to dem- cific cause of HF. Moreover, a supine chest x-ray has limited onstrate the importance of this factor. Reports of cardiac value in acute decompensated HF. computed tomography in patients with suspected HF are Although a complete history and physical examination are limited. Furthermore, both cardiac computed tomography important first steps, the most useful diagnostic test in the and magnetic resonance imaging lose accuracy with high evaluation of patients with or at risk for HF (eg, postacute MI) heart rates. Radionuclide ventriculography may also be is a comprehensive 2-dimensional echocardiogram; coupled used for evaluation of cardiac function when other tests are with Doppler flow studies, the transthoracic echocardiogram unavailable or inadequate. However, as a planar technique, can identify abnormalities of myocardium, heart valves, and radionuclide ventriculography cannot directly assess val- pericardium. Echocardiography can reveal subclinical HF and vular structure, function, or ventricular wall thickness; it predict risk of subsequent events.291–295 Use of echocardio- may be more useful for assessing LV volumes in patients grams in patients with suspected HF improves disease identi- with significant baseline wall motion abnormalities or dis- fication and provision of appropriate medical care.296 torted geometry. Ventriculography is highly reproducible.300 Echocardiographic evaluation should address whether LVEF Single photon emission computed tomography or positron is reduced, LV structure is abnormal, and other structural emission tomography scans are not primarily used to deter- abnormalities are present that could account for the clinical mine LV systolic global and regional function unless these presentation. This information should be quantified, including parameters are quantified from the resultant images dur- numerical estimates of EF measurement, ventricular dimen- ing myocardial perfusion and/or viability assessment.301,302 sions, wall thickness, calculations of ventricular volumes, and Candidates for coronary revascularization who present with evaluation of chamber geometry and regional wall motion. a high suspicion for obstructive CAD should undergo coro- Documentation of LVEF is an HF quality-of-care performance nary angiography. Stress nuclear imaging or echocardiog- measure.297 Right ventricular size and function as well as atrial raphy may be an acceptable option for assessing ischemia size and dimensions should also be measured. All valves should in patients presenting with HF who have known CAD and be evaluated for anatomic and flow abnormalities. Secondary no angina unless they are ineligible for revascularization.303 changes, particularly the severity of mitral and tricuspid valve Although the results of the STICH (Surgical Treatment for insufficiency, should be determined. Noninvasive hemody- Ischemic Heart Failure) trial have cast doubt on the role of namic data constitute important additional information. Mitral myocardial viability assessment to determine the mode of valve inflow pattern, pulmonary venous inflow pattern, and therapy,304 the data are nevertheless predictive of a positive mitral annular velocity provide data about LV filling and left outcome. When these data are taken into consideration with atrial pressure. The tricuspid valve regurgitant gradient, cou- multiple previous studies demonstrating the usefulness of pled with measurement of inferior vena cava diameter and this approach,281–285 it becomes reasonable to recommend its response during respiration, provides estimates of systolic viability assessment when treating patients with HFrEF pulmonary artery pressure and central venous pressure. Many who have known CAD.14 of these abnormalities are prognostically important and can be See Online Data Supplement 9 for additional data on present without manifest HF. imaging−echocardiography. Serial echocardiographic evaluations are useful because evidence of cardiac reverse remodeling can provide important 6.5. Invasive Evaluation: Recommendations information in patients who have had a change in clinical sta- See Table 11 for a summary of recommendations from this tus or have experienced or recovered from an event or treat- section. ment that affects cardiac function. However, the routine repeat Class I assessment of ventricular function in the absence of chang- ing clinical status or a change in treatment intervention is not 1. Invasive hemodynamic monitoring with a pulmo- indicated. nary artery catheter should be performed to guide The preference for echocardiography as an imaging therapy in patients who have respiratory distress modality is due to its widespread availability and lack of or clinical evidence of impaired perfusion in whom ionizing radiation; however, other imaging modalities the adequacy or excess of intracardiac filling pres- may be of use. Magnetic resonance imaging assesses LV sures cannot be determined from clinical assessment. volume and EF measurements at least as accurately as (Level of Evidence: C) Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e259
Table 11. Recommendations for Invasive Evaluation
Recommendations COR LOE Monitoring with a pulmonary artery catheter should be performed in patients with respiratory I C distress or impaired systemic perfusion when clinical assessment is inadequate Invasive hemodynamic monitoring can be useful for carefully selected patients with acute IIa C HF with persistent symptoms and/or when hemodynamics are uncertain When ischemia may be contributing to HF, coronary arteriography is reasonable IIa C Endomyocardial biopsy can be useful in patients with HF when a specific diagnosis is IIa C suspected that would influence therapy Routine use of invasive hemodynamic monitoring is not recommended in normotensive III: No Benefit305 B patients with acute HF Endomyocardial biopsy should not be performed in the routine evaluation of HF III: Harm C COR indicates Class of Recommendation; HF, heart failure; and LOE, Level of Evidence.
Class IIa clinically indeterminate volume status and those refractory to initial therapy, particularly if intracardiac filling pressures and 1. Invasive hemodynamic monitoring can be useful for cardiac output are unclear. Patients with clinically significant carefully selected patients with acute HF who have hypotension (systolic blood pressure typically <90 mm Hg persistent symptoms despite empiric adjustment of or symptomatic low systolic blood pressure) and/or worsen- standard therapies and ing renal function during initial therapy might also benefit a. whose fluid status, perfusion, or systemic or pul- from invasive hemodynamic measurements.305,306 Patients monary vascular resistance is uncertain; being considered for cardiac transplantation or placement of b. whose systolic pressure remains low, or is associ- an MCS device are also candidates for complete right-heart ated with symptoms, despite initial therapy; catheterization, including an assessment of pulmonary vascu- c. whose renal function is worsening with therapy; lar resistance, a necessary part of the initial transplantation d. who require parenteral vasoactive agents; or evaluation. Invasive hemodynamic monitoring should be per- e. who may need consideration for MCS or trans- formed in patients with 1) presumed cardiogenic shock requir- plantation. (Level of Evidence: C) 2. When ischemia may be contributing to HF, coronary ing escalating pressor therapy and consideration of MCS; 2) arteriography is reasonable for patients eligible for severe clinical decompensation in which therapy is limited by revascularization. (Level of Evidence: C) uncertain contributions of elevated filling pressures, hypoper- 3. Endomyocardial biopsy can be useful in patients pre- fusion, and vascular tone; 3) apparent dependence on intrave- senting with HF when a specific diagnosis is suspected nous inotropic infusions after initial clinical improvement; or that would influence therapy. (Level of Evidence: C) 4) persistent severe symptoms despite adjustment of recom- mended therapies. On the other hand, routine use of invasive Class III: No Benefit hemodynamic monitoring is not recommended in normoten- sive patients with acute decompensated HF who have a symp- 1. Routine use of invasive hemodynamic monitoring is tomatic response to diuretics and vasodilators. This reinforces not recommended in normotensive patients with acute the concept that right-heart catheterization is best reserved for decompensated HF and congestion with symptom- those situations where a specific clinical or therapeutic ques- atic response to diuretics and vasodilators.305 (Level of tion needs to be addressed. Evidence: B) 6.5.2. Left-Heart Catheterization Class III: Harm Left-heart catheterization or coronary angiography is indi- cated for patients with HF and angina and may be useful 1. Endomyocardial biopsy should not be performed in for those patients without angina but with LV dysfunction. the routine evaluation of patients with HF. (Level of Invasive coronary angiography should be used in accordance Evidence: C) with the ACCF/AHA coronary artery bypass graft (CABG) and percutaneous coronary intervention guidelines10,12 and 6.5.1. Right-Heart Catheterization should only be performed in patients who are potentially eli- There has been no established role for routine or periodic gible for revascularization.307–309 In patients with known CAD invasive hemodynamic measurements in the management of and angina or with significant ischemia diagnosed by ECG or HF. Most drugs used for the treatment of HF are prescribed noninvasive testing and impaired ventricular function, coro- on the basis of their ability to improve symptoms or survival nary angiography is indicated. Among those without a prior rather than their effect on hemodynamic variables. The initial diagnosis, CAD should be considered as a potential etiology and target doses of these drugs are generally selected on the of impaired LV function and should be excluded wherever basis of controlled trial experience rather than changes pro- possible. Coronary angiography may be considered in these duced in cardiac output or pulmonary capillary wedge pres- circumstances to detect and localize large-vessel coronary sure. Hemodynamic monitoring is indicated in patients with obstructions. In patients in whom CAD has been excluded as Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e260 Circulation October 15, 2013 the cause of LV dysfunction, coronary angiography is gener- calcium antagonists and alpha blockers in reducing the risk ally not indicated unless a change in clinical status suggests for incident HF. interim development of ischemic disease. 7.1.2. Treatment of Dyslipidemia and Vascular Risk 6.5.3. Endomyocardial Biopsy Patients with known atherosclerotic disease are likely to develop Endomyocardial biopsy can be useful when seeking a spe- HF. Clinicians should seek to control vascular risk factors in cific diagnosis that would influence therapy, and biopsy such patients according to guidelines.28 Aggressive treatment should thus be considered in patients with rapidly progressive of hyperlipidemia with statins reduces the likelihood of HF in clinical HF or worsening ventricular dysfunction that persists at-risk patients.315,316 Long-term treatment with ACE inhibitors despite appropriate medical therapy. Endomyocardial biopsy in similar patients may also decrease the risk of HF.314,317 should also be considered in patients suspected of having 7.1.3. Obesity and Diabetes Mellitus acute cardiac rejection status after heart transplantation or Obesity and overweight have been repeatedly linked to an having myocardial infiltrative processes. A specific example increased risk for HF.99,318,319 Presumably, the link between is to determine chemotherapy for primary cardiac amyloido- obesity and risk for HF is explained by the clustering of risk sis. Additional other indications for endomyocardial biopsy factors for heart disease in those with elevated BMI (ie, the include in patients with rapidly progressive and unexplained metabolic syndrome). Similarly, insulin resistance, with or cardiomyopathy, those in whom active myocarditis, espe- without diabetes mellitus, is also an important risk factor for 310 cially giant cell myocarditis, is being considered. Routine the development of HF.92,320–323 Diabetes mellitus is an espe- endomyocardial biopsy is not recommended in all cases of cially important risk factor for women and may, in fact, triple HF, given limited diagnostic yield and the risk of procedure- the risk for developing HF.91,324 Dysglycemia appears to be related complications. directly linked to risk, with HbA1c concentrations power- See Online Data Supplement 10 for additional data on fully predicting incident HF. Those with HbA1c >10.5% had a biopsy. nearly 4-fold increase in the risk for HF compared with those with a value of <6.5%.322 Current consensus advocates that 7. Treatment of Stages A to D clinicians should make every effort to control hyperglycemia, 7.1. Stage A: Recommendations although such control has not yet been shown to reduce the subsequent risk of HF. Additionally, standard therapies for dia- Class I betes mellitus, such as use of ACE inhibitors or ARBs, can pre- vent the development of other risk factors for HF, such as renal 1. Hypertension and lipid disorders should be con- dysfunction,325,326 and may themselves directly lower the likeli- trolled in accordance with contemporary guidelines hood of HF.327–329 Although risk models for the development of to lower the risk of HF.27,94,311–314 (Level of Evidence: A) incident HF in patients with diabetes mellitus have been devel- 2. Other conditions that may lead to or contribute to oped,323 their prospective use to reduce risk has not been vali- HF, such as obesity, diabetes mellitus, tobacco use, dated. Despite the lack of supportive, prospective, randomized and known cardiotoxic agents, should be controlled or avoided. (Level of Evidence: C) data, consensus exists that risk factor recognition and modifi- cation are vital for the prevention of HF among at-risk patients 7.1.1. Recognition and Treatment of Elevated Blood (eg, obese patients or patients with diabetes mellitus). Pressure 7.1.4. Recognition and Control of Other Conditions That The lifetime risk for development of hypertension is consid- May Lead to HF erable and represents a major public health issue.97 Elevated A substantial genetic risk exists in some patients for the devel- blood pressure is a major risk factor for the development of both opment of HF. As noted in Section 6.1, obtaining a 3-genera- HFpEF and HFrEF, 91,92 a risk that extends across all age ranges. tion family history of HF is recommended. Adequate therapy of Long-term treatment of both systolic and diastolic hypertension AF is advisable, given a clear association between uncontrolled has been shown to reduce the risk of incident HF by approxi- heart rate and development of HF. Many therapeutic agents can mately 50%.94,311–314 Treatment of hypertension is particularly exert important cardiotoxic effects, with consequent risk for beneficial in older patients.311 One trial of a diuretic-based pro- HF, and clinicians should be aware of such risk. For example, gram demonstrated a number needed to treat of 52 to prevent cardiotoxic chemotherapy regimens (particularly anthracycline 1 HF event in 2 years.311 In another study, elderly patients with based) and trastuzumab may increase the risk for HF in cer- a history or ECG evidence of prior MI had a >80% risk reduc- tain patients330–332; it may be reasonable to evaluate those who tion for incident HF with aggressive blood pressure control.94 are receiving (or who have received) such agents for LV dys- Given the robust outcomes with blood pressure reduction, clini- function. The use of advanced echocardiographic techniques cians should lower both systolic and diastolic blood pressure in or biomarkers to identify increased HF risk in those receiving accordance with published guidelines.27 chemotherapy may be useful but remain unvalidated as yet.333 Choice of antihypertensive therapy should also follow Tobacco use is strongly associated with risk for incident guidelines,27 with specific options tailored to concomitant HF, 92,320,334 and patients should be strongly advised about the medical problems, such as diabetes mellitus or CAD. Diuretic- hazards of smoking, with attendant efforts at quitting. Cocaine based antihypertensive therapy has repeatedly been shown to and amphetamines are anecdotally but strongly associated with prevent HF in a wide range of patients; ACE inhibitors, ARBs, HF, and their avoidance is mandatory. Although it is recog- and beta blockers are also effective. Data are less clear for nized that alcohol consumption is associated with subsequent Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e261 development of HF,92,139,140 there is some uncertainty about the 4. In patients with structural cardiac abnormalities, amount of alcohol ingested and the likelihood of developing including LV hypertrophy, in the absence of a history HF, and there may be sex differences as well. Nevertheless, of MI or ACS, blood pressure should be controlled the heavy use of alcohol has repeatedly been associated with in accordance with clinical practice guidelines for heightened risk for development of HF. Therefore, patients hypertension to prevent symptomatic HF.27,94,311–313 should be counseled about their alcohol intake. (Level of Evidence: A) Although several epidemiological studies have revealed 5. ACE inhibitors should be used in all patients with a an independent link between risk for incident HF and bio- reduced EF to prevent symptomatic HF, even if they 65,344 markers such as natriuretic peptides,335,336 highly sensitive do not have a history of MI. (Level of Evidence: A) troponin,337 and measures of renal function such as creati- 6. Beta blockers should be used in all patients with a reduced EF to prevent symptomatic HF, even if they nine, phosphorus, urinary albumin, or albumin-creatinine do not have a history of MI. (Level of Evidence: C) ratio,320,323,334,336,338–340 it remains unclear whether the risk for HF reflected by any of these biomarkers is modifiable. Although routine screening with BNP before echocardiog- Class IIa raphy may be a cost-effective strategy to identify high-risk 1. To prevent sudden death, placement of an ICD is rea- patients,341 routine measurement of biomarkers in stage A sonable in patients with asymptomatic ischemic car- patients is not yet justified. diomyopathy who are at least 40 days post-MI, have See Online Data Supplement 11 for additional data on an LVEF of 30% or less, are on appropriate medical stage A HF. therapy, and have reasonable expectation of survival with a good functional status for more than 1 year.355 7.2. Stage B: Recommendations (Level of Evidence: B) See Table 12 for a summary of recommendations from this section. Class III: Harm Class I 1. Nondihydropyridine calcium channel blockers with 1. In all patients with a recent or remote history of MI negative inotropic effects may be harmful in asymp- or ACS and reduced EF, ACE inhibitors should be tomatic patients with low LVEF and no symptoms of used to prevent symptomatic HF and reduce mor- HF after MI. (Level of Evidence: C) tality.342–344 In patients intolerant of ACE inhibitors, ARBs are appropriate unless contraindicated.314,345 Patients with reduced LVEF may not have HF symptoms and (Level of Evidence: A) are most often identified during an evaluation for another disor- 2. In all patients with a recent or remote history of MI der (eg, abnormal heart sounds, abnormal ECG, abnormal chest or ACS and reduced EF, evidence-based beta block- x-ray, hypertension or hypotension, an arrhythmia, acute MI, or ers should be used to reduce mortality.346–348 (Level of pulmonary or systemic thromboembolic event). However, the Evidence: B) cost-effectiveness of routine periodic population screening for 3. In all patients with a recent or remote history of MI asymptomatic reduced LVEF is not recommended at this time. or ACS, statins should be used to prevent symptom- Echocardiographic evaluation should be performed in selected atic HF and cardiovascular events.104,349–354 (Level of patients who are at high risk of reduced LVEF (eg, those with Evidence: A) a strong family history of cardiomyopathy, long-standing
Table 12. Recommendations for Treatment of Stage B HF
Recommendations COR LOE References In patients with a history of MI and reduced EF, ACE inhibitors or ARBs I A 314, 342–345 should be used to prevent HF In patients with MI and reduced EF, evidence-based beta blockers I B 346–348 should be used to prevent HF In patients with MI, statins should be used to prevent HF I A 104, 349–354 Blood pressure should be controlled to prevent symptomatic HF I A 27, 94, 311–313 ACE inhibitors should be used in all patients with a reduced EF to prevent HF I A 65, 344 Beta blockers should be used in all patients with a reduced EF to prevent HF I C N/A An ICD is reasonable in patients with asymptomatic ischemic cardiomyopathy IIa B 355 who are at least 40 d post-MI, have an LVEF ≤30%, and on GDMT Nondihydropyridine calcium channel blockers may be harmful in patients with low LVEF III: Harm C N/A ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; COR, Class of Recommendation; EF, ejection fraction; GDMT, guideline- directed medical therapy; HF, heart failure; ICD, implantable cardioverter-defibrillator; LOE, Level of Evidence; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and N/A, not available. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e262 Circulation October 15, 2013 hypertension, previous MI, or those receiving cardiotoxic ther- Table 13. Other ACCF/AHA Guidelines Addressing Patients apies). In addition, it should be acknowledged that many adults With Stage B HF may have asymptomatic valvular abnormalities or congenital Consideration Reference heart lesions that if unrecognized could lead to the develop- 16 ment of clinical HF. Although these asymptomatic patients are Patients with an acute MI who have not developed 2013 UA/NSTEMI Guideline HF symptoms treated according to GDMT 2013 STEMI Guideline15 in stage B as well, the management of valvular and congenital 12 heart disease is beyond the scope of this guideline. Coronary revascularization for patients without 2011 PCI Guideline symptoms of HF in accordance with GDMT 2011 CABG Guideline10 14 7.2.1. Management Strategies for Stage B 2012 SIHD Guideline In general, all recommendations for patients with stage A HF also Valve replacement or repair for patients with 2008 Focused Update hemodynamically significant valvular stenosis incorporated into the apply to those with stage B HF, particularly with respect to con- 17 27,94,311,312 or regurgitation and no symptoms of HF in 2006 VHD Guideline trol of blood pressure in the patient with LV hypertrophy accordance with GDMT and the optimization of lipids with statins.349,356 CAD is a major ACCF indicates American College of Cardiology Foundation; AHA, American risk factor for the development of HF and a key target for preven- Heart Association; CABG, coronary artery bypass graft; GDMT, guideline- tion of HF. The 5-year risk of developing HF after acute MI is 7% directed medical therapy; HF, heart failure; MI, myocardial infarction; and 12% for men and women, respectively; for men and women PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; between the ages of 40 and 69 and those >70 years of age, the risk STEMI, ST-elevation myocardial infarction; UA/NSTEMI, unstable angina/non– is 22% and 25%, respectively.51 Current evidence supports the use ST-elevation myocardial infarction; and VHD, valvular heart disease. of ACE inhibitors and (to a lower level of evidence) beta-blocker therapy to impede maladaptive LV remodeling in patients with ACE inhibitors and beta blockers are also effective in the pre- stage B HF and low LVEF to improve mortality and morbidity.344 vention of HF.27 Nevertheless, neither ACE inhibitors nor beta At 3-year follow-up, those patients treated with ACE inhibitors blockers as single therapies are superior to other antihyperten- demonstrated combined endpoints of reduced hospitalization or sive drug classes, including calcium channel blockers, in the death, a benefit that extended up to a 12-year follow-up.65 ARBs reduction of all cardiovascular outcomes. However, in patients are reasonable alternatives to ACE inhibitors. In 1 study, losartan with type 2 diabetes mellitus, ACE inhibitors and ARBs signifi- reduced adverse outcomes in a population with hypertension,357 cantly reduced the incidence of HF in patients.327–329 In contrast, and in another study of patients post-MI with low LVEF, valsar- calcium channel blockers and alpha blockers were less effective tan was equivalent to captopril.345 Data with beta blockers are in preventing the HF syndrome, particularly in HFrEF. 359 less convincing in a population with known CAD, although in 1 The Framingham studies have shown a 60% increased risk of trial346 carvedilol therapy in patients with stage B and low LVEF death in patients with asymptomatic low LVEF compared with was associated with a 31% relative risk reduction in adverse long- those with normal LVEF; almost half of these patients remained term outcomes. In patients with previously established structural free of HF before their death.62–65 MADIT-II (Multicenter heart disease, the administration of agents known to have nega- Automatic Defibrillator Implantation Trial II)362 demonstrated tive inotropic properties such as nondihydropyridine calcium a 31% relative risk reduction in all-cause mortality in patients channel blockers and certain antiarrhythmics should be avoided. with post-MI with LVEF ≤30% receiving a prophylactic ICD Elevations in both systolic and diastolic blood pressure are compared with standard of care.355 These findings provided major risk factors for developing LV hypertrophy, another justification for broad adoption of ICDs for primary prevention form of stage B.91,92 Although the magnitude of benefit varies of SCD in the post-MI setting with reduced LVEF, even in the with the trial selection criteria, target blood pressure reduc- absence of HF symptoms, that is, patients in stage B HF. tion, and HF criteria, effective hypertension treatment invari- Several other ACCF/AHA guidelines addressing the appro- ably reduces HF events. Consequently, long-term treatment priate management of patients with stage B—those with car- of both systolic and diastolic hypertension reduces the risk diac structural abnormalities but no symptoms of HF—are of moving from stage A or B to stage C HF.93,94,311,329 Several listed in Table 13. large controlled studies have uniformly demonstrated that See Online Data Supplement 12 for additional data on optimal blood pressure control decreases the risk of new HF stage B HF. by approximately 50%.96 It is imperative that strategies to con- trol hypertension be part of any effort to prevent HF. 7.3. Stage C Clinicians should lower both systolic and diastolic blood pres- See Online Data Supplement 13 for additional data on stage C HF. 27 sure in accordance with published guidelines. Target levels of 7.3.1. Nonpharmacological Interventions blood pressure lowering depend on major cardiovascular risk factors, (eg, CAD, diabetes mellitus, or renal disease).358 Thus, 7.3.1.1. Education: Recommendation when an antihypertensive regimen is devised, optimal control of Class I blood pressure should remain the primary goal, with the choice of drugs determined by the concomitant medical problems. 1. Patients with HF should receive specific education to Diuretic-based antihypertensive therapy has been shown to facilitate HF self-care.363–368 (Level of Evidence: B) prevent HF in a wide range of target populations.359,360 In refrac- tory hypertensive patients, spironolactone (25 mg) should be The self-care regimen for patients with HF is complex and considered as an additional agent.27 Eplerenone, in synergy with multifaceted.363 Patients need to understand how to monitor enalapril, has also demonstrated reduction in LV mass.361 their symptoms and weight fluctuations, restrict their sodium Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e263 intake, take their medications as prescribed, and stay physi- more complicated, the 3 RCTs that assessed outcomes with cally active. Education regarding these recommendations is sodium restriction have all shown that lower sodium intake is necessary, albeit not always sufficient, to significantly improve associated with worse outcomes in patients with HFrEF. 384–386 outcomes. After discharge, many patients with HF need dis- These limitations make it difficult to give precise recommenda- ease management programs, which are reviewed in Section 11. tions about daily sodium intake and whether it should vary with A systematic review of 35 educational intervention studies respect to the type of HF (eg, HFrEF versus HFpEF), disease for patients with HF demonstrated that education improved severity (eg, NYHA class), HF-related comorbidities (eg, renal knowledge, self-monitoring, medication adherence, time to dysfunction), or other characteristics (eg, age or race). Because hospitalization, and days in the hospital.363 Patients who receive of the association between sodium intake and hypertension, LV in-hospital education have higher knowledge scores at discharge hypertrophy, and cardiovascular disease, the AHA recommenda- and 1 year later when compared with those who did not receive tion for restriction of sodium to 1500 mg/d appears to be appropri- in-hospital education.364 Data have called into question the sur- ate for most patients with stage A and B HF.387–392 However, for vival benefit of discharge education.369,370 However, prior data patients with stage C and D HF, currently there are insufficient data have suggested that discharge education may result in fewer to endorse any specific level of sodium intake. Because sodium days of hospitalization, lower costs, and lower mortality rates intake is typically high (>4 g/d) in the general population, clini- within a 6-month follow-up.365 Patients educated in all 6 catego- cians should consider some degree (eg, <3 g/d) of sodium restric- ries of the HF core measures from The Joint Commission were tion in patients with stage C and D HF for symptom improvement. significantly less likely to be readmitted for any cause, includ- 7.3.1.4. Treatment of Sleep Disorders: Recommendation ing HF.366 Even a single home-based educational intervention for patients and families has been shown to decrease emergency Class IIa visits and unplanned hospitalizations in adults with HF.367 See Online Data Supplement 14 for additional data on 1. Continuous positive airway pressure can be benefi- patient nonadherence. cial to increase LVEF and improve functional status in patients with HF and sleep apnea.393–396 (Level of 7.3.1.2. Social Support Evidence: B) Social support is thought to buffer stress and promote treatment adherence and a healthy lifestyle.371 Most studies examining the Sleep disorders are common in patients with HF. A study of relationship between social support and hospitalization in adults adults with chronic HF treated with evidence-based therapies with HF have found that a lack of social support is associated found that 61% had either central or obstructive sleep apnea.397 with higher hospitalization rates 372,373 and mortality risk.374,375 Despite having less sleep time and sleep efficiency compared with those without HF, patients with HF, including those with 7.3.1.3. Sodium Restriction: Recommendation documented sleep disorders, rarely report excessive daytime Class IIa sleepiness.398 Thus, a high degree of suspicion for sleep disorders should be maintained for these patients. The decision to refer a 1. Sodium restriction is reasonable for patients with patient to a sleep study should be based on clinical judgment. symptomatic HF to reduce congestive symptoms. The primary treatment for obstructive sleep apnea is noc- (Level of Evidence: C) turnal continuous positive airway pressure. In a major trial, Dietary sodium restriction is commonly recommended to continuous positive airway pressure for obstructive sleep apnea was effective in decreasing the apnea–hypopnea index, patients with HF and is endorsed by many guidelines.18,376,377 The improving nocturnal oxygenation, increasing LVEF, lowering data on which this recommendation is drawn upon, however, are norepinephrine levels, and increasing the distance walked in modest, and variances in protocols, fluid intake, measurement 6 minutes; these benefits were sustained for up to 2 years.394 of sodium intake and compliance, and other clinical and thera- Smaller studies suggest that continuous positive airway pres- peutic characteristics among these studies make it challenging sure can improve cardiac function, sympathetic activity, and to compare data and draw definitive conclusions. Observational HRQOL in patients with HF and obstructive sleep apnea.395,396 data suggest an association between dietary sodium intake with See Online Data Supplement 15 for additional data on the fluid retention and risk for hospitalization.378,379 Other studies, treatment of sleep disorders. however, have signaled a worsening neurohormonal profile with sodium restriction in HF.380–390 Sodium homeostasis is altered in 7.3.1.5. Weight Loss patients with HF as opposed to healthy individuals, which may Obesity is defined as a BMI≥ 30 kg/m2. Patients with HF who partially explain these trends. In most of these studies, patients have a BMI between 30 and 35 kg/m2 have lower mortality and were not receiving GDMT; no study to date has evaluated the hospitalization rates than those with a BMI in the normal range.99 effects of sodium restriction on neurohormonal activation Weight loss may reflect cachexia caused by the higher total and outcomes in optimally treated patients with HF. With the energy expenditure associated with HF compared with that of exception of 1 observational study that evaluated patients with healthy sedentary subjects.399 The diagnosis of cardiac cachexia HFpEF, 383 all other studies have focused on patients with HFrEF. independently predicts a worse prognosis.191 At the other end These data are mostly from white patients; when the differences of the continuum, morbidly obese patients may have worse in cardiovascular and renal pathophysiology among races are outcomes compared with patients within the normal weight considered, the effects of sodium restriction in nonwhite patients range and those who are obese. A U-shaped distribution curve with HF cannot be ascertained from these studies. To make this has been suggested in which mortality is greatest in cachectic Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e264 Circulation October 15, 2013 patients; lower in normal, overweight, and mildly obese patients; benefits include improved endothelial function, blunted cat- and higher again in more severely obese patients.400 echolamine spillover, increased peripheral oxygen extraction, Although there are anecdotal reports about symptomatic and reduced hospital admission.405,407,410,411 improvement after weight reduction in obese patients with Many RCTs of exercise training in HF have been con- HF, 401,402 large-scale clinical trials on the role of weight loss in ducted, but the statistical power of most was low.408 A major patients with HF with obesity have not been performed. Because trial of exercise and HF randomly assigned 2331 patients of reports of development of cardiomyopathy, sibutramine is (mean EF, 25%; ischemic etiology, 52%) to either exercise contraindicated in HF.403 training for 3 months or usual care.406 In unadjusted analyses, there was no significant difference at the end of the study in 7.3.1.6. Activity, Exercise Prescription, and Cardiac either total mortality or hospitalizations. When adjusted for Rehabilitation: Recommendations coronary heart disease risk factors, there was an 11% reduc- Class I tion in all-cause mortality, cardiovascular disease mortality, or hospitalizations (P<0.03) in the exercise training group.406 A 1. Exercise training (or regular physical activity) is rec- meta-analysis demonstrated improved peak oxygen consump- ommended as safe and effective for patients with HF tion and decreased all-cause mortality with exercise.409 who are able to participate to improve functional sta- See Online Data Supplement 16 for additional data on car- 404–407 tus. (Level of Evidence: A) diac exercise. Class IIa 7.3.2. Pharmacological Treatment for Stage C HFrEF: Recommendations 1. Cardiac rehabilitation can be useful in clinically sta- Class I ble patients with HF to improve functional capacity, 404,406–411 exercise duration, HRQOL, and mortality. 1. Measures listed as Class I recommendations for (Level of Evidence: B) patients in stages A and B are recommended where appropriate for patients in stage C. (Levels of Exercise training in patients with HF is safe and has numer- Evidence: A, B, and C as appropriate) ous benefits. Meta-analyses show that cardiac rehabilitation 2. GDMT as depicted in Figure 1 should be the mainstay reduces mortality; improves functional capacity, exercise of pharmacological therapy for HFrEF. 108,343,345,346,412–426 duration, and HRQOL; and reduces hospitalizations.409 Other (Level of Evidence: A)
HFrEF Stage C NYHA Class I – IV Treatment:
ClassI,LOE A ACEI or ARB AND Beta Blocker
Forpersistently symptomatic ForNYHA class II-IVpatients. For all volume overload, African Americans, Provided estimatedcreatinine NYHA class II-IV patients NYHA classIII-IV >30mL/minand K+ <5.0 mEq/dL
Add Add Add
Class I, LOEA ClassI,LOE C ClassI,LOE A Aldosterone LoopDiuretics Hydral-Nitrates Antagonist
Figure 1. Stage C HFrEF: evidence-based, guideline-directed medical therapy. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin-receptor blocker; HFrEF, heart failure with reduced ejection fraction; Hydral-Nitrates, hydralazine and isosorbide dini- trate; LOE, Level of Evidence; and NYHA, New York Heart Association. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e265
7.3.2.1. Diuretics: Recommendation Table 14. Oral Diuretics Recommended for Use in the Treatment of Chronic HF Class I Maximum 1. Diuretics are recommended in patients with HFrEF Total Duration who have evidence of fluid retention, unless contrain- Drug Initial Daily Dose(s) Daily Dose of Action dicated, to improve symptoms. (Level of Evidence: C) Loop diuretics Bumetanide 0.5 to 1.0 mg once 10 mg 4 to 6 h Diuretics inhibit the reabsorption of sodium or chloride at spe- or twice cific sites in the renal tubules. Bumetanide, furosemide, and Furosemide 20 to 40 mg once or 600 mg 6 to 8 h torsemide act at the loop of Henle (thus, the term loop diuretics), twice whereas thiazides, metolazone, and potassium-sparing agents Torsemide 10 to 20 mg once 200 mg 12 to 16 h (eg, spironolactone) act in the distal portion of the tubule.427,428 Thiazide diuretics Loop diuretics have emerged as the preferred diuretic agents for use in most patients with HF. Thiazide diuretics may be consid- Chlorothiazide 250 to 500 mg once 1000 mg 6 to 12 h or twice ered in hypertensive patients with HF and mild fluid retention because they confer more persistent antihypertensive effects. Chlorthalidone 12.5 to 25.0 mg once 100 mg 24 to 72 h Controlled trials have demonstrated the ability of diuretic Hydrochlorothiazide 25 mg once or twice 200 mg 6 to 12 h drugs to increase urinary sodium excretion and decrease phys- Indapamide 2.5 mg once 5 mg 36 h ical signs of fluid retention in patients with HF.429,430 In inter- Metolazone 2.5 mg once 20 mg 12 to 24 h mediate-term studies, diuretics have been shown to improve Potassium-sparing diuretics* 431–433 symptoms and exercise tolerance in patients with HF ; Amiloride 5 mg once 20 mg 24 h however, diuretic effects on morbidity and mortality are not Spironolactone 12.5 to 25.0 mg once 50 mg† 1 to 3 h known. Diuretics are the only drugs used for the treatment Triamterene 50 to 75 mg twice 200 mg 7 to 9 h of HF that can adequately control the fluid retention of HF. Appropriate use of diuretics is a key element in the success Sequential nephron blockade of other drugs used for the treatment of HF. The use of inap- Metolazone‡ 2.5 to 10.0 mg once N/A N/A propriately low doses of diuretics will result in fluid retention. plus loop diuretic Conversely, the use of inappropriately high doses of diuretics Hydrochlorothiazide 25 to 100 mg once N/A N/A will lead to volume contraction, which can increase the risk of or twice plus loop diuretic hypotension and renal insufficiency. Chlorothiazide (IV) 500 to 1000 mg once N/A N/A 7.3.2.1.1. Diuretics: Selection of Patients. Diuretics should plus loop diuretic be prescribed to all patients who have evidence of, and to *Eplerenone, although also a diuretic, is primarily used in chronic HF. most patients with a prior history of, fluid retention. Diuret- †Higher doses may occasionally be used with close monitoring. ics should generally be combined with an ACE inhibitor, beta ‡See Section 8.4. blocker, and aldosterone antagonist. Few patients with HF will HF indicates heart failure; IV, intravenous; and N/A, not applicable. be able to maintain target weight without the use of diuretics. 7.3.2.1.2. Diuretics: Initiation and Maintenance. The most become unresponsive to high doses of diuretic drugs if they commonly used loop diuretic for the treatment of HF is furose- consume large amounts of dietary sodium, are taking agents mide, but some patients respond more favorably to other agents that can block the effects of diuretics (eg, nonsteroidal anti- in this category (eg, bumetanide, torsemide) because of their inflammatory drugs [NSAIDs], including cyclooxygenase-2 436–438 increased oral bioavailability.434,435 Table 14 lists oral diuretics inhibitors) or have a significant impairment of renal func- 434 recommended for use in the treatment of chronic HF. In outpa- tion or perfusion. Diuretic resistance can generally be over- tients with HF, diuretic therapy is commonly initiated with low come by the intravenous administration of diuretics (including 439 doses, and the dose is increased until urine output increases the use of continuous infusions) or combination of different 440–443 and weight decreases, generally by 0.5 to 1.0 kg daily. Further diuretic classes (eg, metolazone with a loop diuretic). increases in the dose or frequency (ie, twice-daily dosing) of 7.3.2.1.3. Diuretics: Risks of Treatment. The principal adverse diuretic administration may be required to maintain an active effects of diuretics include electrolyte and fluid depletion, as well diuresis and sustain weight loss. The ultimate goal of diuretic as hypotension and azotemia. Diuretics can cause the depletion treatment is to eliminate clinical evidence of fluid retention. of potassium and magnesium, which can predispose patients to Diuretics are generally combined with moderate dietary serious cardiac arrhythmias.444 The risk of electrolyte depletion sodium restriction. Once fluid retention has resolved, treatment is markedly enhanced when 2 diuretics are used in combination. with the diuretic should be maintained in some patients to pre- See Online Data Supplement 17 for additional data on diuretics. vent the recurrence of volume overload. Patients are commonly prescribed a fixed dose of diuretic, but the dose of these drugs 7.3.2.2. ACE Inhibitors: Recommendation frequently may need adjustment. In many cases, this adjust- Class I ment can be accomplished by having patients record their weight each day and adjusting the diuretic dosage if weight 1. ACE inhibitors are recommended in patients with increases or decreases beyond a specified range. Patients may HFrEF and current or prior symptoms, unless Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e266 Circulation October 15, 2013
contraindicated, to reduce morbidity and mortal- available ACE inhibitors in their effects on symptoms or sur- ity.343,412–414 (Level of Evidence: A) vival.414 Treatment with an ACE inhibitor should be initiated at low doses (Table 15), followed by gradual dose increments 7.3.2.2.1. ACE Inhibitors: Selection of Patients. ACE inhibi- if lower doses have been well tolerated. Renal function and tors can reduce the risk of death and reduce hospitalization in serum potassium should be assessed within 1 to 2 weeks of HFrEF. The benefits of ACE inhibition were seen in patients initiation of therapy and periodically thereafter, especially with mild, moderate, or severe symptoms of HF and in patients in patients with preexisting hypotension, hyponatremia, dia- with or without CAD. ACE inhibitors should be prescribed betes mellitus, azotemia, or in those taking potassium sup- to all patients with HFrEF. Unless there is a contraindication, plements. In controlled clinical trials that were designed to ACE inhibitors are used together with a beta blocker. Patients evaluate survival, the dose of the ACE inhibitor was not deter- should not be given an ACE inhibitor if they have experienced mined by a patient’s therapeutic response but was increased life-threatening adverse reactions (ie, angioedema) during pre- until the predetermined target dose was reached.343,413,414 Cli- vious medication exposure or if they are pregnant or plan to nicians should attempt to use doses that have been shown to become pregnant. Clinicians should prescribe an ACE inhibitor reduce the risk of cardiovascular events in clinical trials. If with caution if the patient has very low systemic blood pres- these target doses of an ACE inhibitor cannot be used or are sures (systolic blood pressure <80 mm Hg), markedly increased serum levels of creatinine (>3 mg/dL), bilateral renal artery ste- poorly tolerated, intermediate doses should be used with the nosis, or elevated levels of serum potassium (>5.0 mEq/L). expectation that there are likely to be only small differences in efficacy between low and high doses. Abrupt withdrawal of 7.3.2.2.2. ACE Inhibitors: Initiation and Maintenance. The treatment with an ACE inhibitor can lead to clinical deteriora- available data suggest that there are no differences among tion and should be avoided.
Table 15. Drugs Commonly Used for Stage C HFrEF
Mean Doses Achieved in Drug Initial Daily Dose(s) Maximum Dose(s) Clinical Trials ACE inhibitors Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d422 Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/d413 Fosinopril 5 to 10 mg once 40 mg once N/A Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg/d445 Perindopril 2 mg once 8 to 16 mg once N/A Quinapril 5 mg twice 20 mg twice N/A Ramipril 1.25 to 2.5 mg once 10 mg once N/A Trandolapril 1 mg once 4 mg once N/A ARBs Candesartan 4 to 8 mg once 32 mg once 24 mg/d420 Losartan 25 to 50 mg once 50 to 150 mg once 129 mg/d421 Valsartan 20 to 40 mg twice 160 mg twice 254 mg/d108 Aldosterone antagonists Spironolactone 12.5 to 25.0 mg once 25 mg once or twice 26 mg/d425 Eplerenone 25 mg once 50 mg once 42.6 mg/d446 Beta blockers Bisoprolol 1.25 mg once 10 mg once 8.6 mg/d117 Carvedilol 3.125 mg twice 50 mg twice 37 mg/d447 Carvedilol CR 10 mg once 80 mg once N/A Metoprolol succinate extended release 12.5 to 25 mg once 200 mg once 159 mg/d448 (metoprolol CR/XL) Hydralazine and isosorbide dinitrate Fixed-dose combination424 37.5 mg hydralazine/20 mg 75 mg hydralazine/40 mg isosorbide ~175 mg hydralazine/90 mg isosorbide dinitrate dinitrate 3 times daily isosorbide dinitrate daily 3 times daily Hydralazine and isosorbide dinitrate449 Hydralazine: 25 to 50 mg, 3 Hydralazine: 300 mg daily in divided N/A or 4 times daily and doses and isosorbide dinitrate: 120 mg isosorbide dinitrate: 20 to 30 mg daily in divided doses 3 or 4 times daily ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CR, controlled release; CR/XL, controlled release/extended release; HFrEF, heart failure with reduced ejection fraction; and N/A, not applicable. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e267
7.3.2.2.3. ACE Inhibitors: Risks of Treatment. The majority of ACE-inhibition intolerance primarily related to cough is the the adverse reactions of ACE inhibitors can be attributed to the most common indication. In addition, an ARB may be used 2 principal pharmacological actions of these drugs: those related as an alternative to an ACE inhibitor in patients who are to angiotensin suppression and those related to kinin potentia- already taking an ARB for another reason, such as hyperten- tion. Other types of adverse effects may also occur (eg, rash and sion, and who subsequently develop HF. Angioedema occurs taste disturbances). Up to 20% of patients will experience an ACE in <1% of patients who take an ACE inhibitor, but it occurs inhibitor–induced cough. With the use of ACE inhibitors, particu- more frequently in blacks. Because its occurrence may be lar care should be given to the patient’s volume status, renal func- life-threatening, clinical suspicion of this reaction justifies the tion, and concomitant medications (Sections 7.3.2.1 and 7.3.2.9). subsequent avoidance of all ACE inhibitors for the lifetime However, most HF patients (85% to 90%) can tolerate these drugs. of the patient. ACE inhibitors should not be initiated in any See Online Data Supplement 18 for additional data on ACE patient with a history of angioedema. Although ARBs may inhibitors. be considered as alternative therapy for patients who have developed angioedema while taking an ACE inhibitor, there 7.3.2.3. ARBs: Recommendations are some patients who have also developed angioedema with Class I ARBs, and caution is advised when substituting an ARB in a patient who has had angioedema associated with use of an 1. ARBs are recommended in patients with HFrEF with ACE inhibitor.458–461 current or prior symptoms who are ACE inhibitor intolerant, unless contraindicated, to reduce morbid- 7.3.2.3.2. ARBs: Initiation and Maintenance. When used, ity and mortality.108,345,415,450 (Level of Evidence: A) ARBs should be initiated with the starting doses shown in Class IIa Table 15. Many of the considerations with initiation of an ARB are similar to those with initiation of an ACE inhibitor, 1. ARBs are reasonable to reduce morbidity and mor- as discussed previously. Blood pressure (including postural tality as alternatives to ACE inhibitors as first-line blood pressure changes), renal function, and potassium should therapy for patients with HFrEF, especially for be reassessed within 1 to 2 weeks after initiation and followed patients already taking ARBs for other indications, closely after changes in dose. Patients with systolic blood unless contraindicated.451–456 (Level of Evidence: A) pressure <80 mm Hg, low serum sodium, diabetes mellitus, Class IIb and impaired renal function merit close surveillance during therapy with inhibitors of the renin angiotensin-aldosterone 1. Addition of an ARB may be considered in persis- tently symptomatic patients with HFrEF who are system. Titration is generally achieved by doubling doses. already being treated with an ACE inhibitor and a For stable patients, it is reasonable to add therapy with beta- beta blocker in whom an aldosterone antagonist is blocking agents before full target doses of either ACE inhibi- not indicated or tolerated.420,457 (Level of Evidence: A) tors or ARBs are reached. Class III: Harm 7.3.2.3.3. ARBs: Risks of Treatment. The risks of ARBs are attributed to suppression of angiotensin stimulation. These 1. Routine combined use of an ACE inhibitor, ARB, risks of hypotension, renal dysfunction, and hyperkalemia are and aldosterone antagonist is potentially harmful for patients with HFrEF. (Level of Evidence: C) greater when combined with another inhibitor of this neurohor- monal axis, such as ACE inhibitors or aldosterone antagonists. ARBs were developed with the rationale that a) angiotensin II See Online Data Supplement 19 for additional data on production continues in the presence of ACE inhibition, driven ARBs. through alternative enzyme pathways and b) interference with the renin-angiotensin system without inhibition of kininase 7.3.2.4. Beta Blockers: Recommendation would produce all of the benefits of ACE inhibitors while min- Class I imizing the risk of adverse reactions to them. However, it is now known that some of the benefits of ACE inhibitors may be 1. Use of 1 of the 3 beta blockers proven to reduce related to the accumulation of kinins rather than to the suppres- mortality (eg, bisoprolol, carvedilol, and sustained- sion of angiotensin II formation, whereas some of the adverse release metoprolol succinate) is recommended for all effects of ACE inhibitors in HF are related to the suppression patients with current or prior symptoms of HFrEF, of angiotensin II formation. unless contraindicated, to reduce morbidity and In several placebo-controlled studies, long-term therapy with mortality.346,416–419,448 (Level of Evidence: A) ARBs produced hemodynamic, neurohormonal, and clinical Long-term treatment with beta blockers can lessen the symp- effects consistent with those expected after interference with toms of HF, improve the patient’s clinical status, and enhance the renin-angiotensin system. Reduced hospitalization and mor- the patient’s overall sense of well-being.462–469 In addition, like tality have been demonstrated. ACE inhibitors remain the first ACE inhibitors, beta blockers can reduce the risk of death and choice for inhibition of the renin-angiotensin system in systolic the combined risk of death or hospitalization.117,447,448,470,471 HF, but ARBs can now be considered a reasonable alternative. These benefits of beta blockers were seen in patients with or 7.3.2.3.1. ARBs: Selection of Patients. ARBs are used in without CAD and in patients with or without diabetes mel- patients with HFrEF who are ACE inhibitor intolerant; an litus, as well as in women and blacks. The favorable effects Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e268 Circulation October 15, 2013 of beta blockers were also observed in patients already taking blockers shown to be effective in major clinical trials. Even ACE inhibitors. if symptoms do not improve, long-term treatment should be Three beta blockers have been shown to be effective in maintained to reduce the risk of major clinical events. Abrupt reducing the risk of death in patients with chronic HFrEF: withdrawal of treatment with a beta blocker can lead to clini- bisoprolol and sustained-release metoprolol (succinate), which cal deterioration and should be avoided.477 selectively block beta-1–receptors; and carvedilol, which 7.3.2.4.3. Beta Blockers: Risks of Treatment. Initiation of treat- blocks alpha-1–, beta-1–, and beta-2–receptors. Positive find- ment with a beta blocker may produce 4 types of adverse reac- ings with these 3 agents, however, should not be considered tions that require attention and management: fluid retention and a beta-blocker class effect. Bucindolol lacked uniform effec- worsening HF; fatigue; bradycardia or heart block; and hypoten- tiveness across different populations, and short-acting meto- sion. The occurrence of fluid retention or worsening HF is not prolol tartrate was less effective in HF clinical trials. Beta-1 generally a reason for the permanent withdrawal of treatment. selective blocker nebivolol demonstrated a modest reduction Such patients generally respond favorably to intensification of in the primary endpoint of all-cause mortality or cardiovas- conventional therapy, and once treated, they remain excellent cular hospitalization but did not affect mortality alone in an candidates for long-term treatment with a beta blocker. The elderly population that included patients with HFpEF. 472 slowing of heart rate and cardiac conduction produced by beta 7.3.2.4.1. Beta Blockers: Selection of Patients. Beta blockers blockers is generally asymptomatic and thus requires no treat- should be prescribed to all patients with stable HFrEF unless ment; however, if the bradycardia is accompanied by dizziness or they have a contraindication to their use or are intolerant of lightheadedness or if second- or third-degree heart block occurs, these drugs. Because of its favorable effects on survival and clinicians should decrease the dose of the beta blocker. Clini- disease progression, a clinical trial–proven beta blocker should cians may minimize the risk of hypotension by administering the be initiated as soon as HFrEF is diagnosed. Even when symp- beta blocker and ACE inhibitor at different times during the day. toms are mild or improve with other therapies, beta-blocker Hypotensive symptoms may also resolve after a decrease in the therapy is important and should not be delayed until symp- dose of diuretics in patients who are volume depleted. If hypo- toms return or disease progression is documented. Therefore, tension is accompanied by other clinical evidence of hypoperfu- even if patients have little disability and experience seemingly sion, beta-blocker therapy should be decreased or discontinued minimal symptomatic benefit, they should still be treated with pending further patient evaluation. The symptom of fatigue is a beta blocker to reduce the risks of disease progression, clini- multifactorial and is perhaps the hardest symptom to address cal deterioration, and sudden death.117,448,469–471 with confidence. Although fatigue may be related to beta block- Patients need not take high doses of ACE inhibitors before ers, other causes of fatigue should be considered, including sleep initiation of beta-blocker therapy. In patients taking a low dose apnea, overdiuresis, or depression. of an ACE inhibitor, the addition of a beta blocker produces a See Online Data Supplement 20 for additional data on beta greater improvement in symptoms and reduction in the risk of blockers. death than does an increase in the dose of the ACE inhibitor, 7.3.2.5. Aldosterone Receptor Antagonists: even to the target doses used in clinical trials.445,473 In patients Recommendations with a current or recent history of fluid retention, beta blockers should not be prescribed without diuretics, because diuretics Class I are needed to maintain sodium and fluid balance and prevent 1. Aldosterone receptor antagonists (or mineralocor- the exacerbation of fluid retention that can accompany the ticoid receptor antagonists) are recommended in initiation of beta-blocker therapy.474,475 Beta blockers may be patients with NYHA class II–IV HF and who have considered in patients who have reactive airway disease or LVEF of 35% or less, unless contraindicated, to asymptomatic bradycardia but should be used cautiously in reduce morbidity and mortality. Patients with NYHA patients with persistent symptoms of either condition. class II HF should have a history of prior cardiovas- 7.3.2.4.2. Beta Blockers: Initiation and Maintenance. Treat- cular hospitalization or elevated plasma natriuretic ment with a beta blocker should be initiated at very low doses peptide levels to be considered for aldosterone recep- (Table 15), followed by gradual increments in dose if lower tor antagonists. Creatinine should be 2.5 mg/dL or less doses have been well tolerated. Patients should be monitored in men or 2.0 mg/dL or less in women (or estimated glomerular filtration rate >30 mL/min/1.73 m2), and closely for changes in vital signs and symptoms during this potassium should be less than 5.0 mEq/L. Careful uptitration period. Planned increments in the dose of a beta monitoring of potassium, renal function, and diuretic blocker should be delayed until any adverse effects observed dosing should be performed at initiation and closely with lower doses have disappeared. When such a cautious followed thereafter to minimize risk of hyper- approach was used, most patients (approximately 85%) kalemia and renal insufficiency.425,426,478 (Level of enrolled in clinical trials who received beta blockers were Evidence: A) able to tolerate short- and long-term treatment with these 2. Aldosterone receptor antagonists are recommended drugs and achieve the maximum planned trial dose.117,447,448,470 to reduce morbidity and mortality following an acute Data show that beta blockers can be safely started before dis- MI in patients who have LVEF of 40% or less who charge even in patients hospitalized for HF, provided they do develop symptoms of HF or who have a history of not require intravenous inotropic therapy for HF.476 Clinicians diabetes mellitus, unless contraindicated.446 (Level of should make every effort to achieve the target doses of the beta Evidence: B) Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e269
Table 16. Drug Dosing for Aldosterone Receptor Antagonists
Eplerenone Spironolactone eGFR (mL/min/1.73 m2) ≥50 30 to −49 ≥50 30 to 49 Initial dose (only if K+ ≤5 mEq/L) 25 mg once daily 25 mg once every other day 12.5 to 25.0 mg once daily 12.5 mg once daily or every other day Maintenance dose (after 4 wk for K+ 50 mg once daily 25 mg once daily 25 mg once or twice daily 12.5 to 25.0 mg once daily ≤5 mEq/L)* *After dose initiation for K+, increase ≤6.0 mEq/L or worsening renal function, hold until K+ <5.0 mEq/L. Consider restarting reduced dose after confirming resolution of hyperkalemia/renal insufficiency for at least 72 h. eGFR indicates estimated glomerular filtration rate; and, +K , potassium. Adapted from Butler et al.481
Class III: Harm a QRS duration of >130 ms on ECG). To minimize the risk of life-threatening hyperkalemia in euvolemic patients with HFrEF, 1. Inappropriate use of aldosterone receptor antago- patients should have initial serum creatinine <2.5 mg/dL (or an nists is potentially harmful because of life-threat- estimated glomerular filtration rate >30 mL/min/1.73 2m ) with- ening hyperkalemia or renal insufficiency when out recent worsening and serum potassium <5.0 mEq/L without serum creatinine is greater than 2.5 mg/dL in men a history of severe hyperkalemia. Careful patient selection and or greater than 2.0 mg/dL in women (or estimated risk assessment with availability of close monitoring is essential glomerular filtration rate <30 mL/min/1.73 2m ), in initiating the use of aldosterone receptor antagonists. and/or potassium greater than 5.0 mEq/L.479,480 (Level of Evidence: B) 7.3.2.5.2. Aldosterone Receptor Antagonists: Initiation and Maintenance. Spironolactone should be initiated at a dose of The landmark RALES trial (Randomized Aldactone 12.5 to 25 mg daily, while eplerenone should be initiated at a Evaluation Study)425 showed a 30% reduction in all-cause mor- dose of 25 mg/d, increasing to 50 mg daily. For those with con- tality as well as a reduced risk of SCD and HF hospitalizations cerns of hyperkalemia or marginal renal function (estimated 2 with the use of spironolactone in patients with chronic HFrEF glomerular filtration rate 30 to 49 mL/min/1.73 m ), an initial and LVEF <35%. Eplerenone has been shown to reduce all- regimen of every-other-day dosing is advised (Table 16). After cause deaths, cardiovascular deaths, or HF hospitalizations in initiation of aldosterone receptor antagonists, potassium sup- a wider range of patients with HFrEF. 426,446 plementation should be discontinued (or reduced and carefully monitored in those with a history of hypokalemia; Table 17), 7.3.2.5.1. Aldosterone Receptor Antagonists: Selection of and patients should be counseled to avoid foods high in potas- Patients. Clinicians should strongly consider the addition of the sium and NSAIDs. Potassium levels and renal function should aldosterone receptor antagonists spironolactone or eplerenone for be rechecked within 2 to 3 days and again at 7 days after initia- all patients with HFrEF who are already on ACE inhibitors (or tion of an aldosterone receptor antagonist. Subsequent moni- ARBs) and beta blockers. Although the entry criteria for the tri- toring should be dictated by the general clinical stability of als of aldosterone receptor antagonists excluded patients with a renal function and fluid status but should occur at least monthly creatinine >2.5 mg/dL, the majority of patients had much lower for the first 3 months and every 3 months thereafter. The addi- creatinine (95% of patients had creatinine ≤1.7 mg/dL).425,426,446 tion or an increase in dosage of ACE inhibitors or ARBs should In contrast, one third of patients in EMPHASIS-HF (Eplerenone trigger a new cycle of monitoring. in Mild Patients Hospitalization and Survival Study in Heart There are limited data to support or refute that spironolac- Failure) had an estimated glomerular filtration rate of <60 mL/ tone and eplerenone are interchangeable. The perceived differ- min/1.73 m2.426 Note also that the entry criteria for the EMPHA- ence between eplerenone and spironolactone is the selectivity SIS-HF trial were age of at least ≥55 years, NYHA class II of aldosterone receptor antagonism and not the effectiveness symptoms, and an EF of no more than 30% (or, if >30% to 35%, of blocking mineralocorticoid activity. In RALES, there was
Table 17. Strategies to Minimize the Risk of Hyperkalemia in Patients Treated With Aldosterone Antagonists
1. Impaired renal function is a risk factor for hyperkalemia during treatment with aldosterone antagonists. The risk of hyperkalemia increases progressively when serum creatinine is >1.6 mg/dL.* In elderly patients or others with low muscle mass in whom serum creatinine does not accurately reflect glomerular filtration rate, determination that glomerular filtration rate or creatinine clearance is >30 mL/min/1.73 2m is recommended. 2. Aldosterone antagonists would not ordinarily be initiated in patients with baseline serum potassium >5.0 mEq/L. 3. An initial dose of spironolactone of 12.5 mg or eplerenone 25 mg is typical, after which the dose may be increased to spironolactone 25 mg or eplerenone 50 mg if appropriate. 4. The risk of hyperkalemia is increased with concomitant use of higher doses of ACE inhibitors (captopril ≥75 mg daily; enalapril or lisinopril ≥10 mg daily). 5. In most circumstances, potassium supplements are discontinued or reduced when initiating aldosterone antagonists. 6. Close monitoring of serum potassium is required; potassium levels and renal function are most typically checked in 3 d and at 1 wk after initiating therapy and at least monthly for the first 3 mo. *Although the entry criteria for the trials of aldosterone antagonists included creatinine <2.5 mg/dL, the majority of patients had much lower creatinine; in 1 trial,425 95% of patients had creatinine ≤1.7 mg/dL. ACE indicates angiotensin-converting enzyme.
Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e270 Circulation October 15, 2013 increased incidence (10%) of gynecomastia or breast pain hydralazine and isosorbide dinitrate to standard therapy with with use of spironolactone (a nonselective antagonist). The an ACE inhibitor or ARB, a beta blocker, and an aldosterone incidence of these adverse events was <1% in EPHESUS antagonist offered significant benefit.424 (Eplerenone Post-Acute Myocardial Infarction Heart Failure 7.3.2.6.1. Hydralazine and Isosorbide Dinitrate: Selection of Efficacy and Survival Study) and EMPHASIS-HF without Patients. The combination of hydralazine and isosorbide dini- any difference in adverse events between the eplerenone and trate is recommended for African Americans with HFrEF who placebo.426,446 remain symptomatic despite concomitant use of ACE inhibi- 7.3.2.5.3. Aldosterone Receptor Antagonists: Risks of Treat- tors, beta blockers, and aldosterone antagonists. Whether this ment. The major risk associated with use of aldosterone recep- benefit is evident in non–African Americans with HFrEF tor antagonists is hyperkalemia due to inhibition of potassium remains to be investigated. The combination of hydralazine excretion, ranging from 2% to 5% in large clinical trials425,426,446 and isosorbide dinitrate should not be used for the treatment to 24% to 36% in population-based registries.479,480 Routine of HFrEF in patients who have no prior use of standard neu- triple combination of an ACE inhibitor, ARB, and aldosterone rohumoral antagonist therapy and should not be substituted receptor antagonist should be avoided. for ACE inhibitor or ARB therapy in patients who are tolerat- The development of potassium levels >5.5 mEq/L ing therapy without difficulty. Despite the lack of data with (approximately 12% in EMPHASIS-HF426) should gen- the vasodilator combination in patients who are intolerant of erally trigger discontinuation or dose reduction of the ACE inhibitors or ARBs, the combined use of hydralazine and aldosterone receptor antagonist unless other causes are isosorbide dinitrate may be considered as a therapeutic option identified. The development of worsening renal function in such patients. should lead to careful evaluation of the entire medical regi- 7.3.2.6.2. Hydralazine and Isosorbide Dinitrate: Initiation men and consideration for stopping the aldosterone recep- and Maintenance. If the fixed-dose combination is avail- tor antagonist. Patients should be instructed specifically to able, the initial dose should be 1 tablet containing 37.5 mg stop the aldosterone receptor antagonist during an episode of hydralazine hydrochloride and 20 mg of isosorbide dini- of diarrhea or dehydration or while loop diuretic therapy trate 3 times daily. The dose can be increased to 2 tablets 3 is interrupted. times daily for a total daily dose of 225 mg of hydralazine 7.3.2.6. Hydralazine and Isosorbide Dinitrate: hydrochloride and 120 mg of isosorbide dinitrate. When the 2 Recommendations drugs are used separately, both pills should be administered at Class I least 3 times daily. Initial low doses of the drugs given sepa- rately may be progressively increased to a goal similar to that 1. The combination of hydralazine and isosorbide achieved in the fixed-dose combination trial.424 dinitrate is recommended to reduce morbidity and mortality for patients self-described as African 7.3.2.6.3. Hydralazine and Isosorbide Dinitrate: Risks of Americans with NYHA class III–IV HFrEF receiv- Treatment. Adherence to this combination has generally ing optimal therapy with ACE inhibitors and beta been poor because of the large number of tablets required, blockers, unless contraindicated.423,424 (Level of frequency of administration, and the high incidence of Evidence: A) adverse reactions.412,449 Frequent adverse effects include headache, dizziness, and gastrointestinal complaints. Nev- Class IIa ertheless, the benefit of these drugs can be substantial and warrant a slower titration of the drugs to enhance tolerance 1. A combination of hydralazine and isosorbide dini- of the therapy. trate can be useful to reduce morbidity or mortal- See Table 18 for a summary of the treatment benefit of ity in patients with current or prior symptomatic GDMT in HFrEF. HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or 449 Table 18. Medical Therapy for Stage C HFrEF: Magnitude of renal insufficiency, unless contraindicated. (Level Benefit Demonstrated in RCTs of Evidence: B) NNT for Mortality RR Reduction In a large-scale trial that compared the vasodilator combina- RR Reduction in Reduction in HF tion with placebo, the use of hydralazine and isosorbide dini- Mortality (Standardized Hospitalizations trate reduced mortality but not hospitalizations in patients with GDMT (%) to 36 mo) (%) HF treated with digoxin and diuretics but not an ACE inhibitor ACE inhibitor or ARB 17 26 31 or beta blocker.449 However, in 2 other trials that compared Beta blocker 34 9 41 the vasodilator combination with an ACE inhibitor, the ACE Aldosterone antagonist 30 6 35 412,482 inhibitor produced more favorable effects on survival. Hydralazine/nitrate 43 7 33 A post hoc retrospective analysis of these vasodilator trials ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor demonstrated particular efficacy of isosorbide dinitrate and blocker; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, 423 hydralazine in the African American cohort. In a subse- heart failure with reduced ejection fraction; NNT, number needed to treat; RCTs, quent trial, which was limited to patients self-described as randomized controlled trials; and RR, relative risk. African American, the addition of a fixed-dose combination of Adapted with permission from Fonarow et al.483 Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e271
7.3.2.7. Digoxin: Recommendation 7.3.2.7.3. Digoxin: Risks of Treatment. When administered with attention to dose and factors that alter its metabolism, Class IIa digoxin is well tolerated by most patients with HF.499 The 1. Digoxin can be beneficial in patients with HFrEF, principal adverse reactions occur primarily when digoxin unless contraindicated, to decrease hospitalizations is administered in large doses, especially in the elderly, for HF.484–491 (Level of Evidence: B) but large doses are not necessary for clinical benefits.500–502 The major adverse effects include cardiac arrhythmias (eg, Several placebo-controlled trials have shown that treatment with ectopic and re-entrant cardiac rhythms and heart block), digoxin for 1 to 3 months can improve symptoms, HRQOL, and gastrointestinal symptoms (eg, anorexia, nausea, and exercise tolerance in patients with mild to moderate HF.485–491 vomiting), and neurological complaints (eg, visual distur- These benefits have been seen regardless of the underlying bances, disorientation, and confusion). Overt digoxin tox- rhythm (normal sinus rhythm or AF), cause of HF (ischemic icity is commonly associated with serum digoxin levels or nonischemic cardiomyopathy), or concomitant therapy (with >2 ng/mL. or without ACE inhibitors). In a long-term trial that primarily However, toxicity may also occur with lower digoxin enrolled patients with NYHA class II or III HF, treatment with levels, especially if hypokalemia, hypomagnesemia, or digoxin for 2 to 5 years had no effect on mortality but modestly hypothyroidism coexists.503,504 The concomitant use of reduced the combined risk of death and hospitalization.484 clarithromycin, dronedarone, erythromycin, amiodarone, itraconazole, cyclosporine, propafenone, verapamil, or 7.3.2.7.1. Digoxin: Selection of Patients. Clinicians may con- quinidine can increase serum digoxin concentrations and sider adding digoxin in patients with persistent symptoms of may increase the likelihood of digoxin toxicity.505–507 The HFrEF during GDMT. Digoxin may also be added to the ini- dose of digoxin should be reduced if treatment with these tial regimen in patients with severe symptoms who have not drugs is initiated. In addition, a low lean body mass and yet responded symptomatically during GDMT. impaired renal function can also elevate serum digoxin lev- Alternatively, treatment with digoxin may be delayed until els, which may explain the increased risk of digoxin toxicity the patient’s response to GDMT has been defined and may be in elderly patients. used only in patients who remain symptomatic despite ther- apy with the neurohormonal antagonists. If a patient is taking 7.3.2.8. Other Drug Treatment digoxin but not an ACE inhibitor or a beta blocker, treatment 7.3.2.8.1. Anticoagulation: Recommendations with digoxin should not be withdrawn, but appropriate ther- Class I apy with the neurohormonal antagonists should be instituted. Digoxin is prescribed occasionally in patients with HF and 1. Patients with chronic HF with permanent/persistent/ AF, but beta blockers are usually more effective when added paroxysmal AF and an additional risk factor for to digoxin in controlling the ventricular response, particularly cardioembolic stroke (history of hypertension, dia- during exercise.492–495 betes mellitus, previous stroke or transient ischemic Patients should not be given digoxin if they have signifi- attack, or ≥75 years of age) should receive chronic 508–514 cant sinus or atrioventricular block unless the block has been anticoagulant therapy.* (Level of Evidence: A) 2. The selection of an anticoagulant agent (warfarin, addressed with a permanent pacemaker. The drug should be dabigatran, apixaban, or rivaroxaban) for permanent/ used cautiously in patients taking other drugs that can depress persistent/paroxysmal AF should be individualized on sinus or atrioventricular nodal function or affect digoxin levels the basis of risk factors, cost, tolerability, patient pref- (eg, amiodarone or a beta blocker), even though such patients erence, potential for drug interactions, and other clini- usually tolerate digoxin without difficulty. cal characteristics, including time in the international 7.3.2.7.2. Digoxin: Initiation and Maintenance. Therapy with normalized ratio therapeutic range if the patient has digoxin is commonly initiated and maintained at a dose of been taking warfarin. (Level of Evidence: C) 0.125 to 0.25 mg daily. Low doses (0.125 mg daily or every Class IIa other day) should be used initially if the patient is >70 years of age, has impaired renal function, or has a low lean body 1. Chronic anticoagulation is reasonable for patients mass.496 Higher doses (eg, digoxin 0.375 to 0.50 mg daily) are with chronic HF who have permanent/persistent/ rarely used or needed in the management of patients with HF. paroxysmal AF but are without an additional risk There is no reason to use loading doses of digoxin to initiate factor for cardioembolic stroke.*509–511,515–517 (Level of therapy in patients with HF. Evidence: B) Doses of digoxin that achieve a plasma concentration of drug in the range of 0.5 to 0.9 ng/mL are suggested, given Class III: No Benefit the limited evidence currently available. There has been no prospective, randomized evaluation of the relative efficacy 1. Anticoagulation is not recommended in patients with or safety of different plasma concentrations of digoxin. chronic HFrEF without AF, a prior thromboem- Retrospective analysis of 2 studies of digoxin withdrawal bolic event, or a cardioembolic source.518–520 (Level of found that prevention of worsening HF by digoxin at lower Evidence: B) concentrations in plasma (0.5 to 0.9 ng/mL) was as great as that achieved at higher concentrations.497,498 *In the absence of contraindications to anticoagulation. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e272 Circulation October 15, 2013
Patients with chronic HFrEF are at an increased risk of thrombo- newer drugs. Trials comparing new anticoagulants with war- embolic events due to stasis of blood in dilated hypokinetic car- farin have enrolled >10 000 patients with HF. As more detailed diac chambers and in peripheral blood vessels521,522 and perhaps evaluations of the comparative benefits and risks of these due to increased activity of procoagulant factors.523 However, newer agents in patients with HF are still pending, the writ- in large-scale studies, the risk of thromboembolism in clini- ing committee considered their use in patients with HF and cally stable patients has been low (1% to 3% per year), even in nonvalvular AF as an alternative to warfarin to be reasonable. those with a very depressed EF and echocardiographic evidence The benefit afforded by low-dose aspirin in patients with sys- of intracardiac thrombi.524–528 These rates are sufficiently low to tolic HF but no previous MI or known CAD (or specifically in limit the detectable benefit of anticoagulation in these patients. patients proven free of CAD) remains unknown. A Cochrane In several retrospective analyses, the risk of thromboem- review failed to find sufficient evidence to support its use.532 bolic events was not lower in patients with HF taking warfarin Retrospective and observational studies again had conflicting than in patients not treated with antithrombotic drugs.524,526,527 results and used very different criteria to identify patients as The use of warfarin was associated with a reduction in major nonischemic, with some demonstrating protection from aspirin cardiovascular events and death in patients with HF in some overall532 or only in patients with more severe depression of sys- studies but not in others.518,529,530 An RCT that compared the tolic function,518 whereas others found no benefit from aspirin.530 outcome of patients with HFrEF assigned to aspirin, warfa- The high incidence of diabetes mellitus and hypertension in most rin, or clopidogrel was completed,519 but no therapy appeared HF studies, combined with a failure to use objective methods to to be superior. Another trial compared aspirin with warfarin exclude CAD in enrolled patients, may leave this question unan- in patients with reduced LVEF, sinus rhythm, and no cardio- swered. Currently, data are insufficient to recommend aspirin for embolic source and demonstrated no difference in either the empiric primary prevention in HF patients known to be free of primary outcome of death, stroke, or intracerebral hemor- atherosclerotic disease and without additional risk factors. rhage.520 There was also no difference in the combined out- See Online Data Supplement 21 for additional data on come of death, ischemic stroke, intracerebral hemorrhage, anticoagulants. MI, or HF hospitalization. There was a significant increase in major bleeding with warfarin. Given that there is no overall 7.3.2.8.2. Statins: Recommendation benefit of warfarin and an increased risk of bleeding, there is Class III: No Benefit no compelling evidence to use warfarin or aspirin in patients 1. Statins are not beneficial as adjunctive therapy with HFrEF in the absence of a specific indication. when prescribed solely for the diagnosis of HF in the The efficacy of long-term warfarin for the prevention absence of other indications for their use.533–538 (Level of stroke in patients with AF is well established. However, of Evidence: A) the ACCF/AHA guidelines for AF6 recommend use of the
CHADS2 [Congestive heart failure, Hypertension, Age ≥75 Statin therapy has been broadly implicated in prevention years, Diabetes mellitus, previous Stroke/transient ischemic of adverse cardiovascular events, including new-onset HF. attack (doubled risk weight)] score to assess patient risk for Originally designed to lower cholesterol in patients with car- adverse outcomes before initiating anticoagulation therapy. diovascular disease, statins are increasingly recognized for More recently, a revised score, CHADS2-VASc, has been sug- their favorable effects on inflammation, oxidative stress, and gested as more applicable to a wider range of patients,531 but this vascular performance. Several observational and post hoc revised score has not yet been fully studied in patients with HF. analyses from large clinical trials have implied that statin Regardless of whether patients receive rhythm or rate control, therapy may provide clinical benefit to patients with HF.533–536 anticoagulation is recommended for patients with HF and AF However, 2 large RCTs have demonstrated that rosuvastatin for stroke prevention in the presence of at least 1 additional risk has neutral effects on long-term outcomes in patients with factor. For patients with HF and AF in the absence of another chronic HFrEF when added to standard GDMT.537,538 At pres- cardioembolic risk factor, anticoagulation is reasonable. ent, statin therapy should not be prescribed primarily for the Trials of newer oral anticoagulants have compared efficacy treatment of HF to improve clinical outcomes. and safety with warfarin therapy rather than placebo. Several See Online Data Supplement 22 for additional data on new oral anticoagulants are now available, including the factor statin therapy. Xa inhibitors apixaban and rivaroxaban and the direct throm- bin inhibitor dabigatran.508,512–514 These drugs have few food 7.3.2.8.3. Omega-3 Fatty Acids: Recommendation and drug interactions compared with warfarin and no need for Class IIa routine coagulation monitoring or dose adjustment. The fixed 1. Omega-3 polyunsaturated fatty acid (PUFA) supple- dosing together with fewer interactions may simplify patient mentation is reasonable to use as adjunctive therapy management, particularly with the polypharmacy commonly in patients with NYHA class II–IV symptoms and seen in HF. These drugs have a potential for an improved HFrEF or HFpEF, unless contraindicated, to reduce benefit–risk profile compared with warfarin, which may mortality and cardiovascular hospitalizations.539,540 increase their use in practice, especially in those at increased (Level of Evidence: B) bleeding risk. However, important adverse effects have been noted with these new anticoagulants, including gastrointesti- Supplementation with omega-3 PUFA has been evaluated as an nal distress, which may limit compliance. At present, there is adjunctive therapy for cardiovascular disease and HF.541 Trials no commercially available agent to reverse the effect of these in primary and secondary prevention of coronary heart disease Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e273 showed that omega-3 PUFA supplementation results in a 10% to routine vitamin, nutritional, or hormonal supplementation.565 20% risk reduction in fatal and nonfatal cardiovascular events. In most data or other literature regarding nutraceuticals, there The GISSI (Gruppo Italiano per lo Studio della Sopravvivenza are issues, including outcomes analyses, adverse effects, and nell’Infarto miocardico) Prevenzione trial demonstrated a drug-nutraceutical interactions, that remain unresolved. 21% reduction in death among post-MI patients taking 1 g of No clinical trials have demonstrated improved survival omega-3 PUFA (850 mg to 882 mg of eicosapentaenoic acid rates with use of nutritional or hormonal therapy, with the [EPA] and docosahexaenoic acid [DHA] as ethyl esters in the exception of omega-3 fatty acid supplementation as previ- ratio of 1:1.2).542 Post hoc subgroup analysis revealed that this ously noted. Some studies have suggested a possible effect for reduction in mortality and SCD was concentrated in the approx- coenzyme Q10 in reduced hospitalization rates, dyspnea, and imately 2000 patients with reduced LVEF.539 The GISSI-HF edema in patients with HF, but these benefits have not been investigators randomized 6975 patients in NYHA class II–IV seen uniformly.566–569 Because of possible adverse effects and chronic HF to 1 g daily of omega-3 PUFA (850 mg to 882 mg drug interactions of nutritional supplements and their wide- EPA/DHA) or matching placebo. Death from any cause was spread use, clinicians caring for patients with HF should rou- reduced from 29% with placebo to 27% in those treated with tinely inquire about their use. Until more data are available, omega-3 PUFA.540 The outcome of death or admission to hos- nutritional supplements or hormonal therapies are not recom- pital for a cardiovascular event was also significantly reduced. mended for the treatment of HF. In reported studies, this therapy has been safe and very well 7.3.2.9.2. Antiarrhythmic Agents. With atrial and ventricular tolerated.540–543 Further investigations are needed to better define arrhythmias contributing to the morbidity and mortality of HF, optimal dosing and formulation of omega-3 PUFA supple- various classes of antiarrhythmic agents have been repeatedly ments. The use of omega-3 PUFA supplementation is reason- studied in large RCTs. Instead of conferring survival benefit, able as adjunctive therapy in patients with chronic HF. however, nearly all antiarrhythmic agents increase mortality in See Online Data Supplement 23 for additional data on the HF population.548–550 Most antiarrhythmics have some nega- omega-3 fatty acids. tive inotropic effect and some, particularly the class I and class 7.3.2.9. Drugs of Unproven Value or That May Worsen HF: III antiarrhythmic drugs, have proarrhythmic effects. Hence, Recommendations class I sodium channel antagonists and the class III potassium channel blockers d-sotalol and dronedarone should be avoided Class III: No Benefit in patients with HF. Amiodarone and dofetilide are the only antiarrhythmic agents to have neutral effects on mortality in 1. Nutritional supplements as treatment for HF are clinical trials of patients with HF and thus are the preferred not recommended in patients with current or prior drugs for treating arrhythmias in this patient group.570–573 symptoms of HFrEF. 544,545 (Level of Evidence: B) 2. Hormonal therapies other than to correct deficien- See Online Data Supplement 24 for additional data on anti- cies are not recommended for patients with current arrhythmic agents. or prior symptoms of HFrEF. (Level of Evidence: C) 7.3.2.9.3. Calcium Channel Blockers: Recommendation
Class III: Harm Class III: No Benefit
1. Drugs known to adversely affect the clinical status of 1. Calcium channel–blocking drugs are not recom- mended as routine treatment for patients with patients with current or prior symptoms of HFrEF HFrEF. 551,574,575 (Level of Evidence: A) are potentially harmful and should be avoided or withdrawn whenever possible (eg, most antiarrhyth- By reducing peripheral vasoconstriction and LV afterload, cal- mic drugs, most calcium channel–blocking drugs cium channel blockers were thought to have a potential role [except amlodipine], NSAIDs, or thiazolidinedio- in the management of chronic HF. However, first-generation nes).546–557 (Level of Evidence: B) 2. Long-term use of infused positive inotropic drugs is dihydropyridine and nondihydropyridine calcium channel potentially harmful for patients with HFrEF, except as blockers also have myocardial depressant activity. Several palliation for patients with end-stage disease who can- clinical trials have demonstrated either no clinical benefit or not be stabilized with standard medical treatment (see even worse outcomes in patients with HF treated with these recommendations for stage D). (Level of Evidence: C) drugs.546,547,551–553 Despite their greater selectivity for calcium channels in vascular smooth muscle cells, second-generation 7.3.2.9.1. Nutritional Supplements and Hormonal Therapies. calcium channel blockers, dihydropyridine derivatives such Patients with HF, particularly those treated with diuretics, as amlodipine and felodipine, have failed to demonstrate may become deficient in vitamins and micronutrients. Sev- any functional or survival benefit in patients with HF.575–579 eral nutritional supplements (eg, coenzyme Q10, carnitine, Amlodipine, however, may be considered in the management taurine, and antioxidants) and hormonal therapies (eg, growth of hypertension or ischemic heart disease in patients with HF hormone or thyroid hormone) have been proposed for the because it is generally well tolerated and had neutral effects treatment of HF.558–563 Testosterone has also been evaluated on morbidity and mortality in large RCTs. In general, calcium for its beneficial effect in HF with modest albeit preliminary channel blockers should be avoided in patients with HFrEF. effects.564 Aside from replenishment of documented deficien- See Online Data Supplement 25 for additional data on cal- cies, published data have failed to demonstrate benefit for cium channel blockers. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e274 Circulation October 15, 2013
7.3.2.9.4. Nonsteroidal Anti-Inflammatory Drugs. NSAIDs Trials using comparable and efficacious agents for HFrEF inhibit the synthesis of renal prostaglandins, which mediate have generally been disappointing when used in patients with vasodilation in the kidneys and directly inhibit sodium resorp- HFpEF. 590 Thus, most of the recommended therapies for HFpEF tion in the thick ascending loop of Henle and collecting tubule. are directed at symptoms, especially comorbidities, and risk fac- Hence, NSAIDs can cause sodium and water retention and blunt tors that may worsen cardiovascular disease. the effects of diuretics. Several observational cohort studies have Blood pressure control concordant with existing hyperten- revealed increased morbidity and mortality in patients with HF sion guidelines remains the most important recommendation using either nonselective or selective NSAIDs.554–556,580–582 in patients with HFpEF. Evidence from an RCT has shown See Online Data Supplement 26 for additional data on NSAIDs. that improved blood pressure control reduces hospitalization for HF,591 decreases cardiovascular events, and reduces HF 7.3.2.9.5. Thiazolidinediones. Thiazolidinediones increase mortality in patients without prevalent HF.311 In hypertensive insulin sensitivity by activating nuclear peroxisome prolifer- patients with HFpEF, aggressive treatment (often with several ator-activated receptor gamma. Expressed in virtually all tis- drugs with complementary mechanisms of action) is recom- sues, peroxisome proliferator-activated receptor gamma also mended. ACE inhibitors and/or ARBs are often considered regulates sodium reabsorption in the collecting ducts of the as first-line agents. Specific blood pressure targets in HFpEF kidney. In clinical trials, thiazolidinediones have been asso- have not been firmly established; thus, the recommended tar- ciated with increased incidence of HF events, even in those gets are those used for general hypertensive populations. without any prior history of clinical HF.557,583–588 CAD is common in patients with HFpEF592; however, there are See Table 19 for a summary of recommendations from no studies to determine the impact of revascularization on symp- this section and Table 20 for strategies for achieving optimal toms or outcomes specifically in patients with HFpEF. In general, GDMT; see Online Data Supplement 27 for additional data on contemporary revascularization guidelines10,12 should be used in thiazolidinediones. the care of patients with HFpEF and concomitant CAD. Specific 7.3.3. Pharmacological Treatment for Stage C HFpEF: to this population, it might be reasonable to consider revascular- Recommendations ization in patients for whom ischemia appears to contribute to HF See Table 21 for a summary of recommendations from this symptoms, although this determination can be difficult. section. Theoretical mechanisms for the worsening of HF symptoms by AF among patients with HFpEF include shortened diastolic Class I filling time with tachycardia and the loss of atrial contribution to 1. Systolic and diastolic blood pressure should be con- LV diastolic filling. Conversely, chronotropic incompetence is trolled in patients with HFpEF in accordance with also a concern. Slowing the heart rate is useful in tachycardia but published clinical practice guidelines to prevent mor- not in normal resting heart rate; a slow heart rate prolongs diasta- bidity.27,91 (Level of Evidence: B) sis and worsens chronotropic incompetence. Currently, there are 2. Diuretics should be used for relief of symptoms due no specific trials of rate versus rhythm control in HFpEF. to volume overload in patients with HFpEF. (Level of Evidence: C) 7.3.4. Device Therapy for Stage C HFrEF: Recommendations Class IIa See Table 22 for a summary of recommendations from this section. 1. Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demon- Class I strable myocardial ischemia is judged to be having 1. ICD therapy is recommended for primary prevention an adverse effect on symptomatic HFpEF despite of SCD to reduce total mortality in selected patients GDMT. (Level of Evidence: C) with nonischemic DCM or ischemic heart disease at 2. Management of AF according to published clinical least 40 days post-MI with LVEF of 35% or less and practice guidelines in patients with HFpEF is reason- NYHA class II or III symptoms on chronic GDMT, able to improve symptomatic HF (Section 9.1). (Level who have reasonable expectation of meaningful sur- of Evidence: C) vival for more than 1 year.†355,593 (Level of Evidence: A) 3. The use of beta-blocking agents, ACE inhibitors, and 2. CRT is indicated for patients who have LVEF of 35% ARBs in patients with hypertension is reasonable or less, sinus rhythm, left bundle-branch block (LBBB) to control blood pressure in patients with HFpEF. with a QRS duration of 150 ms or greater, and NYHA (Level of Evidence: C) class II, III, or ambulatory IV symptoms on GDMT. 38,78,116,594 Class IIb (Level of Evidence: A for NYHA class III/IV ; Level of Evidence: B for NYHA class II 595,596) 1. The use of ARBs might be considered to decrease hospitalizations for patients with HFpEF. 589 (Level of †Counseling should be specific to each individual patient and should Evidence: B) include documentation of a discussion about the potential for sudden death and nonsudden death from HF or noncardiac conditions. Information should be provided about the efficacy, safety, and potential complications Class III: No Benefit of an ICD and the potential for defibrillation to be inactivated if desired in the future, notably when a patient is approaching end of life. This will 1. Routine use of nutritional supplements is not recom- facilitate shared decision making between patients, families, and the mended for patients with HFpEF. (Level of Evidence: C) medical care team about ICDs.30 Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e275
Table 19. Recommendations for Pharmacological Therapy for Management of Stage C HFrEF
Recommendations COR LOE References Diuretics Diuretics are recommended in patients with HFrEF with fluid retention I C N/A ACE inhibitors ACE inhibitors are recommended for all patients with HFrEF I A 343, 412–414 ARBs ARBs are recommended in patients with HFrEF who are ACE inhibitor intolerant I A 108, 345, 415, 450 ARBs are reasonable as alternatives to ACE inhibitors as first-line therapy in HFrEF IIa A 451–456 Addition of an ARB may be considered in persistently symptomatic patients with HFrEF on IIb A 420, 457 GDMT Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially III: Harm C N/A harmful Beta blockers Use of 1 of the 3 beta blockers proven to reduce mortality is recommended for all stable I A 346, 416–419, 448 patients Aldosterone receptor antagonists Aldosterone receptor antagonists are recommended in patients with NYHA class II–IV who I A 425, 426, 478 have LVEF ≤35% Aldosterone receptor antagonists are recommended in patients following an acute MI who I B 446 have LVEF ≤40% with symptoms of HF or DM Inappropriate use of aldosterone receptor antagonists may be harmful III: Harm B 479, 480 Hydralazine and isosorbide dinitrate The combination of hydralazine and isosorbide dinitrate is recommended for African I A 423, 424 Americans with NYHA class III–IV HFrEF on GDMT A combination of hydralazine and isosorbide dinitrate can be useful in patients with HFrEF IIa B 449 who cannot be given ACE inhibitors or ARBs Digoxin Digoxin can be beneficial in patients with HFrEF IIa B 484–491 Anticoagulation Patients with chronic HF with permanent/persistent/paroxysmal AF and an additional risk I A 508–514 factor for cardioembolic stroke should receive chronic anticoagulant therapy* The selection of an anticoagulant agent should be individualized I C N/A Chronic anticoagulation is reasonable for patients with chronic HF who have permanent/ IIa B 509–511, 515–517 persistent/paroxysmal AF but are without an additional risk factor for cardioembolic stroke* Anticoagulation is not recommended in patients with chronic HFrEF without AF, a prior III: No Benefit B 518–520 thromboembolic event, or a cardioembolic source Statins Statins are not beneficial as adjunctive therapy when prescribed solely for HF III: No Benefit A 533–538 Omega-3 fatty acids Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy in HFrEF or HFpEF IIa B 539, 540 patients Other drugs Nutritional supplements as treatment for HF are not recommended in HFrEF III: No Benefit B 544, 545 Hormonal therapies other than to correct deficiencies are not recommended in HFrEF III: No Benefit C N/A Drugs known to adversely affect the clinical status of patients with HFrEF are potentially III: Harm B 546–557 harmful and should be avoided or withdrawn Long-term use of an infusion of a positive inotropic drug is not recommended and may be III: Harm C N/A harmful except as palliation Calcium channel blockers Calcium channel–blocking drugs are not recommended as routine treatment in HFrEF III: No Benefit A 551, 574, 575 *In the absence of contraindications to anticoagulation. ACE indicates angiotensin-converting enzyme; AF, atrial fibrillation; ARB, angiotensin-receptor blocker; COR, Class of Recommendation; DM, diabetes mellitus; GDMT, guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LOE, Level of Evidence; LVEF, left ventricular ejection fraction; MI, myocardial infarction; N/A, not available; NYHA, New York Heart Association; and PUFA, polyunsaturated fatty acids.
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Table 20. Strategies for Achieving Optimal GDMT
1. Uptitrate in small increments to the recommended target dose or the highest tolerated dose for those medications listed in Table 15 with an appreciation that some patients cannot tolerate the full recommended doses of all medications, particularly patients with low baseline heart rate or blood pressure or with a tendency to postural symptoms. 2. Certain patients (eg, the elderly, patients with chronic kidney disease) may require more frequent visits and laboratory monitoring during dose titration and more gradual dose changes. However, such vulnerable patients may accrue considerable benefits from GDMT. Inability to tolerate optimal doses of GDMT may change after disease-modifying interventions such as CRT. 3. Monitor vital signs closely before and during uptitration, including postural changes in blood pressure or heart rate, particularly in patients with orthostatic symptoms, bradycardia, and/or “low” systolic blood pressure (eg, 80 to 100 mm Hg). 4. Alternate adjustments of different medication classes (especially ACE inhibitors/ARBs and beta blockers) listed in Table 15. Patients with elevated or normal blood pressure and heart rate may tolerate faster incremental increases in dosages. 5. Monitor renal function and electrolytes for rising creatinine and hyperkalemia, recognizing that an initial rise in creatinine may be expected and does not necessarily require discontinuation of therapy; discuss tolerable levels of creatinine above baseline with a nephrologist if necessary. 6. Patients may complain of symptoms of fatigue and weakness with dosage increases; in the absence of instability in vital signs, reassure them that these symptoms are often transient and usually resolve within a few days of these changes in therapy. 7. Discourage sudden spontaneous discontinuation of GDMT medications by the patient and/or other clinicians without discussion with managing clinicians. 8. Carefully review doses of other medications for HF symptom control (eg, diuretics, nitrates) during uptitration. 9. Consider temporary adjustments in dosages of GDMT during acute episodes of noncardiac illnesses (eg, respiratory infections, risk of dehydration, etc). 10. Educate patients, family members, and other clinicians about the expected benefits of achieving GDMT, including an understanding of the potential benefits of myocardial reverse remodeling, increased survival, and improved functional status and HRQOL. ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; and HRQOL, health-related quality of life.
3. ICD therapy is recommended for primary prevention NYHA class III/ambulatory class IV symptoms on of SCD to reduce total mortality in selected patients at GDMT.78,116,594,596 (Level of Evidence: A) least 40 days post-MI with LVEF of 30% or less, and 2. CRT can be useful for patients who have LVEF of 35% NYHA class I symptoms while receiving GDMT, who or less, sinus rhythm, LBBB with a QRS duration of have reasonable expectation of meaningful survival 120 to 149 ms, and NYHA class II, III, or ambula- for more than 1 year.†362,597,598 (Level of Evidence: B) tory IV symptoms on GDMT.78,116,594–596,599(Level of Evidence: B) Class IIa 3. CRT can be useful in patients with AF and LVEF of 35% or less on GDMT if a) the patient requires 1. CRT can be useful for patients who have LVEF of ventricular pacing or otherwise meets CRT cri- 35% or less, sinus rhythm, a non-LBBB pattern teria and b) atrioventricular nodal ablation or with a QRS duration of 150 ms or greater, and pharmacological rate control will allow near 600–605 †Counseling should be specific to each individual patient and should 100% ventricular pacing with CRT. (Level of include documentation of a discussion about the potential for sudden death Evidence: B) and nonsudden death from HF or noncardiac conditions. Information 4. CRT can be useful for patients on GDMT who have should be provided about the efficacy, safety, and potential complications LVEF of 35% or less and are undergoing placement of an ICD and the potential for defibrillation to be inactivated if desired in the future, notably when a patient is approaching end of life. This will of a new or replacement device implantation with facilitate shared decision making between patients, families, and the anticipated requirement for significant (>40%) medical care team about ICDs.30 ventricular pacing.155,602,606,607 (Level of Evidence: C)
Table 21. Recommendations for Treatment of HFpEF
Recommendations COR LOE
Systolic and diastolic blood pressure should be controlled according to published clinical I B27,91 practice guidelines Diuretics should be used for relief of symptoms due to volume overload. I C Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial IIa C ischemia is present despite GDMT Management of AF according to published clinical practice guidelines for HFpEF to improve IIa C symptomatic HF Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFpEF IIa C 589 ARBs might be considered to decrease hospitalizations in HFpEF IIb B Nutritional supplementation is not recommended in HFpEF III: No Benefit C ACE indicates angiotensin-converting enzyme; AF, atrial fibrillation; ARBs, angiotensin-receptor blockers; CAD, coronary artery disease; COR, Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; and LOE, Level of Evidence. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e277
Table 22. Recommendations for Device Therapy for Management of Stage C HF
Recommendations COR LOE References ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF I A 355, 593 at least 40 d post-MI with LVEF ≤35% and NYHA class II or III symptoms on chronic GDMT, who are expected to live >1 y* CRT is indicated for patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS I A (NYHA class III/IV) 38, 78, 116, 594 ≥150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT B (NYHA class II) 595, 596 ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF I B 362, 597, 598 at least 40 d post-MI with LVEF ≤30% and NYHA class I symptoms while receiving GDMT, who are expected to live >1 y* CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with IIa A 78, 116, 594, 596 QRS ≥150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT CRT can be useful for patients who have LVEF ≤35%, sinus rhythm, LBBB with a QRS 120 to IIa B 78, 116, 594–596, 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT 599 CRT can be useful in patients with AF and LVEF ≤35% on GDMT if a) the patient requires IIa B 600–605 ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation or rate control allows near 100% ventricular pacing with CRT CRT can be useful for patients on GDMT who have LVEF ≤35% and are undergoing new or IIa C 155, 602, 606, 607 replacement device implantation with anticipated ventricular pacing (>40%) An ICD is of uncertain benefit to prolong meaningful survival in patients with a high risk of IIb B 608–611 nonsudden death such as frequent hospitalizations, frailty, or severe comorbidities* CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern IIb B 596, 612 with a QRS duration of 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMT CRT may be considered for patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern IIb B 595, 596 with QRS ≥150 ms, and NYHA class II symptoms on GDMT CRT may be considered for patients who have LVEF ≤30%, ischemic etiology of HF, sinus IIb C 595, 596 rhythm, LBBB with QRS ≥150 ms, and NYHA class I symptoms on GDMT CRT is not recommended for patients with NYHA class I or II symptoms and non-LBBB III: No Benefit B 595, 596, 612 pattern with QRS <150 ms CRT is not indicated for patients whose comorbidities and/or frailty limit survival to <1 y III: No Benefit C 38 *Counseling should be specific to each individual patient and should include documentation of a discussion about the potential for sudden death and nonsudden death from HF or noncardiac conditions. Information should be provided about the efficacy, safety, and potential complications of an ICD and the potential for defibrillation to be inactivated if desired in the future, notably when a patient is approaching end of life. This will facilitate shared decision making between patients, families, and the medical care team about ICDs.30 AF indicates atrial fibrillation; AV, atrioventricular; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; LBBB, left bundle-branch block; LOE, Level of Evidence; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NYHA, New York Heart Association; and SCD, sudden cardiac death.
Class IIb 3. CRT may be considered for patients who have LVEF of 35% or less, sinus rhythm, a non-LBBB pattern with a 1. The usefulness of implantation of an ICD is of QRS duration of 150 ms or greater, and NYHA class II uncertain benefit to prolong meaningful survival in symptoms on GDMT.595,596 (Level of Evidence: B) patients with a high risk of nonsudden death as pre- 4. CRT may be considered for patients who have LVEF dicted by frequent hospitalizations, advanced frailty, of 30% or less, ischemic etiology of HF, sinus rhythm, or comorbidities such as systemic malignancy or LBBB with a QRS duration of 150 ms or greater, and severe renal dysfunction.†608–611 (Level of Evidence: B) NYHA class I symptoms on GDMT.595,596 (Level of 2. CRT may be considered for patients who have LVEF Evidence: C) of 35% or less, sinus rhythm, a non-LBBB pattern with QRS duration of 120 to 149 ms, and NYHA Class III: No Benefit class III/ambulatory class IV on GDMT.596,612 (Level of Evidence: B) 1. CRT is not recommended for patients with NYHA class I or II symptoms and non-LBBB pattern with QRS duration less than 150 ms.595,596,612 (Level of †Counseling should be specific to each individual patient and should include documentation of a discussion about the potential for sudden death Evidence: B) and nonsudden death from HF or noncardiac conditions. Information 2. CRT is not indicated for patients whose comorbidi- should be provided about the efficacy, safety, and potential complications ties and/or frailty limit survival with good functional of an ICD and the potential for defibrillation to be inactivated if desired capacity to less than 1 year.38 (Level of Evidence: C) in the future, notably when a patient is approaching end of life. This will facilitate shared decision making between patients, families, and the medical care team about ICDs.30 See Figure 2, indications for CRT therapy algorithm. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e278 Circulation October 15, 2013
Patient with cardiomyopathy on GDMT for ≥3 mo or on GDMT and ≥40 d after MI, or with implantation of pacing or defibrillation device for special indications
LVEF ≤35%
Comorbidities and/or frailty Continue GDMT without Evaluate general health status limit survival with good implanted device functional capacity to <1 y
Acceptable noncardiac health
Evaluate NYHA clinical status
NYHA class III & Special CRT NYHA class I NYHA class II Ambulatory class IV Indications • LVEF ≤30% • LVEF ≤35% • LVEF ≤35% • Anticipated to require • QRS ≥150 ms • QRS ≥150 ms • QRS ≥150 ms frequent ventricular • LBBB pattern • LBBB pattern • LBBB pattern pacing (>40%) • Ischemic • Sinus rhythm • Sinus rhythm • Atrial fibrillation, if cardiomyopathy • LVEF ≤35% • LVEF ≤35% ventricular pacing is • QRS ≤150 ms • QRS 120-149 ms • QRS 120-149 ms required and rate • Non-LBBB pattern • LBBB pattern • LBBB pattern control will result in • Sinus rhythm • Sinus rhythm near 100% ventricular pacing • LVEF ≤35% • LVEF ≤35% with CRT • QRS ≥150 ms • QRS ≥150 ms • Non-LBBB pattern • Non-LBBB pattern • Sinus rhythm • Sinus rhythm • QRS ≤150 ms • LVEF ≤35% • Non-LBBB pattern • QRS 120-149 ms • Non-LBBB pattern • Sinus rhythm
Colors correspond to the class of recommendations in the ACCF/AHA Table 1. Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival.
Figure 2. Indications for CRT therapy algorithm. CRT indicates cardiac resynchronization therapy; CRT-D, cardiac resynchronization therapy-defibrillator; GDMT, guideline-directed medical therapy; HF, heart failure; ICD, implantable cardioverter-defibrillator; LBBB, left bundle-branch block; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and NYHA, New York Heart Association.
7.3.4.1. Implantable Cardioverter-Defibrillator SCD and total mortality are highest in patients with HFrEF Patients with reduced LVEF are at increased risk for ventricu- with class IV symptoms, in whom ICDs are not expected to lar tachyarrhythmias leading to SCD. Sudden death in HFrEF prolong meaningful survival and are not indicated except in has been substantially decreased by neurohormonal antagonists those for whom heart transplantation or MCS is anticipated. that alter disease progression and also protect against arrhyth- The use of ICDs for primary prevention in patients with HFrEF mias. Nonetheless, patients with systolic dysfunction remain should be considered only in the setting of optimal GDMT and at increased risk for SCD due to ventricular tachyarrhythmias. with a minimum of 3 to 6 months of appropriate medical ther- Patients who have had sustained ventricular tachycardia, ven- apy. A repeat assessment of ventricular function is appropriate tricular fibrillation, unexplained syncope, or cardiac arrest are at to assess any recovery of ventricular function on GDMT that highest risk for recurrence. Indications for ICD therapy as sec- would be above the threshold where an ICD is indicated. This ondary prevention of SCD in these patients are also discussed in therapy will often improve ventricular function to a range for the ACCF/AHA/HRS device-based therapy guideline.4 which the risk of sudden death is too low to warrant placement The use of ICDs for primary prevention of SCD in patients of an ICD. In addition, the trials of ICDs for primary prevention with HFrEF without prior history of arrhythmias or syncope of SCD studied patients who were already on GDMT. has been evaluated in multiple RCTs. ICD therapy for primary ICDs are highly effective in preventing death from ventric- prevention was demonstrated to reduce all-cause mortality. For ular arrhythmias, but frequent shocks can decrease HRQOL patients with LVEF ≤30% after remote MI, use of ICD therapy and lead to posttraumatic stress syndrome.615 Therapy with led to a 31% decrease in mortality over 20 months, for an abso- antiarrhythmic drugs and catheter ablation for ventricular lute decrease of 5.6%.362 For patients with mild to moderate tachycardia can decrease the number of ICD shocks given symptoms of HF with LVEF ≤35% due either to ischemic or and can sometimes improve ventricular function in cases of nonischemic etiology, there was a 23% decrease in mortality very frequent ventricular tachyarrhythmias. Refined device over a 5-year period, for an absolute decrease of 7.2%.593 For programming can optimize pacing therapies to avert the need both these trials, the survival benefit appeared after the first year. for shocks, minimize inappropriate shocks, and avoid aggra- Other smaller trials were consistent with this degree of benefit, vation of HF by frequent ventricular pacing. Although there except for patients within the first 40 days after acute MI, in have been occasional recalls of device generators, these are whom SCD was decreased but there was an increase in other exceedingly rare in comparison to complications related to events such that there was no net benefit for survival.598,614 Both intracardiac device leads, such as fracture and infection.
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ICDs are indicated only in patients with a reasonable expec- Although it is still not possible to predict with confidence tation of survival with good functional status beyond a year, but which patients will improve with CRT, further experiences the range of uncertainty remains wide. The complex decision have provided some clarification. Benefit appears confined about the relative risks and benefits of ICDs for primary pre- largely to patients with a QRS duration of at least 150 ms and vention of SCD must be individualized for each patient. Unlike LBBB pattern.624–628 The weight of the evidence has been accu- other therapies that can prolong life with HF, the ICD does not mulated from patients with sinus rhythm, with meta-analyses modify the disease except in conjunction with CRT. Patients indicating substantially less clinical benefit in patients with with multiple comorbidities have a higher rate of implant com- permanent AF.604,605 Because effective CRT requires a high rate plications and higher competing risks of death from noncardiac of ventricular pacing,629 the benefit for patients with AF is most causes.616 Older patients, who are at a higher risk of nonsudden evident in patients who have undergone atrioventricular nodal death, are often underrepresented in the pivotal trials where the ablation, which ensures obligate ventricular pacing.601–603 average patient is <65 years of age.617 The major trials for sec- In general, most data derive from patients with class III ondary prevention of SCD showed no benefit in patients >75 symptoms. Patients labeled as having class IV symptoms years of age,618 and a meta-analysis of primary prevention of account for a small minority of patients enrolled. Furthermore, SCD also suggested lesser effectiveness of ICDs.619 Populations these patients, characterized as “ambulatory” NYHA class IV, of patients with multiple HF hospitalizations, particularly in the are not refractory due to fluid retention, frequently hospital- setting of chronic kidney disease, have a median survival rate ized for HF, or dependent on continuous intravenous inotropic of <2 years, during which the benefit of the ICD may not be therapy. CRT should not be considered as “rescue” therapy for realized.608 There is widespread recognition of the need for fur- stage D HF. In addition, patients with significant noncardiac ther research to identify patients most and least likely to benefit limitations are unlikely to derive major benefit from CRT. from ICDs for primary prevention of SCD in HF. Similar con- Since publication of the 2009 HF guideline,38 new evidence siderations apply to the decision to replace the device generator. supports extension of CRT to patients with milder symptoms. Consideration of ICD implantation is highly appropriate for LV remodeling was consistently reversed or halted, with ben- shared decision making.30 The risks and benefits carry differ- efit also in reduction of HF hospitalizations.595,596,599 In this ent relative values depending on patient goals and preferences. population with low 1-year mortality, reduction of HF hos- Discussion should include the potential for SCD and nonsud- pitalization dominated the composite primary endpoints, but den death from HF or noncardiac conditions. Information a mortality benefit was subsequently observed in a 2-year should be provided in a format that patients can understand extended follow-up study630 and in a meta-analysis of 5 trials about the estimated efficacy, safety, and potential complica- of CRT in mild HF that included 4213 patients with class II tions of an ICD and the ease with which defibrillation can symptoms.631 Overall benefits in class II HF were noted only be inactivated if no longer desired.620 As the prevalence of in patients with QRS ≥150 ms and LBBB, with an adverse implantable devices increases, it is essential that clearly impact with shorter QRS duration or non-LBBB. defined processes be in place to support patients and families The entry criterion for LVEF in CRT trials has ranged when decisions about deactivation arise.621 from ≤30% to ≤40%. The trials with class III–IV symptoms included patients with LVEF ≤35%.78,116,594 The 2 individual 7.3.4.2. Cardiac Resynchronization Therapy trials showing improvement in mortality with class II HF In approximately one third of patients, HF progression is included patients with LVEF ≤30%.632,633 Trials demonstrat- accompanied by substantial prolongation of the QRS inter- ing significant improvement in LV size and EF have included val, which is associated with worse outcome.622 Multisite patients with LVEF ≤35%115 and LVEF ≤40%,599 which also ventricular pacing (termed CRT or biventricular pacing) can showed reduction in the secondary endpoint of time to hos- improve ventricular contractile function, diminish second- pitalization and a reduction in the composite of clinical HF ary mitral regurgitation, reverse ventricular remodeling, and events comparable to that of all of the CRT trials.624 The con- sustain improvement in LVEF. Increased blood pressure with gruence of evidence from the totality of CRT trials with regard CRT can allow increased titration of neurohormonal antago- to remodeling and HF events supports a common threshold of nist medications that may further contribute to improvement. 35% for benefit from CRT in patients with class II, III, and IV Benefits were proven initially in trials of patients with NYHA HF symptoms. For patients with class II HF, all but 1 of the class III or ambulatory class IV HF symptoms and QRS dura- trials tested CRT in combination with an ICD, whereas there tion of ≥120 to 130 ms. These results have included a decrease is evidence for benefit with both CRT-defibrillator and CRT of approximately 30% in rehospitalization and reductions in alone in patients with class III–IV symptoms.78,116 all-cause mortality in the range of 24% to 36%. Improvement Although the weight of evidence is substantial for patients in survival is evident as early as the first 3 months of therapy. with class II symptoms, these CRT trials have included only Functional improvements have been demonstrated on aver- 372 patients with class I symptoms, most with concomitant age as a 1 to 2 mL/kg/min increase in peak oxygen consump- ICD for the postinfarction indication.595,599 Considering the tion, 50- to 70-meter increase in 6-minute walk distance, and risk–benefit ratio for class I, more concern is raised by the a reduction of 10 points or more in the 0- to 105-point scale early adverse events, which in 1 trial occurred in 13% of of the Minnesota Living With Heart Failure Questionnaire, patients with CRT-ICD compared with 6.7% in patients with all considered clinically significant. These results include ICD only.596 On the basis of limited data from MADIT-CRT patients with a wide range of QRS duration and, in most cases, (Multicenter Automatic Defibrillator Implantation Trial- sinus rhythm.78,116,594,623 Cardiac Resynchronization Therapy), CRT-ICD may be
Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e280 Circulation October 15, 2013 considered for patients with class I symptoms >40 days after Table 24. Clinical Events and Findings Useful for Identifying MI, LVEF ≤30%, sinus rhythm, LBBB, and QRS ≥150 ms.595 Patients With Advanced HF These indications for CRT all include expectation for ongo- Repeated (≥2) hospitalizations or ED visits for HF in the past year ing GDMT and diuretic therapy as needed for fluid reten- Progressive deterioration in renal function (eg, rise in BUN and creatinine) tion. In addition, regular monitoring is required after device implantation because adjustment of HF therapies and repro- Weight loss without other cause (eg, cardiac cachexia) gramming of device intervals may be required. The trials Intolerance to ACE inhibitors due to hypotension and/or worsening renal function establishing the benefit of these interventions were conducted Intolerance to beta blockers due to worsening HF or hypotension in centers offering expertise in both implantation and follow- Frequent systolic blood pressure <90 mm Hg up. Recommendations for CRT are made with the expectation Persistent dyspnea with dressing or bathing requiring rest that they will be performed in centers with expertise and out- Inability to walk 1 block on the level ground due to dyspnea or fatigue come comparable to that of the trials that provide the bases of Recent need to escalate diuretics to maintain volume status, often reaching evidence. The benefit–risk ratio for this intervention would be daily furosemide equivalent dose >160 mg/d and/or use of supplemental anticipated to be diminished for patients who do not have access metolazone therapy to these specialized care settings or who are nonadherent. Progressive decline in serum sodium, usually to <133 mEq/L See Online Data Supplements 28 and 29 for additional data Frequent ICD shocks on device therapy and CRT. ACE indicates angiotensin-converting enzyme; BUN, blood urea nitrogen; ED, emergency department; HF, heart failure; and ICD, implantable 7.4. Stage D cardioverter-defibrillator. 642 7.4.1. Definition of Advanced HF Adapted from Russell et al. A subset of patients with chronic HF will continue to progress has developed a definition of advanced HF with objective cri- and develop persistently severe symptoms despite maximum teria that can be useful32 (Table 23). There are clinical clues GDMT. Various terminologies have been used to describe this that may assist clinicians in identifying patients who are pro- group of patients who are classified with ACCF/AHA stage gressing toward advanced HF (Table 24). The Interagency D HF, including “advanced HF,” “end-stage HF,” and “refrac- Registry for Mechanically Assisted Circulatory Support tory HF.” In the 2009 ACCF/AHA HF guideline, stage D was (INTERMACS) has developed 7 profiles that further stratify defined as “patients with truly refractory HF who might be patients with advanced HF (Table 25).635 eligible for specialized, advanced treatment strategies, such as MCS, procedures to facilitate fluid removal, continuous 7.4.2. Important Considerations in Determining If the inotropic infusions, or cardiac transplantation or other inno- Patient Is Refractory vative or experimental surgical procedures, or for end-of-life Patients considered to have stage D HF should be thoroughly care, such as hospice.”38 The European Society of Cardiology evaluated to ascertain that the diagnosis is correct and that there are no remediable etiologies or alternative explanations for advanced symptoms. For example, it is important to determine Table 23. ESC Definition of Advanced HF that HF and not a concomitant pulmonary disorder is the basis 1. Severe symptoms of HF with dyspnea and/or fatigue at rest or with minimal of dyspnea. Similarly, in those with presumed cardiac cachexia, exertion (NYHA class III or IV) other causes of weight loss should be ruled out. Likewise, other 2. Episodes of fluid retention (pulmonary and/or systemic congestion, peripheral reversible factors such as thyroid disorders should be treated. edema) and/or reduced cardiac output at rest (peripheral hypoperfusion) Severely symptomatic patients presenting with a new diagno- 3. Objective evidence of severe cardiac dysfunction shown by at least 1 of the sis of HF can often improve substantially if they are initially following: stabilized. Patients should also be evaluated for nonadherence a. LVEF <30% to medications,636–639 sodium restriction,640 and/or daily weight b. Pseudonormal or restrictive mitral inflow pattern monitoring.641 Finally, a careful review of prior medical man- c. Mean PCWP >16 mm Hg and/or RAP >12 mm Hg by PA catheterization agement should be conducted to verify that all evidence-based d. High BNP or NT-proBNP plasma levels in the absence of noncardiac causes therapies likely to improve clinical status have been considered. 4. Severe impairment of functional capacity shown by 1 of the following: See Online Data Supplements 30 and 31 for additional data a. Inability to exercise b. 6-Minute walk distance ≤300 m on therapies—important considerations and sildenafil. · c. Peak V o <12 to 14 mL/kg/min 2 7.4.3. Water Restriction: Recommendation 5. History of ≥1 HF hospitalization in past 6 mo Class IIa 6. Presence of all the previous features despite “attempts to optimize” therapy, including diuretics and GDMT, unless these are poorly tolerated or contraindicated, and CRT when indicated 1. Fluid restriction (1.5 to 2 L/d) is reasonable in stage D, especially in patients with hyponatremia, to BNP indicates B-type natriuretic peptide; CRT, cardiac resynchronization reduce congestive symptoms. (Level of Evidence: C) therapy; ESC, European Society of Cardiology; GDMT, guideline-directed medical therapy; HF, heart failure; LVEF, left ventricular ejection fraction; Recommendations for fluid restriction in HF are largely driven NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; PA, pulmonary artery; PWCP, pulmonary capillary wedge pressure; by clinical experience. Sodium and fluid balance recommenda- and RAP, right atrial pressure. tions are best implemented in the context of weight and symp- Adapted from Metra et al.32 tom monitoring programs. Routine strict fluid restriction in all Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e281
Table 25. INTERMACS Profiles
Profile* Profile Description Features 1 Critical cardiogenic shock Life-threatening hypotension and rapidly escalating inotropic/pressor support, with critical organ hypoperfusion often (“Crash and burn”) confirmed by worsening acidosis and lactate levels. 2 Progressive decline “Dependent” on inotropic support but nonetheless shows signs of continuing deterioration in nutrition, renal function, (“Sliding fast” on inotropes) fluid retention, or other major status indicator. Can also apply to a patient with refractory volume overload, perhaps with evidence of impaired perfusion, in whom inotropic infusions cannot be maintained due to tachyarrhythmias, clinical ischemia, or other intolerance. 3 Stable but inotrope dependent Clinically stable on mild-moderate doses of intravenous inotropes (or has a temporary circulatory support device) after repeated documentation of failure to wean without symptomatic hypotension, worsening symptoms, or progressive organ dysfunction (usually renal). 4 Resting symptoms on oral therapy Patient who is at home on oral therapy but frequently has symptoms of congestion at rest or with activities of daily living at home (dressing or bathing). He or she may have orthopnea, shortness of breath during dressing or bathing, gastrointestinal symptoms (abdominal discomfort, nausea, poor appetite), disabling ascites, or severe lower-extremity edema. 5 Exertion intolerant (“housebound”) Patient who is comfortable at rest but unable to engage in any activity, living predominantly within the house or housebound. 6 Exertion limited Patient who is comfortable at rest without evidence of fluid overload but who is able to do some mild activity. Activities of (“walking wounded”) daily living are comfortable and minor activities outside the home such as visiting friends or going to a restaurant can be performed, but fatigue results within a few minutes or with any meaningful physical exertion. 7 Advanced NYHA class III Patient who is clinically stable with a reasonable level of comfortable activity, despite a history of previous decompensation that is not recent. This patient is usually able to walk more than a block. Any decompensation requiring intravenous diuretics or hospitalization within the previous month should make this person a Patient Profile 6 or lower. *Modifier options: Profiles 3–6 can be modified with the designation frequent flyer for patients with recurrent decompensations leading to frequent (generally at least 2 in last 3 mo or 3 in last 6 mo) emergency department visits or hospitalizations for intravenous diuretics, ultrafiltration, or brief inotropic therapy. Profile 3 can be modified in this fashion if the patient is usually at home. If a Profile 7 patient meets the definition of frequent flyer, the patient should be moved to Profile 6 or worse. Other modifier options include arrhythmia, which should be used in the presence of recurrent ventricular tachyarrhythmias contributing to the overall clinical course (eg, frequent implantable cardioverter-defibrillator shocks or requirement of external defibrillation, usually more than twice weekly); or temporary circulatory support for hospitalized patients profiles 1–3.635 INTERMACS indicates Interagency Registry for Mechanically Assisted Circulatory Support; and NYHA, New York Heart Association. Adapted from Stevenson et al.643 patients with HF regardless of symptoms or other considerations support to maintain systemic perfusion and preserve does not appear to result in significant benefit.644 Limiting fluid end-organ performance. (Level of Evidence: C) intake to around 2 L/d is usually adequate for most hospitalized patients who are not diuretic resistant or significantly hypona- Class IIa tremic. In 1 study, patients on a similar sodium and diuretic regi- 1. Continuous intravenous inotropic support is reason- men showed higher readmission rates with higher fluid intake, able as “bridge therapy” in patients with stage D HF suggesting that fluid intake affects HF outcomes.385 Strict fluid refractory to GDMT and device therapy who are eli- restriction may best be used in patients who are either refractory gible for and awaiting MCS or cardiac transplanta- to diuretics or have hyponatremia. Fluid restriction, especially tion.647,648 (Level of Evidence: B) in conjunction with sodium restriction, enhances volume man- agement with diuretics. Fluid restriction is important to man- Class IIb age hyponatremia, which is relatively common with advanced HF and portends a poor prognosis.645,646 Fluid restriction may 1. Short-term, continuous intravenous inotropic support improve serum sodium concentration; however, it is difficult to may be reasonable in those hospitalized patients pre- achieve and maintain. In hot or low-humidity climates, exces- senting with documented severe systolic dysfunction sive fluid restriction predisposes patients with advanced HF to who present with low blood pressure and significantly the risk of heat stroke. Hyponatremia in HF is primarily due to depressed cardiac output to maintain systemic per- an inability to excrete free water. Norepinephrine and angioten- fusion and preserve end-organ performance.592,649,650 sin II activation result in decreased sodium delivery to the distal (Level of Evidence: B) tubule, whereas arginine vasopressin increases water absorption 2. Long-term, continuous intravenous inotropic support from the distal tubule. In addition, angiotensin II also promotes may be considered as palliative therapy for symptom thirst. Thus, sodium and fluid restriction in advanced patients control in select patients with stage D HF despite opti- with HF is important. mal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation.651–653 (Level 7.4.4. Inotropic Support: Recommendations of Evidence: B) Class I Class III: Harm 1. Until definitive therapy (eg, coronary revasculariza- tion, MCS, heart transplantation) or resolution of the 1. Long-term use of either continuous or intermittent, acute precipitating problem, patients with cardiogenic intravenous parenteral positive inotropic agents, shock should receive temporary intravenous inotropic in the absence of specific indications or for reasons Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e282 Circulation October 15, 2013
Table 26. Intravenous Inotropic Agents Used in Management of HF
Dose (mcg/kg) Effects Drug Kinetics Special Inotropic Agent Bolus Infusion (/min) and Metabolism CO HR SVR PVR Adverse Effects Considerations Adrenergic agonists
Dopamine N/A 5 to 10 t½: 2 to 20 min ↑ ↑ ↔ ↔ T, HA, N, tissue Caution: MAO-I N/A 10 to 15 R,H,P ↑ ↑ ↑ ↔ necrosis
Dobutamine N/A 2.5 to 5 t½: 2 to 3 min ↑ ↑ ↓ ↔ ↑/↓BP, HA, T, N, F, Caution: MAO-I; N/A 5 to 20 H ↑ ↑ ↔ ↔ hypersensitivity CI: sulfite allergy PDE inhibitor
Milrinone N/R 0.125 to 0.75 t½: 2.5 h H ↑ ↑ ↓ ↓ T, ↓BP Renal dosing, monitor LFTs BP indicates blood pressure; CI, contraindication; CO, cardiac output; F, fever; H, hepatic; HA, headache; HF, heart failure; HR, heart rate; LFT, liver function test; MAO-I, monoamine oxidase inhibitor; N, nausea; N/A, not applicable; N/R, not recommended; P, plasma; PDE, phosphodiesterase; PVR, pulmonary vascular resistance;
R, renal; SVR, systemic vascular resistance; T, tachyarrhythmias; and t ½, elimination half-life.
other than palliative care, is potentially harmful in cardiac transplantation) or cardiac recovery is antic- the patient with HF.416,654–659 (Level of Evidence: B) ipated or planned.660–667 (Level of Evidence: B) 2. Use of parenteral inotropic agents in hospitalized 2. Nondurable MCS, including the use of percutaneous patients without documented severe systolic dysfunc- and extracorporeal ventricular assist devices (VADs), tion, low blood pressure, or impaired perfusion and evi- is reasonable as a “bridge to recovery” or “bridge dence of significantly depressed cardiac output, with or to decision” for carefully selected‡ patients with without congestion, is potentially harmful.592,649,650 (Level HFrEF with acute, profound hemodynamic compro- of Evidence: B) mise.668–671 (Level of Evidence: B) 3. Durable MCS is reasonable to prolong survival for Despite improving hemodynamic compromise, positive inotro- carefully selected‡ patients with stage D HFrEF. 672–675 pic agents have not demonstrated improved outcomes in patients (Level of Evidence: B) with HF in either the hospital or outpatient setting.416,654–658 Regardless of their mechanism of action (eg, inhibition of MCS has emerged as a viable therapeutic option for patients phosphodiesterase, stimulation of adrenergic or dopaminergic with advanced stage D HFrEF refractory to optimal GDMT receptors, calcium sensitization), chronic oral inotrope treat- and cardiac device intervention. Since its initial use 50 years ment increased mortality, mostly related to arrhythmic events. ago for postcardiotomy shock,676 the implantable VAD contin- Parenteral inotropes, however, remain as an option to help the ues to evolve. subset of patients with HF who are refractory to other therapies Designed to assist the native heart, VADs are differenti- and are suffering consequences from end-organ hypoperfusion. ated by the implant location (intracorporeal versus extra- Inotropes should be considered only in such patients with sys- corporeal), approach (percutaneous versus surgical), flow tolic dysfunction who have low cardiac index and evidence of characteristic (pulsatile versus continuous), pump mecha- systemic hypoperfusion and/or congestion (Table 26). To mini- nism (volume displacement, axial, centrifugal), and the mize adverse effects, lower doses are preferred. Similarly, the ventricle(s) supported (left, right, biventricular). VADs are ongoing need for inotropic support and the possibility of dis- effective in both the short-term (hours to days) management continuation should be regularly assessed. of acute decompensated, hemodynamically unstable HFrEF See Online Data Supplements 32 and 33 for additional data that is refractory to inotropic support, and the long-term on inotropes. (months to years) management of stage D chronic HFrEF. 7.4.5. Mechanical Circulatory Support: Recommendations Nondurable or temporary, MCS provides an opportunity for decisions about the appropriateness of transition to defini- Class IIa tive management such as cardiac surgery or durable, that is, permanent, MCS or, in the case of improvement and 1. MCS is beneficial in carefully selected‡ patients with recovery, suitability for device removal. Nondurable MCS stage D HFrEF in whom definitive management (eg, thereby may be helpful as either a bridge to decision or a bridge to recovery. ‡Although optimal patient selection for MCS remains an active More common scenarios for MCS, however, are long- area of investigation, general indications for referral for MCS therapy term strategies, including 1) bridge to transplantation, 2) include patients with LVEF <25% and NYHA class III–IV functional status despite GDMT, including, when indicated, CRT, with either high bridge to candidacy, and 3) destination therapy. Bridge to predicted 1- to 2-year mortality (eg, as suggested by markedly reduced transplant and destination therapy have the strongest evi- peak oxygen consumption and clinical prognostic scores) or dependence dence base with respect to survival, functional capacity, and on continuous parenteral inotropic support. Patient selection requires a HRQOL benefits. multidisciplinary team of experienced advanced HF and transplantation cardiologists, cardiothoracic surgeons, nurses, and ideally, social workers Data from INTERMACS provides valuable information and palliative care clinicians. on risk factors and outcomes for patients undergoing MCS. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e283
The greatest risk factors for death among patients undergoing Cardiac transplantation is considered the gold standard for bridge to transplant include acuity and severity of clinical con- the treatment of refractory end-stage HF. Since the first suc- dition and evidence of right ventricular failure.677 MCS may cessful cardiac transplantation in 1967, advances in immu- also be used as a bridge to candidacy. Retrospective studies nosuppressive therapy have vastly improved the long-term have shown reduction in pulmonary pressures with MCS ther- survival of transplant recipients with a 1-, 3-, and 5-year post- apy in patients with HF considered to have “fixed” pulmonary transplant survival rate of 87.8%, 78.5%, and 71.7% in adults, hypertension.661–663 Thus, patients who may be transplant-inel- respectively.681 Similarly, cardiac transplantation has been igible due to irreversible severe pulmonary hypertension may shown to improve functional status and HRQOL.682–688 The become eligible with MCS support over time. Other bridge- greatest survival benefit is seen in those patients who are at to-candidacy indications may include obesity and tobacco use highest risk of death from advanced HF.689 Cardiopulmonary in patients who are otherwise candidates for cardiac transplan- exercise testing helps refine candidate selection.690–696 Data tation. There is ongoing interest in understanding how MCS suggest acceptable posttransplant outcomes in patients with facilitates LV reverse remodeling. Current scientific and trans- reversible pulmonary hypertension,697 hypertrophic car- lational research in the area aims to identify clinical, cellular, diomyopathy,698 peripartum cardiomyopathy,699 restrictive molecular, and genomic markers of cardiac recovery in the cardiomyopathy,700,701 and muscular dystrophy.702 Selected patient with VAD.678,679 patients with stage D HF and poor prognosis should be See Online Data Supplements 34 and 35 for additional data referred to a cardiac transplantation center for evaluation and on MCS and left VADs. transplant consideration. Determination of HF prognosis is 7.4.6. Cardiac Transplantation: Recommendation addressed in Sections 6.1.2 and 7.4.2. The listing criteria and evaluation and management of patients undergoing cardiac Class I transplantation are described in detail by the International 1. Evaluation for cardiac transplantation is indicated Society for Heart and Lung Transplantation.680 for carefully selected patients with stage D HF despite See Table 27 for a summary of recommendations from this GDMT, device, and surgical management.680 (Level of section, Figure 3 for the stages of HF development; and Online Evidence: C) Data Supplement 36 for additional data on transplantation.
Table 27. Recommendations for Inotropic Support, MCS, and Cardiac Transplantation
Recommendations COR LOE References Inotropic support Cardiogenic shock pending definitive therapy or resolution I C N/A BTT or MCS in stage D refractory to GDMT IIa B 647, 648 Short-term support for threatened end-organ dysfunction in hospitalized patients with IIb B 592, 649, 650 stage D and severe HFrEF Long-term support with continuous infusion palliative therapy in select stage D HF IIb B 651–653 Routine intravenous use, either continuous or intermittent, is potentially harmful in stage D HF III: Harm B 416, 654–659 Short-term intravenous use in hospitalized patients without evidence of shock or III: Harm B 592, 649, 650 threatened end-organ performance is potentially harmful MCS MCS is beneficial in carefully selected* patients with stage D HF in whom definitive IIa B 660–667 management (eg, cardiac transplantation) is anticipated or planned Nondurable MCS is reasonable as a “bridge to recovery” or “bridge to decision” for IIa B 668–671 carefully selected* patients with HF and acute profound disease Durable MCS is reasonable to prolong survival for carefully selected* patients with IIa B 672–675 stage D HFrEF Cardiac transplantation Evaluation for cardiac transplantation is indicated for carefully selected patients with I C 680 stage D HF despite GDMT, device, and surgical management *Although optimal patient selection for MCS remains an active area of investigation, general indications for referral for MCS therapy include patients with LVEF <25% and NYHA class III–IV functional status despite GDMT, including, when indicated, CRT, with either high predicted 1- to 2-year mortality (eg, as suggested by markedly reduced peak oxygen consumption and clinical prognostic scores) or dependence on continuous parenteral inotropic support. Patient selection requires a multidisciplinary team of experienced advanced HF and transplantation cardiologists, cardiothoracic surgeons, nurses and ideally, social workers and palliative care clinicians. BTT indicates bridge to transplant; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LOE, Level of Evidence; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; N/A, not applicable; and NYHA, New York Heart Association. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e284 Circulation October 15, 2013
At Risk for Heart FailureHeart Failure
STAGE A STAGE B STAGE C STAGE D At high risk for HF but Structural heart disease Structural heart disease Refractory HF without structural heart but without signs or with prior or current disease or symptoms of HF symptoms of HF symptoms of HF
e.g., Patients with: • HTN • Atherosclerotic disease e.g., Patients with: • DM e.g., Patients with: • Previous MI e.g., Patients with: Refractory • Obesity Development of symptoms of HF •Marked HF symptoms at Structural heart • LV remodeling including • Known structural heart disease and • Metabolic syndrome symptoms of HF at rest, despite rest disease LVH and low EF • HF signs and symptoms or GDMT Recurrent hospitalizations • Asymptomatic valvular • Patients disease despite GDMT • Using cardiotoxins • With family history of cardiomyopathy
HFpEF HFrEF
THERAPY THERAPY THERAPY THERAPY THERAPY Goals Goals Goals Goals Goals • Control symptoms • Control symptoms • Heart healthy lifestyle • Prevent HF symptoms • Control symptoms • Patient education • Improve HRQOL • Prevent vascular, • Prevent further cardiac • Improve HRQOL • Prevent hospitalization • Reduce hospital coronary disease remodeling • Prevent hospitalization • Prevent mortality readmissions • Prevent LV structural • Prevent mortality • Establish patient’s end- abnormalities Drugs Drugs for routine use of-life goals Diuretics for fluid retention • ACEI or ARB as Strategies • appropriate • ACEI or ARB Options Drugs • Identification of • Beta blockers • Advanced care • Beta blockers as • ACEI or ARB in comorbidities • Aldosterone antagonists measures appropriate patients for appropriate • Heart transplant vascular disease or DM Treatment Drugs for use in selected patients • Chronic inotropes In selected patients • Hydralazine/isosorbide dinitrate • Temporary or permanent • Statins as appropriate Diuresis to relieve • ICD • • ACEI and ARB MCS symptoms of congestion • Revascularization or • Digitalis • Experimental surgery or valvular surgery as • Follow guideline driven drugs appropriate indications for In selected patients • Palliative care and comorbidities, e.g., HTN, • CRT hospice ICD ICD deactivation AF, CAD, DM • • • Revascularization or valvular surgery as appropriate
Figure 3. Stages in the development of HF and recommended therapy by stage. ACEI indicates angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin-receptor blocker; CAD, coronary artery disease; CRT, cardiac resynchronization therapy; DM, diabetes mellitus; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HRQOL, health-related quality of life; HTN, hypertension; ICD, implantable cardioverter-defibrillator; LV, left ventricular; LVH, left ventricular hypertrophy; MCS, mechanical circulatory support; and MI, myocardial infarction. Adapted from Hunt et al.38
8. The Hospitalized Patient such patients are elderly or near elderly, equally male or female, and typically have a history of hypertension, as well as other 8.1. Classification of Acute Decompensated HF medical comorbidities, including chronic kidney disease, hypo- Hospitalization for HF is a growing and major public health natremia, hematologic abnormalities, and chronic obstructive 703 issue. Presently, HF is the leading cause of hospitalization pulmonary disease.107,706,708–713 A relatively equal percentage of 51 among patients >65 years of age ; the largest percentage of patients with acutely decompensated HF have impaired versus expenditures related to HF are directly attributable to hospi- preserved LV systolic function707,714,715; clinically, patients with tal costs. Moreover, in addition to costs, hospitalization for preserved systolic function are older, more likely to be female, acutely decompensated HF represents a sentinel prognostic to have significant hypertension, and to have less CAD. The event in the course of many patients with HF, with a high overall morbidity and mortality for both groups is high. risk for recurrent hospitalization (eg, 50% at 6 months) and Hospitalized patients with HF can be classified into impor- a 1-year mortality rate of approximately 30%.211,704 The AHA tant subgroups. These include patients with acute coronary has published a scientific statement about this condition.705 ischemia, accelerated hypertension and acutely decompen- There is no widely accepted nomenclature for HF syndromes sated HF, shock, and acutely worsening right HF. Patients requiring hospitalization. Patients are described as having who develop HF decompensation after surgical procedures “acute HF,” “acute HF syndromes,” or “acute(ly) decompen- also bear mention. Each of these various categories of HF has sated HF”; while the third has gained greatest acceptance, it specific etiologic factors leading to decompensation, presenta- too has limitations, for it does not make the important distinc- tion, management, and outcomes. tion between those with a de novo presentation of HF from Noninvasive modalities can be used to classify the patient those with worsening of previously chronic stable HF. with hospitalized HF. The history and physical examination Data from HF registries have clarified the profile of patients allows estimation of a patient’s hemodynamic status, that with HF requiring hospitalization.107,704,706,707 Characteristically, is, the degree of congestion (“dry” versus “wet”), as well as Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e285
729 Congestion at rest? may be missed. For the patient with newly discovered HF, (e.g. orthopnea, elevated jugular venous pressure, pulmonary rales, S3 gallop, edema) clinicians should always consider the possibility that CAD is an underlying cause of HF.726 No Yes Besides ACS, several other precipitating causes of acute HF decompensation must be carefully assessed to inform appro- No Warm and Dry Warm and Wet priate treatment, optimize outcomes, and prevent future acute events in patients with HF.730 See list below.
Common Factors That Precipitate Acute Decompensated HF Low perfusion at rest? Yes Cold and Dry Cold and Wet • Nonadherence with medication regimen, sodium and/or fluid restriction • Acute myocardial ischemia
(e.g. narrow pulse pressure, cool extremities, hypotension) • Uncorrected high blood pressure • AF and other arrhythmias Figure 4. Classification of patients presenting with acutely decom- pensated heart failure. Adapted with permission from Nohria et al.716 • Recent addition of negative inotropic drugs (eg, verapamil, nifedipine, diltiazem, beta blockers) • Pulmonary embolus the adequacy of their peripheral perfusion (“warm” versus • Initiation of drugs that increase salt retention (eg, steroids, “cold”)716 (Figure 4). Chest x-ray is variably sensitive for the thiazolidinediones, NSAIDs) presence of interstitial or alveolar edema, even in the presence • Excessive alcohol or illicit drug use of elevated filling pressures. Thus, a normal chest x-ray does • Endocrine abnormalities (eg, diabetes mellitus, hyperthy- not exclude acutely decompensated HF.717 The utility of natri- roidism, hypothyroidism) uretic peptides in patients with acutely decompensated HF • Concurrent infections (eg, pneumonia, viral illnesses) has been described in detail in Section 6.3.1. Both BNP and • Additional acute cardiovascular disorders (eg, valve disease NT-proBNP are useful for the identification or exclusion of endocarditis, myopericarditis, aortic dissection) acutely decompensated HF in dyspneic patients,247,249,250,718,719 Hypertension is an important contributor to acute HF, par- particularly in the context of uncertain diagnosis.720–722 Other ticularly among blacks, women, and those with HFpEF. 731 In options for diagnostic evaluation of patients with suspected the ADHERE registry, almost 50% of patients admitted with acutely decompensated HF, such as acoustic cardiography,723 HF had blood pressure >140/90 mm Hg.107 Abrupt discon- bioimpedance vector monitoring,724 or noninvasive cardiac tinuation of antihypertensive therapy may precipitate wors- output monitoring725 are not yet validated. ening HF. The prevalence of AF in patients with acute HF is >30%.731 Infection increases metabolic demands in general. 8.2. Precipitating Causes of Decompensated HF: Pulmonary infections, which are common in patients with Recommendations HF, may add hypoxia to the increased metabolic demands Class I and are associated with worse outcomes.730 The sepsis syn- drome is associated with reversible myocardial depression 1. ACS precipitating acute HF decompensation that is likely mediated by cytokine release.732 Patients with should be promptly identified by ECG and serum HF are hypercoagulable, and the possibility of pulmonary biomarkers, including cardiac troponin testing, embolus as an etiology of acute decompensation should be and treated optimally as appropriate to the over- considered. Deterioration of renal function can be both a con- all condition and prognosis of the patient. (Level of sequence and contributor to decompensated HF. Restoration Evidence: C) of normal thyroid function in those with hypothyroidism or 2. Common precipitating factors for acute HF should hyperthyroidism may reverse abnormal cardiovascular func- be considered during initial evaluation, as recogni- tion.733 In patients treated with amiodarone, thyroid distur- tion of these conditions is critical to guide appropri- bances should be suspected. ate therapy. (Level of Evidence: C) Excessive sodium and fluid intake may precipitate acute ACS is an important cause of worsening or new-onset HF.726 HF. 379,384 Medication nonadherence for financial or other rea- Although acute ST-segment elevation myocardial infarction sons is a major cause of hospital admission.734 Several drugs can be readily apparent on an ECG, other ACS cases may may precipitate acute HF (eg, calcium channel blockers, anti- be more challenging to diagnose. Complicating the clinical arrhythmic agents, glucocorticoids, NSAIDs and cyclooxy- scenario is that many patients with acute HF, with or with- genase-2 inhibitors, thiazolidinediones, and over-the-counter out CAD, have serum troponin levels that are elevated.727 agents like pseudoephedrine). Finally, excessive alcohol intake However, many other patients may have low levels of and use of illicit drugs, such as cocaine and methamphet- detectable troponins not meeting criteria for an acute ischemic amine, also need to be investigated as potential causes of HF event.278,728 Registry data have suggested that the use of coro- decompensation. nary angiography is low for patients hospitalized with decom- See Online Data Supplement 37 for additional data on pensated HF, and opportunities to diagnose important CAD comorbidities in the hospitalized patient. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e286 Circulation October 15, 2013
8.3. Maintenance of GDMT During Hospitalization: be measured during the use of intravenous diuretics or Recommendations active titration of HF medications. (Level of Evidence: C) Class I Class IIa 1. When diuresis is inadequate to relieve symptoms, it 1. In patients with HFrEF experiencing a symptomatic is reasonable to intensify the diuretic regimen using exacerbation of HF requiring hospitalization dur- either: ing chronic maintenance treatment with GDMT, it a. higher doses of intravenous loop diuretics38,739 is recommended that GDMT be continued in the (Level of Evidence: B); or absence of hemodynamic instability or contraindica- b. addition of a second (eg, thiazide) diuretic.740–743 tions.195,735,736 (Level of Evidence: B) (Level of Evidence: B). 2. Initiation of beta-blocker therapy is recommended after optimization of volume status and successful Class IIb discontinuation of intravenous diuretics, vasodilators, 1. Low-dose dopamine infusion may be considered in and inotropic agents. Beta-blocker therapy should be addition to loop diuretic therapy to improve diuresis initiated at a low dose and only in stable patients. and better preserve renal function and renal blood Caution should be used when initiating beta blockers flow.744,745 (Level of Evidence: B) in patients who have required inotropes during their hospital course.195,735,736 (Level of Evidence: B) Patients with significant fluid overload should be initially The patient’s maintenance HF medications should be carefully treated with loop diuretics given intravenously during hospi- reviewed on admission, and it should be decided whether adjust- talization. Therapy should begin in the emergency department ments should be made as a result of the hospitalization. In the without delay, as early therapy has been associated with better 37,738 majority of patients with HFrEF who are admitted to the hos- outcomes. Patients should be carefully monitored, includ- pital, oral HF therapy should be continued, or even uptitrated, ing serial evaluation of volume status and systemic perfusion. during hospitalization. It has been demonstrated that continu- Monitoring of daily weight, supine and standing vital signs, ation of ACE inhibitors or ARBs and beta blockers for most and fluid input and output is necessary for daily management. patients is well tolerated and results in better outcomes.195,735,736 Assessment of daily electrolytes and renal function should Withholding of, or reduction in, beta-blocker therapy should be performed while intravenous diuretics are administered or be considered only in patients hospitalized after recent initia- HF medications are actively titrated. Intravenous loop diuret- tion or increase in beta-blocker therapy or with marked volume ics have the potential to reduce glomerular filtration rate, fur- overload or marginal/low cardiac output. Patients admitted with ther worsen neurohumoral activation, and produce electrolyte significant worsening of renal function should be considered disturbances. Thus, although the use of diuretics may relieve for a reduction in, or temporary discontinuation of ACE inhibi- symptoms, their impact on mortality has not been well studied. tors, ARBs, and/or aldosterone antagonists until renal function Diuretics should be administered at doses sufficient to achieve improves. Although it is important to ensure that evidence- optimal volume status and relieve congestion without induc- based medications are instituted before hospital discharge, it is ing an excessively rapid reduction in intravascular volume, equally critical to reassess medications on admission and adjust which could result in hypotension, renal dysfunction, or both. their administration in light of the worsening HF. Because loop diuretics have a relatively short half-life, sodium reabsorption in the tubules will occur once the tubular concen- 8.4. Diuretics in Hospitalized Patients: tration of the diuretics declines. Therefore, limiting sodium Recommendations intake and dosing the diuretic continuously or multiple times Class I per day will enhance diuretic effectiveness.434,737,746–748 Some patients may present with moderate to severe renal 1. Patients with HF admitted with evidence of signifi- dysfunction such that the diuretic response may be blunted, cant fluid overload should be promptly treated with necessitating higher initial diuretic doses. In many cases, reduc- 737,738 intravenous loop diuretics to reduce morbidity. tion of fluid overload may improve congestion and improve (Level of Evidence: B) renal function, particularly if significant venous congestion is 2. If patients are already receiving loop diuretic therapy, reduced.749 Clinical experience suggests it is difficult to deter- the initial intravenous dose should equal or exceed their mine whether congestion has been adequately treated in many chronic oral daily dose and should be given as either patients, and registry data have confirmed that patients are fre- intermittent boluses or continuous infusion. Urine out- put and signs and symptoms of congestion should be seri- quently discharged after a net weight loss of only a few pounds. ally assessed, and the diuretic dose should be adjusted Although patients may rapidly improve symptomatically, they accordingly to relieve symptoms, reduce volume excess, may remain congested or hemodynamically compromised. and avoid hypotension.739 (Level of Evidence: B) Routine use of serial natriuretic peptide measurement or Swan- 3. The effect of HF treatment should be monitored with Ganz catheter has not been conclusively shown to improve out- careful measurement of fluid intake and output, vital comes among these patients. Nevertheless, careful evaluation signs, body weight that is determined at the same time of all physical findings, laboratory parameters, weight change, each day, and clinical signs and symptoms of systemic and net fluid change should be considered before discharge. perfusion and congestion. Daily serum electrolytes, When a patient does not respond to initial intravenous diuret- urea nitrogen, and creatinine concentrations should ics, several options may be considered. Efforts should be made to Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e287 make certain that congestion persists and that another hemody- 8.6. Parenteral Therapy in Hospitalized HF: namic profile or alternate disease process is not evident. If there Recommendation is doubt about the fluid status, consideration should be given for assessment of filling pressures and cardiac output using right- Class IIb heart catheterization. If volume overload is confirmed, the dose of 1. If symptomatic hypotension is absent, intravenous the loop diuretic should be increased to ensure that adequate drug nitroglycerin, nitroprusside, or nesiritide may be levels reach the kidney. Adding a second diuretic, typically a thia- 435,442,443 considered an adjuvant to diuretic therapy for relief zide, can improve diuretic responsiveness. Theoretically, of dyspnea in patients admitted with acutely decom- continuous diuretic infusion may enhance diuresis because con- pensated HF.760–763 (Level of Evidence: A) tinuous diuretic delivery to the nephron avoids rebound sodium and fluid reabsorption.440,441,750,751 However, the DOSE (Diuretic The different vasodilators include 1) intravenous nitroglyc- Optimization Strategies Evaluation) trial did not find any signifi- erin, 2) sodium nitroprusside, and 3) nesiritide. cant difference between continuous infusion versus intermittent Intravenous nitroglycerin acts primarily through venodi- bolus strategies for symptoms, diuresis, or outcomes.739 It is rea- lation, lowers preload, and may help to rapidly reduce pul- sonable to try an alternate approach of using either bolus or con- monary congestion.764,765 Patients with HF and hypertension, tinuous infusion therapy different from the initial strategy among coronary ischemia, or significant mitral regurgitation are often patients who are resistant to diuresis. Finally, some data suggest cited as ideal candidates for the use of intravenous nitroglyc- that low-dose dopamine infusion in addition to loop diuretics erin. However, tachyphylaxis to nitroglycerin may develop may improve diuresis and better preserve renal function, although within 24 hours, and up to 20% of those with HF may develop ongoing trials will provide further data on this effect.744 resistance to even high doses.766–768 See Online Data Supplement 17 for additional data on Sodium nitroprusside is a balanced preload-reducing veno- diuretics. dilator and afterload-reducing arteriodilator that also dilates 8.5. Renal Replacement Therapy—Ultrafiltration: the pulmonary vasculature.769 Data demonstrating efficacy Recommendations are limited, and invasive hemodynamic blood pressure moni- toring (such as an arterial line) is typically required; in such Class IIb cases, blood pressure and volume status should be monitored frequently. Nitroprusside has the potential for producing 1. Ultrafiltration may be considered for patients with marked hypotension and is usually used in the intensive care obvious volume overload to alleviate congestive setting as well; longer infusions of the drug have been rarely symptoms and fluid weight.752 (Level of Evidence: B) 2. Ultrafiltration may be considered for patients with associated with thiocyanate toxicity, particularly in the setting refractory congestion not responding to medical of renal insufficiency. Nitroprusside is potentially of value therapy. (Level of Evidence: C) in severely congested patients with hypertension or severe mitral valve regurgitation complicating LV dysfunction. If all diuretic strategies are unsuccessful, ultrafiltration may be Nesiritide (human BNP) reduces LV filling pressure but has considered. Ultrafiltration moves water and small- to medium- variable effects on cardiac output, urinary output, and sodium weight solutes across a semipermeable membrane to reduce excretion. An initial study demonstrated that the severity volume overload. Because the electrolyte concentration is of dyspnea is reduced more rapidly compared with diuret- similar to plasma, relatively more sodium can be removed ics alone.760 A large randomized trial in patients with acute than by diuretics.753–755 Initial studies supporting use of ultra- decompensated HF demonstrated nesiritide had no impact on filtration in HF were small but provided safety and efficacy mortality, rehospitalization, or renal function, a small but sta- data in acute HF.755–757 Use of ultrafiltration in HF has been tistically significant impact on dyspnea, and an increased risk shown to reduce neurohormone levels and increase diuretic of hypotension.762 Because nesiritide has a longer effective responsiveness. In a larger trial of 200 unselected patients with acute HF, ultrafiltration did reduce weight compared with half-life than nitroglycerin or nitroprusside, adverse effects bolus or continuous diuretics at 48 hours, had similar effects such as hypotension may persist longer. Overall, presently on the dyspnea score compared with diuretics, and improved there are no data that suggest that intravenous vasodilators readmission rate at 90 days.752 A randomized acute HF trial improve outcomes in the patient hospitalized with HF; as such, in patients with cardiorenal syndrome and persistent con- use of intravenous vasodilators is limited to the relief of dys- gestion has failed to demonstrate a significant advantage of pnea in the hospitalized HF patient with intact blood pressure. ultrafiltration over bolus diuretic therapy.758,759 Cost, the need Administration of intravenous vasodilators in patients with for veno-venous access, provider experience, and nursing sup- HFpEF should be done with caution because these patients port remain concerns about the routine use of ultrafiltration. are typically more volume sensitive. Consultation with a nephrologist is appropriate before initiat- The use of inotropic support as indicated for hospitalized ing ultrafiltration, especially in circumstances where the non- HF with shock or impending shock and/or end-organ perfu- nephrology provider does not have sufficient experience with sion limitations is addressed in Section 7.4.4. See Table 26 for ultrafiltration. drug therapies and Online Data Supplements 32 and 33 for See Online Data Supplements 17 and 38 for additional data additional information on inotropic support. on diuretics versus ultrafiltration in acute decompensated HF See Online Data Supplement 39 for additional data on and worsening renal function and mortality. nesiritide. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e288 Circulation October 15, 2013
8.7. Venous Thromboembolism Prophylaxis in No adequate trials have evaluated anticoagulant benefit in Hospitalized Patients: Recommendation patients with chronic but stable HF admitted to the hospital for other reasons. However, the MEDENOX (Medical Patients Class I with Enoxaparin) trial suggested that the benefit of enoxaparin 770,773,774 1. A patient admitted to the hospital with decompensated may extend to this population. 784 HF should receive venous thromboembolism prophy- A systematic review failed to demonstrate prophylactic laxis with an anticoagulant medication if the risk– efficacy of graded compression stockings in general medical benefit ratio is favorable.21,770 (Level of Evidence: B) patients, but significant cutaneous complications were associ- ated with their use. No studies were performed exclusively on HF has long been recognized as affording additional risk for patients with HF. Two RCTs in patients with stroke found no venous thromboembolic disease, associated with a number of efficacy of these devices.785,786 pathophysiologic changes, including reduced cardiac output, See Online Data Supplement 20 for additional data on increased systemic venous pressure, and chemical changes anticoagulation. promoting blood clotting. When patients are hospitalized for decompensated HF or when patients with chronic stable HF 8.8. Arginine Vasopressin Antagonists: are hospitalized for other reasons, they are at increased risk for Recommendation venous thromboembolic disease, although accurate numerical estimates are lacking in the literature. Class IIb Most early data on the effectiveness of different anticoagulant regimens to reduce the incidence of venous thromboembolic dis- 1. In patients hospitalized with volume overload, ease in hospitalized patients were either observational, retrospec- including HF, who have persistent severe hypona- tremia and are at risk for or having active cognitive tive reports776,777 or prospective studies using a variety of drugs and symptoms despite water restriction and maximiza- differing definitions of therapeutic effect and endpoints,774,778–780 tion of GDMT, vasopressin antagonists may be con- making summary conclusions difficult. Early studies involved sidered in the short term to improve serum sodium patients with far longer hospital lengths of stay than occur pres- concentration in hypervolemic, hyponatremic states ently and were performed well before present standard-of-care with either a V receptor selective or a nonselective 774,778–780 2 treatments and diagnostic tests were available. Newer vasopressin antagonist.787,788 (Level of Evidence: B) trials using presently available antithrombotic drugs often were not limited to patients with HF but included those with other Even mild hyponatremia may be associated with neurocogni- 789 acute illnesses, severe respiratory diseases, or simply a broad tive problems, including falls and attention deficits. Treatment 771–774,781 spectrum of hospitalized medical patients. In most stud- of hypervolemic hyponatremia with a V2-selective vasopressin ies, patients were categorized as having HF by admitting diag- antagonist (tolvaptan) was associated with a significant improve- nosis, clinical signs, or functional class, whereas only 1 study782 ment in the mental component of the Medical Outcomes Study 788 provided LVEF data on enrolled study patients. All included tri- Short Form General Health Survey. Hyponatremia may be als tried to exclude patients perceived to have an elevated risk of treated with water restriction and maximization of GDMT that bleeding complications or with an elevated risk of toxicity from modulate angiotensin II, leading to improved renal perfusion the specific agent tested (eg, enoxaparin in patients with com- and decreased thirst. Alternative causes of hyponatremia (eg, promised renal function). Patients with HF typically made up syndrome of inappropriate antidiuretic hormone, hypothyroid- a minority of the study cohort, and significance of results were ism, and hypoaldosteronism) should be assessed. Vasopressin not always reported by the authors, making ACCF/AHA class I antagonists improve serum sodium in hypervolemic, hypo- 787,788 recommendations difficult to support using this guideline meth- natremic states ; however, longer-term therapy with a V2- odology. In some trials, concurrent aspirin was allowed but not selective vasopressin antagonist did not improve mortality in 790,791 controlled for as a confounding variable.772,783 patients with HF. Currently, 2 vasopressin antagonists are For patients admitted specifically for decompensated HF and available for clinical use: conivaptan and tolvaptan. It may be with adequate renal function (serum creatinine <2.0 mg/dL), reasonable to use a nonselective vasopressin antagonist to treat randomized trials suggest that enoxaparin 40 mg subcutaneously hyponatremia in patients with HF with cognitive symptoms due once daily770,773,774,783 or unfractionated heparin 5000 units subcu- to hyponatremia. However, the long-term safety and benefit of taneously every 8 hours771 will reduce radiographically demon- this approach remains unknown. A summary of the recommen- strable venous thrombosis. Effects on mortality or clinically dations for the hospitalized patient appears in Table 28. significant pulmonary embolism rates are unclear. Lower doses of enoxaparin do not appear superior to placebo,770,773 whereas 8.9. Inpatient and Transitions of Care: continuing weight-based enoxaparin therapy up to 3 months after Recommendations hospital discharge does not appear to provide additional benefit.782 See Table 29 for a summary of recommendations from this A single prospective study failed to demonstrate certoparin section. to be noninferior to unfractionated heparin,783 whereas retro- Class I spective analysis of a prospective trial of dalteparin was under- powered to determine benefit in its HF cohort.776 Fondaparinux 1. The use of performance improvement systems and/or failed to show significant difference from placebo in an RCT evidence-based systems of care is recommended in the that included a subgroup of 160 patients with HF.781 hospital and early postdischarge outpatient setting to Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e289
identify appropriate HF patients for GDMT, provide visit, and in subsequent follow-up visits, the following clinicians with useful reminders to advance GDMT, should be addressed.204,795,797–799 (Level of Evidence: B): and assess the clinical response.82,365,706,792–796 (Level of a. initiation of GDMT if not previously established Evidence: B) and not contraindicated; 2. Throughout the hospitalization as appropriate, b. precipitant causes of HF, barriers to optimal care before hospital discharge, at the first postdischarge transitions, and limitations in postdischarge support;
Table 28. Recommendations for Therapies in the Hospitalized HF Patient
Recommendations COR LOE References HF patients hospitalized with fluid overload should be treated with intravenous I B 737, 738 diuretics HF patients receiving loop diuretic therapy should receive an initial parenteral I B 739 dose greater than or equal to their chronic oral daily dose; then dose should be serially adjusted HFrEF patients requiring HF hospitalization on GDMT should continue GDMT I B 195, 735, 736 except in cases of hemodynamic instability or where contraindicated Initiation of beta-blocker therapy at a low dose is recommended after I B 195, 735, 736 optimization of volume status and discontinuation of intravenous agents Thrombosis/thromboembolism prophylaxis is recommended for patients I B 21, 770–774 hospitalized with HF Serum electrolytes, urea nitrogen, and creatinine should be measured during I C N/A titration of HF medications, including diuretics When diuresis is inadequate, it is reasonable to IIa a. give higher doses of intravenous loop diuretics; or B 38, 739 b. add a second diuretic (eg, thiazide) B 740–743 Low-dose dopamine infusion may be considered with loop diuretics to improve IIb B 744, 745 diuresis Ultrafiltration may be considered for patients with obvious volume overload IIb B 752 Ultrafiltration may be considered for patients with refractory congestion IIb C N/A Intravenous nitroglycerin, nitroprusside, or nesiritide may be considered an IIb A 760–763 adjuvant to diuretic therapy for stable patients with HF In patients hospitalized with volume overload and severe hyponatremia, IIb B 787, 788 vasopressin antagonists may be considered COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LOE, Level of Evidence; and N/A, not available.
Table 29. Recommendations for Hospital Discharge
Recommendations or Indications COR LOE References Performance improvement systems in the hospital and early postdischarge I B 82, 365, outpatient setting to identify HF for GDMT 706, 792–796 Before hospital discharge, at the first postdischarge visit, and in subsequent I B 204, 795, follow-up visits, the following should be addressed: 797–799 a. initiation of GDMT if not done or contraindicated; b. causes of HF, barriers to care, and limitations in support; c. assessment of volume status and blood pressure with adjustment of HF therapy; d. optimization of chronic oral HF therapy; e. renal function and electrolytes; f . management of comorbid conditions; g. HF education, self-care, emergency plans, and adherence; and h. palliative or hospice care Multidisciplinary HF disease-management programs for patients at high risk for I B 82, hospital readmission are recommended 800–802 A follow-up visit within 7 to 14 d and/or a telephone follow-up within 3 d of IIa B 101, 803 hospital discharge are reasonable Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients IIa B 215 are reasonable COR indicates Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; and LOE, Level of Evidence. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e290 Circulation October 15, 2013
c. assessment of volume status and supine/upright The appropriateness of discussion about advanced therapy or hypotension with adjustment of HF therapy as end-of-life preferences is reviewed in Section 11. appropriate; For patients with HF, the transition from inpatient to outpatient d. titration and optimization of chronic oral HF therapy; care can be an especially vulnerable period because of the pro- e. assessment of renal function and electrolytes where gressive nature of the disease state, complex medical regimens, appropriate; the large number of comorbid conditions, and the multiple clini- f. assessment and management of comorbid cians who may be involved. Patient education and written dis- conditions; charge instructions or educational material given to the patient, g. reinforcement of HF education, self-care, emer- family members, and/or caregiver during the hospital stay or at gency plans, and need for adherence; and discharge to home are essential components of transition care. h. consideration for palliative care or hospice care in These should address all of the following: activity level, diet, selected patients. discharge medications, follow-up appointment, weight monitor- 3. Multidisciplinary HF disease-management programs ing, and what to do if symptoms worsen.297 Thorough discharge are recommended for patients at high risk for hospi- planning that includes special emphasis on ensuring adherence tal readmission, to facilitate the implementation of to an evidence-based medication regimen795 is associated with GDMT, to address different barriers to behavioral improved patient outcomes.792,797,807 More intensive delivery of change, and to reduce the risk of subsequent rehospi- discharge instructions, coupled tightly with subsequent well- talization for HF.82,800–802 (Level of Evidence: B) coordinated follow-up care for patients hospitalized with HF, has 82,793,800 Class IIa produced positive results in several studies. The addition of a 1-hour, nurse educator–delivered teaching session at the time 1. Scheduling an early follow-up visit (within 7 to 14 days) of hospital discharge, using standardized instructions, resulted and early telephone follow-up (within 3 days) of hospi- in improved clinical outcomes, increased self-care and treat- tal discharge are reasonable.101,803 (Level of Evidence: B) ment adherence, and reduced cost of care. Patients receiving the 2. Use of clinical risk-prediction tools and/or biomark- education intervention also had a lower risk of rehospitalization ers to identify patients at higher risk for postdischarge or death and lower costs of care.365 There are ongoing efforts to clinical events are reasonable.215 (Level of Evidence: B) further develop evidence-based interventions in this population. Transitional care extends beyond patient education. Care Decisions about pharmacological therapies delivered dur- information, especially changes in orders and new diagnostic ing hospitalization likely can impact postdischarge outcome. information, must be transmitted in a timely and clearly under- Continuation or initiation of HF GDMT prior to hospital dis- standable form to all of the patient’s clinicians who will be charge is associated with substantially improved clinical out- delivering follow-up care. Other important components of tran- comes for patients with HFrEF. However, caution should be used sitional care include preparation of the patient and caregiver for when initiating beta blockers in patients who have required ino- what to expect at the next site of care, reconciliation of medi- tropes during their hospital course or when initiating ACE inhibi- cations, follow-up plans for outstanding tests, and discussions tors, ARBs, or aldosterone antagonists in those patients who have about monitoring signs and symptoms of worsening conditions. experienced marked azotemia or are at risk for hyperkalemia. Early outpatient follow-up, a central element of transitional care, The patient should be transitioned to oral diuretic therapy to ver- varies significantly across US hospitals. Early postdischarge fol- ify its effectiveness. Similarly, optimal volume status should be low-up may help minimize gaps in understanding of changes achieved. Blood pressure should be adequately controlled, and, to the care plan or knowledge of test results and has been asso- in patients with AF, ventricular response should also be well con- ciated with a lower risk of subsequent rehospitalization.803 A trolled. The hospitalization is a “teachable moment” to reinforce follow-up visit within 7 to 14 days and/or a telephone follow-up patient and family education and develop a plan of care, which within 3 days of hospital discharge are reasonable goals of care. should be communicated to the appropriate healthcare team. See Online Data Supplement 40 for additional data on oral Safety for patients hospitalized with HF is crucial. System medications for the hospitalized patient. changes necessary to achieve safer care include the adoption by all US hospitals of a standardized set of 30 “Safe Practices” 9. Important Comorbidities in HF endorsed by the National Quality Forum804 and National Patient 9.1. Atrial Fibrillation§ 805 Safety Goals espoused by The Joint Commission. Improved Patients with HF are more likely than the general population to communication between clinicians and nurses, medication develop AF.808 There is a direct relationship between the NYHA reconciliation, carefully planned transitions between care set- class and prevalence of AF in patients with HF progressing tings, and consistent documentation are examples of patient from 4% in those who are NYHA class I to 40% in those who safety standards that should be ensured for patients with HF are NYHA class IV.809 AF is also a strong independent risk fac- discharged from the hospital. tor for subsequent development of HF.376,808 In addition to those The prognosis of patients hospitalized with HF, and espe- cially those with serial readmissions, is suboptimal. Hence, §The “ACC/AHA/ESC 2006 Guidelines for the Management of appropriate levels of symptomatic relief, support, and pal- Patients With Atrial Fibrillation” and the 2 subsequent focused updates 6–8 liative care for patients with chronic HF should be addressed from 2011 are considered policy at the time of publication of the present HF Guideline; however, a fully revised AF guideline, which will include as an ongoing key component of the plan of care, especially updated recommendations on AF, is in development, with publication when patients are hospitalized with acute decompensation.806 expected in 2013 or 2014. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e291
Table 30. Clinical Evaluation in Patients With AF
Minimum evaluation 1. History and physical examination, to define • Presence and nature of symptoms associated with AF • Clinical type of AF (paroxysmal, persistent, or permanent) • Onset of first symptomatic attack or date of discovery of AF • Frequency, duration, precipitating factors, and modes of termination of AF • Response to any pharmacological agents that have been administered • Presence of any underlying heart disease or other reversible conditions (eg, hyperthyroidism or alcohol consumption) 2. ECG, to identify • Rhythm (verify AF) • LV hypertrophy • P-wave duration and morphology or fibrillatory waves • Preexcitation • Bundle-branch block • Prior MI • Other atrial arrhythmias • To measure and follow the R-R, QRS, and QT intervals in conjunction with antiarrhythmic drug therapy 3. Transthoracic echocardiogram, to identify • Valvular heart disease • LA and RA size • LV and RV size and function • Peak RV pressure (pulmonary hypertension) • LV hypertrophy • LA thrombus (low sensitivity) • Pericardial disease 4. Blood tests of thyroid, renal, and hepatic function • For a first episode of AF, when the ventricular rate is difficult to control Additional testing (one or several tests may be necessary) 1. 6-Minute walk test • If the adequacy of rate control is in question 2. Exercise testing • If the adequacy of rate control is in question (permanent AF) • To reproduce exercise-induced AF • To exclude ischemia before treatment of selected patients with a type IC antiarrhythmic drug 3. Holter monitoring or event recording • If diagnosis of the type of arrhythmia is in question • As a means of evaluating rate control 4. Transesophageal echocardiography • To identify LA thrombus (in the LA appendage) • To guide cardioversion 5. Electrophysiological study • To clarify the mechanism of wide-QRS-complex tachycardia • To identify a predisposing arrhythmia such as atrial flutter or paroxysmal supraventricular tachycardia • To seek sites for curative ablation or AV conduction block/modification 6. Chest x-ray to evaluate • Lung parenchyma, when clinical findings suggest an abnormality • Pulmonary vasculature, when clinical findings suggest an abnormality Type IC refers to the Vaughan Williams classification of antiarrhythmic drugs. AF indicates atrial fibrillation; AV, atrioventricular; ECG, electrocardiogram; LA, left atrial; LV, left ventricular; MI, myocardial infarction; RA, right atrial; and RV, right ventricular. Reproduced from Fuster et al.6 with HFrEF, patients with HFpEF are also at greater risk for who presents with newly detected HF in the presence of AF with AF than the general age-matched population.811 HF and AF can a rapid ventricular response should be presumed to have a rate- interact to promote their perpetuation and worsening through related cardiomyopathy until proved otherwise. In this situation, mechanisms such as rate-dependent worsening of cardiac func- 2 strategies can be considered. One is rate control of the patient’s tion, fibrosis, and activation of neurohumoral vasoconstrictors. AF and see if HF and EF improve. The other is to try to restore AF can worsen symptoms in patients with HF, and, conversely, and maintain sinus rhythm. In this situation, it is common prac- worsened HF can promote a rapid ventricular response in AF. tice to initiate amiodarone and then arrange for cardioversion Similar to other patient populations, for those with AF and 1 month later. Amiodarone has the advantage of being both an HF, the main goals of therapy are prevention of thromboembo- effective rate-control medication and the most effective antiar- lism and symptom control. Most patients with AF and HF would rhythmic medication with a lower risk of proarrhythmic effect. be expected to be candidates for systemic anticoagulation unless In patients with HF who develop AF, a rhythm-control strat- otherwise contraindicated. General principles of management egy has not been shown to be superior to a rate-control strat- include correction of underlying causes of AF and HF as well as egy.812 If rhythm control is chosen, limited data suggest that AF optimization of HF management (Table 30). As in other patient catheter ablation in HF patients may lead to improvement in LV populations, the issue of rate control versus rhythm control has function and quality of life but is less likely to be effective than been investigated. For patients who develop HF as a result of AF, in patients with intact cardiac function.813,814 Because of their a rhythm control strategy should be pursued. It is important to favorable effect on morbidity and mortality in patients with recognize that AF with a rapid ventricular response is one of the systolic HF, beta-adrenergic blockers are the preferred agents few potentially reversible causes of HF. Because of this, a patient for achieving rate control unless otherwise contraindicated. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e292 Circulation October 15, 2013
PharmacologiPharmacologicmc managementanagement ofof ththepe patientatient witwithnh newlyewly discoverediscoveredAd AF
ParoxysmalParoxysmal PersistentPersistent
NoNo therapytherapy neededneeded unlessunless Rateate controlcontrol andand AcceptAccept permanentpermanent AFAF significantsignificant symptomsymptoms(s (e.g.,e.g., anticoagulatioanticoagulationasnn as neededeeded Figure 5. Pharmacological man- hypotension,hypotension, HF,HF, anginaangina pectoris)pectoris) agement of patients with newly discovered AF. AF indicates atrial fibrillation; and HF, heart failure. Reproduced from Fuster et al.6 AnticoagulationAnticoagulation ConsiderConsider antiarrhythmicantiarrhythmic andand ratratece controlontrol drugdrug therapytherapy AnticoagulatioAnticoagulationasnn as neededeeded asas neededneeded
CardioversionCardioversion
Long-termLong-term antiarrhythmicantiarrhythmic drugdrug theraptherapyasny as necessaryecessary
PharmacologicPharmacologic managementmanagement ofof ththepe patientatient withwith recurrentrecurrent paroxysmaparoxysmalAl AFF
Minimainimalornl or noo symptomssymptoms DisablingDisabling symptomssymptoms inin AFAF
Figure 6. Pharmacological AnticoagulationAnticoagulation andand raterate controlcontrol AnticoagulationAnticoagulation anandrd rateate management of patients with recur- rent paroxysmal AF. AF indicates asas neededneeded controcontrolasnl as neededeeded atrial fibrillation. Reproduced from Fuster et al.6
NoNo drugdrug foforpr preventionrevention ofof AFAF Antiarrhythmintiarrhythmictc therapyherapy
AFAF ablationablation ifif anantitiararrhrhytythmhmicicththererapapyy treatmenttreatment failsfails
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Digoxin may be an effective adjunct to a beta blocker. The non- endpoint of all-cause mortality or first hospitalization for HF dihydropyridine calcium antagonists, such as diltiazem, should was seen (hazard ratio: 0.68; 95% confidence interval: 0.43 to be used with caution in those with depressed EF because of 1.08; P=0.10).834 These favorable data led to the design and their negative inotropic effect. For those with HFpEF, nondihy- initiation of the RED-HF (Phase III Reduction of Events With dropyridine calcium antagonists can be effective for achieving Darbepoetin alfa in Heart Failure) trial.835 rate control but may be more effective when used in combina- Two trials in erythropoiesis-stimulating agents, however, tion with digoxin. For those for whom a rate-control strategy later raised concerns that patients treated with an erythropoi- is chosen, when rate control cannot be achieved either because esis-stimulating agent may have an increased risk of cardio- of drug inefficacy or intolerance, atrioventricular node abla- vascular events.836,837 Because the populations in these trials tion and CRT device placement can be useful.78,116,595,596 See differed, the RED-HF trial was continued. Nevertheless, at Figures 5 and 6 for AF treatment algorithms. the completion of the trial, the investigators concluded that See Online Data Supplement 41 for additional data on AF. treatment with darbepoetin alfa did not improve clinical out- 9.2. Anemia comes in patients with systolic HF and mild-to-moderate 838 Anemia is a common finding in patients with chronic HF. anemia. Finally, a trial using intravenous iron as a supple- Although variably reported, in part due to the lack of con- ment in patients with HFrEF with iron deficiency showed an sensus on the definition of anemia, the prevalence of anemia improvement in functional status.840 There were no untoward among patients with HF increases with HF severity. Anemia adverse effects of iron in this trial. In the absence of a defini- is also more common in women and is seen in both patients tive evidence base, the writing committee has deferred a spe- with HFrEF and HFpEF. 818–823 The World Health Organization cific treatment recommendation regarding anemia. defines anemia as a hemoglobin level of <12 g/dL in women and <13 g/dL in men. Registries have reported anemia to be present 9.3. Depression in 25% to 40% of HF patients.818–820 Anemia is associated with Depression is common in patients with HF; those with an increased mortality risk in HF. In a large study of >150,000 depressive symptoms have lower HRQOL, poorer self-care, patients, the mortality risk was approximately doubled in ane- worse clinical outcomes, and more use of healthcare ser- mic HF patients compared with those without anemia, and this vices.841–843 Although it might be assumed that depression risk persisted after controlling for other confounders, including occurs only among hospitalized patients,844 a multicenter renal dysfunction and HF severity.818 Anemia is also associated study demonstrated that even at least 3 months after a hos- with reduced exercise capacity, impaired HRQOL, and a higher pitalization, 63% of patients with HF reported symptoms risk for hospitalization.225,819,824,825 These risks are inversely and of depression.845 Potential pathophysiologic mechanisms linearly associated with hemoglobin levels, although a U-shaped proposed to explain the high prevalence of depression in risk with the highest hemoglobin levels has been reported.822,826 HF include autonomic nervous system dysfunction, inflam- Multiple etiological factors, many of which coexist within mation, cardiac arrhythmias, and altered platelet function, individual patients, contribute to the development of anemia but the mechanism remains unclear.846 Although remission in HF. Anemia in patients with HF is often normocytic and from depression may improve cardiovascular outcomes, the accompanied by an abnormally low reticulocyte count.825,827 most effective intervention strategy is not yet known.842 Evaluation of anemia in HF requires careful consideration of 9.4. Other Multiple Comorbidities other causes, the most common being secondary causes of iron Although there are additional and important comorbidities deficiency anemia. that afflict patients with HF as shown in Table 31, how best to In persons without identifiable causes of anemia, erythropoi- generate specific recommendations remains uncertain, given esis-stimulating agents have gained significant interest as poten- the status of current evidence. tial adjunctive therapy in the patient with HF. In a retrospective study of erythropoiesis-stimulating agents in 26 patients with HF and anemia, the hemoglobin level, LVEF, and functional 10. Surgical/Percutaneous/Transcatheter class improved.828 These patients required lower diuretic doses Interventional Treatments of and were hospitalized less often. Similar findings were also HF: Recommendations observed in a randomized open-label study of 32 patients.829 A See Table 32 for a summary of recommendations from this single-blind RCT showed that erythropoietin increased hemo- section. globin, peak oxygen uptake, and exercise duration in patients Class I with severe HF and anemia.830 Two further studies confirmed these findings; however, none of these were double blind.831,832 1. Coronary artery revascularization via CABG or These positive data led to 2 larger studies. A 165-patient study percutaneous intervention is indicated for patients showed that darbepoetin alfa was associated with improvement (HFpEF and HFrEF) on GDMT with angina and suit- in several HRQOL measures with a trend toward improved able coronary anatomy, especially for a left main ste- 10,12,14,848 exercise capacity (6-minute walking distance +34±7 m versus nosis (>50%) or left main equivalent disease. +11±10 m, P=0.074).833 In STAMINA-HeFT (Study of Anemia (Level of Evidence: C) in Heart Failure Trial), 319 patients were randomly assigned Class IIa to darbepoetin alfa or placebo for 12 months.834 Although dar- bepoetin alfa did not improve exercise duration, it was well 1. CABG to improve survival is reasonable in patients tolerated, and a trend toward improvement in the composite with mild to moderate LV systolic dysfunction (EF Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e294 Circulation October 15, 2013
Table 31. Ten Most Common Co-Occurring Chronic Conditions Among Medicare Beneficiaries With HF (N=4 947 918), 2011
Beneficiaries Age≥ 65 y (N=4 376 150)* Beneficiaries Age <65 y (N=571 768)† N % N % Hypertension 3 685 373 84.2 Hypertension 461 235 80.7 Ischemic heart disease 3 145 718 71.9 Ischemic heart disease 365 889 64.0 Hyperlipidemia 2 623 601 60.0 Diabetes 338 687 59.2 Anemia 2 200 674 50.3 Hyperlipidemia 325 498 56.9 Diabetes 2 027 875 46.3 Anemia 284 102 49.7 Arthritis 1 901 447 43.5 Chronic kidney disease 257 015 45.0 Chronic kidney disease 1 851 812 42.3 Depression 207 082 36.2 COPD 1 311 118 30.0 Arthritis 201 964 35.3 Atrial fibrillation 1 247 748 28.5 COPD 191 016 33.4 Alzheimer’s disease/dementia 1 207 704 27.6 Asthma 88 816 15.5 *Mean No. of conditions is 6.1; median is 6. †Mean No. of conditions is 5.5; median is 5. COPD indicates chronic obstructive pulmonary disease; and HF, heart failure. Data source: Centers for Medicare and Medicaid Services administrative claims data, January 2011−December 2011, from the Chronic Condition Warehouse (CCW), ccwdata.org.847
35% to 50%) and significant ≥( 70% diameter ste- with critical aortic stenosis who are deemed inoper- nosis) multivessel CAD or proximal left anterior able.853 (Level of Evidence: B) descending coronary artery stenosis when viable myocardium is present in the region of intended Class IIb revascularization.848–850 (Level of Evidence: B) 2. CABG or medical therapy is reasonable to improve 1. CABG may be considered with the intent of improv- morbidity and cardiovascular mortality for patients ing survival in patients with ischemic heart disease with severe LV dysfunction (EF <35%), HF, and sig- with severe LV systolic dysfunction (EF <35%) and nificant CAD.309,851 (Level of Evidence: B) operable coronary anatomy whether or not viable 3. Surgical aortic valve replacement is reasonable for myocardium is present.307–309 (Level of Evidence: B) patients with critical aortic stenosis and a predicted 2. Transcatheter mitral valve repair or mitral valve surgical mortality of no greater than 10%.852 (Level surgery for functional mitral insufficiency is of of Evidence: B) uncertain benefit and should only be considered after 4. Transcatheter aortic valve replacement after careful careful candidate selection and with a background of candidate consideration is reasonable for patients GDMT.854–857 (Level of Evidence: B)
Table 32. Recommendations for Surgical/Percutaneous/Transcatheter Interventional Treatments of HF
Recommendations COR LOE References CABG or percutaneous intervention is indicated for HF patients on GDMT with I C 10, 12, 14, 848 angina and suitable coronary anatomy, especially significant left main stenosis or left main equivalent CABG to improve survival is reasonable in patients with mild to moderate IIa B 848–850 LV systolic dysfunction and significant multivessel CAD or proximal LAD stenosis when viable myocardium is present CABG or medical therapy is reasonable to improve morbidity and mortality for IIa B 309, 851 patients with severe LV dysfunction (EF <35%), HF, and significant CAD Surgical aortic valve replacement is reasonable for patients with critical IIa B 852 aortic stenosis and a predicted surgical mortality of no greater than 10% Transcatheter aortic valve replacement is reasonable for patients with critical IIa B 853 aortic stenosis who are deemed inoperable CABG may be considered in patients with ischemic heart disease, severe IIb B 307–309 LV systolic dysfunction, and operable coronary anatomy whether or not viable myocardium is present Transcatheter mitral valve repair or mitral valve surgery for functional mitral IIb B 854–857 insufficiency is of uncertain benefit Surgical reverse remodeling or LV aneurysmectomy may be considered in HFrEF IIb B 858 for specific indications, including intractable HF and ventricular arrhythmias CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COR, Class of Recommendation; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; LAD, left anterior descending; LOE, Level of Evidence; and LV, left ventricular. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e295
3. Surgical reverse remodeling or LV aneurysmectomy Table 33. Surgical/Percutaneous/Transcatheter Interventions may be considered in carefully selected patients with in Patients With HF HFrEF for specific indications, including intractable HF References and ventricular arrhythmias.858 (Level of Evidence: B) Appropriate Guideline-Directed Surgical/Percutaneous/ Surgical therapies and percutaneous interventions that are Transcatheter Interventions for HF commonly integrated, or at least considered, in HF man- 1. Surgical or percutaneous revascularization 10, 12, 14 agement include coronary revascularization (eg, CABG, angioplasty, stenting); aortic valve replacement; mitral valve 2. Surgical or transcatheter aortic valve replacement 852, 853 replacement or repair; septal myectomy or alcohol septal 3. Surgical myomectomy or alcohol ablation for hypertrophic 11 ablation for hypertrophic cardiomyopathy; surgical ablation cardiomyopathy of ventricular arrhythmia; MCS; and cardiac transplanta- 4. Nondurable MCS for cardiogenic shock 668–671 tion.675,680,859,860 Surgical placement of ICDs or LV pacing leads 5. Durable MCS for advanced HF 672–675 is of historical importance but may be considered in situations 6. Heart transplantation 680 where transvenous access is not feasible. 7. Surgical/electrophysiological ablation of ventricular tachycardia 866 The most common reason for intervention is CAD. Surgical/Percutaneous/Transcatheter Interventions Under Myocardial viability indicates the likelihood of improved out- Evaluation in Patients With HF comes with either surgical or medical therapy but does not 1. Transcatheter intervention for functional mitral 854–857 identify patients with greater survival benefit from revascular- insufficiency 304 ization. The dictum of CABG for left main CAD and reduced 2. Left atrial resection/left atrial appendage removal, surgical 867 LV function was considered absolute and subsequently extrap- or percutaneous, for AF olated to all severities of LV dysfunction without a confirma- 3. MCS for advanced HF as a bridge to recovery 868, 869 tory evidence base.848 Newer studies have addressed patients AF indicates atrial fibrillation; HF, heart failure; and MCS, mechanical with multivessel CAD, HF, and at least moderately severe to circulatory support. severe LV systolic dysfunction.861,862 Both surgical and medical therapies have similar outcomes, and decisions about revas- carefully selected patients with HFrEF for specified indica- cularization should be made jointly by the HF team and car- tions, including retractable HF and ventricular arrhythmias.858 diothoracic surgeon. The most important considerations in the decision to proceed with a surgical or interventional approach 11. Coordinating Care for Patients include coronary anatomy that is amenable to revasculariza- With Chronic HF tion and appropriate concomitant GDMT. Valvular heart dis- 11.1. Coordinating Care for Patients With Chronic ease is not an infrequent cause of HF; however, when valvular HF: Recommendations disease is managed correctly and pre-emptively, its adverse consequences on ventricular mechanics can be ameliorated. Class I The advent of effective transcatheter approaches to both mitral 1. Effective systems of care coordination with special atten- and aortic disease creates the need for greater considerations tion to care transitions should be deployed for every of structural interventions for patients with LV systolic dys- patient with chronic HF that facilitate and ensure effec- function and valvular heart disease. To date, the surgical or tive care that is designed to achieve GDMT and prevent transcatheter management of functional mitral insufficiency hospitalization.80,82,793,870–884 (Level of Evidence: B) has not been proven superior to medical therapy. A decision 2. Every patient with HF should have a clear, detailed, to intervene in functional mitral regurgitation should be made and evidence-based plan of care that ensures the on a case-by-case basis, and consideration should be given to achievement of GDMT goals, effective management participation in clinical trials and/or databases. The surgical or of comorbid conditions, timely follow-up with the transcatheter management of critical aortic stenosis is an effec- healthcare team, appropriate dietary and physical tive strategy with reasonable outcomes noted even in patients activities, and compliance with secondary prevention with advanced age (>80 years). Indications for other surgical guidelines for cardiovascular disease. This plan of or percutaneous interventions in the setting of HF are driven care should be updated regularly and made readily by other relevant guidelines or other sections of this guideline, available to all members of each patient’s healthcare 13 including myomectomy for hypertrophic cardiomyopathy, sur- team. (Level of Evidence: C) gical or electrophysiological procedures for AF, nondurable or 3. Palliative and supportive care is effective for patients durable MCS, and heart transplantation. with symptomatic advanced HF to improve quality of life.30,885–888 (Level of Evidence: B) Several procedures under evaluation hold promise but are not yet appropriate for a guideline-driven indication (Table 33). Education, support, and involvement of patients with HF and This includes revascularization as a means to support cel- their families are critical and often complex, especially dur- lular regenerative therapies. For patients willing to consider ing transitions of care. Failure to understand and follow a regenerative technologies, the ideal strategy is referral to an detailed and often nuanced plan of care likely contributes to enrolling clinical trial at a center experienced in both high- the high rates of HF 30-day rehospitalization and mortality risk revascularization and cell-based science.863–865 Surgical seen across the United States.61,889 One critical intervention to reverse-ventricular remodeling (ventricular reconstruction) ensure effective care coordination and transition is the provi- does not appear to be of benefit but may be considered in sion of a comprehensive plan of care, with easily understood, Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e296 Circulation October 15, 2013 culturally sensitive, and evidence-based educational materials, 11.3. Palliative Care for Patients With HF to patients with HF and/or caregivers during both hospital and The core elements of comprehensive palliative care for HF office-based encounters. A comprehensive plan of care should delivered by clinicians include expert symptom assessment and promote successful patient self-care.870,884,890 Hence, the plan of management. Ongoing care should address symptom control, care for patients with HF should continuously address in detail psychosocial distress, HRQOL, preferences about end-of-life a number of complex issues, including adherence to GDMT, care, caregiver support, and assurance of access to evidence-based timely follow-up with the healthcare professionals who man- disease-modifying interventions. The HF team can help patients age the patient’s HF and associated comorbidities, appropriate and their families explore treatment options and prognosis. The dietary and physical activities, including cardiac rehabilitation, HF and palliative care teams are best suited to help patients and and adherence to an extensive list of secondary prevention rec- families decide when end-of-life care (including hospice) is ommendations based on established guidelines for cardiovas- appropriate.30,885–888,904 Assessment for frailty and dementia is part cular disease (Table 34). Clinicians must maintain vigilance of this decision care process offered to the patient and family. about psychosocial, behavioral, and socioeconomic issues that Data suggest that advance directives specifying limitations in patients with HF and their caregivers face, including access to end-of-life care are associated with significantly lower levels of care, risk of depression, and healthcare disparities.639,891–895 For Medicare spending, lower likelihood of in-hospital death, and example, patients with HF who live in skilled nursing facilities higher use of hospice care in regions characterized by higher lev- are at higher risk for adverse events, with a 1-year mortality rate els of end-of-life spending.905 In newly diagnosed cancer patients, 896 >50%. Furthermore, community-dwelling patients with HF palliative care interventions delivered early have had a positive are often unable to afford the large number of medications pre- impact on survival and HRQOL. This approach may also be 897 scribed, thereby leading to suboptimal medication adherence. relevant for HF.906 Access to formally trained palliative care spe- cialists may be limited in ambulatory settings. Therefore, cardi- 11.2. Systems of Care to Promote Care ologists, primary care physicians, physician assistants, advanced Coordination for Patients With Chronic HF practice nurses, and other members of the HF healthcare team Improved communication between clinicians and nurses, med- should be familiar with these local treatment options. Evaluation ication reconciliation, carefully planned transitions between for cardiac transplantation or MCS in experienced centers should care settings, and consistent documentation are examples of include formal palliative care consultation, which can improve patient safety standards that should be ensured for all patients advanced care planning and enhance the overall quality of deci- with HF. The National Quality Forum has also endorsed a set of sion making and integrated care for these patients, regardless of patient-centered “Preferred Practices for Care Coordination,”898 the advanced HF therapy selected.907 which detail comprehensive specifications for successful care coordination for patients and their families. 12. Quality Metrics/Performance Systems of care designed to support patients with HF and Measures: Recommendations other cardiac diseases can produce a significant improvement in Class I outcomes. Furthermore, the Centers for Medicare and Medicaid Services is now financially penalizing hospitals for avoidable 1. Performance measures based on professionally devel- hospitalizations and readmissions, thereby emphasizing the oped clinical practice guidelines should be used with importance of such systems-based care coordination of patients the goal of improving quality of care for HF.706,801,917 with HF.899 However, the quality of evidence is mixed for specific (Level of Evidence: B) components of HF clinical management interventions, such as Class IIa home-based care,871,872 disease management,873,874,880 and remote 1. Participation in quality improvement programs and telemonitoring programs.80,875,876,878 Unfortunately, numerous patient registries based on nationally endorsed, clini- and nonstandardized definitions of disease management,873,879,880 cal practice guideline–based quality and performance including the specific elements that compose disease manage- measures can be beneficial in improving the quality of ment, impede efforts to improve the care of patients with HF. HF care.706,801 (Level of Evidence: B) Hence, more generic multidisciplinary strategies for improv- ing the quality and cost-effectiveness of systems-based HF care Quality measurement and accountability have become inte- should be evaluated with equal weight to those interventions gral parts of medical practice over the past 2 decades. HF has focused on improving adherence to GDMT. For example, multi- been a specific target of quality measurement, improvement, disciplinary approaches can reduce rates of hospitalization for HF. and reporting because of its substantial impact on population Programs involving specialized follow-up by a multidisciplinary morbidity and mortality. Commonly used performance mea- team decrease all-cause hospitalizations and mortality; however, sures for HF can be considered in 2 distinct categories: pro- this has not been shown for “disease management programs” that cess measures and outcomes measures. focus only on self-care activities.82,793,881,882,900 Furthermore, patient Process performance measures focus on the aspects of care characteristics may be important predictors of HF and other car- that are delivered to a patient (eg, the prescription of a particu- diac disease–related survival and hospitalization. Overall, very lar drug such as an ACE inhibitor in patients with LV systolic few specific interventions have been consistently identified and dysfunction and without contraindications). Process measures successfully applied in clinical practice.204,214,901–903 derive from the most definitive guideline recommendations See Online Data Supplements 42 and 43 for additional data (ie, class I and class III recommendations). A small group on disease management and telemonitoring. of process measures for hospitalized patients with HF have Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e297
Table 34. Plan of Care for Patients With Chronic HF
Plan of Care Relevant Guideline Section/Reference Guideline-directed medical and device therapy ACE inhibitor/ARB Sections 7.3.2.2 and 7.3.2.3 Beta blocker Section 7.3.2.4 Aldosterone receptor antagonist Section 7.3.2.5 Diuretic Sections 7.3.2.1 and 8.4 Hydralazine and isosorbide dinitrate Section 7.3.2.6 Digoxin Section 7.3.2.7 Discontinuation of drugs that may worsen HF Section 7.3.2.9 Biomarker-related therapeutic goals Section 6.3 HF-related devices (MCS, CRT, ICD) Sections 7.3.4 and 7.4.5 Management of comorbidities (examples) Ischemic heart disease 2012 ACCF/AHA SIHD Guideline14 Antithrombotic therapies Section 7.3.2.8.1 Arrhythmia/arrhythmia risk Sections 7.3.2.9.2 and 9.1 Hypertension Section 7.1.1, JNC-VII27 Diabetes mellitus 2012 ADA Standards90 Chronic renal failure Section 8.5 Chronic obstructive pulmonary disease 2011 ACCP/ATS/ERS Guideline908 Secondary prevention interventions (eg, lipids, smoking cessation, 2011 AHA/ACCF Secondary Prevention and Risk Reduction Guidelines and influenza and pneumococcal vaccines) Centers for Disease Control Adult Vaccinations13,909,910 Patient/family education Diet and fluid restriction, weight monitoring Sections 7.3.1.1, 7.3.1.3, 7.3.1.5, and 7.4.3 Recognizing signs and symptoms of worsening HF Table 24 Risk assessment and prognosis Sections 3, 4.6, 6.1.2 QOL assessment 2012 AHA Scientific Statement on Advanced HF30 Advance care planning (eg, palliative care and advance directives) Section 11.330,888 CPR training for family members AHA Family & Friends CPR911 Social support Section 7.3.1.2 Physical activity/cardiac rehabilitation Exercise regimen Sections 7.3.1.5 and 7.3.1.6 Activities of daily living Section 7.3.1.6 Functional status assessment and classification Section 3 Psychosocial factors Sex-specific issues 2011 AHA Guidelines for the Prevention of Cardiovascular Disease in Women912 Sexual activity 2012 AHA Scientific Statement on Sexual Activity913 Depression screening US Preventive Services Task Force Guidelines914 Clinician follow-up and care coordination Cardiologists and other relevant specialists 2000 AHA Scientific Statement for Team Management of Patients With HF900 Primary care physician NQF Preferred Practices for Care Coordination898 Advanced practice nurse Section 11.1–11.3, Joint Commission 2013 National Patient Safety Goals915 Other healthcare providers (eg, home care) Medication reconciliation HHS Meaningful Use Criteria Establishment of electronic personal health records Socioeconomic and cultural factors Culturally sensitive issues NQF: A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency916 Education and health literacy Section 7.3.1.1 Social support Section 7.3.1.2 ACCF indicates American College of Cardiology Foundation; ACCP, American College of Chest Physicians; ACE, angiotensin-converting enzyme; ADA, American Diabetes Association; AHA, American Heart Association; ARB, angiotensin-receptor blocker; ATS, American Thoracic Society; CPR, cardiopulmonary resuscitation; CRT, cardiac resynchronization therapy; ERS, European Respiratory Society; HF, heart failure; HHS, Health and Human Services; ICD, implantable cardioverter-defibrillator; JNC, Joint National Committee; MCS, mechanical circulatory support; NQF, National Quality Forum; QOL, quality of life; and SIHD, stable ischemic heart disease. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e298 Circulation October 15, 2013
Table 35. Outcome Measures for HF consensus process using an explicit methodology focusing on measurability, validity, reliability, feasibility, and ideally, Measure Developer correlation with patient outcomes,919,920 and with transparent Congestive HF mortality rate Agency for Health Research and Quality disclosure and management of possible conflicts of interest. (NQF endorsed) In the case of HF, several national outcome measures are HF 30-day mortality rate Centers for Medicare and Medicaid Services currently in use (Table 35), and the ACCF/AHA/American (NQF endorsed) Medical Association–Physician Consortium for Performance Congestive HF admission rate Agency for Health Research and Quality (NQF endorsed) Improvement recently published revised performance mea- HF 30-day risk-standardized Centers for Medicare and Medicaid Services sures document includes several process measures for both HF readmission rate inpatient and outpatient HF care (Table 36).921 Of note, the (NQF endorsed) ACCF/AHA distinguish between processes of care that can be HF indicates heart failure; and NQF, National Quality Forum. considered “Performance Measures” (ie, suitable for use for accountability purposes) and “Quality Metrics” (ie, suitable been reported to the public by the Centers for Medicare and for use for quality improvement but not accountability).922 Medicaid Services as part of the Hospital Compare program.918 Measures are appealing for several reasons; by definition, Measures used to characterize the care of patients with they reflect the strongest guideline recommendations. When HF should be those developed in a multiorganizational appropriately specified, they are relatively easy to calculate and
Table 36. ACCF/AHA/AMA-PCPI 2011 HF Measurement Set
Measure Description* Care Setting Level of Measurement
1. LVEF assessment Percentage of patients aged ≥18 y with a diagnosis of HF for whom the quantitative Outpatient Individual practitioner or qualitative results of a recent or prior (any time in the past) LVEF assessment is documented within a 12-mo period 2. LVEF assessment Percentage of patients aged ≥18 y with a principal discharge diagnosis of HF with Inpatient • Individual practitioner documentation in the hospital record of the results of an LVEF assessment • Facility performed either before arrival or during hospitalization, OR documentation in the hospital record that LVEF assessment is planned for after discharge 3. Symptom and activity Percentage of patient visits for those patients aged ≥18 y with a diagnosis of HF with Outpatient Individual practitioner assessment quantitative results of an evaluation of both current level of activity and clinical symptoms documented 4. Symptom management† Percentage of patient visits for those patients aged ≥18 y with a diagnosis of HF Outpatient Individual practitioner and with quantitative results of an evaluation of both level of activity AND clinical symptoms documented in which patient symptoms have improved or remained consistent with treatment goals since last assessment OR patient symptoms have demonstrated clinically important deterioration since last assessment with a documented plan of care 5. Patient self-care education†‡ Percentage of patients aged ≥18 y with a diagnosis of HF who were provided with self- Outpatient Individual practitioner care education on ≥3 elements of education during ≥1 visits within a 12-mo period 6. Beta-blocker therapy for Percentage of patients aged ≥18 y with a diagnosis of HF with a current or prior LVEF Inpatient and • Individual practitioner LVSD (outpatient and <40% who were prescribed beta-blocker therapy with bisoprolol, carvedilol, or outpatient • Facility inpatient setting) sustained-release metoprolol succinate either within a 12-mo period when seen in the outpatient setting or at hospital discharge 7. ACE inhibitor or ARB therapy Percentage of patients aged ≥18 y with a diagnosis of HF with a current or prior LVEF Inpatient and • Individual practitioner for LVSD (outpatient and <40% who were prescribed ACE inhibitor or ARB therapy either within a 12-mo outpatient • Facility inpatient setting) period when seen in the outpatient setting or at hospital discharge 8. Counseling about ICD Percentage of patients aged ≥18 y with a diagnosis of HF with current LVEF ≤35% Outpatient Individual practitioner implantation for patients despite ACE inhibitor/ARB and beta-blocker therapy for at least 3 mo who were with LVSD on combination counseled about ICD implantation as a treatment option for the prophylaxis of medical therapy†‡ sudden death 9. Postdischarge appointment Percentage of patients, regardless of age, discharged from an inpatient facility to Inpatient Facility for HF patients ambulatory care or home health care with a principal discharge diagnosis of HF for whom a follow-up appointment was scheduled and documented, including location, date, and time for a follow-up office visit or home health visit (as specified) NB, Regarding test measure no. 8, implantation of ICD must be consistent with published guidelines. This measure is intended to promote counseling only. *Refer to the complete measures for comprehensive information, including measure exception. †Test measure designated for use in internal quality improvement programs only. These measures are not appropriate for any other purpose (eg, pay for performance, physician ranking, or public reporting programs). ‡New measure. ACCF indicates American College of Cardiology Foundation; ACE, angiotensin-converting enzyme; AHA, American Heart Association; AMA-PCPI, American Medical Association−Physician Consortium for Performance Improvement; ARB, angiotensin-receptor blocker; HF, heart failure; ICD, implantable cardioverter-defibrillator; LVEF, left ventricular ejection fraction; and LVSD, left ventricular systolic dysfunction. Adapted from Bonow et al.921 Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e299 they provide a clear target for improvement. However, they do excluded patients with significant other comorbidities from not capture the broader range of care; they apply only to those enrollment, thus limiting our ability to generalize our recom- patients without contraindications to therapy. Evidence of the mendations to many real-world patients. Therefore, the clini- relation between better performance with respect to process mea- cian must, as always, practice the art of using the best of the sures and patient outcomes is conflicting, and performance rates guideline recommendations as they apply to a specific patient. for those measures that have been used as part of public report- Future research will need to focus on novel pharmaco- ing programs are generally high for all institutions, limiting the logical therapies, especially for hospitalized HF; regenerative ability of these measures to identify high- and low-performing cell-based therapies to restore myocardium; and new device centers. platforms that will either improve existing technologies (eg, These limitations of process measures have generated CRT, ICD, left VAD) or introduce simpler, less morbid devices interest in the use of outcomes measures as a complementary that are capable of changing the natural history of HF. What is approach to characterize quality. With respect to HF, 30-day critically needed is an evidence base that clearly identifies best mortality and 30-day readmission are reported by the Centers processes of care, especially in the transition from hospital to for Medicare and Medicaid Services as part of the Hospital home. Finally, preventing the burden of this disease through Compare program (Table 35) and are incorporated in the more successful risk modification, sophisticated screening, Centers for Medicare and Medicaid Services value-based pur- perhaps using specific omics technologies (ie, systems biol- chasing program.918 Outcomes measures are appealing because ogy) or effective treatment interventions that reduce the pro- they apply universally to almost all patients, and they provide gression from stage A to stage B is an urgent need. a perspective on the performance of health systems.923 On the other hand, they are limited by the questionable adequacy of Presidents and Staff risk adjustment and by the challenges of improvement. The ACCF and AHA have published criteria that characterize the American College of Cardiology Foundation necessary attributes of robust outcomes measures.924 John Gordon Harold, MD, MACC, President See Online Data Supplement 44 for additional data on Shalom Jacobovitz, Chief Executive Officer quality metrics and performance measures. William J. Oetgen, MD, MBA, FACC, Senior Vice President, Science and Quality 13. Evidence Gaps and Future Charlene L. May, Senior Director, Science and Clinical Policy Research Directions American College of Cardiology Foundation/ Despite the objective evidence compiled by the writing com- American Heart Association mittee on the basis of hundreds of clinical trials, there are huge Lisa Bradfield, CAE, Director, Science and Clinical Policy gaps in our knowledge base about many fundamental aspects Debjani Mukherjee, MPH, Associate Director, Evidence- of HF care. Some key examples include an effective manage- Based Medicine ment strategy for patients with HFpEF beyond blood pressure Ezaldeen Ramadhan III, Specialist, Science and Clinical control; a convincing method to use biomarkers in the opti- Policy mization of medical therapy; the recognition and treatment Sarah Jackson, MPH, Specialist, Science and Clinical Policy of cardiorenal syndrome; and the critical need for improving patient adherence to therapeutic regimens. Even the widely embraced dictum of sodium restriction in HF is not well sup- American Heart Association ported by current evidence. Moreover, the majority of the Donna K. Arnett, PhD, MD, FAHA, President clinical trials that inform GDMT were designed around the Nancy Brown, Chief Executive Officer Rose Marie Robertson, MD, FAHA, Chief Science Officer primary endpoint of mortality, so that there is less certainty Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice about the impact of therapies on the HRQOL of patients. It President, Office of Science Operations is also of major concern that the majority of RCTs failed to Judy Bezanson, DSN, RN, CNS-MS, FAHA, Science and randomize a sufficient number of the elderly, women, and Medicine Advisor underrepresented minorities, thus, limiting insight into these Jody Hundley, Production Manager, Scientific Publications, important patient cohorts. A growing body of studies on Office of Science Operations patient-centered outcomes research is likely to address some of these deficiencies, but time will be required. HF is a syndrome with a high prevalence of comorbidi- References ties and multiple chronic conditions, but most guidelines are 1. ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. developed for patients with a single disease. 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Available at: ventricular assistance, cardiomyopathy ◼ epidemiology ◼ health policy and http://www.heart.org/HEARTORG/CPRAndECC/CommunityTraining/ outcome research ◼ heart failure ◼ other heart failure
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Appendix 1. Author Relationships With Industry and Other Entities (Relevant)—2013 ACCF/AHA Guideline for the Management of Heart Failure
Institutional, Ownership/ Organizational, or Voting Committee Speaker’s Partnership/ Personal Other Financial Expert Recusals by Member Employment Consultant Bureau Principal Research Benefit Witness Section* Clyde W. Northwestern None None None None None None None Yancy, Chair University—Chief, Division of Cardiology and Magerstadt Professor of Medicine Mariell Jessup, University of None None None • Amgen None None 7.4.4 Vice Chair Pennsylvania— • Celladon 7.4.5 Professor of Medicine • HeartWare 7.4.6 10 Biykem Michael E. DeBakey VA None None None None None None None Bozkurt Medical Center—The Mary and Gordon Cain Chair and Professor of Medicine Javed Butler Emory Healthcare— • Amgen None None None • Amgen None 6.4 Director of Heart • CardioMEMS • Biotronic 7.1 Failure Research; • Gambro • Boston Scientific 7.2 Emory University • Takeda • CardioMEMS 7.3.2 School of Medicine— • Corthera† 7.3.3 Professor of Medicine • FoldRx 7.3.4 • iOcopsys 7.4.4 • Johnson & 7.4.5 Johnson 7.4.6 • Medtronic 8.6 • Thoratec 8.7 • World Heart 10 Donald E. Clinically Integrated None None None None None None None Casey, Jr Physician Network, NYU Langone Medical Center—Vice President and Medical Director Mark H. University of Texas None None None • HeartWare • Medtronic None 7.1 Drazner Southwestern Medical • Scios/Johnson & • Thoratec† 7.2 Center—Professor, Johnson† 7.3.2 Internal Medicine 7.3.4 7.4.4 7.4.5 7.4.6 8.6 8.7 10 Gregg C. Director Ahmanson— • Gambro None None • Gambro (formerly • Medtronic None 7.1 Fonarow UCLA Cardiomyopathy (formerly CHF CHF Solutions) 7.2 Center; Co-Chief— Solutions) • Novartis† (Class IIa) UCLA Division of • Medtronic 7.3.2 Cardiology • Novartis† 7.3.4 • Takeda 8.3 8.4 8.7 10 Stephen A. Quillen College None None None None None None None Geraci of Medicine/East Tennessee State University—Chairman of Internal Medicine (continued)
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Appendix 1. Continued
Institutional, Ownership/ Organizational, or Voting Committee Speaker’s Partnership/ Personal Other Financial Expert Recusals by Member Employment Consultant Bureau Principal Research Benefit Witness Section*
Tamara Ahmanson—UCLA None None None None None None None Horwich Cardiomyopathy Center—Assistant Professor of Medicine, Cardiology James L. Harvard Medical • Critical None None • Critical None None 6.2 Januzzi School—Associate Diagnostics† Diagnostics† 6.3 Professor of Medicine; • Roche • Roche Massachusetts General Diagnostics† Diagnostics† Hospital—Director, Cardiac Intensive Care Unit Maryl R. University of None None None None None None None Johnson Wisconsin, Madison— Professor of Medicine, Director Heart Failure and Transplantation Edward K. Johns Hopkins None None None None None None None Kasper Hospital— E. Cowles Andrus Professor in Cardiology Director, Clinical Cardiology Wayne C. Levy University of • Cardiac • Amarin None • Amgen† • Amgen None 6.4 Washington— Dimensions† • Boehringer • HeartWare† • Epocrates 6.5 Professor of Medicine, • CardioMEMS Ingelheim • GE Healthcare 7.1 Division of Cardiology • GE/Scios/ • GlaxoSmithKline • HeartWare 7.2 Johnson & • Thoratec 7.3.1 Johnson 7.3.2 7.3.4 7.4.5 8.3 8.6 8.7 10 Frederick A. University of Colorado, None None None None None None None Masoudi Denver—Associate Professor of Medicine, Division of Cardiology Patrick E. University of Wisconsin None None None None None None None McBride School of Medicine and Public Health— Professor of Medicine and Family Medicine, Associate Dean for Students, Associate Director, Preventive Cardiology John J.V. University of Glasgow, None None None • GlaxoSmithKline† • Novartis None 6.2 McMurray Scotland, BHF Glasgow • Novartis (PARADIGM–PI) 6.3 Cardiovascular • Roche (DSMB) 7.1 Research Center— 7.2 Professor of Medical (Class I and Cardiology Class III) 7.3.2 8.3 8.7 (continued)
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Appendix 1. Continued
Institutional, Ownership/ Organizational, or Voting Committee Speaker’s Partnership/ Personal Other Financial Expert Recusals by Member Employment Consultant Bureau Principal Research Benefit Witness Section*
Judith E. SUNY Downstate Medical None None None None None None None Mitchell Center—Director, Heart Failure Center; Associate Professor of Medicine Pamela N. University of Colorado, None None None None None None None Peterson Denver Health Medical Center—Associate Professor of Medicine, Division of Cardiology Barbara Riegel University of None None None None None None None Pennsylvania School of Nursing—Professor Flora Sam Boston University None None None None None None None School of Medicine, Whitaker Cardiovascular Institute—Associate Professor of Medicine, Division of Cardiology/ Cardiomyopathy Program Lynne W. Brigham and Women’s None None None • Biosense Webster None None 7.3.4 Stevenson Hospital Cardiovascular Division—Director, Cardiomyopathy and Heart Failure Program W.H. Wilson Cleveland Clinic • Medtronic None None • Abbott† None None 6.2 Tang Foundation—Associate • St. Jude Medical • FoldRx 6.3 Professor of Medicine, • Johnson & 7.1 Research Director for Johnson 7.2 Heart Failure/Transplant • Medtronic† 7.3.2 • St. Jude Medical† 7.3.3 7.3.4 8.6 8.7 10 Emily J. Tsai Temple University School None None None None None None None of Medicine—Assistant Professor of Medicine, Cardiology Bruce L. Cleveland Clinic— None None None • Biotronic None None 7.2 Wilkoff Director, Cardiac Pacing • Boston Scientific (Class IIa) and Tachyarrhythmia • Medtronic 7.3.4 Devices; Director, • St. Jude Medical 10 Clinical EP Research This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$10 000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person’s household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in thedocument . *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Section numbers pertain to those in the full-text guideline. †Indicates significant relationship. DSMB indicates Data Safety Monitoring Board; EP, electrophysiology; NYU, New York University; PARADIGM, a Multicenter, Randomized, Double-blind, Parallel Group, Active-controlled Study to Evaluate the Efficacy and Safety of LCZ696 Compared to Enalapril on Morbidity and Mortality in Patients With Chronic Heart Failure and Reduced Ejection Fraction; PI, Principal Investigator; SUNY, State University of New York; UCLA, University of California, Los Angeles; and VA, Veterans Affairs.
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Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant)—2013 ACCF/AHA Guideline for the Management of Heart Failure
Institutional, Ownership/ Organizational, or Speaker’s Partnership/ Personal Other Financial Expert Reviewer Representation Employment Consultant Bureau Principal Research Benefit Witness Nancy Albert Official Kaufman Center for • BG Medicine None None None None None Reviewer— Heart Failure—Senior • Medtronic ACCF/AHA Director of Nursing • Merck† Task Force Research on Practice Guidelines Kathleen Grady Official Bluhm Cardiovascular None None None None None None Reviewer—AHA Institute— Administrative Director, Center for Heart Failure Paul Hauptman Official St Louis University • BG Medicine None None None • EvaHeart† None Reviewer—AHA School of Medicine— • BioControl Medical Professor of Internal • Otsuka* Medicine, Division of Cardiology Hector Ventura Official Ochsner Clinic • Otsuka • Actelion None None None None Reviewer— Foundation— ACCF Board of Director, Section of Governors Cardiomyopathy and Heart Transplantation Mary Norine Official St. Vincent Heart • United Healthcare None None None None None Walsh Reviewer— Center of Indiana— ACCF Board of Medical Director Trustees Jun Chiong Organizational Loma Linda None None None None • Otsuka (DSMB) None Reviewer— University—Associate ACCP Clinical Professor of Medicine David DeLurgio Organizational The Emory Clinic— None None None None None None Reviewer—HRS Associate Professor, Director of EP Laboratory Folashade Organizational Morehouse School of None None None None None None Omole Reviewer—AAFP Medicine—Associate Professor of Clinical Family Medicine Robert Rich, Jr Organizational Bladen Medical None None None None None None Reviewer—AAFP Associates—Family Practice David Taylor Organizational Cleveland Clinic, None None None None • Biotronix† None Reviewer— Department of • Genentech† ISHLT Cardiology— • HeartWare† Professor of Medicine • ISHLT • Novartis† • St. Jude’s Medical† Kimberly Content University of None None None None None None Birtcher Reviewer— Houston College of ACCF Pharmacy—Clinical Cardiovascular Professor Team Council Kay Blum Content Medstar Southern None None None None None None Reviewer— Maryland Hospital ACCF Center—Nurse Cardiovascular Practitioner Team Council (continued) Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 e324 Circulation October 15, 2013
Appendix 2. Continued
Institutional, Ownership/ Organizational, or Speaker’s Partnership/ Personal Other Financial Expert Reviewer Representation Employment Consultant Bureau Principal Research Benefit Witness
Michael Chan Content Royal Alexandra None None None None • Medtronic None Reviewer— Hospital—Co- ACCF Director, Heart Cardiovascular Function Program; Team Council University of Alberta—Associate Clinical Professor of Medicine Jane Chen Content Washington University • Medtronic None None None None None Reviewer— School of Medicine— • St. Jude Medical ACCF EP Assistant Professor of Committee Medicine Michael Clark Content North Texas None • Abbott None None None None Reviewer— Cardiology and EP— Pharma ACCF Associate Professor Cardiovascular Team Council Marco Costa Content University Hospital for • Abbott Vascular • Daiichi- None None • Abbott Vascular* None Reviewer— Cleveland—Professor • Boston Scientific Sankyo • Boston Scientific ACCF Imaging of Medicine • Cardiokinetix* • Eli Lilly • Cardiokinetix† Council • Medtronic • Sanofi • Medtronic* • St. Jude Medical • St. Jude Medical Anita Deswal Content Baylor College of None None None • Amgen† None None Reviewer Medicine—Associate • Novartis† Professor of Medicine Steven Dunn Content University of Virginia None None None None None None Reviewer— Health System— ACCF Prevention Clinical Pharmacy Committee Specialist Andrew Epstein Content University of • Biotronic None None • Biosense • Boston Scientific* None Reviewer Pennsylvania— • Boehringer Webster* • St. Jude Medical* Professor of Medicine Ingelheim • Boston • Medtronic Scientific* • Zoll • Cameron Health* Justin Ezekowitz Content Mazankowski Alberta • Abbott Labs None None • Amgen None None Reviewer—AHA Heart Institute— • AstraZeneca • Bristol-Myers Director, Heart • Pfizer Squibb Function Clinic Gerasimos Content University of None None None None • Corthera None Filippatos Reviewer Athens—Department • Vifor of Cardiology Linda Gillam Content Morristown Medical None None None None • Edwards None Reviewer— Center—Professor of Lifesciences† ACCF Imaging Cardiology Council Paul Content Stanford VA Palo Alto None None None • Medtronic† None None Heidenreich Reviewer Medical Center— Assistant Professor of Medicine Paul Hess Content Duke University None None None None None None Reviewer— School of ACCF EP Medicine—Fellow Committee
(continued)
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Appendix 2. Continued
Institutional, Ownership/ Organizational, or Speaker’s Partnership/ Personal Other Financial Expert Reviewer Representation Employment Consultant Bureau Principal Research Benefit Witness
Sharon Ann Content Stanford None None None None None None Hunt Reviewer University Medical Center—Professor, Department of Cardiovascular Medicine Charles McKay Content Harbor-UCLA Medical None None None None None None Reviewer— Center—Professor of ACCF Council on Medicine Cardiovascular Care for Older Adults James Content Temple University None None None None None None McClurken Reviewer— School of ACCF Surgeons’ Medicine—Director Scientific of Cardiothoracic Council Perioperative Services Wayne Miller Content Mayo Clinic— None None None None None None Reviewer— Professor of Medicine ACCF Heart Failure and Transplant Council Rick Nishimura Content Mayo Clinic— None None None None None None Reviewer Professor of Medicine Donna Content Lehigh Valley None None None None None None Petruccelli Reviewer— Health Network— ACCF Heart Heart Failure Failure and Nurse Practitioner/ Transplant Clinical Nurse Council Specialist, Center for Advanced Heart Failure Geetha Content Children’s Mercy None None None None None None Raghuveer Reviewer— Hospital—Associate ACCF Board of Professor of Governors Pediatrics Pasala Content Oregon Health & None None None None None None Ravichandran Reviewer— Science University— ACCF Surgeons’ Associate Professor Scientific Council Michael Rich Content Washington University None None None None None None Reviewer— School of Medicine— ACCF Council on Professor of Medicine Cardiovascular Care for Older Adults Anitra Romfh Content Children’s Hospital None None None None None None Reviewer— Boston—Clinical ACCF Adult Fellow in Pediatrics Congenital and Pediatric Cardiology Council (continued)
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Appendix 2. Continued
Institutional, Ownership/ Organizational, or Speaker’s Partnership/ Personal Other Financial Expert Reviewer Representation Employment Consultant Bureau Principal Research Benefit Witness
Andrea Russo Content Cooper University • Biotronik None None • Cameron None None Reviewer— Hospital—Professor • Boston Scientific Health ACCF Task of Medicine • Cameron Health • Medtronic Force on • Medtronic Appropriate Use • St. Jude Medical Criteria Dipan Shah Content Methodist None • AstraZeneca* None None • Astellas Pharma None Reviewer—ACCF DeBakey Heart • Lantheus • Siemens Medical Imaging Council Center—Director Medical Solutions* Imaging Randy Starling Content Cleveland Clinic, • Novartis None None None • Biotronik None Reviewer Department of • Medtronic Cardiovascular Medicine—Vice Chairman Karen Stout Content University of None None None None None None Reviewer— Washington— ACCF Adult Director, Adult Congenital Congenital Heart and Pediatric Disease Program Cardiology Council John Teerlink Content San Francisco VA • Amgen* None None None • Amgen* None Reviewer Medical Center— • Anexon • Merck Professor of Medicine • CardioMEMS* • Novartis* • Cytokinetics • Novartis* • St. Jude Medical* • Scios/Johnson & Johnson • Trevena Robert Touchon Content Marshall University, None None None None None None Reviewer— Joan C. Edwards ACCF Prevention School of Medicine— Committee Professor of Medicine Hiroyuki Tsutsui Content Hokkaido • Daiichi-Sankyo* None None None None None Reviewer University—Professor • Novartis* of Medicine • Pfizer • Takeda* Robert Vincent Content Emory University None None None None • AGA None Reviewer—ACCF School of Medicine— Adult Congenital Professor of and Pediatric Pediatrics Cardiology Council This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$10 000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person’s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in thedocument . *Significant relationship. †No financial benefit. AAFP indicates American Academy of Family Physicians; ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians; AHA, American Heart Association; DSMB, data safety monitoring board; EP, electrophysiology; HRS, Heart Rhythm Society; ISHLT, International Society for Heart and Lung Transplantation; and VA, Veterans Affairs. Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 Yancy et al 2013 ACCF/AHA Heart Failure Guideline e327
Appendix 3. Abbreviations
ACE = angiotensin-converting enzyme ACS = acute coronary syndrome AF = atrial fibrillation ARB = angiotensin-receptor blocker BMI = body mass index BNP = B-type natriuretic peptide CABG = coronary artery bypass graft CAD = coronary artery disease CRT = cardiac resynchronization therapy DCM = dilated cardiomyopathy ECG = electrocardiogram EF = ejection fraction GDMT = guideline-directed medical therapy HbA1c = hemoglobin A1c HF = heart failure HFpEF = heart failure with preserved ejection fraction HFrEF = heart failure with reduced ejection fraction HRQOL = health-related quality of life ICD = implantable cardioverter-defibrillator LBBB = left bundle-branch block LV = left ventricular LVEF = left ventricular ejection fraction MCS = mechanical circulatory support MI = myocardial infarction NSAIDs = nonsteroidal anti-inflammatory drugs NT-proBNP = N-terminal pro-B-type natriuretic peptide NYHA = New York Heart Association PUFA = polyunsaturated fatty acids RCT = randomized controlled trial SCD = sudden cardiac death VAD = ventricular assist device
Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Clyde W. Yancy, Mariell Jessup, Biykem Bozkurt, Javed Butler, Donald E. Casey, Jr, Mark H. Drazner, Gregg C. Fonarow, Stephen A. Geraci, Tamara Horwich, James L. Januzzi, Maryl R. Johnson, Edward K. Kasper, Wayne C. Levy, Frederick A. Masoudi, Patrick E. McBride, John J.V. McMurray, Judith E. Mitchell, Pamela N. Peterson, Barbara Riegel, Flora Sam, Lynne W. Stevenson, W.H. Wilson Tang, Emily J. Tsai and Bruce L. Wilkoff
Circulation. 2013;128:e240-e327; originally published online June 5, 2013; doi: 10.1161/CIR.0b013e31829e8776 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2013 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
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Downloaded from http://circ.ahajournals.org/ by guest on February 16, 2016 2013 Heart Failure Guideline Data Supplements (Section numbers correspond to the full-text guideline.)
Table of Contents Data Supplement 1. HFpEF (Section 2.2)...... 3 Data Supplement 2. NYHA and AHA/ACC Class (Section 3) ...... 4 Data Supplement 3. Prognosis – Mortality (Section 4.1)...... 5 Data Supplement 4. Health-Related Quality of Life and Functional Capacity (Section 4.4) ...... 7 Data Supplement 5. Stress Testing (Initial and Serial Evaluation) of the HF Patient (Section 6.1.1) ...... 11 Data Supplement 6. Clinical Evaluation – History (Orthopnea) (Section 6.1.1) ...... 13 Data Supplement 7. Clinical Evaluation – Examination (Section 6.1.1) ...... 13 Data Supplement 8. Clinical Evaluation – Risk Scoring (Section 6.1.2) ...... 16 Data Supplement 9. Imaging Echocardiography (Section 6.4) ...... 18 Data Supplement 10. Biopsy (Section 6.5.3) ...... 21 Data Supplement 11. Stage A: Prevention of HF (Section 7.1) ...... 22 Data Supplement 12. Stage B: Preventing the Syndrome of Clinical HF With Low EF (Section 7.2) ...... 28 Data Supplement 13. Stage C: Factors Associated With Outcomes, All Patients (Section 7.3) ...... 30 Data Supplement 14. Nonadherence (Section 7.3.1.1) ...... 38 Data Supplement 15. Treatment of Sleep Disorders (Section 7.3.1.4) ...... 47 Data Supplement 16. Cardiac Rehabilitation-Exercise (Section 7.3.1.6) ...... 49 Data Supplement 17. Diuretics Versus Ultrafiltration in Acute Decompensated HF (Section 7.3.2.1) ...... 60 Data Supplement 18. ACE Inhibitors (Section 7.3.2.2) ...... 76 Data Supplement 19. ARBs (Section 7.3.2.3) ...... 82 Data Supplement 20. Beta Blockers (Section 7.3.2.4) ...... 85 Data Supplement 21. Anticoagulation (Section 7.3.2.8.1) ...... 89 Data Supplement 22. Statin Therapy (Section 7.3.2.8.2) ...... 94 Data Supplement 23. Omega 3 Fatty Acids (Section 7.3.2.8.3) ...... 101 Data Supplement 24. Antiarrhythmic Agents to Avoid in HF (7.3.2.9.2) ...... 104 Data Supplement 25. Calcium Channel Blockers to Avoid in HF (Section 7.3.2.9.3) ...... 105 Data Supplement 26. NSAIDs Use in HF (Section 7.3.2.9.4) ...... 106 Data Supplement 27. Thiazolidinediones in HF (Section 7.3.2.9.5) ...... 107 Data Supplement 28. Device-Based Management (Section 7.3.4) ...... 108 Data Supplement 29. CRT (Section 7.3.4.2) ...... 109 Data Supplement 30. Therapies, Important Considerations (Section 7.4.2) ...... 114 Data Supplement 31. Sildenafil (Section Section 7.4.2) ...... 120 © American College of Cardiology Foundation and American Heart Association, Inc. 1
Data Supplement 32. Inotropes (Section 7.4.4) ...... 123 Data Supplement 33. Inotropic Agents in HF (Section 7.4.4) ...... 135 Data Supplement 34. Mechanical Circulatory Support (Section 7.4.5) ...... 136 Data Supplement 35. LVADs (Section 7.4.5) ...... 138 Data Supplement 36. Transplantation (Section 7.4.6) ...... 149 Data Supplement 37. Comorbidities in the Hospitalized Patient (Section 8.1) ...... 159 Data Supplement 38. Worsening Renal Function, Mortality and Readmission in Acute HF (Section 8.5) ...... 161 Data Supplement 39. Nesiritide (Section 8.7) ...... 165 Data Supplement 40. Hospitalized Patients – Oral Medications (Section 8.8) ...... 177 Data Supplement 41. Atrial Fibrillation (Section 9.1) ...... 186 Data Supplement 42. HF Disease Management (Section 11.2) ...... 187 Data Supplement 43. Telemonitoring (Section 11.2) ...... 189 Data Supplement 44. Quality Metrics and Performance Measures (Section 12) ...... 191 References ...... 192
© American College of Cardiology Foundation and American Heart Association, Inc. 2
Data Supplement 1. HFpEF (Section 2.2) Study Name, Aim of Study Study Type Study Patient Population Endpoints Statistical Analysis Study Limitations Findings/ Comments Author, Year Size (Results)
Inclusion Criteria Exclusion Criteria Masoudi JACC To assess factors Cross 19,710 Medicare beneficiary; No documentation of Preserved LVSF Multivariable logistic Limited to Medicare Factors associated with 2003;41:217- associated with sectional hospitalized with LVEF regression to assess population; limited to preserved LVSF, which 223 preserved LVSF in cohort study principal discharge factors associated with hospitalized pts; missing included gender, advanced 12535812 (1) pts with HF diagnosis of HF; acute preserved LVSF LVEF in a portion of the age, HTN, AF; and absence care hospitalization; population of coronary disease hospitalized between 4/1998-3/1999 Owan NEJM Define temporal Retrospective 4,596 Consecutive pts admitted No documentation of Proportion of pts with Linear regression and Limited to Olmsted County, Overall, more than half the 2006;355:251- trends in prevalence cohort study to Mayo Clinic hospitals; LVEF preserved LVSF; survival analysis MN; limited to hospitalized population had preserved 259 of HF with preserved Discharge code for HF; survival pts; missing LVEF in a LVSF; this proportion 16855265 (2) LVEF over 15 y 1987-2001 portion of the population increased overtime; survival period in pts with HFpEF was only slightly better than for those with HFrEF (HR:0.96) Bhatia NEJM Evaluate the Retrospective 2,802 Pts admitted to 103 No documentation of Death within 1 y; Multivariable survival Limited to Ontario; limited 31% had HFpEF; HFpEF 2006;355:260- epidemiological cohort study Ontario hospitals; LVEF readmission for HF analysis to hospitalized pts; missing more often female, older, with 269 features and 4/1999-3/2001; LVEF in a portion of the AF, and HTN; Unadjusted 16855266 (3) outcomes of pts with discharge diagnosis of population mortality similar (22% for HFpEF vs. HFrEF HF HFpEF vs. 26% for HFrEF); adjusted mortality also similar (aHR:1.13); readmission rates also similar between groups. Lee Circulation Assess the Retrospective 534 Framingham N/A Factors associated Multivariable logistic Limited to Framingham Factors associated with 2009;119:3070- contribution of risk cohort study participants; incident HF with HFpEF; Mortality regression (risk cohort; relatively small HFpEF included female 3077 factors and disease factors); multivariable sample size gender; elevated SBP; AF; 19506115 (4) pathogenesis to survival analysis and absence of CAD. Long- HFpEF (mortality) term prognosis equally poor (overall cohort median survival of 2.1 y; 5-y mortality 74%).
© American College of Cardiology Foundation and American Heart Association, Inc. 3
Kane JAMA Measure changes in Retrospective 2042 Random sample from N/A Diastolic function Multivariable survival Limited to Olmsted County, In 4 y between baseline and 2011;306:856- diastolic function and cohort study Olmsted County MN in grade; incident HF analysis MN; limited to those follow-up, prevalence of 863 assess the 1997; age ≥45; following up for 2nd diastolic dysfunction 21862747 (5) relationship between participating in baseline examination increased from 23.8% to diastolic and follow up 39.2%. Diastolic dysfunction abnormalities and HF assessments associated with incident HF risk (HR:1.81) AF indicates atrial fibrillation; CAD, coronary artery disease; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; HTN, hypertension; LVEF, left ventricular ejection fraction; LVSF, left ventricular systolic function; MN, Minnesota; N/A, not applicable; pts, patients, and SBP, systolic blood pressure.
Data Supplement 2. NYHA and AHA/ACC Class (Section 3)
Study Name, Study Statistical Analysis Findings/ Aim of Study Study Type Patient Population Endpoints Study Limitations Author, Year Size (Results) Comments
Inclusion Exclusion Primary Secondary Criteria Criteria Endpoint Endpoint Madsen BK, 1994 Predict CHF mortality Longitudinal 190 N/A Must be Death N/A Kaplan-Meier N/A Conducted primarily 8013501 (6) registry ambulatory Mortality increased with outside U.S. increased NYHA class and with decreased EF Holland R, 2010 Predict CHF mortality Longitudinal 293 Adults with CHF N/A Readmission MLHF Survival analysis No clinician assessment Conducted primarily 20142027 (7) using self-assessed registry after CHF over 6 mo questionnaire and Readmission rate increased to compare to pt outside U.S. NYHA class admission death with higher NYHA class assessment Anmar KA, 2007 Measure association of Cross- 2,029 Residents of N/A 5-y survival rates BNP Survival analysis Retrospective N/A 17353436 (8) HF stages with mortality sectional Olmsted Co, MN HF stages associated with classification of stage cohort progressively worsening 5-y survival rates Goldman L, 1981 Reproducibility for Longitudinal 75 All those referred N/A Reproducibility N/A NYHA classification N/A Reproducibility only 7296795 (9) assessing CV functional registry for treadmill testing 56% class testing BNP indicates B-type natriuretic peptide; CHF, congestive heart failure; CV, cardiovascular; EF, ejection fraction; HF, heart failure; MLHF, Minnesota Living with Heart Failure; N/A, not applicable; NYHA, New York Heart Association; and pt, patient.
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Data Supplement 3. Prognosis - Mortality (Section 4.1) Statistical Study Name, Aim of P Values Findings/ Study Type Study Size Patient Population Endpoints Analysis Study Limitations Author, Year Study & 95% CI: Comments (Results) Primary Secondary Inclusion Criteria Exclusion Criteria Endpoint Endpoint The Seattle HF Develop and Cohort Derivation: 1,125 Derivation Cohort: EF N/A Prediction of N/A Predicted vs. ROC: Population not 24 variables Model: Prediction validate a risk Validation: 9,942 <30%, NYHA class III-IV 1,2,3-y actual survival for 0.729; 95% representative of HF included in risk of Survival in HF model for Validation Cohort: EF mortality 1, 2, and 3 y: CI: 0.714- population in general: score Levy, Wayne Circ 1,2,and 3-y <40%, NYHA class II-IV 88.2% vs 87.8%, 0.744 clinical trial 2006 mortality Both derivation and 79.2% vs 77.6%, populations, restricted 16534009 (10) validation cohorts primarily 71.8% vs. 68.0% to HF with LVSD. out-pts (both clinical trial Estimation of risk populations) score is complex and requires computer/calculator. Predicting Develop and Cohort Derivation: 2,624 No EF requirement; Pts who developed HF after 30-d and 1-y N/A Derivation Cohort: ROC: 0.79 N/A Variables in Mortality Among validate a risk Validation: 1,407 Community-based pts admit, transferred from mortality in-hospital for 30-d Model: age, Pts Hospitalized model for 30-d hospitalized with HF in different facility, over 105 y, mortality: 8.9%, mortality; SBP, resp rate, with HF and 1-y Canada (met modified nonresidents 30-d mortality: ROC; 0.76 Na <136, Hbg (EFFECT) Lee, mortality Framingham HF criteria) 10.7%; 1-y for 1-y <10, BUN, CVD, Douglas JAMA mortality: 32.9% mortality COPD, 2003 Validation cohort: dementia, 14625335 (11) in-hospital cirrhosis, cancer mortality: 8.2%, 30-d mortality: 10.4%; 1-y mortality:30.5% Predictors of Develop Cohort 4,402 No EF criteria (49% with N/A Death at 60- Hospitalization; 60-90 d mortality: c index: Validity - assessed by Developed a Mortality After models study/registry LVSD), pts hospitalized 90 d death or 8.6%; death or 0.735; bootstraping nomogram. Discharge in pts predictive of with HF at institutions rehospitalization rehospitalization: bias- Variables Hospitalized w/ 60 and 90 d participating in OPIMIZE- 36.2% corrected c included in HF (OPTIMIZE- mortality HF performance- index: score: Age, HF) O'Connor, improvement program 0.723 weight, SBP, Christopher sodium, Cr, liver AHJ 2008 disease, 18926148 (12) depression, RAD
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Predictors of Develop Cohorts: used 7,599 No EF criteria; out-pts; K >5.5; Cr >265 umol/L; MI or Mortality CV death or N/A ROC:0.75, Population studied 23 variables Mortality and prognostic pts in the symptomatic HF stroke in prior 4 wk; hospitalization bias not representative of included in Morbidity in Pts models for 2-y CHARM noncardiac disease limiting corrected: HF in general (pts model with Chronic HF mortality program survival 0.74; ROC: enrolled in CHARM); Pocock, Stuart 0.73 in low validity - assessed by EHJ 2006 EF and in bootstrapping; 16219658 (13) preserved laboratory data not EF cohorts available.
Risk Stratification Estimate Cohort/registry Derivation:33,046 Pts admitted with HF to None In-hospital N/A Classification and N/A N/A Classifies pts for Inhospital mortality risk in Validation: 32,229 hospital participating in the mortality regression tree into 5 risk Mortality in pts ADHERE registry; no EF analysis; categories. Acutely hospitalized criteria; In-hospital Discriminating Decompensated with HF mortality: 4.1%; nodes: BUN; HF: Classification 95% CI:2.1%- SBP; Cr and Regression 21.9% Tree Analysis Fonarow, Gregg JAMA 2005 15687312 (14) A validated risk Develop a risk Cohort/registry Derivation:27,850; Pts admitted with HF to Transfers, missing LVEF data Inhospital Inhospital mortality N/A Validation cohort from Variables score of in- score for Validation:11,933 hospitals participating in mortality 2.86%; C index same population. included in risk hospital mortality inhospital the GWTG-HF program 0.75 GWTG is a voluntary score: SBP, in pts with HF mortality registry BUN, Sodium, from the AHA age, heart rate, GWTG Program race, COPD Peterson, Pamela CircCQO 2010 20123668 (15) Predictors of Develop a Cohort/registry 40,201 Pts admitted to hospital N/A Inhospital Inhospital N/A Validity - assessed by Risk prediction inhospital clinical participating in OPTIMIZE- mortality mortality: 3.8%; C bootstrapping nomogram: age, mortality in pts predictive HF (registry/performance index 0.77 HR, SBP, hospitalized for model of in- improvement program); no sodium, Cr, HF. Insights from hospital EF criteria (LVSD in 49% primary cause OPTIMIZE-HF mortality of those with measured for admit, LVSD Abraham, William EF); included those JACC 2008 admitted with different 18652942 (16) diagnosis than the discharge diagnosis of HF Predictors of fatal Develop Cohort 3,342 Pts enrolled in the Recent CV event or Composite: All-cause Total mortality: C N/A Used a clinical trial Elderly pts on and non-fatal prognostic CORONA study. Pts ≥60 procedure/operation, acute or CV mortality, mortality; CV index of 0.719; population; limited to contemporary outcomes in the models in y; NYHA class II-IV HF; chronic liver disease or ALT nonfatal MI or mortality; fatal or death due to HF: ischemic etiology HF therapy; NT- CORONA: elderly pts and investigator reported >2x ULN; BUN >2.5 mg/dL; nonfatal nonfatal MI; C index of 0.80; proBNP added © American College of Cardiology Foundation and American Heart Association, Inc. 6
incremental value evaluate the ischemic etiology; EF chronic muscle disease or stroke (time death from any all-cause mortality predictive of apolipoprotein relative ≤40% (or 35% if NYHA II) unexplained CK >2.5x ULNl; to event) cause or or HF information A-1, high- prognostic TSH >2x ULN; any condition hospitalization hospitalization: C sensitivity C- significance of substantially reducing life for HF index of 0.701 (all reactive peptide new expectancy models included and NT proBNP biomarkers NT-proBNP) Wedel, Hans EJHF 2009 19168876 (17) Comparison of Examine the Cohort 33,533 Pts with primary ICD-9 N/A Inhospital N/A Inhospital N/A N/A Variability Four Clinical performance discharge diagnosis of HF mortality; in- mortality: 4.5%; among rules in Prediction Rules of 4 clinical admitted at one of 2 hospital Inhospital mortality the number of for Estimating prediction Pennsylvania hospitals mortality or or serious medical pts assigned to Risk in HF rules from the ED serious complication: risk groups and Auble, Thomas E (ADHERE complication; 11.2%; 30-d the observed Annals of decision tree, 30-d mortality mortality: 7.9% mortality within Emergency ADHERE ADHERE rules risk group. Medicine 2007 regression could not be used EFFECT 17449141 (18) model, in 4.1% because identified pts at EFFECT, BUN or SCr were the lowest risk, Brigham and N/A. ADHERE tree Women's identified largest Hospital rule) proportion of pts for inpatient in the lowest risk death, 30-d group death, and inhospital death or serious complications ADHERE indicates Acute Decompensated Heart Failure National Registry; AHA, American Heart Association; BUN, blod urea nitrogen; CHARM, Candesartan in Heart Failure: Assessment of Reduction in Mortality and morbidity; COPD, chronic obstructive pulmonary disease; CORONA, Controlled Rosuvastatin Multinational Trial in HF; CV, cardiovascular; CVD, cardiovascular disease; ED, emergency department; EF, ejection fraction; EFFECT, Enhanced Feedback for Effective Cardiac Treatment; GWTG, Get With the Guidelines; HF, heart failure; Hgb, hemoglobin; HR, heart rate; ICD-9, international classification of diseases; LVSD, left ventricular systolic dysfunction; MI, myocardial infarction; Na, sodium, N/A, not applicable; NT-proBNP; n-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; OPIMIZE-HF, Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure; pts, patients; RAD, reactive airway disease; ROC, receiver operating characteristic curve; SBP, systolic blood pressure; SCr, serum creatinine; TSH, thyroid stimulating hormone; ULN, upper limit of normal.
Data Supplement 4. Health-Related Quality of Life and Functional Capacity (Section 4.4) Study Name, Study Aim of Study Study Type Patient Population Endpoints Statistical Analysis (Results) Study Limitations Findings/Comments Author, Year Size Inclusion Exclusion Primary Secondary
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Criteria Criteria Endpoint Endpoint Improvement in To determine the Secondary 425 Hospitalized for Significant HRQoL Event-free At baseline HRQoL was severely impaired Potential for survivor bias. In pts hospitalized with HRQoL after frequency, analysis of NYHA class IV, at comorbid condition measured with survival but improved on average at 1 mo (74.2 ± Self-reported HRQoL. severe HF hospitalization durability, and data from the least 1 sign of fluid that could shorten the MLHFQ 17.4 vs 56.7 ± 22.7) and improved most at Relatively short follow-up decompensation, HRQoL is predicts event- prognostic ESCAPE trial overload life (e.g. cancer), 6 mo. HRQOL worsened in 51 (16.3%) pts period of 6 mo. seriously impaired but free survival in significance of EF <30% pulmonary artery and remained the same in 49 (15.7%). improves substantially pts with advanced improved history of prior HF catheter, OR: 3.3; p<.009 within 1 mo for most pts HF. Moser et al HRQoL after hospitalization or mechanical The only characteristic that distinguished and remains improved for 6 2009 hospitalization for chronic high circulatory or among these groups was whether or not mo. Pts for whom HRQoL 19879462 (19) decompensated maintenance ventilatory support, the pt was too ill to perform the 6-min does not improve by 1 mo HF. diuretic doses IV milrinone within walk. There was a group by time after hospital admission survived to 48 h, dobutamine/ interaction; the degree of improvement merit specific attention both discharge from dopamine within across time differed between pts who to improve HRQoL and to index admission 24 h, listed for CTX survived without an event and those who address high risk for poor died or were rehospitalized by 6 mo. Pts event-free survival with events between 1 and 6 mo did not experience as much improvement in HRQoL. A decrease in MLHFQ of >5 points predicted better event-free survival. (p<.0001 group time interaction) QoL and To examine Secondary 781 NYHA II-IV, ≥18 y, Enrollment in a QoL measured Chronic QoL significantly impaired in HF pts Manner in which comorbid HF has a large impact on depressive whether there are analysis of structural heart study requiring with Medical conditions compared to matched elderly. Largest conditions were assessed QoL and depressive symptoms in the differences in COACH trial disease. additional research Outcome Study abstracted differences were in physical functioning differed between HF pts symptoms, especially in elderly: a QoL and data plus visits or invasive 36-item General from chart of and vitality. Role limitations due to and controls. List used was women with HF. comparison depressive enrollment of Community sample intervention within Health Survey pts, self- physical functioning very low in HF pts. not all inclusive. Differences persist, even in between pts with symptoms a community randomly selected last 6 mo or next 3 and Cantril reported by QoL was lower in HF pts with COPD or the absence of common HF and age and between HF pts sample from from population mo, terminal Ladder of Life. community diabetes. comorbidities. Results gender matched and an age and Netherlands ≥55 y and not disease, active Depressive sample. Depressive symptoms higher in HF pts demonstrate the need for community gender matched living at same psychiatric symptoms with (39% vs 21%) all p<0.001. studies of representative controls. Lesman- group of address. 45% diagnosis. CES-D. HF pts with direct Leegte et al, community- response rate. comparisons to age- and 2009. dwelling elderly gender-matched controls. 19181289 (20) and determine how chronic comorbid conditions qualify the answer
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Ethnic To compare Longitudinal 1,212 Established Recent MI, USA, HRQoL N/A HRQoL improved over time (baseline to 3- Secondary analysis of Cultural differences in the Differences in HRQoL in non- comparative diagnosis of cognitive measured with and 6-mo) in all groups but most existing data. Hispanic interpretation of and QoL in Persons Hispanic white, study with chronic HF impairment, severe the MLHFQ dramatically among Hispanics. Hispanics sample was primarily response to chronic illness With HF. black, and propensity psychiatric improved more than whites (p<0.0001). Mexican so results cannot may explain why Riegel et al 2008 Hispanic adults scoring problems, Hispanics improved more than blacks be generalized to all HRQoL improves more 18226772 (21) with HF homeless, or (p=0.004). Hispanics. Samples over time in Hispanic pts discharged to an received different with HF compared with extended care or treatments at various sites; white and black skilled nursing treatment was controlled in pts. facility the analysis. Other factors that could explain these differences were not measured. Cultural bias in the data obtained from the MLHFQ is possible. The impact of To assess the RCT 813 NYHA II-IV HF None specified QoL Euroquol N/A There is a relationship between the EQ-5D Pts assessed in the study The impact of HF varies chronic HF on QoL of pts with EQ-5D and score and gender, on average females are not a random sample of amongst pts but the overall HRQoL data HF, due to LV MLHFQ enrolled had a worse QoL than male pts with severe HF. burden of disease appears acquired in the dysfunction, participants. CARE-HF is an int’l study to be comparable to other baseline phase of taking optimal r=-0.08; 95% CI: -0.13 to -04; p=0.00004 but used available chronic conditions such as the CARE-HF medical therapy Mean EQ-5D score for NYHA III pts was normative data from a motor neurone or study. Calvert, using baseline higher than for NYHA IV pts (mean representative sample of Parkinson’s disease. The Melanie. 2005 QoL assessments difference 0.17) the UK population to EQ-5D appears to be an 15701474 (22) from the CARE- p<0.0001; 95% CI: 0.08-0.25 evaluate burden of disease. acceptable valid measure HF trial, and to Association between MLWHF and EQ-5D A study comparing UK and for use in pts with HF evaluate the scores (increasing MLWFH associated Spanish time trade-off although further evidence of appropriateness with a decrease in EQ-5D) values for EQ-5D health the responsiveness of this of using the EQ- r=-0.00795; states demonstrated that measure in such pts is 5D in pts with HF. 95% CI: (-0.00885 to -0.00706); p<0.0001 although the general required. HF is shown to have an important impact pattern of value assignation on all aspects of QoL but particularly on was similar, there were pts mobility and usual activities and leads differences in values to significant reductions in comparison assigned to a number of with a representative sample of the UK health states population.
© American College of Cardiology Foundation and American Heart Association, Inc. 9
Characterization To characterize Secondary 2,709 “CHARM- N/A QoL N/A 9 independent clinical determinants of Population was healthy Independent factors of HRQoL in HF HRQoL in a large analysis of Alternative” pts: worse HRQoL: younger age, higher BMI, enough to enroll so may associated with worse pts population of HF data from the LVEF ≤40% and lower SBP, female sex, worse NYHA have fewer comorbidities. HRQoL in both populations with preserved vs pts with CHARM trial not receiving an class, angina, PND, rest dyspnea, lack of Asymptomatic pts were included female sex, low EF in preserved and ACE-I; “CHARM- ACE-I. Characteristics did not differ by excluded. Only enrolled in younger age, higher BMI, CHARM, Lewis et low LVEF and to Added” pts: LVEF group. LVEF was NS. Canada and US. Groups lower SBP, greater al, 2007 determine the ≤40% and taking without ACE-I therapy may symptom burden, and 17188020 (23) factors ACE-Is. Pts in have affected HRQoL. No worse functional status. associated with NYHA class II gold standard for worse HRQoL. required admission measuring HRQoL. to hospital with a CV problem in prior 6 mo (which increased proportion of NYHA class III/IV in CHARM-Added. “CHARM- Preserved” pts had LVEF >40% with or without ACEI The enigma of To review RCTs Brief N/A Clinical trials N/A QoL Survival N/A N/A Life prolonging therapies, QoL in pts with that assessed the communicatio such as ACE-Is and ARBs HF. Dobre D, impact of n improve modestly or only 2008 pharmacologic delay the progressive 17400313 (24) treatments on worsening of QoL in HF. QoL Beta blockers do not affect QoL in any way. Therapies that improve QoL (e.g., inotropic agents) do not seem beneficial in relation to survival.
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QoL in individuals To evaluate Prospective 192 Admitted to Cognitively HRQoL The no. of all- The overall MLHFQ score was better Conducted the trial in a Transitional Care has an with HF. Harrison, whether the use randomized hospital with a impaired (score >8 (MLWHF), cause ED among the Transitional Care pts than the naturalistic manner in the important role to play in Margaret. 2002 of usual providers trial diagnosis of CHF on Short Portable symptom visits, hospital usual care pts: usual setting of care with altering the course of pts 12021683 (25) and a Residing in the Mental Status distress and readmissions, At 6 wk after hospital discharge (p=0.002) usual providers. hospitalized with HF. Our reorganization of regional home Exam) function at 6- and QoL At 12 wk after hospital discharge Possibility of contamination results suggest that with discharge care radius. and 12-wk measured with (p<0.001) with the hospital nurses modest adjustments to planning and Expected to be postdischarge a generic The MLHFQ’s Physical Dimension providing usual care. usual discharge and transition care discharged with measure, subscale score was better among the Pts may have inadvertently transition from hospital-to- with improved home nursing care Medical Transitional Care pts than the usual care alerted the research home, pts with CHF can intersector English or French Outcome Study pts: coordinators of their experience improved QoL, linkages speaking Short Form At 6 wk after hospital discharge (p=0.01) assignment to usual care or and decreased use of ED, between nurses, Admitted for more At 12 wk after hospital discharge transitional care. for 3 mo after could improve than 24 h to the (p<0.001) With multiple interventions hospitalization. This QoL and health nursing units The MLHFQ’s Emotional Dimension it's not easy to assess approach will provide the services subscale score was better among the neither the relative needed adjunct to current utilization for Transitional Care pts than the usual care contribution of each management of HF. individuals pts at 6 wk after hospital discharge component nor the admitted (p=0.006) synergistic effect of the sum to hospital with 46% of the Usual Care group visited the of the parts. HF. ED compared with 29% in the Transitional Care group (p=0.03) At 12 wk postdischarge, 31% of the Usual Care pts had been readmitted compared with 23% of the Transitional Care pts (p=0.26). ACEI; angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; BMI, body mass index; CARE-HF Cardiac Resynchronisation in Heart Failure; CES-D, Center for Epidemiological Studies-Depression scale; CHARM, Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity; CHF, congestive heart failure; COACH, Comparative study on guideline adherence and patient compliance in heart failure patients; CTX, chest x-ray; CV, cardiovascular; ED, emergency department; EF, ejection fraction; ESCAPE, Evaluation Study of Congestive Heart Failure and PulmonaryArtery Catheterization Effectiveness; HF, heart failure; HRQoL, health-related quality of life; MI, myocardial infarction; MLHFQ score, Minnesota Living With Heart Failure; N/A, not applicable; NYHA, New York Heart Association; pts, patients; PND, Paroxysmal nocturnal dyspnea; QoL, quality of life; RCT, randomized control trial; and SBP, systolic blood pressure.
Data Supplement 5. Stress Testing (Initial and Serial Evaluation) of the HF Patient (Section 6.1.1) Statistical Analysis Study Name, Study Background Trial (Results) Study Author, Year Aim of Study Type Therapy Study Size Etiology Patient Population Severity Endpoints Mortality Duration Limitations N (Total) Severity Study Pre-trial n Ischemic/ of HF Entry standard (Experimental) Non- Inclusion Exclusio Sympto Sverity Primary Secondary Annualize 1st Year treatment. n (Control) Ischemic Criteria n Criteria ms Criteria Endpoint Endpoint d Mortality Mortality
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Defining the Assess the Cohort 1 year 791 51% HF and LV NYHA N/A Major Cardiac N/A 75 36 mo For 24 mo post Observation Optimal change in ischemic dysfunction 2.4 +/- cardiac mortality deaths FU CPX (high vs. al Prognostic prognostic 0.67 events - (of 791) low Ve/VCO2): Window for CPX characteristic mortality, cardiac events in Pts with HF. s of CPX at LV device p<0.001 (95% Arena et al. Circ different time implantatio CI: 2.1 - 5.5); Heart Fail 2010; intervals n, urgent cardiac 3: 405-411 heart mortality 20200329 (26) transplant p<0.001 (95% CI: 2.2 - 5.8) HR:dichotomou s3.4; 3.5 Value of peak To determine Observati Focus on 122 46% Ambulatory Unable 70% N/A Survival N/A N/A 94% 2 y FU p<0.005 Wide exercise oxygen if maximal onal hemodynami 52 ischemic pts referred to NYHA survival complex consumption for exercise prospectiv c and NYHA (PKVO2>14) for heart perform III in those tachycardia optimal timing of testing and e cohort class 35 transplant exercise with high in 1 pt cardiac measurement (PKVO2=<14) testing PKVO2 transplantation of PKVO2 due to vs. 70% in ambulatory identifies pts angina for those pts with HF. in whom heart with low Mancini et al. transplant can PKVO2 Circulation be safely 1991;83;778- deferred 786 1999029 (27) Peak Oxygen To determine Observati Cutoff of 14 2,105; 52% Referral for Age <20, N/A N/A Death Death or N/A N/A N/A Pts on beta N/A Consumption as whether onal mL/kg1 n=909 on beta ischemic HF with ESRD, transplantatio blockers: a Predictor of PKVO2 is a prospectiv blocker; LVEF<35% prior n Death p<0.001, Death in Pts reliable e cohort n=1,196 no OHT (95% CI: 1.18– With HF indicator of beta blocker 1.36); death Receiving Beta prognosis in and transplant Blockers. O'Neill the beta p<0.001, JO et al. blocker era (95% CI: 1.18– Circulation 1.32) 2005;111;2313- aHR: 1.26; 2318 1.25 per 1- 15867168 (28) mL/min/kg CPX indicates cardiopulmonary exercise testing; EF, ejection fraction; ESRD, end-stage renal disease; FU, follow up; HF, heart failure; pts, patients; LVEF, left ventricular ejection fraction; N/A, not applicable; NYHA, New York Heart Association; OHT, orthotopic heart transplantation; PKVO2; peak oxygen consumption; and RCT, randomized control trial.
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Data Supplement 6. Clinical Evaluation – History (Orthopnea) (Section 6.1.1) Study Name, Author, Year Study Type Study Size Patient Population Utility in Detecting Elevated PCWP Stevenson, LW; Perloff Single center, prospective 50 Stage D Orthopnea within preceding wk JAMA 1989:261:884-888 91% of 43 pts with PCWP ≥22 2913385 (29) 0/7 pts with PCWP <22 Chakko et al; Am J Medicine Single center, prospective 42 Stage D For PCWP >20 1991:90:353-9 Sensitivity 66%, Specificity 47%, PPV 61%, NPV 37% 1825901 (30) Drazner et al Circ HF Multicenter substudy of ESCAPE 194 (with PAC) Stage D Orthopnea (≥ 2 pillows) 2008:1:170-177 OR 2.1 (95% CI: 1.0-4.4); PPV 66%, NPV 51%; +LR 1.15, (-) LR 1.8; all for PCWP>22 19675681 (31) OR 3.6 (95% CI: 1.02 -12.8) for PCWP>30 ESCAPE indicates Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; LR, likelihood ratio; NPV, negative predictive value; OR, odds ratio; PAC, pulmonary artery catheter; PCWP, Pulmonary Capillary Wedge Pressure; PPV, positive predictive value; and pts, patients.
Data Supplement 7. Clinical Evaluation - Examination (Section 6.1.1) Study Name, Study Type Study Size Patient Population Utility in Detecting Elevated PCWP Author, Year Jugular venous pressure for assessing right atrial pressure Stevenson, LW; Single center, 50 Stage D 21/28 (75%) of pts with RAP ≥10 had elevated JVP Perloff prospective JAMA 1989:261:884-888 2913385 (29) Butman et al Single center, 52 Stage D RAP associated with JVD and HJR JACC prospective –HJR,-JVD: RAP 4 (2) 1993:22:968-974 +HJR, -JVD: RAP 8 (5) 8409071 (32) +HJR, +JVD: RAP 13 (5)
Stein et al Single center 25 Class 3-4 RAP estimated from JVP vs. measured RA: r=0.92. AJC Clinical estimates underestimate elevated JVP. Interaction between utility of estimated RAP and measured RAP (more of an 1997;80:1615-1618 underestimate as measured RAP increased). Bias 0.1 (RAP 0-8), 3.6 (RAP 9-14), 5 (RAP ≥15). 9416951 (33) Drazner et al Multicenter Circ HF 194 (with Estimated RAP for RAP >12 substudy of Stage D 2008:1:170-177 PAC) AUC 0.74 ESCAPE 19675681 (31)
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Jugular Venous Pressure for Detecting Elevated PCWP Stevenson, LW; Single center, 50 Stage D Elevated JVP associated with PCWP ≥22 Perloff prospective 58% sensitivity JAMA 100% specificity (0/7 with PCWP ≤18 mm Hg) 1989:261:884-888 However 8/18 pts with PCWP ≥35 mm Hg without elevated JVP 2913385 (29) Chakko et al Single center, 52 Stage D “High JVP” for PCWP >20 mm Hg Am J Medicine prospective Sensitivity 70%, Specificity 79%, PPV 85%, NPV 62% 1991;90:353-359 1825901 (30)
Butman et al Single center, 52 Stage D JVD at rest or with HJR for PCWP>18 mm Hg: Sens 81%, Spec 80%, PPV 91%, NPV 63% JACC prospective 1993:22:968-974 8409071 (32) Badgett et al Literature review NA Stage D citing above Suggested algorithm: JAMA “Rational Clinical 3 studies If known low LVEF, and population with high prevalence of increased filling pressure, then elevated JVP is “very helpful” and 1997; 277:1712- Examination” associated with >90% chance of elevated filling pressures 1719 series 9169900 (34) Drazner et al Multicenter 194 (with Stage D JVP≥12 mm Hg for PCWP>22 Circ HF substudy of PAC) Sensitivity: 65%, Specificity: 64%, PPV 75%, NPV 52%, +LR 1.79, (-)LR 1.8 2008:1:170-177 ESCAPE 19675681 (31) Prognostic Utility of JVP Drazner et al Retrospective 2569 Stage C Multivariate analysis for elevated JVP NEJM analysis of Mean f/u 32 months 2001;345:574-81 SOLVD Death RR 1.15 (95% CI: 0.95-1.38) 11529211 (35) Treatment Trial HF hospitalization 1.32 (95% CI: 1.08-1.62) Death/HF hospitalization 1.30 (95% CI: 1.11-1.53) Drazner et al Retrospective 4102 Stage B Multivariate analysis for elevated JVD Am J Med analysis of Mean follow-up 34 mo 2003;114:431-437 SOLVD Development of HF RR 1.38 (95% CI: 1.1-1.7) 12727575 (36) Prevention Trial Death or Development of HF RR 1.34 (95% CI: 1-1,1.6)
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Drazner et al Multicenter 194 (with Stage D Multivariate analysis Circ HF substudy of PAC) 2008:1:170-177 ESCAPE Enrollment estimated RAP associated with survival outside hospital at 6 mo (Referent RAP<13) 19675681 (31) RAP 13-16 HR 1.2 (95% CI: 0.96-1.5) RAP >16 HR 1.6 (95% CI: 1.2-2.1) Meyer et al Retrospective 7788 Stage C Mean follow-up 34 mo AJC analysis of DIG 2009 103:839-844 trial Univariate analysis 19268742 (37) Elevated JVP associated with Death: HR 1.7 (95% CI: 1.54-1.88) All-cause hosp: HR 1.35 (95% CI: 1.25-1.47) After adjusting for propensity score associations no longer significant; aHR: 0.95 (death), aHR:0.97 (hosp), p>0.5 Utility of Valsalva Maneuver for Detecting Elevated PCWP Schmidt et al Prospective 38 Unknown Utility of square wave for LVEDP ≥15 mm Hg: sens 100%, spec 91%, PPV 82%, NPV 100% AJC 1993;71:462-5 single center (%HF not stated) 8430644 (38) Rocca et al Single center, 45 Stage C Pulse amplitude ratio by Valsalva correlated with BNP (r=0.6, p<0.001) Chest prospective 1999; 116:861-7 study 10531144 (39) Givertz et al Single center, 30 men Class 3/4 Predicted PCWP by Valsalva vs measured PCWP: r=0.9, p<0.001. AJC prospective Mean difference 0.07 ±2.9 mm Hg 2001 1213-1215 study of Vericor Predicted PCWP had sensitivity: 91%, specificity: 100% for PCWP ≥18 mm Hg 11356404 (40) system Sharma et al Prospective 57 pts (2 Unknown Pulse amplitude ratio correlated with LVEDP (r=0.86) Arch Intern Med study of women) Majority pts with CAD 84% of measurements within 4 mm Hg of LVEDP 2002:162:2084- commercial 2088 device (VeriCor) 12374516 (41) at 2 centers Felker et al Review paper N/A N/A Significant correlation between CV response to Valsalva and LV filling pressures Am J Medicine 2006;119:117-132 16443410 (42) AUC indicates area under the concentration curve; BNP, B-Type Natriuretic Peptide; CAD, coronary artery disease; CV, cardiovascular; DIG, Digitalis Investigation Group; f/u, follow-up; ESCAPE, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness HJR, hepatojugular reflux; LVEF, left ventricular ejection fraction; LVEDP, Left Ventricular End-Diastolic Pressure; JVD, jugular venous distension; JVP, jugular venous pressure; N/A, not applicable; NPV, negative predictive value; PCWP, Pulmonary Capillary Wedge Pressure; PPV, positive predictive value, Pts, patients; r, Pearson’s correlation coefficient; RAP, right arterial pressure; and SOLVD, Studies of left ventricular dysfunction.
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Data Supplement 8. Clinical Evaluation – Risk Scoring (Section 6.1.2) Study Name, Author, Study Type Study Size Patient population Variables Utility Year Stage C Levy et al Derivation cohort (PRAISE 1125 Largely Stage C Available on website 2 year survival for scores 0, 1,2,3,4 was: Circulation 1); then tested in 5 (Derivation) 93%, 89%, 78% 58%, 30%, 11% 2006;113:1424-1433 additional trial databases 9942 AUC 0.729 (0.71 to 0.74) Seattle HF score (Validation) 16534009 (10) Pocock et al Analysis of CHARM 7,599 Stage C HF 21 variables 2 year mortality Eur Heart J Lowest to highest deciles 2.5% to 44% 2006;27:65-75 C statistic 0.75 CHARM 16219658 (13) Stage D Aaronson et al Derivation and Validation 268 Stage D Ischemic cardiomyopathy, resting 3 strata Circulation 2 transplant centers (Derivation) heart rate, LVEF, IVCD (QRS Event-free survival rates at 1 y for the low-, medium-, and high-risk 1997;95:2660-7 199 duration 0.12 sec of any cause), HFSS strata were 93±2%, 72±5%, and 43±7% HF Survival Score (Validation) mean resting BP, peak O2, and AUC 1 y 0.76-0.79 9193435 (2) serum sodium PCWP (invasive)
Lucas et al Retrospective, single center 146 Stage D Congestion score: orthopnea, JVD, Post discharge (4-6 wk) score vs. 2 y death Am Heart J edema, weight gain, new increase 0: 54% 2000;140:840-7 diuretics 1-2: 67% “Congestion Score” 3-5: 41% 11099986 (43) Nohria et al Prospective, single center 452 pts Stage D Stevenson classification Profile B associated with death+urgent transplant in multivariate JACC Profiles A,B,C,L analysis (HR: 2.5, p=0.003). 2003:41:1797-1804 “Stevenson profiles” 12767667 (44) Drazner et al Substudy of ESCAPE 388 Stage D Stevenson classification Discharge profile “wet or cold” HR 1.5 (1.1, 2.1) for number of d Circ HF alive outside hosp at 6 mo in multivariate analysis 2008;1:170-7 “Stevenson profiles” 19675681 (31) Levy et al Retrospective analysis of 129 Stage D Seattle HF Score The 1-y ROC was 0.71 (95% CI: 0.62-0.80). J Heart Lung Tx REMATCH REMATCH
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2009:28: 231-236. Seattle HF Score 19285613 (45) Gorodeski et al Single center study of 215 (between Stage D Seattle HF score ACM, VAD, Urgent HT Circ Heart Fail ambulatory pts presented to 2004-2007) 2 y f/u 2010;3:706-714 transplant committee C index 0.68 (1 yr), 0.65 (2 yr) Seattle HF Score Calibration overestimated survival among UNOS 2 pts 20798278 (46) Hospitalized Patients Lee et al Retrospective study of 2624 Hospitalized pts Age, SBP, RR, Na<136, Hgb <10, Predicted and observed mortality rates matched well JAMA multiple hospitals in Ontario (derivation BUN, CVA, Dementia, COPD, 2003:290:2581-2587 Canada 1999-2001) cirrhosis, Cancer 30 d mortality 14625335 (11) 1407 AUC derivation 0.82 (validation Validation 0.79 1997-1999) 1 y mortality AUC Derivation 0.77 Validation 0.76 Fonarow et al CART analysis of ADHERE 33,046 Hospitalized pts BUN ≥43, SBP<115, SCr ≥2.75 In-hospital mortality JAMA national registry 2001-2003 (derivation) AUC 67-69% 2005:293:572-580 32,229 Morality ranges from 1.8(low risk) to ~25% (high risk) ADHERE (Validation) 15687312 (14) Rohde et al Single center study 2000- 779 Hospitalized pts Cancer, SBP ≤124, Cr >1,4m In-hospital mortality J Cardiac Failure 2004 BUN>37, Na <136, Age>70 Bootstrap C=0.77 (0.689-0.85) 2006;12:587-593 6 increasing groups: 0,5%, 7%, 10%, 29%, 83% “HF Revised Score” 17045176 (47) Abraham et al Analysis of OPTIMIZE-HF 48,612 pts Hospitalized pts 19 variables In-hospital mortality JACC registry Validated in C statistic 0.77 2008;52:347-356 2003-2004 ADHERE Validation C statistic 0.746 OPTIMIZE-HF Excellent reliability for mortality 18652942 (16)
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Peterson et al Analysis of GWTG admitted 27,850 Hospitalized pts Age, SBP, BUN, HR, Na, COPD, In-hospital mortality Circ Cardiovasc Qual 2005-2007 (Derivation) nonblack race C index 0.75 Outcomes 11,933 Predicted probability mortality over deciles ranged from 0.4% - 9.7% 2010:3:25-32 (Validation) and corresponded with true mortality GWTG 20123668 (15) Other Gheorghiade et al Scientific Statement from N/A N/A Congestion score Needs to be tested Eur J of Heart Failure Acute HF Committee of HF Bedside assessment (Orthopnea, 2010:12:423-433 Association of ESC JVD, HM, Edema) ESC Congestion Score Lab (BNP or NT proBNP) 20354029 (48) Orthostatic BP 6 min walk test Valsalva ACM indicates all cause mortality; ADHERE, Acute Decompensated Heart Failure National Registry; AUC, area under the curve; BNP, B-type natriuretic peptide; BP, blood pressure; BUN, blood urea nitrogen; CART, Classification and regression trees; CHARM, Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity; COPD, chronic obstructive pulmonary disease; CVA, Cerebrovascular Accident; ESC, European Society of Cardiology; ESCAPE, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; GWTG, Get With the Guidelines; HF, heart failure; HFSS, heart failure survival score; Hgb, hemoglobin; HR, heart rate; HT, heart transplantation; HM, hepatomegaly; IVCD, intraventricular conduction delay; JVD, jugular venous distension; LVEF, left ventricular ejection fraction; N/A, not applicable; Na, sodium; NT proBNP, n-terminal pro-B-type natriuretic peptide; OPTIMIZE-HF, Organized Program to Initiate Lifesaving Treatment in Hospitalized Pts with HF; PCWP, Pulmonary Capillary Wedge Pressure; PRAISE, Prospective Randomized Amlodipine Survival Evaluation; pts, patients; REMATCH, Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure; ROC, receiver operating characteristic curve; RR, respiratory rate; SBP, systolic blood pressure; SCr, serum creatinine; UNOS, United Network of Organ Sharing; and VAD, ventricular assist device.
Data Supplement 9. Imaging Echocardiography (Section 6.4) Study Aim of Study Study Type Study Size Patient Population Endpoints Statistical Analysis (Results) Study Limitations Name, Author, Year Inclusion Criteria Exclusion Criteria IS. Syed Evaluate LGE-CMR Observational 120 (35 with Histologically proven Prior MI, myocarditis, LGE-CMR presentation Of the 35 pts with histology, abnormal LGE was present in No control group, 2010 in identifying CA; positive cardiac amyloidosis and, in the prior peripheral blood in pts with amyloidosis; 97% of the 49 with echo evidence, abnormal LGE was cardiac histology was only 20159642 investigate histology, 49 case of AL amyloidosis, stem cell associations between present in 86% of the 36 without histology or ECHO evidence present in a subset of pts (49) associations without cardiac confirmatory evidence of transplantation, or LGE and clinical, of CA, abnormal LGE was present in 47%. contraindication to the use of between LGE and histology but with monoclonal protein in the prior heart morphologic, functional, In all pts, LGE presence and pattern was associated with Gd clinical, morphologic, echo evidence of serum or urine and/or a transplantation and biochemical NYHA functional class, ECG voltage, LV mass index, RV wall functional, and CA, 36 without monoclonal population of features. thickness, troponin-T, and BNP levels. biochemical histology or echo plasma cells in the bone features. evidence of CA) marrow.
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V Rizzello Evaluate the Observational 90; group 1: Pts were already Pts who had Cardiac events were Cardiac event rate was low (4%) in group 1, intermediate N/A 2009 prognosis of viable viable pts with scheduled for coronary undergone mitral evaluated during a 4-y (21%) in group 2 and high (33%) in group 3. 19443475 pts with and without LVEF revascularization valvuloplasty or follow-up (cardiac death, After revascularization, the mean (SD) LVEF improved from (50) improvement of improvement according to clinical aneurismectomy in new MI, admission to 32 (9)% to 42 (10)% in group 1, but did not change LVEF after coronary (n = 27); group 2, criteria of reduced LVEF association with hospital for HF) significantly in group 2 and in group 3, p,0.001 by ANOVA. revascularisation. viable pts without (40%), symptoms of HF revascularisation HF symptoms improved in both groups 1 (mean (SD) NYHA LVEF and/or angina, were excluded. class from 3.1 (0.9) to 1.7 (0.7)) and 2 (from 3.2 (0.7)-1.7 improvement presence/absence of (0.9)), but not in group 3 (from 2.8 (1.0)-2.7 (0.5)), p=0.001 (n = 15), group 3, ischemia and presence of by ANOVA. non-viable pts critical coronary disease The difference in event rate was not statistically significant (n = 48) at angiography. between groups 1 and 2 -small number of pts- but it was Only pts who had significant between the 3 groups using Kaplan–Meier p=0.01 undergone coronary revascularisation alone were included in the study Kevin C Examines late Meta-analysis of 3,088 (viability Pts with CAD and LV Those not reporting Annual mortality rates, For pts with defined myocardial viability, annual mortality rate The individual studies are Allman survival with observational demonstrated in dysfunction who were deaths or where pts followed for 25±10 was 16% in medically treated pts but only 3.2% in observational, 2002 revascularization vs studies 42%) tested for myocardial deaths could not be mo. revascularized pts (χ2 =147, p<0.0001). This represents a nonrandomized, 11923039 medical therapy after viability with cardiac apportioned to pts 79.6% relative reduction in risk of death for revascularized unblinded and subject to (51) myocardial viability imaging procedures from with vs without pts. For pts without viability, annual mortality was not publication and other biases. testing in pts with 24 viability studies viability were significantly different by treatment method: 7.7% with In this metaanalysis, viability severe CAD and LV reporting pt survival using excluded revascularization vs 6.2% for medical therapy (p=NS). could only be interpreted as dysfunction thallium perfusion “present” or “absent” based imaging, F-18 on individual studies’ fluorodeoxyglucose definitions metabolic imaging or dobutamine ECHO. Beanlands Whether the extent Prospective 82; Complete Pts CAD and severe LV PTs with MI within the Absolute change in EF Amount of scar was a significant independent predictor of LV Pt population in this study RS. 2002 of viability or scar is multicenter follow-up was dysfunction with EF 35% preceding 6 wk, determined by function recovery after revascularization. included pts who were 12446055 important in the cohort available on 70 by any quantitative severe valve disease radionuclide angiograms Across tertiles of scar scores (I, small: 0% to 16%; II, predominantly men, (52) amount of recovery pts. technique, who were requiring valve 3 mo moderate: 16% to 27.5%; III, large: 27.5% to 47%), the predominately between 53- of LV function being scheduled for replacement, postrevascularization changes in EFs were 9.0±1.9%, 3.7±1.6%, and 1.3±1.5% 71 y of age (1 SD from the and to develop a revascularization requirement for (p=0.003: I vs. III), respectively. mean), had multivessel model for predicting aneurysm resection, disease, and had bypassable recovery after and inability to obtain vessels. revascularization informed consent. Although improvement in LV that could be tested function has been noted at 3 in a randomized trial. mo of follow-up in many previous studies, recent data suggest that more recovery may be observed with longer follow-up time
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Paul R. Hypothesized that Retrospective 70 Pts with EFs <40% Prior CABG, CV death or cardiac The viability index was significantly related to 3-y survival N/A Pagley 1997 pts with poor cohort without significant valvular coexisting valvular transplantation; median free of cardiac event (cardiac death or heart transplant) after 9264484 ventricular function disease who were disease and time to follow-up was bypass surgery (p=0.011) and was independent of age, EF, (53) and predominantly referred for a first underwent concurrent 1177 d (range, 590 to and number of diseased coronary vessels. Survival free of viable myocardium coronary bypass surgery aortic or MV 1826) cardiac death or transplantation was significantly better in have a better and underwent replacement, or those group 1 pts on Kaplan-Meier analysis (p=0.018). outcome after preoperative quantitative with SPECT imaging bypass surgery planar 201Tl imaging for compared with those viability determination. with less viability. Senior R, To evaluate the Observational 87 CHF (NYHA class II-IV) Significant valvular Cardiac deaths were Pts with at least 5 segments showing myocardial viability Single-center study where 1999 effect of prospective for at least 3 mo that was disease, unstable defined as those underwent revascularization, mortality was reduced by an selection bias is unavoidable. 10362184 revascularization on treated medically; angina, MI within resulting from acute MI, average of 93% which was associated with improvement in Selection bias may have (54) survival in pts with LVEF ≤35%; three months, refractory CHF or NYHA class as well as LVEF. Pts with favored taking one group to CHF due to ischemic clinical evidence of CAD sustained ventricular occurring suddenly and <5 segments showing myocardial viability who underwent surgery over another. LV systolic tachycardia or AF not being attributed to revascularization (and thus, showing mostly scar), and those dysfunction based other known causes with at least 5 segments demonstrating myocardial viability on the presence of after a mean follow-up of who were treated medically, had a much higher mortality. myocardial viability 40 ± 17 mo (95% CI: 22%-99%) Kwon DH To determine Observational 349 Pts with documented ICM Pts with standard All-cause mortality was Mean scar percentage and transmurality score were higher in Selection bias of an 2009 whether the extent of (on the basis of 70% CMR ascertained by social pts with events vs those without observational study 19356530 LV scar, measured stenosis in at least 1 contraindications security death index (39±22 vs 30±20, p=0.003, and 9.7±5 vs. 7.8±5, p=0.004). conducted at a large tertiary (55) with DHE-CMR epicardial coronary vessel including severe after a mean of follow-up *On Cox proportional hazard survival analysis, quantified referral center. Only the predicts survival in on angiography and/or claustrophobia, AF, 2.6 ± 1.2 y (median 2.4 scar was greater than the median (30% of total myocardium), pts with no contraindications pts with ischemic history of MI or coronary and the presence of y) and female gender predicted events to CMR underwent the cardiomyopathy ICM revascularization), who pacemakers, (RR: 1.75; 95% CI: 1.02-3.03 and RR:1.83; 95% CI: 1.06- examination. and severely were referred for the defibrillators, or 3.16, respectively, both p=0.03). reduced LVEF. assessment of myocardial aneurysm clips viability with CMR Ordovas N/A Review paper N/A N/A N/A N/A An international multicenter study (54) reported a sensitivity N/A KG. 2011 of 99% for detection of acute infarction and 94% for detection 22012903 of chronic infarction. (56) Delayed enhancement occurs in both acute and chronic (scar) infarctions and in an array of other myocardial processes that cause myocardial necrosis, infiltration, or fibrosis. These include myocarditis, hypertrophic cardiomyopathy, amyloidosis, sarcoidosis, and other myocardial conditions. In several of these diseases, the presence and extent of delayed enhancement has prognostic implications. AF, atrial fibrillation; AL, Amyloid Light-chain; ANOVA, analysis of variance; CA, cardiac amyloidosis; CABG, coronary artery bypass graft; CAD, coronary artery disease; CHF, congestive heart failure; CMR, cardiovascular magnetic resonance; CV, cardiovascular; DHE-CMR, delayed hyperenhancement cardiac magnetic resonance; ECHO, echocardiography; EF, ejection fraction; Gd, gadolinium; ICM, ischemic cardiomyopathy; LGE-CMR, late gadolinium enhancement cardiac magnetic resonance; LV, left ventricular; LVEF, left ventricular ejection fraction; MI, myocardial infarction; N/A, not applicable; NS, not significant; NYHA, New York Heart Association; pts, patients; RV, right ventricular; SD, standard deviation; and SPECT, single-photon emission computed tomography.
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Data Supplement 10. Biopsy (Section 6.5.3) Study Name, Author, Year Aim of Study Study Type Study Size Patient Population Results Cooper LT, Baughman KL, Feldman AM et al. The role of Role of A scientific statement N/A N/A N/A endomyocardial biopsy in the management of CV disease: endomyocadial from the AHA, ACC, & Circulation 2007 November 6;116(19):2216-33. biopsy for ESC 17959655 (57) management of CV disease Kasper EK, Agema WR, Hutchins GM, Deckers JW, Hare To document causes Retrospective Cohort 673 DCM pts with symptoms Most common causes of DCM: idiopathic (47%), myocarditis (12%) JM, Baughman KL. The causes of dilated cardiomyopathy: a of DCM in a large within 6 mo, evaluated at and CAD (11%), other causes (31%) clinicopathologic review of 673 consecutive pts. J Am Coll group of adult HF pts Johns Hopkins Hospital Cardiol 1994 March 1;23(3):586-90. 1982-1991 8113538 (58) Fowles RE, Mason JW. Endomyocardial biopsy. Ann Intern Complication risk Review N/A N/A Complication rate of 1% in 4000 biopsies (performed in Med 1982 December;97(6):885-94. with RV biopsies transplantation and CMP pts) 6756241 (59) 4 tamponade (0.14%), 3 pneumothorax, 3 AF, 1 ventricular arrhythmia, and 3 focal neurological complications Deckers JW, Hare JM, Baughman KL. Complications of To determine the Prospective Cohort 546 546 consecutive biopsies 33 total complications (6%): transvenous right ventricular endomyocardial biopsy in adult incidence, nature and for DCM pts at single 15 (2.7%) during catheter insertion: 12 arterial punctures (2%), 2 pts with cardiomyopathy: a seven-year survey of 546 subsequent center, vasovagal reactions (0.4%) and 1 prolonged bleeding (0.2%), consecutive diagnostic procedures in a tertiary referral management of 18 (3.3%) during biopsy: 6 arrhythmias (1.1%), 5 conduction center. J Am Coll Cardiol 1992 January;19(1):43-7. complications abnormalities (1%), 4 possible perforations (0.7%) and 3 definite 1729344 (60) occurring during RV perforations (0.5%). endomyocardial 2 (0.4%) of the 3 pts with a perforation died biopsy in pts with cardiomyopathy Ardehali H, Qasim A, Cappola T et al. Endomyocardial To evaluate the utility Retrospetive chart 845 Pts with initially Clinical assessment of the etiology inaccurate in 31% biopsy plays a role in diagnosing pts with unexplained of RV biopsy in review unexplained EMBx helps establish the final diagnosis in most cardiomyopathy. Am Heart J 2004 May;147(5):919-23. confirming or cardiomyopathy (1982- 15131552 (61) excluding a clinically 1997) at The Johns suspected diagnosis Hopkins Hospital.
Holzmann M, Nicko A, Ku¨hl U, et al. Complication rate of To determine Cohort 2415 1919 pts underwent 2505 Major complications cardiac tamponade requiring pericardiocentesis right ventricular endomyocardial biopsy via the femoral complication rate of endomyocardial biopsy or complete AV block requiring permanent pacing rare: 0.12% in the approach. A retrospective and prospective study analyzing RV biopsy retrospectively (1995- retrospective study and 0% in the prospective study. 3048 diagnostic procedures over an 11-year period. 2003), and 496 pts Minor complications such as pericardial effusion, conduction Circulation 2008;118:1722–8. underwent 543 abnormalities, or arrhythmias in 0.20% in the retrospective study © American College of Cardiology Foundation and American Heart Association, Inc. 21
18838566 (62) endomyocardial biopsy and 5.5% in the prospective study prospectively (2004- 2005) to evaluate unexplained LV dysfunction Elliott P, Arbustini E. The role of endomyocardial biopsy in N/A Commentary N/A N/A Emphasizes genetic causes of CMP the management of CV disease: a commentary on joint AHA/ACC/ESC guidelines. Heart 2009 May;95(9):759-760. 19221107 (63)
ACC indicates American College of Cardiology; AHA, American Heart Association; AF, atrial fibrillation; AV, atrioventricular; CAD, coronary artery disease; CMP, cardiomyopathy; DCM, dilated cardiomyopathy; EMBx, endomyocardial biopsy; ESC, European Society of Cardiology; LV, left ventricular; N/A, not applicable; pts, patients; and RV, right ventricular.
Data Supplement 11. Stage A: Prevention of HF (Section 7.1) Study Name, Aim of Study Study Type Study Size Patient Population Endpoints Trial Statistical Analysis (Results) Study Limitations Author, Year Duration (Years) N (Total) n (Experimental) n (Control) Inclusion Criteria Exclusion Criteria Lloyd-Jones et al, The Examine lifetime risk of Prospective 8229 Free of CHF at N/A N/A N/A Lifetime risk is 1 in 5 for men and Subjects mostly white and results not lifetime risk for developing CHF among cohort baseline women; significant association generalizable to other races. developing HF; those without incident between MI and HTN in lifetime Circulation, 2002; or prevalent disease risk of CHF. 106:3068-3072 12473553 (64) Vasan et al, Residual Quantify risk of HTN Prospective 1298 Ages 55-65 y and N/A N/A N/A Residual lifetime risk for Measured HTN in middle age, when a lifetime risk for development cohort free of HTN at developing HTN was 90%. Risk large portion of people develop HTN at developing HTN in baseline. did not differ by sex or age, younger ages so actual risk may be middle-aged women lifetime risk for women vs men different for younger people. Did not take and men; JAMA, aged 55 y, HR: 0.91 (95% CI, into account other risks for HTN like 2002:287:1003-1010. 0.80-1.04); for those aged 65 y, obesity, family history of high BP, dietary 11866648 (65) HR:0.88 (95% CI, 0.76-1.04) sodium and potassium intake, and alcohol consumption Levy et al, The Analysis of expected Prospective 5,143 Free of CHF at N/A Developmen 20 Those with HTN at a higher risk Subjects mostly white and results not progression from HTN rates of HF associated cohort baseline. t of HF for CHF: generalizable to other races. Possible to CHF; JAMA, with diagnosis of HTN Men, HR: 2.04; 95% CI: 1.50- misclassification bias as some subjects 1996;275:1557-62 2.78; diagnosed w/HTN before use of 8622246 (66) Women, HR: 3.21; 95% CI: 2.20- echocardiography. 4.67
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PAR for CHF in those with HTN: 39% for men and 59% in women. Wilhelmsen et al, HF in Identification of risk Population- 7,495 N/A N/A Developmen 27 CAD and HTN were the most N/A the general population associated with HTN based t of HF common concomitant diseases in of men: morbidity, risk intervention HF pts (79.1%). factors, and prognosis; trial J Intern Med 2001;249:253-261 11285045 (67) Kostis, et al, Prevention To assess the effect of RCT 4,736; 2,365; 2,371 Age ≥60y, Isolated Recent MI, CABG, Fatal and 4.5 49% reduction Noteworthy that pts with prior MI had an of HF by antihypertensive care systolic HTN: SBP DM, alcohol abuse, non-fatal HF RR: 0.51; 95% CI: 0.37-0.71; 80% risk reduction. antihypertensive drug on the incidence of HF 160-219 mm Hg with demential stroke, AF, p<.001 treatment in older in older pts with systolic DBP <90 mm Hg. AV block, multiform persons with isolated HTN premature ventricular systolic HTN; JAMA contractions, 1997;278:212-216. bradycardia <50 9218667 (68) beats/min; diuretic therapy. Staessen, Wang and Assessment of various Meta analysis 120,574 N/A N/A CV events N/A CCB, resulted in better stroke N/A Thijs; CV prevention drugs and their protection than older drugs: and BP reduction: a reduction of HF including (-8%, p=0.07) or quantitative overview excluding verapamil (-10%, updated until 1 March p=0.02), as well as ARB (-24%, 2003; J Hypertens p=0.0002). The opposite trend 2003;21:1055-1076 was observed for ACEI (+10%, 12777939 (69) Pp=0.03). The risk of HFwas higher (p< 0.0001) on CCB (+33%) and alpha blockers (+102%) than on conventional therapy involving diuretics Sciaretta, et al; Compare various drugs Meta analysis 223,313 Studies had to be N/A HF N/A Diuretics vs. placebo: OR: 0.59; N/A Antihypertensive and risk for HF RCTs from 1997- 95% CrI: 0.47-0.73; treatment and 2009; pts with HTN ACE-I vs. placebo: OR: 0.71; 95% development of HF in or a population CrI: 0.59-0.85; hypertension: a characterized as ARB: OR: 0.71; 95% CrI: 0.59- Bayesian network meta- having a “high” CV 0.85. analysis of studies in risk profile and a Beta blockers and CCB less pts with HTN and high predominance of pts effective CV risk. with HTN (>65%); the Arch Intern Med. 2011 sample size ≥200 Mar 14;171(5):384-94. pts; and information 21059964 (70) on the absolute incidence of HF and
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other major CV events Lind et al, Glycaemic Assessment of glycemic Meta analysis 20,985 Type 1 DM N/A HF N/A A1C ≥10.5% vs A1C <6.5%: Used hospital admissions and did not control and incidence of control and risk for HF or higher aHR: 3.98; 95% CI: 2.23-7.14; include asymptomatic HF pts, so true HF in 20985 pts with A1C <6.5% p<.001; incidence of HF underestimated. type 1 diabetes: an observational study. Lancet 2011; Jun 24. 21705065 (71) Pfister, et al, A clinical Identification of risk RCT 4,951 Type 2 DM N/A HF 3 Medium risk: HR: 3.5; 95% CI: HF was pre-defined by investigator, but risk score for HF in pts associated with DM 2.0-6.2; p<0.0001 rather reported as SAE in the trial. Trial with type 2 diabetes High risk: HR: 10.5; 95% CI: 6.3- population may not be generalizable to and macrovascular 17.6; p<0.0001 clinical population. disease: an analysis of the PROactive study. Int J Cardiol. 2011;May 31. 21636144 (72) Kenchaiah et al, Assessment of HF risk Prospective 5,881 ≥30 y; BMI N/A HF 14 Women, HR: 2.12; 95% CI: 1.51- Possible misclassification of HF and Obesity and the risk of associated with obesity cohort ≥18.5;free of HF at 2.97 subjects mostly white and results not HF. NEJM, baseline Men, HR: 1.90; 95% CI: 1.30-2.79 generalizable to other races. 2002;347:305-313. 12151467 (73) Kenchaiah, Sesso, Assessment of risk Prospective 21,094 Free of known heart N/A Incidence of 20.5 Every 1 kg/m2 increase in BMI is Low incidence of HF as cohort comprised Gaziano, Body mass associated with obesity cohort, disease at baseline. HF associated with 11% (95% CI: 9- of physicians who are healthier than the index and vigorous and effect of exercise secondary 13) increase in risk of HF. general population. BMI measures and physical activity and the analysis of Compared to lean active men: physical activity were self-reported. risk of HF among men. RCT Lean inactive: HR:1.19; 95% CI: These measures were only taken at Circulation, 0.94-1.51, Overweight active: baseline and tend to change over time. 2009;119:44-52. HR:1.49; 95% CI: 1.30-1.71), This cohort consisted only of men and 19103991 (74) Overweight inactive: HR: 1.78; results not generalizable to women. 95% CI: 1.43- 2.23), Obese active: HR: 2.68; 95% CI: 2.08-3.45, Obese inactive: HR: 3.93; 95% CI: 2.60-5.96
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Verdecchia et al, Evaluate effects of RCT 23,165 for Hx of CAD, PAD, N/A LVH 5 Telmisartan vs placebo: Diagnosis of LVH was based on ECG, Effects of telmisartan, ACE, ARB, or both on ONTARGET, cerebrovascular OR: 0.79; 95% CI: 0.68-0.91; which is less sensitive than ramipril and their development of LVH in 5,343 in disease. p=0.0017. echocardiography and was binary combination on LVH in pts with atherosclerotic TRANSCEND Telmisartan vs. ramipril: (yes/no) instead of quantitative. individuals at high disease. OR: 0.92; 95% CI; 0.83-1.01; vascular risk in p=0.07 ONTARGET and Telmisartan + ramipril vs. ramipril: TRANSCEND. OR: 0.93; 95% CI: 0.84-1.02; Circulation p=0.12) 2009;120:1380-1389. Telmisartan vs telmisartan + 19770395 (75) ramipril: OR: 1.01; 95% CI: 0.91-1.12 Braunwald et al; ACE Evaluate the effect of RCT 8,290; Stable CAD N/A Major CV 4.8 HR: 0.95; 95% CI: 0.88-1.06; Results not significant possibly because inhibition in stable trandolapril on vascular 4,158 (trandolpril); events p=0.43 the pts enrolled were at lower risk for CV coronary artery disease. events 4,132 (placebo) events compared to other trials of ACEI. NEJM 2004;351:2058- 2068. 15531767 (76) Mills et al, Primary Evaluation of primary Meta analysis 53,371 N/A N/A Major CV N/A RR: 0.84; 95% CI: 0.77-0.95; N/A prevention of prevention of CV events events p=0.004 cardiovascualr mortality with statins and events with statin treatments. J Am Coll Cardiol; 2008;52:1769- 1781 19022156 (77) Taylor et al, Statins for Assess benefit and risk Meta analysis 34,272 RCTs of statins with N/A All-cause N/A All-cause mortality: N/A the primary prevention of statins for prevention minimum duration of mortality and RR: 0.84; 95% CI: 0.73-0.96) of CV disease. of CVD 1 y and f/u of 6 mo, in fatal/nonfatal Fatal/non-fatal CVD: Cocrane Database Syst adults with no CVD RR: 0.70, 95% CI: 0.61-0.79 Rev, 2011; CD004816 restrictions on their 21249663 (78) total LDL or HDL cholesterol levels, and where ≤10% had a hx of CVD, were included. Abramson et al; Assessment of risk Prospective 2,235 Age ≥65 y; lived in Heavy alcohol New HF N/A No alcohol: aRR: 1.00 (referent), Observational study, could not account Moderate alcohol associated with alcohol cohort New Haven, Conn, consumption (>70 1-20 oz: aRR: 0.79; 95% CI: 0.60- for all possible confounders, alcohol consumption and risk fo use in older adults. and free of HF at oz.) 1.02), consumption was self-reported. HF among older baseline 21-70 oz: aRR: 0.53; 95% CI: persons. JAMA, 0.32-0.88. 2001;285:1971-1977. (p for trend=0.02) 11308433 (79)
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Walsh et al; Alcohol Assessment of risk Community 7,223 N/A N/A New CHF N/A Compared to men who consumed Self-reported alcohol consumption. consumption and risk associated with alcohol based cohort <1 drink/wk, men who consumed for CHF in the use 8-14 drinks/wk: HR for CHF: 0.41; Framingham Heart 95% CI: 0.21-0.81. Study. Ann Intern Med, In women: those who consumed 2002; 136:181-191. 3-7 drinks/wk HR: 0.49; 95% CI: 11827493 (80) 0.25-0.96, compared with those who consumed <1 drink/wk. Choueiri et al, CHF risk Risk of CHF pts with Meta analysis 3,784 RCTs published N/A New CHF N/A RR: 4.74; 95% CI; 1.84-12.19; Data on other risk factors for CHF were in pts with breast breast cancer receiving between January p=0.001) not collected or unavailable. cancer treaated with bevacizumab 1966-March 2010 in bevacizumab. J Clin English. Oncol, 2011; 29:632- 638. 21205755 (81) Du et al; Cardiac risk New HF Registry 47,806 Women with breast N/A New HF N/A HR: 1.19 anthracycline alone, HR: N/A associated with the cancer ≥65 y 1.97 trastuzumab alone, HR: 2.37 receipt of anthracycline combo and trastuzumab in a alarge nationwide cohort of older women with breast cancer, 1998-2005. Med Oncol, 2010;Oct 22. 20967512 (82) Sawaya et al; Early To assess whether Prospective 43 >18 y of age Pts with LVEFs Cardiotoxicit N/A Elevated hsTnI at 3 mo (p =0.02) Small sample size detection and prediction early ECHO cohort diagnosed with HER- ≤50% y and a decrease in longitudinal of cardiotoxicity in measurements of 2-overexpressing strain chemotherapy treated myocardial deformation breast cancer and between baseline and 3 mo (p pts. Am J Cardiol, and biomarkers (hsTnI either scheduled to =0.02) remained independent 2011; 107:1375-80. and NT-proBNP) receive treatment predictors of later cardiotoxicity. 21371685 (83) could predict the including Neither the change in NT-proBNP development of anthracyclines and between baseline and 3 mo nor chemotherapy-induced trastuzumab or an NT-proBNP level higher than cardiotoxicity in pts scheduled to receive normal limits at 3 mo predicted treated with trastuzumab after cardiotoxicity anthracyclines and previous trastuzumab. anthracycline treatment.
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McKie et al; The NT-proBNP as a Cohort 1,991 Age ≥45 y, lives in Symptomatic Death, HF, 8.9 years HR:1.26 per log increase in fully Underpowered to detect association of prognostic value of NT- predictor of death, CV Olmsted County, HF (stages C and D CVA, MI adjusted model in stage A/B pts NT-proBNP with adverse outcomes in the proBNP for death and events Minnesota HF) (95% CI: 1.05–1.51; p=0.015). healthy normal subgroup. CV events in healthy NT-proBNP was not predictive of normal and stage A/B death or CV events in the healthy HF subjects. J Am Coll normal subgroup. Cardiol, 2010;55:2140- 2147. 20447539 (84) Velagaleti et al; Evaluation of markers Cohort 2,754 Free of HF N/A HF N/A BNP: aHR: 1.52; 95% CI: 1.24– Subjects mostly white and results not Multimarker approach for HF development in 1.87; p<0.0001 generalizable to other races. for the prediction of HF the community UACR: aHR: 1.35; 95% CI: 1.11– incidence in the 1.66; p=0.004 community. Circulation, 2010;122:1700-1706. 20937976 (85) Blecker et al; High Evaluation of Cohort 10,975 Free of HF N/A HF 8.3 aHR: 1.54 (95% CI,:1.12-2.11) N/A normal albuminuria and albuminuria as risk for UACR normal to intermediate- risk of HF in the new HF normal; aHR: 1.91 (95% CI: 1.38- community. Am J 2.66) high-normal; aHR: 2.49 Kidney Dis, 2011; (95% CI: 1.77-3.50) micro; aHR: 58:47-55. 3.47 (95% CI: 2.10-5.72) macro 21549463 (86) (p<0.001) deFilippi et al; Assessment as to Cohort 4,221 N/A N/A HF 11.8 Complex Samples were available in ~3/4 of the Association of serial whether baseline cTnT >99th percentile at baseline: 6.4; cohort at baseline, and differential measures of cardiac or changes predict HF change from neg to pos: 1.61 absence of cTnT measures may have troponin T using a increase. introduced bias into the estimates of sensitive assay with associations with HF and CV death. incident HF and CV mortality in older adults. JAMA, 2010; 304:2494- 2502. 21078811 (87) Heidenreich, et al, Cost- Cost effectiveness of Cost benefit N/A Asymptomatic pts. N/A N/A N/A BNP testing followed by Did not evaluate other effectiveness of BNP screening analysis echocardiography is a cost- blood tests such as pro-BNP as screening with BNP to effective screening prevalence and outcome data were not identify pts with reduced strategy for men and possibly available. LVEF. J Am Coll women at age 60 y - for every Cardiol, 2004;43:1019- 125 men screened,1 y of life 1026. would be gained at a cost of 15028361 (88) $23,500. ACEI indicates angiotensin-converting-enzyme inhibitor; AF, atrial fibrillation; AV, atrioventricular; BMI, body mass index; BP, blood pressure; CABG, coronary artery bypass graft; CAD, coronary artery disease; CCB, calcium channel blocker; CHF, congestive heart failure; cTnT, cardiac troponin T; CV, cardiovascular; CVA, cerebrovascular accident; CVD, cardiovascular disease; DM, diabetes mellitus; DBP, diastolic blood pressure; ECG, electrocardiography; HDL, high density lipoprotein; HF, heart failure; hsTnI,
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high-sensitivity troponin I; HTN, hypertension; LDL, low density lipoprotein; Hx, history; LVH, left ventricular hypertrophy; MI, myocardial infarction; N/A, not applicable; N-terminal pro–B-type natriuretic peptide; ONTARGET, Ongoing Telmisartan Along and in Combination with Ramipril Global Endpoint Trial; PAD, peripheral arterial disease; PAR, population attributable risk; pro-BNP, pro–B-type natriuretic peptide; pts, patients; RCT, randomized clinical trial; SAE, serious adverse event; SBP, systolic blood pressure; TRANSCEND, Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with CV Disease; and UACR, urinary albumin-to-creatinine ratio.
Data Supplement 12. Stage B: Preventing the Syndrome of Clinical HF With Low EF (Section 7.2) Statistical Study Name, Study Study Analysis P Values & OR: HR: Study Findings/ Author, Year Aim of Study Type Size Patient Population Endpoints (Results) 95% CI: RR: Limitations Comments Inclusion Exclusion Primary Secondary Criteria Criteria Endpoint Endpoint ACE Inhibitors Effect of Investigate RCT 2,331 Within 3-60 d of Cr > 2.5 mg/dL; All-cause N/A N/A Risk Reduction: Low rate of beta Reduction in Captopril on whether captopril MI; EF <40%; no relative mortality; CV All-cause mortality 19% (95% blocker use; severe HF and Mortality and could reduce overt HF or contraindication to mortality; CI: 3-32% p=0.019); Recruitment 1987- HF Morbidity in Pts morbidity and ischemic ACEI; need for mortality & death from CV cause 21% (95% 1990: significant hospitalization with LVD after MI mortality in pts symptoms; age ACEI to treat derease in EF of CI: 5-35%; p<0.001); changes in among pts with Pfeffer, Marc A; with LVSD after 21-80 y; symptomatic HF or 9 units; development of severe HF 37% revascularization MI and LVSD NEJM 1992 an MI HTN; other development of (95% CI: 20-50%; p<0.001); strategies without (SAVE) conditions limiting overt HF (despite HF hospitalization 22% (95% CI: symptoms of HF 1386652 (89) survival; "unstable diuretics and 4-37%; p= 0.019); recurrent MI course" after MI digoxin therapy); 25% (95% CI: 5-40%; p=0.015) hospitalization for HF; fatal or nonfatal MI; mean f/u 42 months Effect of Enalapril Study the effect RCT 4228 EF<35%; not N/A All-cause Development of N/A Risk Reduction: Low rate of beta- Reduction in on Mortality and of an ACEI, receiving mortality; mean HF & mortality; HF All-cause mortality 8% (95% CI: blocker use combined the Development enalapril, on diuretics, digoxin f/u 37.4 months hospitalization & 95% CI -8 - 21%; p=0.3); CV endpoints of of HF in outcomes in pts or vasodilators for mortality mortality 12% (95% CI: -3 - development of Asymptomatic with LVSD not HF (asymptomatic 26%; p=0.12); HF & mortality Pts with Reduced receiving drug LVSD) mortality & development of HF and HF LVEF. The therapy for HF 29% (95% CI: 21-36%; hospitalization SOLVD p<0.001); and mortality Investigators. mortality & HF hospitalization among pts with NEJM 1992 20% (95% CI: 9-30%; p<0.001) asymptomatic (SOLVD LVSD Prevention) 1463530 (90)
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Effect of enalapril 12-y follow-up of Cohort 5,165 SOLVED N/A All-cause N/A In combined trials In the Prevention Trial mortality N/A Mortality benefit on 12-y survival SOLVD to prevention and mortality (Prevention and 50.9% in enalapril group vs. of enalapril and life establish if the treatment trial Treatment), 56.4% in placebo group; among pts with expectancy in pts mortality populations alive enalapril p=0.001. asymptomatic with LVSD: a reduction with at completion of extended median In overall cohort, HR for LVSD follow-up study. enalapril among RCTs survival 9.4 mo mortality 0.9 (0.84-0.95); Jong, P pts with HF was (95% CI 2.8-16.5; p=0.0003 for enalapril vs. Lancet 2003 sustained and p=0.004) placebo 12788569 (91) wheather susequent reduction in mortality would emerge among those with asymptomatic ventricular dysfunction Statins Intensive Statin Determine RCT 4,162 ACS (AMI or high- Life-expectancy <2 Hospitalization for MI Meta-analysis of Atorvastatin 80mg associated Sub-study of In pts with ACS, Therapy and the whether risk UA) within 10 y; PCI within the HF (time to first 4 large RCTs of with reduction in HF PROVE IT-TIMI 22. intensive statin Risk of intensive satin d; total cholesterol prior 6 mo (other HF hospitalization statin therapy hospitalization: 1.6% vs. 3.1%; Did not exclude therapy reduced Hospitalization therapy reduces <240 mg/dL; than for qualifying that occurred 30 d (TNT, A to Z, HR 0.55; 95% CI: 0.35-0.85; those with prior HF new onset HF for HF After an hospitalization stable condition; event); CABG or longer after IDEAL, PROVE- p=0.008 (low rates) Also perfomred ACS in the for HF in high within 2 mo; randomization) IT) N=27,546 when adjusted for history or meta-analysis of PROVE IT-TIMI risk pts (intensive planned CABG Reduction in HF prior HF HR 0.55; 95% CI: 0.35- 4 large statin 22 Study statin therapy hospitalization: 0.36; p=0.008 trials (2 ACS, 1 Scirica, Benjamin simvastatin 80 OR: 0.73; 95% hx of MI, 1 M JACC vs. moderate CI: 0.63-0.84; clinically evident 2006 statin therapy p<0.001 [x2 for CHD) 16750703 (92) pravastatin heterogeneity = demonstrating 40mg) 2.25, p=0.523) benefit of intensive stating therapy in preventing HF hospitalizaiton Early Intensive vs To compare RCT 4,479 STEMI or Receiving statin Composite: CV Individual N/A New onset HF reduced with Development of HF In pts with ACS, a Delayed early initiation of NSTEMI; total therapy, planned death, non-fatal components of intensive therapy: 5% vs 3.7%; was a secondary intensive statin Conservative an intensive cholesterol ≤250 CABG, PCI MI, readmission primary endpoint HR 0.72; 95% CI: 0.53-0.98; endpoint Did therapy reduced Simvastatin statin regimen mg/dL; age 21-80; planned within 2 for ACS, stroke and p=0.04 not achieve primary new onset HF Strategy in Pts with delayed at least 1 high-risk wks of enrollment, reascularization Primary endpoint did not endpoint with ACS. Phase initiation of a less characteristic ALT level >20% due to achieve significance: 16.7% vs Z of the A to Z intensive (>70, DM, hx of ULN, Cr documented 14.4%; HR 0.89; 95% CI: 0.76- Trial. regimen in pts CAD, PVD or >2.0mg/dL, ischemia, all-cause 1.04; p=0.14 © American College of Cardiology Foundation and American Heart Association, Inc. 29
de Lemos, James with ACS stroke, elevated concomitant mortality, new- A. JAMA CKMB or therapy with onset HF 2004 trooponin levels, agents known to (requiring 15337732 (93) recurrent angina enhance myopathy medications or with ST changes, risk; prior hx of hospitalization), ECG evidence of non-exercise CV hosptialization ischemia on pre- related elevations discharge stress in CK or test, multivessel nontraumatic disease) rhabdomyolysis ACEI indicates angiotensin-converting-enzyme inhibitor; ACS acute coronary syndrome; ALT, alanine aminotransferase; AMI, acute myocardial infarction; CABG, coronary artery bypass surgery; CAD, coronary artery disease; CHD, chronic heart disease; CKMB, creatine kinase-MB; Cr, creatinine; CV, cardiovascular; DM, diabetes mellitus; ESG, electrocardiogram; EF, ejection fraction; f/u, follow-up; HF, heart failure; HTN, hypertension; hx, history; LVSD, left ventricular systolic dysfunction; LVD, left ventricular dysfunction; MI, myocardial infarction; NSTEMI, non-ST elevation mysocardial infarction; PCI, Percutaneous coronary intervention; PROVE IT-TIMI 22, Pravastatin or Atorvastatin Evaluation and Infection Therapy -- Thrombolysis in Myocardial Infarction 22; Pts, patients; PVD, Peripheral artery disease; RCT, randomized control trial; SAVE, The Survival and Ventricular Enlargement trial; SOVLD, Studies of Left Ventricular Dysfunction; STEMI, ST elevation myocardial infarction; UA, unstable angina; and ULN, upper limit of normal.
Data Supplement 13. Stage C: Factors Associated With Outcomes, All Patients (Section 7.3) Study Name, Study Author, Year Aim of Study Study Type Size Patient Population Endpoints Statistical Analysis (Results) Study Limitations Findings/Comments
Inclusion Exclusion Primary Secondary Criteria Criteria Endpoint Endpoint
Education
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Long-term To determine RCT 350 Diagnosed with N/A Combined death Hospitalization, In the intervention group: Absence of blinding. Despite modest adherence prospective RCT whether a HF or unplanned first QoL improved and Perception of better QoL in program reduced unplanned using repetitive disease hospitalization death and the intervention group due hospitalization, total hospital education at 6-mo management and QoL adherence. Lower: deaths (p<0.003) or unplanned healthcare provider support d, the need for emergency intervals and program with changes hospitalizations (p=0.008; 95% CI: as needed. Confouding by care and improved QoL. monitoring for the repeated 0.43- 0.88) , hospitalizations(p<0.001) , social conditions. adherence in HF multidisciplinary total hospital d during follow-up outpt (The education and (p<0.001), and ED visits (p<0.001) REMADHE Trial). telephone Bocchi, Edimar monitoring No difference in estimated total Alcides. 2008 benefits HF mortality (p=ns; 95% CI: 0.55-1.13) or outpt already death during hospitalization (p=ns; 12196335 (94) under the care 95%CI: 0.53-1.41) of a with HF experience cardiologist.
Effect of discharge To determine Retrospective 782 Age >18 y, Pts discharged Time to: N/A 68% of pts received all instructions, and Discharge instructions given Documentation of discharge instructions on whether study principal to skilled death and 6% received no instructions. but not documented. information readmission of documentation diagnosis of HF, nursing facilities readmission for Discharge instructions could and pt education appears to hospitalized pts with of compliance hypertensive or other acute- HF or Pts with all instructions (compared to be a surrogate indicator for be associated with reductions HF: do all of the with any or all of heart disease care hospitals. readmission for those who missed at least one type of another intervention such as in both mortality and joint commission on the 6 required with HF, or any cause instruction) were significantly less likely higher quality nursing care. readmissions. accreditation of discharge hypertensive to be readmitted for any cause or HF Pt factor could have healthcare instructions is heart and renal (p= 0.003) influenced confounding organizations HF correlated with disease with HF, results. core measures readmissions to discharged to Documentation of discharge Generalizability limited. reflect better care? hospital or home, home instructions was correlated with No active follow-up. VanSuch, M. 2006 mortality. care or home reduced readmission rates. Not all quality of care care with IV outcomes were assessed. 17142589 (95) treatment No association between documentation of discharge and instructions and mortality.
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Discharge To assess RCT 223 Admitted to Evaluation for Total number of d Clinical events, The intervention group versus controls May not be generalizable- A 1-h teaching session at the education improves whether a pt hospital with a cardiac surgery, hospitalized or symptoms, and had fewer d hospitalized or dead in the only 223 (38%) participated. time of hospital discharge clinical outcomes in discharge diagnosis of HF Noncardiac dead in the 180-d self-care practices. 180-d follow-up period (p= 0.009), pts being evaluated for resulted in improved clinical pts with chronic HF. education and documented illness likely to follow-up period. lower risk of rehospitalization or death transplantation not studied. outcomes, increased self- Koelling, T. 2005 program (the left ventricular increase 6-mo (RR: 0.65; 95% CI: 0.45-0.93, p= Pts followed by the UMHFP care and adherence, and study systolic mortality or 0.018), as well as lower costs of care, not enrolled. Nurse reduced cost of care in pts 15642765 (96) intervention) dysfunction (EF hospitalization including cost of the intervention (lower coordinator unblined. Lack of with systolic HF. improves clinical <40%) risk, Inpatient by $2823 per pt, p= 0.035). reliability of self-reported outcomes in cardiac self-care measures. chronic HF pts. transplantation evaluation
Effects of an To evaluate the RCT 230 Diagnosis of HF Somatic Difference in rate N/A Intervention group achieved better Only 37% completed Additional education of HF interactive CD- impact of added (either LVEF < disease, of all cause knowledge and a marginally better questionnaire, pts had to pts with an interactive program on 6 mo CD-ROM 40% by ECHO or physical readmission and outcome (p=NS). come twice to the CD-based program had no effect on readmission rate in education on at least 2 of handicap with death within 6 mo education, first as inpts, then readmission rate or death pts with HF- a RCT. readmission rate these criteria: difficulty after discharge. 2 wk after discharge. within 6 mo after discharge. Linne, A. 2006 or death during pulmonary rates, communicating Returning to the hospital may 6 mo. peripheral or handling have discouraged 16796760 (97) edema, a 3rd technical participation, heart sound and equipment, especially in sicker pts. signs of HF on inability to speak chest x-ray). Swedish, incompliance due to alcohol/drug abuse or major psychiatric illness, Participation in another trial
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Computer-based To evaluate the RCT 154 Diagnosis of HF None specified Knowledge of N/A Computer-based group (intervention), Data on knowledge collected Computer-based education education for pts effects of a HF, treatment knowledge increased: After 1 mo: p= through questionnaire, increased knowledge about with chronic HF. A single-session, compliance, self- 0.07, small sample size. HF compared to traditional randomized, interactive care and QoL. After 6 mo: p= 0.03 teaching alone. controlled, computer-based multicenter trial of educational Women: significantly lower QoL and did the effects on program on not improve after 6 mo as men did (p= knowledge, knowledge, 0.0001). compliance and compliance and QoL. Stromberg, A. QoL in HF pts. No differences between groups in 2006 To assess compliance, self-care or QoL. gender 16469469 (98) differences.
Long-term result To assess rate Follow-up after 1,518 Outpt with None specified Death and Long term benefits Rate of death or hospitalization for HF Classification bias of events Benefit observed during the after a telephone of death and a RCT stable, chronic hospitalization for lower in the intervention group: due to open trial design. intervention period persisted intervention in hospitalization HF HF, 1 and 3 y 1 y: RR: 0.81; p= 0.013 95% CI: 0.69- and was sustained 1 and 3 y chronic HF. for HF 1 and 3 y after intervention 0.96 after the intervention ended. Ferrante, D. 2010 after a ended. 3 y : RR: 0.72; p= 0.0004 95% CI: This maybe due to the randomized trial 0.60-0.87 intervention impact on pt 20650358 (99) of telephone behavior and habits. intervention with Benefit caused by a reduction in education to admission for HF after 3 y improve compliance in Functional capacity better in stable HF pts intervention group with HF. Pts who showed improvement in 1 or more of 3 key compliance indicators (diet, weight control, and medication) had lower risks of events (p< 0.0001).
HF self- To identify Systematic 7,413 pts RCTs evaluating Not randomized, Satisfaction, N/A Programs incorporated 20 educational Unable to combine all the Review supports the benefits management educational review of RCTs from 35 a self- No control learning, self- topics in 4 categories- knowledge and results. Difficult to compare of educational interventions education: a content and trials management group, care behavior, self-management, social interaction interventions due to poor in chronic HF and suggests systematic review of techniques that education Not in English, medication, and support, fluid management, and descriptions, and lack of that some topics are related the evidence. lead to program with Failure to clinical diet and activity. 113 unique outcomes transparency. All to certain outcomes. Boren, S. 2009 successful self- patient-specific identify the improvement, were measured and 53% showed interventions not management outcome content of the social significant improvement in at least one reproducible. 21631856 (100) and improve measures. program, functioning, study. outcomes. Providing similar hospital Education on: sodium restriction educational admissions and associated with decreased mortality content in all readmissions, (p=0.07), appropriate follow-up study arms, mortality, and associated with decreased cost © American College of Cardiology Foundation and American Heart Association, Inc. 33
Did not identify cost. (p=0.10), management and recognition educational of worsening function associated with techniques lower social functioning (p= 0.10). used, Discussion of fluids associated with Measured only increased hospitalization (p=0.01) knowledge as and increased cost (p=0.10). an outcome.
Effect of sequential To determine if Retrospective 412 Under Unable to attend Change in QoL Influence of the Improved in the DMP intervention QoL can be confounding. Improvement of QoL is a education and a DMP applied analysis ambulatory care educational components QoL score at group: Loss of data due to morality fundamental target for the monitoring program over the long- (Extension of in a tertiary sessions or who during follow-up baseline on pt Global QoL scores: p<0.01 during follow-up may have success of treatment of pts on QoL components term could REMADHE referral center could not be survival. Physical component: p<0.01 influenced QoL scores. with HF. Specific components in HF. Cruz, Fatima produce trial, a RCT) and followed by monitored due Emotional component: p<0.01 Retrospective analysis of of the QoL assessment can das Dores. 2010 different effects a cardiologist to lack of quality of life components. behave differently over time on each of the with experience transportation, and should stimulate the 20670963 (101) QoL in HF. or social or identification and components. Age >18 communication development of new Irreversible HF barriers, strategies and interventions. based on the MI or unstable Targeting male pts and the modified angina within emotional components of the Framingham past 6 mo, QoL assessment in DMPs criteria for at cardiac surgery may be important in order to least 6-mo or angioplasty achieve a greater early within past 6 improvement in QoL. mo, hospitalized or recently discharged, any severe systemic disease that could impair expected survival, procedures that could influence follow-up, pregnancy or child-bearing potential
Social Support
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Long-term effect of To evaluate the Follow-up 119 Diagnosed with Unable to Perceived social N/A Social isolation a significant predictor Small sample size Perceived social social relationships effects of social study HF complete support and of mortality (controlling for neuroticism, isolation an independent on mortality in pts relationships on the isolation. HF severity, functional status, gender, predictor of mortality in HF with CHF. Murberg, morality risk in questionnaires age): RR= 1.36; 95% CI: 1.04-1.78; pts during a 6-y follow-up Terje. 2004 pts with stable, due to mental p<0.03 period. Experience of social symptomatic debilitation, isolation seems to be more 15666956 (102) HF. previous heart critical than lack of social transplantation support.
The importance and To review the Review 17 Studies that None specified Social support N/A 4 studies found clear relationships None noted Social support is a strong impact of social literature on studies investigated the and different between social support and predictor of hospital support on what is relationship outcomes in HF rehospitalizations and mortality; the readmissions and mortality in outcomes in pts with scientifically between social (readmission, relationship between QoL and HF pts. Emotional support in HF: An overview of known about the support and mortality, QoL depression was less clear. particular is important. Some the literature. Luttik, impact of social different and depression). studies show that support is M.L. 2005 support on outcomes in HF. also related to the prevalence outcomes in of depression and with 15870586 (103) pts with HF. remission of major depression in HF. Less evidence to support a relationship between social support and QoL.
Social deprivation To examine Cohort study 478 Admitted with an None specified Emergency N/A Social deprivation significantly Assessed adherence by Social deprivation increases increases cardiac whether social MI between hospital associated with an increase in the whether pt had enough the chance of hospitalisations deprivation has January 1989- admissions (all number of cardiac hospitalizations tablets in the rehospitalization in chronic HF an independent December 1992 causes and for (p=0.007). house to cover the independent of disease independent of effect on and cardiac causes appropriate time period- severity. Possible disease emergency subsequently only) Effect mainly caused by increasing the measuring pt’s maximum explanations are that doctors severity and diuretic cardiac admitted for proportion of pts hospitalized in each possible level of adherence. who look after socially non-adherence. hospitalization in chronic HF deprivation category. 26% in Poor adherence was deprived pts have a lower Struthers, A. 2000 pts with chronic between January deprivation category 1–2 vs. 40% in associated with being male threshold for cardiac HF. 1989- December deprivation category 5–6 (p= 0.03). versus female but not with hospitalization or that social 10618326 (104) 1992, ≥3 diuretic age, social deprivation, or deprivation alters the way a prescriptions had Effect of deprivation: independent of diuretic dose. It is possible HF pt accesses medical care to have been disease severity (as judged by the that diuretics caused more during decompensation. dispensed dose of prescribed diuretic), death troublesome Understanding how social between January rate, and duration of each hospital urinary symptoms in men deprivation influences both 1993- January stay. Non-adherence with diuretic because of prostatism, doctor and pt behavior in the 1994. treatment could not account for these leading to poorer adherence. prehospital phase is crucial to findings either. reduce the amplifying effect that social deprivation has
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cardiac hospitalizations.
Social support and To determine Cross- 333 Admitted to Undergone Self-care and N/A High level of support, compared to low Secondary analysis. Social The presence of social self-care in HF. the types of sectional, hospital for HF at cardiac surgery social support or moderate levels reported support not prespecified in support by a partner is not Gallager, R. 2011 social support descriptive least once or PCI in the significantly better self-care (p= .002) COACH trial. sufficient to influence HF pts’ provided to HF (COACH sub- before the initial previous 6 mo, The measure and categories self-care. Social support 21372734 (105) pts and the study ) hospitalization of or if these High level of social support, compared of social support have not provided by partners needs impact the original study procedures or medium or low levels, significantly been used previously either to be of a quality and content of differing Age >18 y heart more likely to: consult with a health separately or as a composite that matches HF pts’ levels of social NYHA II-IV; transplantation professional for weight gain (p= 0.011), measure. perception of need to support on HF evidence of was planned, limit fluid intake (p= 0.02), take their It is likely that other important influence self-care. pts’ self-care underlying Unable to medication (p= 0.017), get a flu factors influence HF self-care structural heart participate in the shot(p= 0.001), and exercise on a behavior as the multivariate disease COACH regular basis (p< 0.001). model was not adequate. intervention or to complete the data collection forms
Comorbidities
A qualitative meta- To explore how Qualitative 99 pts Mixed method None specified Perceptions about N/A Narrative accounts revealed the most Generalizability limited due to Individuals with multiple analysis of HF self- comorbidity meta-analysis from 3 studies. HF and HF selfcare challenging self-care skills: adherence homogeneous sample. chronic conditions are care practices influences HF trials Included pts with to diet, symptom monitoring, and Interpretation of findings vulnerable to poor self-care among individuals self-care HF with at least differentiating symptoms of multiple relied on interview data because of difficulties with multiple 1 comorbid conditions. available from the primary prioritizing and integrating comorbid condition studies. multiple protocols. Adherence conditions. Dickson, Emerging themes included: 1) Findings may be baised to a low-salt diet, symptom V. 2011 attitudes drive self-care prioritization because samples were monitoring, and differentiating and 2) fragmented self-care instruction recruited from HF specialty symptoms of HF from other 21549299 (106) leads to poor self-care integration and settings, possibly better chronic conditions are self-care skill deficits. managed clinically than particularly challenging. community samples. Difficulty integrating self-care of different diseases and fragmented instructions regarding those conditions may contribute to poor outcomes.
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Psychiatric To explore Cohort study 21429 Medicare HF was not a Psychiatric N/A Overall, 15.8% of pts hospitalized for Claims usage based Psychiatric comorbidity comorbidity and associations beneficiaries primary cause of comorbidity and HF had a coded psychiatric administrative data. appears in a significant greater between hospitalized any admission rehospitalization risk, comorbidity. Information unavailable minority of pts hospitalized hospitalization risk, psychiatric during 1999. during 1999, length of regarding the severity of HF for HF and may affect their longer length of stay comorbidity and Comorbid hospitalization, and Most commonly coded comorbid in the sample. clinical and economic and higher rehospitalization dementia or costs. psychiatric disorder was depression The possibility that outcomes outcomes. The associations hospitalization costs risk, length of organic brain (8.5% of the sample) (p< 0.001). may be worse for pts with between psychiatric in older adults with hospitalization, syndrome coded comorbid psychiatric comorbidity and use of HF. Sayers, Steven. and costs in diagnosis Most forms of psychiatric comorbidity diagnoses inpatient care are likely to be 2007 adults with HF. were associated with greater inpatient as opposed to the presence underestimated because utilization, including risk of additional of the conditions themselves psychiatric illness is known to 17714458 (107) hospitalizations, d of stay, and cannot be excluded. Cross- be under detected in older hospitalization charges (p< 0.001). sectional design. adults and in hospitalized medical pts. Additional hospitalization costs associated with psychiatric comorbidity ranged up to $7,763, and additional length of stay ranged up to 1.4 d (p< 0.001).
The relevance of To determine Descriptive 11,062 Diagnosis of None specified Influence of pt Combined drug regimens given to 48% Drug regimens defined to Pt characteristics have a comorbidities for HF the impact of pt study chronic HF characteristics on of HF pts (2.2 drugs on average). Pt make comparisons within clear impact on prescribing in treatment in primary characteristics and/or a history drug regimens characteristics accounted for 35%, levels of similar treatment European primary care. Up to care: A European and of MI during a 2- 42% and 10% of the variance in 1-, 2- intensity possible. 56% of drug regimens were survey. Sturm, H. comorbidities on mo period in and 3-drug regimens, respectively. Adherence rates depend on rational, taking pt 2006 chronic HF 1999 the indicators used. characteristics into account. management, MI, AF, DM, HTN, and lung disease Situations of insufficient 16084761 (108) and to identify influenced prescribing most (OR=1.3; prescribing, such as pts post areas of 95% CI: 1.2-1.4) MI, need to be addressed prescribing that specifically. could be AF made all combinations containing improved. beta blockers more likely.
For single drug regimes, MI increased the likelihood of non-recommended beta blocker monotherapy while for combination therapy, recommended regimes were most likely.
For both HTN and DM, ACEI were the most likely single drug, while the most likely second drugs were beta blockers in HTN and digoxin in DM.
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Frequent non- To discuss in Review 37 None specified None specified N/A N/A About 50% of pts with untreated HTN No limitations addressed. This review of the literature cardiac more detail the studies will develop HF. Pressure overload clearly demonstrates that comorbidities in pts impact of co- leads to the development of LV noncardiac comorbidities are with chronic HF. existing hypertrophy and diastolic dysfunction. common in pts with HF and Dahlstrom, Ulf. HTN, DM, that it is important to 2005 COPD in pts DM occurs in about 20–30% of pts recognize these conditions with HF. with HF. and 15718170 (109) take them into consideration COPD occurs in approximately 20– when selecting treatment for 30% of HF pts. these pts. Appropriate treatment of the HF as well Anemia occurs in 20–30% of HF pts as the concomitant diseases and is associated with functional will improve the prognosis of impairment and increased mortality these pts. and morbidity. Combined treatment with erythropoietin and intravenous iron has shown beneficial effects on clinical symptoms and morbidity.
ACEI indicates angiotensin-converting-enzyme inhibitor; AF, atrial fibrillation; CHF, congestive heart failure; COACH, Community Outreach and Cardiovascular Health; DM, diabetes mellitus; DMP, disease management program; ECHO, echocardiogram; ED, emergency department; EF, ejection fraction; HF, heart failure; HTN, hypertension; IV, intravenous; LVEF, left ventricular ejection fraction; MI, myocardial infarction; N/A, not applicable; NS, not significant; NYHA, New York Heart Association; PCI; percutaneous coronary intervention; pts, patients; QoL, quality of life; RCT, randomized control trial; REHMADE, Repetitive Education at Six-Month Intervals and Monitoring for Adherence in Heart Failure; UMHFP, University of Michigan Heart Failure Program
Data Supplement 14. Nonadherence (Section 7.3.1.1) Study Name, Study Findings/ Author, Year Aim of Study Study Type Size Patient Population Endpoints Statistical Analysis (Results) Study Limitations Comments
Inclusion Exclusion Primary Secondary Criteria Criteria Endpoint Endpoint
Noncompliance
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Use of telehealth by To investigate the RCT 284 Admitted to a None specified Self-management N/A Confidence is a predictor of self- Small sample size. Confidence is a older adults to influence of telehealth home health of HF. management behaviors. The home health agencies may positive predictor of manage HF. Dansky, on self-management of agency, have limited the external self-management, K. 2008 HF in older adults. Primary or Pts using a video-based telehealth validity of the study. which should 20078015 (110) secondary system showed the greatest gain Examination of the effects of encourage the diagnosis of HF in confidence levels with time (p= the telehealth interventions on development of 0.035). specific behaviors was not interventions that possible. focus on building self- care confidence in HF pts. These results contradict the stereotype that older adults are unable or unwilling to use technology.
Characteristics and To determine the Cohort study 54,322 Ages >18, pts Pts with new 2 groups: Those Hospital outcomes Multivariate analysis of Rates of nonadherence may be Nonadherence is a inhospital outcomes characteristics, reported in the diagnoses of HF in whom and quality of care characteristics of nonadherence: underestimated due to self common precipitant for nonadherent pts treatments, quality of GWTG-HF nonadherence among Younger age (per y decrease) reporting and biased based on for HF admission. with HF: findings care, and inhospital database from contributed to HF nonadherent pts pt characteristics. GWTG-HF is Medication from GWTG-HF. outcomes of pts January 1, 2005- admission and vs. those who were p<0.0001; 95% CI: 1.019-1.026; a voluntary program so could nonadherence Ambardekar, A. 2009 nonadherent to dietary December 30, those without adherent. over-represent high-performing greater in younger 19781426 (111) and medication advice 2007 nonadherence. Male gender (vs. female) hospitals. Data collected by pts, ethnic minorities as precipitating factors chart reviews, only in-hospital and uninsured for HF hospitalization. p<0.0001; 95% CI: (1.196-1.358); measures were tracked so long whereas dietary Nonwhite race (vs. white) term follow-up unknown. nonadherence was observed in older, p<0.0001; 95% CI: 1.358-1.632 overweight and No health insurance (vs. diabetic pts. insurance) Nonadherent pts p<0.0001; 95% CI: 1.236-1.633 present with evidence of lower EF and Multivariate analysis of outcomes greater volume with vs. without nonadherence: overload yet have an inhospital course Mortality 1.55% v. 3.49%; characterized by a shorter LOS and p<0.0001 95% CI: 0.51-0.86 lower mortality. Care Mean length of stay 4.99 d vs. 5.63 of nonadherent pts p= 0.0017; 95% CI: 0.92-0.97 conformed with Joint Commission core measures but at lower rates with other
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guideline-based therapies.
Utilization of and To determine the N/A 45,572 Living in Stays in nursing Adherence based N/A Odds of having a HF prescription Measures of use and 15.2% of diagnosed adherence to drug number of Medicaid Arkansas, home facilities at on: claim were higher with people: adherence are proxies based beneficiaries were not therapy among beneficiaries with HF, California, Indiana any time during MPR (no. of d a pt Age 65-74 vs. <65: on prescriptions filled versus using any HF Medicaid identify the rate of HF or New Jersey, 1999 is supplied with observations; findings may medications. Adults beneficiaries with drug use, estimate enrolled in fee-for >1 HF drug in p<0.01; 95% CI: 1.193- 1.344 overestimate adherence to HF <65 y, men, ethnic CHF. Bagchi, A. adherence rates, service Medicaid relation to the no. Age 75-84 vs. <65: medications. minorities with 2007 examine factors with pharmacy of dbetween the Diagnoses recorded in claims hospital admissions 17919558 (112) associated with HF benefit coverage pt's first and last p<0.01; 95% CI: 1.458- 1.676 may be incomplete, resulting in for conditions other drug use and treatment during 1998 and prescription Age >85 vs. <65: the omission of some pts from than HF, and adherence, and explore 1999 or until dates), the study. beneficiaries with policy implications. death MP (no.of d of p<0.01; 95% CI: 1.162, 1.353 Limited number of states may high CDPS scores HF (hospitalized continuous use of lead to biased results if had lower adherence.
and diagnosed HF medications Medicaid beneficiaries in study Dual Eligible : during 1998 or per mo) states are different than other diagnosed on ≥ 2 p<0.01; 95% CI: 1.466-1.580 states. ambulatory visits Disabled: during 1998) p<0.01; 95% CI: 1.388-1.537 Had CAD :
p<0.01; 95% CI: 3.309-3.676
Had DM: p<0.01 95% CI: 2.085- 2.284 Hospitalized for HF in 1998: p<0.01; 95% CI: 1.579-1.701
Odds of having a HF prescription claim were lower among - Blacks vs. whites: p<0.01; 95% CI: 0.735-0.795 Other /unknown ethnic group vs. whites: p<0.01 95% CI: 0.840,-0.919 Men vs. women: p<0.01 95% CI: 0.722-0.775
Adherence better among age >85 y than <64 y, men than women, racial and ethnic minorities, dual
© American College of Cardiology Foundation and American Heart Association, Inc. 40
eligible and disabled, those with CAD or DM, those with HF related hospitalization (p<0.01).
Adherence lower among those with larger proportions of claims for generic HF drugs, higher CDPS risk scores and those with non-HF- related Hospitalizations (p<0.01).
Drug copayment and To measure the Retrospective 5,259 In Ingenix Receiving 1 Total cost of N/A For pts taking ACEI, a $10 Using prescription dispensing Among pts with HF, adherence in chronic associations among Cohort Study receiving Research Data dispensing of health care and increase in copayment was data to assess drug adherence higher drug HF: effect on cost prescription copayment, ACE Mart, diagnosed ACEI, hospitalization for associated with a 2.6% decrease eliminates pts to whom a drug copayments were and outcomes. Cole, drug adherence and inhibitor with HF, and receiving 1 HF MPR: in MPR (95% CI: 2.0 - 3.1%) is dispensed only once so may associated with A. 2006 subsequent health enrolled in dispensing of beta proportion of d a have contributed to high poorer adherence, 16863491 (113) outcomes in pts with HF 5,144 commercial blockers, had pt was exposed to This change in adherence was adherence observed. although the receiving and/or Medicare switched ACEI, a drug while associated with: Dispensing data does not magnitude of change Beta supplemental had switched beta receiving a a predicted 0.8% decrease in capture actual usage. was small and did not Blockers plans in 2002; blockers, MPR regimen medical costs (95 %CI: -4.2 - ACEI more expensive than affect total health ≥2 physician <20% or >120%, 2.5%) beta blockers resulting in care costs. It was 2,373 visits or had conflicting a predicted 6.1% increase in the higher copayment. sufficient to increase receiving hospitalizations data in their risk of hospitalization for chronic Total medical costs might have risk of hospitalization both related to HF in dispensing HF (95% CI: 0.5 - 12%). been insensitive to specific for HF though. 2002; records changes in adherence to HF $100-10,000 in For pts taking beta blockers, a $10 therapies. costs associated increase in copayment was with HF associated with a 1.8% decrease diagnoses in in MPR (95% CI: 1.4 - 2.2%) 2002; continuously This change in adherence was enrolled in health associated with: plan for all of a predicted 2.8% decrease in 2002 and at least medical costs (95% CI: -5.9 - 1 d in 2003. 0.1%). ACEI and/or beta a predicted 8.7% increase in the blockers risk of hospitalization for chronic dispensed at least HF (95% CI: 3.8 - 13.8%) twice.
© American College of Cardiology Foundation and American Heart Association, Inc. 41
The impact of To evaluate the impact Retrospective 754 Hospitalized for Invasive Impact of Risk of a related medication Cannot be certain that the A considerable perceived adverse of perceived adverse Cohort Study symptomatic HF procedures in the perceived adverse change significantly increased after reported problems resulted number of HF pts effects on medication HF drug effects NYHA class II-IV mo before or effects on dry cough, nausea, dizziness, or from medication. Focused on perceived possible changes in HF pts. Age >18 planned within 3 likelihood and diarrhea. Dry cough showing the specific medication changes AEs. The likelihood of De Smedt, R. 2010 Evidence of mo after baseline type of changes of highest increase in risk (83%; 95% and did not take all possible medication being 20142025 (114) structural Already enrolled in potential causal CI: 1.35-2.49) adequate actions into account. changed after pts underlying heart other studies cardiovascular Recall bias possible- pts may perceived AEs was disease Follow-up medication & Pts with gout had a 4-fold higher not have reported all perceived low. A high number of treatment at initiation of likelihood of having alleviating problems in the questionnaires. pts perceive another HF clinic medication to medication started or intensified medication AE. alleviate the (95% CI: 2.23-8.05) adverse effect. With dry cough, a 10-fold increase in the likelihood of having ACE inhibitor switched to an ARB (95% CI: 3.2-35.55)
Pts with gout had a 3-fold higher likelihood of having diuretics temporarily discontinued and reinitiated at a lower dosage (95% CI: 1.09-10.04)
Associations To examine the Longitudinal/ 15,177 Clinical diagnosis Noncardiovascular Process-of-care Each 10% improvement in Errors and omissions in the These data between outpt HF relationships Registry of HF or post-MI, medical condition HF measures: composite care was associated medical chart review process demonstrate that process-of-care between adherence to LVEF <35%, ≥2 associated with an ACE inhibitor or with a 13% lower odds of 24-mo could have occurred. adherence to HF measures and several current and office visits with a estimated survival ARB use, beta mortality (p <0.0001; 95% CI: 0.84- NYHA functional status was not process measures for mortality. Fonarow, emerging cardiologist in the of <1 y, received blocker use, 0.90) quantified in many of the ACEI/ARB, beta G. 2011 outpt HF process last 2 y cardiac aldosterone records, and was instead blocker, 21464053 (115) measures and clinical transplantation antagonist use, All process measures, except based on qualitative anticoagulation for outcomes. anticoagulant aldosterone antagonist use, were description. This study AF, and HF education therapy for AF or each independently associated analyzed medications is significantly flutter, CRT with with improved 24-mo survival (p prescribed rather than actual pt associated with defibrillator or <0.01 for all except aldosterone adherence. Follow-up on vital survival in outpts with pacemaker, ICD, antagonist use). status was not achieved for all HF. These HF and HF education pts. Race/ethnicity, measures may be for eligible pts. socioeconomic status or pt useful for assessing adherence may be confounding and improving HF variables. Findings may not care. apply to practices that differ from the IMPROVE HF outpt cardiology practices in this
© American College of Cardiology Foundation and American Heart Association, Inc. 42
study.
A nurse-based To assess the effect of Substudy of 208 Age >60 None specified Pt knowledge of N/A At baseline men knew more about Some pts were included one d Nurse-based outpt management a nurse-based the OPTIMAL Systolic HF and self-care. HF compared to women (p<0.01). after hospitalization and clinic with specially program in HF pts management program project- a dysfunction some the d before discharge; trained nurses affects females and aimed at increasing HF RCT EF <45% Females in the intervention group condition improvement may effective in increasing persons with pts' knowledge about NYHA II-IV increased their knowledge of self- explain low number of pts pt knowledge about cognitive dysfunction disease and self-care care between baseline and 6 mo scoring low on the MMSE; The self-care. Females most. Karlsson, M. and to relate the results compared to the female control drop-out rate was high in the and those with 2005 to gender and cognitive group (p <0.05). MMSE sub-study. cognitive impairment 16009290 (116) function. gain from such Pts with cognitive dysfunction programs. (MMSE <24) presented lower scores on knowledge as compared to those with a MMSE of >24 at baseline. These differences disappeared after the intervention (p<0.01).
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Pharmacist To determine whether a RCT 314 Age >50 y, Dementia Medication Health-related Medication adherence greater in Pts were not permitted to use A pharmacist intervention to pharmacist intervention confirmed adherence QoL, satisfaction the intervention group 78.8% vs. medication container intervention for outpts improve medication improves medication diagnosis of HF, (tracked by using with pharmacy 67.9% usual care group (95% CI: adherence aids. with HF can improve adherence in HF. adherence and health regularly used at electronic services, and total 5.0-16.7). Intervention involved 1 adherence to Murray, M. 2007 outcomes compared least 1 CV monitors) and direct health care pharmacist and a single study cardiovascular 10030506 with usual care for low- medication for clinical costs. At 3 mo, adherence decreased site that served a large, medications and (117) income pts with HF. HF, not using or exacerbations that 70.6% in intervention and 66.7 in indigent, inner-city population decrease health care not planning to required visits to usual care (95% CI: -5.9-6.5). of pts. use and costs, but use a medication the ED or Because the intervention had the benefit probably container hospitalization. Medications were taken on several components, results requires adherence aid, schedule 47.2% in the usual care could not be attributed to a constant intervention access to a and 53.1% in the intervention single component. because the effect working group (95%CI: 0.4-11.5). dissipates when the telephone, and intervention ceases. adequate hearing At the end of intervention, taking of medication on schedule decreased 48.9% for usual care and 48.6% in intervention (95% CI: -5.9-6.5)
ED visits and hospital admissions were 19.4% less in the intervention group (95% CI: 0.73-0.93).
Annual direct health care costs were lower in the intervention group (95% CI: $-7603-$1338)
Short and long-term To evaluate whether RCT 153 Discharged with a Terminal disease, Decrease in Changes in During the 16 +8 mo treatment Results cannot be extrapolated This intervention can results of a program improvement obtained primary diagnosis expected survival readmissions due pharmacological period, intervention group had: to all HF pts since the study reduce HF morbidity for the prevention of during an intervention of HF from the <6 mo, possibility to HF and in all- treatment and Lower rate of HF readmissions included pts discharged from a and mortality and readmissions and program were hospital of specific etiology cause mortality changes in quality cardiology service, who are improve quality of life mortality in pts with maintained after the cardiology ward. treatment, wait list event-free of life MLHFQ (p <0.01), and Less all-cause usually younger and with fewer but favorable effects HF: are effects program was stopped. for heart survival, defined mortality Improvement in QoL co-morbidities. decrease after maintained after transplant on the basis of (p=0.03) program ends. Long- stopping the time to death or term programs are program? Ojeda, S. HF readmission. required to maintain 2005 1 y after the intervention, there beneficial effects. 16051519 were no differences between the (118) groups (p=0.03).
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Excessive daytime To determine if Prospective 280 Chronic stage C Living in a long Self-reported Cognition 62% were nonadherent with Medication adherence was HF pts who are sleepiness is medication adherence cohort HF confirmed, term care setting, medication measured with a medication regimen. self-reported. sleepy have difficulty associated with poor differs in adults with HF comparison able to complete working nights or adherence battery of paying attention and medication and EDS compared to study the protocol rotating shifts, neuropsychological Medication nonadherence was thus forget to take adherence in adults those without EDS and (vision, hearing, renal failure tests significantly more common in those their medications. with HF. Riegel, et al to test cognition as the English literacy), requiring dialysis, with EDS 2011 mechanism of the no more than mild imminently 21440873 (119) effect. cognitive terminal illness, Subjects with EDS and cognitive impairment plans to move out decline were >2 times more likely of the area, history to be nonadherent (aOR 2.36, of serious drug or 95%CI: 1.12-4.99; p=.033). alcohol abuse in prior y, major Secondary models using the depression Epworth Sleepiness score: The odds of nonadherence increased by 11% for each unit increase in ED (aOR 1.11, 95%CI: 1.04-1.19; p=.025).
Subjects with EDS and mild cognitive decline were 1.6 times more likely to be nonadherent over 6 mo follow-up (aOR 1.61; 95%CI: 1-03-2.50; p=.001).
The group with EDS but without cognitive decline was twice as likely to be nonadherent (p=.014).
9% increase in the odds of nonadherence for each unit increase in EDS (p=.001).
Lack of cognitive vigilance associated with nonadherence. (p=.024)
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Compliance with non- To investigate the Secondary 830 Recently Invasive Composite of mortality and Pts non-compliant with ≥1 Almost half had a first HF pts who follow pharmacological association between analysis of hospitalized for intervention within death or HF readmission for HF recommendations had a higher risk diagnosis of HF during the prescribed recommendations compliance with non- data from the symptomatic HF, the last 6 mo or readmission and of mortality or HF readmission index hospitalization and then nonpharmacologic and outcome in HF pharmacological COACH trial confirmed by the planned for the the number of (p=0.01). compliance was evaluated 1 therapy have better pts, van der Wal et recommendations (diet, cardiologist, with next 3 mo, unfavorable d. Non-compliance with exercise was mo after discharge, which outcomes than those al, 2010 fluid restriction, evidence for inclusion in associated with an increased risk could have influenced rates. who do not. Exercise 20436049 (120) weighing, exercise) and underlying heart another study with for mortality or HF readmission 'Unfavorable d' difficult to and monitoring of outcome in pts with HF. disease. additional visits to (p<0.01). evaluate. Self-report instrument daily weights are provider, or Non-compliance with daily used to measure compliance. particularly important. evaluation of CTX. weighing was associated with an Socially desirable responses increased risk of mortality (p=0.02). possible. Non-compliance (overall) and non- compliance with exercise were associated with a higher risk for HF readmission (p<0.05). Pts who were overall non- compliant or with weighing and exercise had more unfavourable d than compliant pts (p= 0.01).
Nonpharmacologic To describe the recall of Descriptive 2,331 Clinical diagnosis Self-reported After hospitalization for HF, pts Younger pts who were more Younger age and Measures and Drug and adherence to survey of pts of HF adherence to recalled receiving 4.1 ± 2.7 items mobile and had greater social prescription of Compliance in Pts nonpharmacologic from 115 nonpharmacologic of advice with some regional support were more likely to appropriate with HF: Data from advice of pts enrolled in hospitals advice differences. Recall of dietary attend interview. Possible pharmacologic the EuroHF Survey, the European HF from 24 advice was higher (63%) than for response bias. treatment are Lainscak et al, 2007 Survey European influenza vaccination (36%) and associated with 17378994 (121) countries avoidance of NSAIDS (17%). higher rates of recall Among those who recalled the and implementation. advice, many did not follow it completely (cholesterol and fat intake 61%; dietary salt 63%; influenza vaccination 75%; avoidance of NSAIDS 80%). A few indicated they ignored the advice completely. Pts who recalled >4 items versus <4 items were younger and more often received ACE-I (71% vs 62%), beta blockers (51% vs 38%), and spironolactone (25% vs 21%).
ACEI indicates angiotensin-converting-enzyme inhibitor; AE, adverse event; AF, atrial fibrillation; ARB, angiotensin receptor blocker; CAD, coronary artery disease; CDPS, Chronic illness and disability payment system; CHF, congestive heart failure; COACH, Community Outreach and Cardiovascular Health; CTX, chest x-ray; CRT, Cardiac resynchronization therapy; CV, cardiovascular; DM, diabetes mellitus; ED, emergency department; EDS, excessive daytime sleepiness; EF, ejection fraction; GWTG-HF; Get with the Guidelines-Heart Failure; HF, heart failure; ICD, implantable cardioverter-defibrillator; IMPROVE-HF, The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting; LOS, length of stay; LVEF, left ventricular © American College of Cardiology Foundation and American Heart Association, Inc. 46
ejection fraction; MI, myocardial infarction; MLHFQ, Minnesota Living with Heart Failure questionnaire; MMSE, Mini Mental State Examination; MP, Medication Persistence; MPR, medication possession ratio, N/A, not applicable; NSAID, nonsteroidal antiinflammatory drugs; NYHA, New York Heart Association; OPTIMAL, optimising congestive heart failure outpatient clinic project; pts, patients; QoL, quality of life; and RCT, randomized clinical trial.
Data Supplement 15. Treatment of Sleep Disorders (Section 7.3.1.4) Study Name, Aim of study Study Study Patient Population Endpoints Statistical Analysis Study Limitations Findings/ Author, Year Type Size (Results) Comments
Inclusion Criteria Exclusion Primary Endpoint Secondary Criteria Endpoint Continuous positive To test the 11 center 258 18-79 y, NYHA II-IV, HF Pregnancy, MI, Death and heart Hospitalizations, No difference between control Underpowered CPAP did not extend airway pressure for hypothesis that RCT due to ischemia, HTN, or USA, cardiac transplantation EF, exercise (n=130) and CPAP (n=128) because trial stopped life, decrease central sleep apnea long-term idiopathic DCM, stable surgery within capacity, QoL, groups in number of early for low transplant rate in CSA and HF (CANPAP). treatment of CSA condition, optimal prior 3 mo, OSA neurohormones hospitalizations, QoL, ANP enrollment but may be indicated Bradley, T.D. et al with CPAP in HF medical therapy for 1+ levels. No difference in overall for OSA. 2005 pts receiving mo, LVEF <40%, CSA event rates (p=0.54). 16282177 (122) optimal medical with ≥15 apnea- therapy reduces hypopnea index (AHI) the combined and >50% of AHI had to rates of death and be central. heart transplant. Suppresion CSA by To investigate Post-hoc 210 Age 18 to 79 y, Pregnancy, Combined rate of all- Apnea-hypopnea Despite similar CPAP pressure Stratification of These results suggest CPAP and transplant- whether analysis of a NYHA II-IV MI, Unstable cause mortality or heart index (AHI) mean and hours of use in the 2 groups, CPAP-treated pts that in HF pts, CPAP free survival in HF. suppression of randomized HF due to ischemic, angina, cardiac transplantation nocturnal SaO2, CPAP-CSA– suppressed based on may improve both Arzt, M. 2007 CSA below trial. hypertensive, or surgery within 3 and LVEF subjects, compared to controls, polysomnogram LVEF and heart 17562959 (123) threshold by idiopathic DCM, mo of enrollment, experienced: performed 3 mo after transplant–free CPAP would stabilized with optimal OSA A greater increase in LVEF at 3 randomization. survival if CSA is improve LVEF and medical therapy for at mo (p=0.001) Because suppressed suppressed soon after heart transplant– least 1 month and unsuppressed it begins. free survival. LVEF <40%, Significantly better transplant- status could not be Central sleep apnea free survival (HR: 0.37; 95% CI: ascertained until 0.142-0.967; p=0.043) completion of PSG, events that occurred during the first 3 mo could not be included; more deaths occurred in the pts randomized to CPAP than control (5 vs. 3). The CPAP-CSA–
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suppressed group was younger, had a lower AHI, and had a slightly lower proportion of central events than the CPAP CSA– unsuppressed group Effect of continuous To determine RCT 205 Age 18 to 79 y; Pregnancy, Apnea-hypopnea index N/A In controls, there no change in Did not classify Attenuation of CSA by positive airway whether NYHA II -IV MI, and frequency of AHI or frequency of arousals. arousals as being CPAP does not reduce pressure on sleep attenuation of CSA HF due to ischemic, UA or cardiac arousals. respiratory or non- arousal frequency in structure in heart by CPAP in pts hypertensive, surgery within 3 In CPAP group, AHI decreased respiratory related, HF pts. Arousals not failure pts with central with HF reduces oridiopathic DCM, mo of enrollment, significantly but neither the and did not examine mainly a consequence sleep apnea. the frequency of stabilized on optimal obstructive sleep frequency of arousals nor sleep their timing. of CSA and may not Ruttanaumpawan, P. arousals from medical therapy ≥ 1 mo, apnea structure changed significantly have been a defense 2009 sleep or improves LVEF <40% by (p<0.001). mechanism to 19189783 (124) sleep structure. radionuclide terminate apneas in angiography, CSA the same way they do defined as an AHI ≥ 15, in OSA. with >50% of apneas and hypopneas central in nature Relationship between To examine the Cohort study 45 Chronic HF NYHA II-III Previous Polysomnography, N/A Pts receiving beta blockers Small sample size. In pts with chronic HF, beta blocker treatment relationship LVEF <50%. cerebrovascular echocardiography, compared to pts not receiving Did not measure CAI was lower and the severity of between use of disease, plasma BNP levels beta blockers had: central according to the dose CSA in chronic HF. beta blockers and Recent (<6 mo) lower AHI, lower CAI. chemosensitivity to of beta blockers. No Tamura, A. 2007 the severity acute coronary Negatively correlated with the CO2. use of beta blockers 17218566 (125) of CSA in HF. syndrome, dose of carvedilol were: AHI was independently chronic CAI associated with CAI. 6 respiratory mo of treatment with disease Multiple regression analysis carvedilol decreased selected no use of beta blockers CAI. These results as an independent factor of CAI. suggest that beta blocker therapy may In 5 pts with CAI >5 who dose-dependently underwent serial sleep studies, suppress CSA in pts CAI decreased significantly after with chronic HF. 6 mo of treatment with carvedilol. Influence of CRT on To investigate the Prospective 77 Eligible for CRT, None specified. Cardiorespiratory N/A CSA was documented in 36 Categorization of In pts with severe HF different types of SDB. influence of CRT non- present with dyspnea, polygraphy. NYHA (47%) pts, OSA in 26 (34%), and hemodynamic eligible for CRT, CSA Oldenburg, O. 2007 on SDB in pts with randomized NYHA III-IV class, frequency of no SDB in 15 (19%). response based on a is common and can be 17467333 (126) severe HF. study LBBB with QRS ≥150 nycturia, novel scoring system influenced by CRT. © American College of Cardiology Foundation and American Heart Association, Inc. 48
msec, LVEDD ≥60mm, cardiopulmonary Sleep disordered parameters not prospectively Improvement depends LVEF of ≤35%, exercise, 6-min walk improved in CSA pts only: validated. on good clinical and peak VO2 during test, and AHI, SaO2min, Desaturation (p< Prospectively hemodynamic standardized echocardiography 0.001) followed CRT pts response to CRT. cardiopulmonary parameters. without calculating exercise testing, ≤18 Daytime capillary pCO2 was statistical power ml/kg/min, during initial significantly lower in CSA pts needed testing of several LV- compared to those without SDB to show results for lead positions with a trend towards increase pts without SDB, (posterolateral veins), with CRT (p=0.02). those with OSA, or RV-stimulation sites CSA in advance. (apex vs. RVOT) After classifying short term and LV vs. biventricular clinical and hemodynamic CRT pacing, pulse pressure effects, improved SDB as a surrogate parameters in CSA occurred in parameter of responders only (p=0.004). haemodynamic acute response had to increase by >10%. AHI indicates apnea hypopnoea index; ANP, atrial natriuretic peptide; BNP, B-Type natriuretic peptide; CAI, central apnea index; CPAP, continuous positive airway pressure; CRT, cardiac resynchronisation therapy; CSA, central sleep apnea; DM, dilated cardiomyopathy; EF, ejection fraction; HF, heart failure; HTN, hypertension; LBBB, left bundle branch block; LVEDD, left ventricular end diastolic diameter; LVEF, left ventricular ejection fraction; MI, myocardial infarction; N/A, not applicable; NYHA, New York Heart Association; OSA, obstructive sleep apnea; pts, patients; QoL, quality of life; RV, right ventricular; RVOT, right ventricular outflow tract; SDB, sleep disordered breathing; UA, unstable angina.
Data Supplement 16. Cardiac Rehabilitation-Exercise (Section 7.3.1.6) Study Name, Aim of Study Study Study Patient Population Endpoints Statistical Analysis (Results) Findings/Comments Author, Year Type Size Inclusion Criteria Exclusion Criteria Primary Endpoint Secondary Endpoint
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Antiremodeling To determine whether RCT 90 HF secondary to idiopathic Any systemic disease Cardiopulmonary N/A Differences from baseline to 6 mo In stable chronic HF, effect of long- long-term exercise DCM, IHD or valvular limiting exercise, exercise testing, improved in the intervention group for: long-term moderate term exercise training may influence disease hypertrophic 6MWT, EF (p<0.001); exercise training has no training in pts LV volume and LVEF <35% by ECHO. cardiomyopathy, echocardiography, Work capacity (p<0.001); detrimental effect on left with stable function in a large Clinical stability for at least Valvular disease requiring and QoL. Peak VO2 (p<0.006); ventricular volumes and chronic HF. cohort of pts with 3 mo under optimized surgery, Walking distance (p<0.001); function; rather, it Giannuzzi, stable chronic HF. therapy Angina pectoris, QoL (p<0.01); attenuates abnormal Pantaleo. 2003 NYHA II-III Sustained ventricular LV volumes (diminished) (p<0.001); remodeling. Furthermore, 12860904 (127) Peak oxygen uptake (VO2) arrhythmias, Trend to fewer readmissions for exercise training is safe < 20mL/kg/min at Severe hypertension, worsening dyspnea (p< 0.05) and effective in ergospirometry Excess variability >10% at improving exercise Echocardiographic images baseline cardiopulmonary LV volumes increased in control group tolerance and QoL. of adequate quality for exercise test (p= 0.05) quantitative analysis Combined To compare the Prospective 58 Chronic HF due to ischemic Recent ACS or Steady-state workload VO2 peak, In the combined endurance-resistance In chronic HF pts, endurance- effects of combined randomized or dilated cardiomyopathy revascularization in the ventilatory training (compared to the endurance combined endurance- resistance endurance-resistance study LVEF <40% past 3 mo, prognostic training group): resistance training had a training vs. training with NYHA II-III. actively listed on the parameters, SSW increased: p=0.007; more pronounced effect endurance endurance Optimal and stable transplant list, upper and Decrease in heart rate at SSW: on submaximal exercise training in pts training only on pharmacological treatment logistic problems, lower limb p=0.002; capacity, muscle with chronic HF: submaximal and exercise limited by angina strength, and VO2 peak halftime was reduced: strength, and quality of a prospective maximal exercise or peripheral arterial QoL p=0.001 life. The absence of randomized capacity, ventilatory occlusive disease, Maximal strength in upper limbs unfavorable effects on study. Beckers, prognostic cerebrovascular or increased: p<0.001 left ventricular Paul. 2008 parameters, safety musculoskeletal disease HRQoL improved (reported decrease of remodelling and outcome 18515805 (128) issues, preventing exercise cardiac symptoms): p= 0.003; 95% CI: parameters is reassuring and QoL in pts with training, 1.11-12.46. and might facilitate chronic HF. respiratory limitation further implementation of this particular training modality.
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Comparison of To compare the Randomized 74 Diagnosed with HF for at Neurological, orthopedic, Exercise capacity, N/A After the exercise programs, significant Both the hospital-based hospital-based effects of home- study least 3 mo, peripheral vascular, or QoL, psychological improvement was observed in both and home-based versus home- based and HF as a result of ischemic severe pulmonary disease, symptoms, and groups (all p<0.05) including: exercise groups based exercise hospital-based and dilated NYHA class IV, hemodynamic Peak VO2; 6MWT; Subscales of improved significantly in training in pts exercise programs on cardiomyopathy, UA pectoris, parameters physical function, general health, and functional with HF: effects exercise capacity, clinical stability for at least 3 poorly controlled or vitality of short form 36 capacity, QoL, on functional QoL, psychological mo, LVEF <40% exercise-induced cardiac Beck Depression Inventory depression symptoms, capacity, QoL, symptoms, and NYHA II-III, optimal and arrhythmias, LVEF and LVEF. Based on psyhcological hemodynamic standard pharmacological recent ACS or these results, we believe symptoms, and parameters in HF pts. treatment, ability to speak revascularization (<3 mo), A comparison of the 2 exercise groups that physicians can hemodynamic and understand Turkish, significant valvular heart revealed no significant differences recommend home-based parameters. absence of psychiatric disease, AF, uncontrolled between them regarding the analyzed exercise under strict Karapolat, Hale. disease, ability to remain arterial HTN, performing variables. supervision for stable HF 2009 stable during exercise tests exercise training at regular pts. 19641843 (129) intervals during the previous 6 wk. Endurance To determine whether RCT 59 Age >60 y, Valvular disease as the Exercise N/A Better in Exercise Training Group: Failed to produce exercise training exercise training diagnosed with HfrEF, primary etiology of HFrEF, performance, LV Mean cycle ergometer distance per consistent benefits in a in older pts with improves exercise LVEF <45% recent stroke or MI, structure and function, session (p=0.001) cohort or elderly pts with HF: results from capacity and HRQoL uncontrolled HTN, neuroendocrine Combined walking & cycling distance HFrEF that included a a randomized, in older persons with any other condition limiting activation and (p=0.001) significant portion of controlled, single- HFrEF. exercise duration HRQoL. Peak exercise workload (watts) women. Exercise time blind trial. (p=0.007) and peak workload Brubaker, Peter. Exercise time (seconds) on the bike increased but VO2 peak, 2009 (p=0.002) the primary outcome, did 20121952 (130) All other outcome measures did not not. Exercise training show significance. failed to provide benefits in any of the 4 primary endpoints.
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Effects of To test the effects of RCT 2,331 Medically stable, HF outpt, Unable to exercise, Health status At 3 mo the KCCQ overall summary Exercise training exercise training exercise training on LVEF <35%, already exercising (assessed by the score improved by a greater degree in conferred modest but on health status health status among NYHA II-IV, regularly (>1/wk), KCCQ) the exercise training group (p< 0.001; statistically significant in pts with pts with HF. ability and willingness to had experienced a major 95% CI: 0.84-3.01) improvements in self- chronic HF. undergo exercise training CV event in the previous 6 reported health status Flynn, Kathryn. wk At 3 mo there were no further significant compared with usual 2009 changes in KCCQ score for either care without training. 19351942 (131) group (p= 0.85), resulting in sustained, Improvements occurred greater improvement overall for the early and persisted over exercise group (p< 0.001). time.
Changes from baseline to 12 mo in the KCCQ overall summary score were associated with changes in exercise time: Cardiopulmonary exercise test: (r=0.28; p< 0.001) Peak O2 consumption: (r=0.21; p< 0.001)
6-min walk distance (r=0.18; p<0.001)
Based on these relationships, a 49.7-m change in distance walked corresponds to an individual's change of 5 points on the KCCQ overall summary score.
Resistance To determine if Systematic 241 pts Adults with chronic HF None specified Cardiac function, N/A Resistance training significantly Resistance training training increases resistance training review with from 8 trials Diagnosis based on clinical exercise capacity, increased 6-min walk distance: WMD: increased 6-min walk 6-min walk improves heart meta- signs or LVEF <40% QoL. 52m; 95% CI: 19-85 distance compared to no distance in function, exercise analysis of training, but had no other people with capacity and QoL in randomized benefits on cardiac chronic HF: a people with chronic trials function, exercise systematic HF more than no capacity, or QoL if used review. Hwang, intervention or usual along or as an adjunct to Chueh-Lung. care. aerobic training in people 2010 with chronic HF. 20482475 (132)
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A randomized To assess the RCT 169 LVEF <40% on ECHO; NYHA IV Disease-specific QoL Composite At 6 mo, there was no between-group This study failed to trial of the effectiveness of a had a severity of at least MI; measured by the outcome of difference in the disease-specific QoL demonstrate a benefit addition of home- home-based exercise NYHA II in the previous 24 revascularization within the MLHFQ death or MLHFQ (95% CI: -7.87-2.80) from the addition of a based exercise to program in addition to mo; past 4 mo; admission with home-based exercise specialist HF specialist HF nurse clinically stable for 4 wk; in hypotension; HF or At 12 mo, there was no between-group program in a community- nurse care: the care. receipt of optimal medical UA; myocardial difference in the disease-specific QoL based HF population. Birmingham treatment and in the care of ventricular or symptomatic infarction. MLHFQ (95% CI: -5.87-4.76) Further evidence is Rehabilitation a specialist HF nurse team arrhythmias; Psychological needed to assess the Uptake from 2 acute hospital trusts obstructive aortic valvular wellbeing, self- suitability Maximization and 1 primary care trust in disease; reported The only secondary outcomes of home-based exercise study for pts with the West-Midlands region, COPD; physical significant for exercise group: programs in this CHF (BRUM- UK; hypertrophic obstructive activity, blood Higher generic QoL scores at 6 mo population. CHF) study. not considered high-risk for cardiomyopathy; pressure, (95% CI: 0.04-0.18) Jolly, Kate. 2009 a home-based exercise severe musculoskeletal generic Lower hospital anxiety and depression 19168520 (133) program. problems preventing HRQoL, and scale score at 12 mo (95% CI: -2.00 - - exercise; health care 0.14) case-note reported utilization. dementia; At 6 mo, the control group showed current severe psychiatric deterioration in physical activity, disorder exercise capacity and generic QoL. Exercise training To test the hypothesis RCT 53 Stable with no medication Contraindication to Peak exercise oxygen QoL; LV Peak exercise oxygen uptake increased This randomized, in older pts with that supervised changes for >6 wk; exercise testing or training; uptake morphology significantly in the exercise treatment controlled, single-blind HF and exercise training in HFpEF defined as history, unable to perform a and function, group compared to the control group study showed that preserved EF. older pts with HFpEF symptoms and signs of HF valid baseline exercise and (p= 0.0002). 16 wk of exercise training Kitzman, Dalane. would improve the Preserved LVEF (>50%); test; neuroendocrine was safe and 2010 primary no evidence of significant currently exercising function There were significant improvements in significantly improved 20852060 (134) outcome of peak coronary, valvular or regularly; peak power output, exercise time, 6- peak and submaximal exercise VO2 and the pulmonary disease or any had known cancer; minute walk distance, and ventilatory exercise performance in secondary outcome of other medical condition that significant renal anaerobic older pts with disease-specific QoL. could mimic HF symptoms. dysfunction; threshold (all p< 0.002). HFpEF. These results substance abuse; suggest that this uncontrolled diabetes; There was improvement in the physical nonpharmacological dementia, quality of life score (but not in the total intervention may be a History of noncompliance; score) (p= 0.03). worthwhile consideration any other disorder that for pts with this common would preclude and increasingly participation in the prevalent disorder. intervention and follow-up.
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Effects of To examine the RCT 181 Documented clinical signs Inability to attend regular 6MWT Peak oxygen Significant increase in 6-min walk Exercise training exercise training effects of exercise and symptoms of HF exercise training sessions; uptake, distance at 3 and 12 mo (p= 0.026) but improves peak oxygen in pts with HF: training on functional LVEF <40%, exercise testing limited by dynamic no between-group differences (p= uptake and strength the exercise capacity in pts with NYHA I-III, angina or leg claudication; muscle 0.081). during supervised rehabilitation trial HF. 6MWT distance <500 abnormal blood pressure strength, QoL, training. Over the final (EXERT). meters response to exercise and cardiac Incremental peak oxygen uptake 9 mo of the study, there McKelvie, testing; function increased in the exercise group was little further Robert. 2002 cerebrovascular or compared with control group: improvement, suggesting 12094184 (135) musculoskeletal At 3 mo: (p=0.014); that some supervision is disease preventing At 12 mo: (p=0.014) required for these pts. exercise testing or training; There were no adverse respiratory limitation; At 3 mo, compared with the control effects on cardiac poorly controlled group, increases were seen in exercise function or clinical cardiac arrhythmias; group for: events. any noncardiac condition Arm Curl and affecting regular exercise Knee Extension: (p=0.014) training or decreasing survival. No significant changes observed in cardiac function or QoL.
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Combined To evaluate the effect Non- 285 Stable chronic HF; Severe pulmonary LVEF, N/A Women had a diagnosis of non-IHD The results of our study endurance and of a combined randomized LVEF <45%; disorders; cardiopulmonary and valvular heart disease more confirm the feasibility of a muscle strength endurance and study of men Peak VO2 <20 ml/min/kg; neurological deficits; performance, QoL commonly than men. combined endurance and training in female muscle strength vs. women. capable of answering cognitive disorders and resistance program, and male pts with training program on questions on HRQoL and physical disabilities which LVEF increased: especially for women. chronic HF. clinical performance psychological well-being. prevented pts from Female: p<0.001 Our findings show a Miche, Eckart. data and health- participating in a training Male: p<0.001 considerably reduced 2008 related psychosocial program. cardiopulmonary 18432395 (136) factors in women and LVEDV decreased: performance, negatively men. Female: p<0.05 affecting physical health. Male: p<0.05 In contrast, no essential restrictions were reported LVESV: by our groups regarding Female: p<0.001 mental health. This Male: p<0.001 underlines the importance of a physical Peak VO2: training program and its Female: p NS continuation at home Male: p<0.001 following the hospital stay in order to influence Wattmax (W): performance data Female: p<0.001 favorably. Male: p<0.001
6MWT (m): Female: p<0.001 Male: p<0.001
Muscle strength training: Female: p<0.001 Male: p<0.001
Physical Health: Female: p<0.001 Male: p<0.001
Mental Health: Female: p<0.01 Male: p<0.05
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Long-term effects To evaluate the long- RCT 80 Stable chronic HF; Acute MI within 4 wk; UA Functional capacity, QoL After 4 mo, in the exercise group: The results support of a group-based term effects of a 4- NYHA II-IIIB; pectoris; evaluated by 6-min Functional capacity improved the implementation of a high-intensity mo, group-based, receiving optimal medical serious rhythm walking distance. (p<0.001), group-based aerobic aerobic interval- high-intensity aerobic treatment; disturbance; QoL improved (p<0.001). interval training program training program interval training LVEF <40% or >40% with symptomatic peripheral to improve long-term in pts with program on functional clinical symptoms of vascular disease; After 12 mo, in the exercise group: effects on functional chronic HF. capacity and the QoL diastolic HF severe obstructive Functional capacity still improved capacity and the QoL in Nilsson, Birgitta. in pts with chronic HF. pulmonary disease; (p<0.001). pts with chronic HF. 2008 6MWT <550 m; QoL still improved (p=0.003). 18940296 (137) workload on the cycle ergometer test >110 W; significant comorbidities that would prevent study entry due to terminal disease or an inability to exercise In a long-term care establishment Efficacy and To test the efficacy RCT 2331 HF Major comorbidities or Composite of all- All-cause NS reductions in primary or secondary Regular exercise training safety of exercise and safety of exercise LVEF <35%, limitations that could cause mortality or all- mortality, the endpoints. in pts with systolic HF training in pts training among pts NYHA II-IV,despite optimal interfere with exercise cause hospitalization. composite was safe. In the protocol- with chronic HF. with HF. HF therapy for at least 6 wk training, recent or planned of CV mortality In prespecificed supplementary specified primary O'Connor, major CV events or or CV analyses adjusting for highly prognostic analysis, exercise Christopher. procedures, hospitalization, baseline characteristics there were training resulted in 2009 performance of regular and the reductions in the exercise training group nonsignificant reductions 19351941 (138) exercise training, composite of for: in the primary endpoint of use of devices that limited CV mortality All-cause mortality or hospitalization: all-cause mortality or the ability to achieve target or HF (p=0.03; 95% CI: 0.81-0.99) hospitalization and in heart rates. hospitalization. secondary endpoints. CV mortality or HF hospitalization: After adjustment for (p=0.03; 95% CI: 0.74-0.99) highly prognostic predictors of the primary endpoint, exercise training was associated with modest significant reductions for both all- cause mortality or hospitalization and CV mortality or HF hospitalization.
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Exercise training To determine the Collaborativ 801 pts Randomized parallel group Trials of arm or single leg Time to death. Death or time Exercise training significantly reduce Meta-analysis of meta-analysis of effect of exercise e meta- from 9 trials controlled trials, training were excluded to admission to mortality (p=0.0015; 95% CI: 0.46-0.92) randomized trials gives trials in pts with training on survival in analysis evaluate exercise training hospital. no evidence that properly chronic HF pts with HF due to LV without any other Exercise training significantly reduced supervised medical (ExTraMATCH). systolic dysfunction. simultaneous intervention, death or admission to hospital (p=0.01 training programs for pts Piepoli. 2004 study pts with stable HF (3 95% CI: 0.56-0.93). with HF might be 14729656 (139) mo or more of stability) due dangerous, and indeed to left systolic ventricular there is clear evidence of dysfunction (LVEF <50%), an overall reduction in have an exercise program mortality. lasting 8 wks or more, utilize training involving at least both legs, have survival follow up of ≥3 mo. Randomized trial To evaluate whether RCT 96 (16 HF Community-dwelling, NYHA class IV, Overall exercise Muscle Women with chronic HF had High-intensity of progressive strength training in 80 control) female, MI within 6 mo, capacity (6-min walk metabolism significantly lower muscle strength than progressive resistance resistance elderly pts with age >65 hospitalization for chronic distance) and muscle and histology, women without chronic HF (p<0.0001). training improves training to chronic HF would be mild to moderate, stable HF within 2 mo, function. body impaired skeletal muscle counteract the well tolerated and systolic HF, change of HF therapy composition, In resistance trainers (vs. controls): characteristics and myopathy of result in improved NYHA I-III, within 1 mo, maximal Strength improved (p<0.0001); overall exercise chronic HF. Pu, overall exercise resting LVEF <45% UA pectoris, fixed oxygen Muscle endurance improved performance in older Charles. 2001 performance without ventricular rate pacemaker, consumption, (p<0.0001); women with chronic HF. 11356801 (140) changes in central abdominal aortic aneurysm and cardiac 6-minute walk distance increased These gains are largely cardiac function. >4 cm, major limb function, (p<0.0003). explained by skeletal amputation, symptomatic muscle and not resting abdominal or inguinal Increases in type 1 fiber area and cardiac adaptations. hernias citrate synthase activity in skeletal Folstein mini-mental state muscle were independently predictive examination score <23, of improved 6-min walk distance (r2 = significant abnormalities on 0.78; p=0.0024). maximal treadmill testing or screening strength testing
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The effects of To investigate the RCT 77 Chronic HF for at least 6 Interfering disease such as LVEF, body N/A Workload and peak oxygen In chronic HF pts, home- physical training effect of physical mo, COPD, composition, daily consumption decreased in the control based training in on workload, training on upper leg NYHA II-III, fasting glucose <7.0 physical activity, group and increased in the training conjunction with a upper leg muscle muscle area, muscle clinically stable for at least mmol/L (DM), exercise performance, group (p<0.05). supervised strength and function and strength and muscle 3 mo, neuromuscular disorders, upper leg muscle area endurance training muscle areas in endurance expressed received optimal medical HTN and isokinetic leg Hamstrings area decreased in the program is safe, feasible pts with chronic as upper leg muscle therapy, muscle variables. control group and did not change in the and effective and does HF. Senden, Jeff. function in relation to physically able to visit the training group (p<0.05). not require complex 2005 exercise outpt clinic, training equipment. 15823638 (141) performance. LVEF <35% Upper leg muscle function improved in Physical training the training group and did not change in prevented loss of the control group (p<0.05). hamstrings muscle mass and improved exercise At baseline and after intervention nearly performance by 60% of the variance in maximal enhancing muscle workload was explained by upper leg strength and endurance. muscle function and quadriceps muscle area. Antiremodeling To determine whether RCT 90 HF secondary to idiopathic Any systemic disease Cardiopulmonary N/A Differences from baseline to 6 mo In stable chronic HF, effect of long- long-term exercise DCM, IHD or valvular limiting exercise, exercise testing, improved in the intervention group for: long-term moderate term exercise training may influence disease, hypertrophic 6MWT, ECHO, and EF (p<0.001), exercise training has no training in pts LV volume and LVEF <35% by ECHO, cardiomyopathy, QoL. Work capacity (p<0.001), detrimental effect on LV with stable function in a large clinical stability for at least 3 valvular disease requiring Peak VO2 (p<0.006), volumes and function; chronic HF. cohort of pts with mo under optimized surgery, Walking distance (p<0.001), rather, it attenuates Giannuzzi, stable CHF. therapy, angina pectoris, QoL (p<0.01), abnormal remodeling. Pantaleo. 2003 NYHA II-III, sustained ventricular LV volumes (diminished) (p<0.006), Furthermore, exercise 12860904 (127) peak oxygen uptake (VO2) arrhythmias, Trend to fewer readmissions for training is safe and <20mL/kg/min at severe HTN, worsening dyspnea (EDV p<0.05 ESV) effective in improving ergospirometry, excess variability >10% at exercise tolerance and echocardiographic images baseline cardiopulmonary LV volumes increased in control group QoL. of adequate quality for exercise test (p<0.0.01 EDV ESV) quantitative analysis
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Exercise training To assess circulating Prospective, 80 LVEF <30%, Recent ACS or Circulating N/A At baseline, adiponectin levels were Circulating adiponectin reduces adiponectin non- NYHA II-III, revascularization, adiponectin significantly higher in chronic HF pts concentrations circulating concentrations in randomized symptoms had been stable valvular disease requiring concentrations, compared with healthy subjects are higher in chronic HF adiponectin chronic HF pts, trial on medical treatment for at surgery, exercise capacity, (p=0.015). pts compared with levels in pts with compare with least 1 mo prior to inclusion exercise-induced anthropometric data healthy subjects and chronic HF. Van controls, and evaluate myocardial ischemia or and NT-proBNP At baseline, stratification of pts increase with disease Berendoncks, the effects of a 4-mo malignant ventricular levels. according to tertiles of NT-proBNP severity. An. 2010 exercise training arrhythmia, acute revealed an increase in adiponectin Exercise training for 4 19656085 (142) program. myocarditis or pericarditis, with disease severity (p<0.001). mo lowers circulating cerebrovascular or adiponectin levels. The musculoskeletal disease Exercise training significantly reduced present findings, together preventing exercise testing circulating adiponectin levels in the with those from other or training, trained chronic HF group (compared to studies, suggest that acute or chronic infections, sedentary chronic HF group) (p=0.008) dysregulation of the allergies, cancer or adiponectin pathway inflammatory disease, DM. contributes to the observed metabolic impairment in chronic HF Effects of To determine the Meta- 35 trials RCTs, Studies in which only Cardiac performance, N/A During maximal exercise, significant Exercise training has exercise training effect of exercise analysis of included pts with chronic respiratory muscles or one exercise capacity and summary effect sizes were found for: clinically important on cardiac training in pts with RCTs HF in the control and in the isolated muscle group was HRQoL. SBP (p=0.03), effects on exercise performance, chronic HF on cardiac intervention group trained. Heart rate (p=0.011), capacity and health- exercise capacity performance, (diagnosis based Cardiac output (p=0.004), related quality of life, and and QoL in pts exercise capacity and on clinical findings or LVEF Peak oxygen uptake (p=0.00), may have small positive with HF. Van Tol, HRQoL. <40%), included at least 1 Anaerobic threshold (p=0.00), effects on cardiac Benno. 2006 treatment group receiving 6MWT (p=0.00). performance during 16713337 (143) exercise training and 1 exercise. control group which The MLHFQ improved by an average of received standard medical 9.7 points (p=0.00). treatment w/o additional exercise training, evaluated outcome measures in terms of cardiac performance, exercise capacity and/or HRQoL, exercise training had to include at least one of the following training modalities: walking, cycling or resistive training of peripheral muscles. 6MWT indicates 6 minute walk test; ACS acute coronary syndrome; AF, atrial fibrillation; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CV, cardiovascular; DCM, dilated cardiomyopathy; DM, diabetes mellitus; ECHO, echocardiography; EF, ejection fraction; EXERT, Exercise Rehabilitation Trial; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fration; HRQoL, health related quality of life; HTN,
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hypertension; IHD, ischemic heart disease; KCCQ, Kansas City Cardiomyopathy Questionnaire; LV, left ventricular; LVEDV, left ventricular end-diastolic volume; LVEF, left ventricular ejection fraction; LVESV, left ventricular end-systolic volume; MI, myocardial infarction; MLHFQ, Minnesota Living with Heart Failure Questionaire; N/A, not applicatble; NT-proBNP, N-terminal pro-B-Type natriuretic peptide; N/A, not applicable; NS, not significant; O2, oygen; pt, patient; QoL, quality of life; r2, coefficient of determination; RCT, randomized control trial; SSW, Stead-state workload; UA, unstable angina; UK, United Kingdom; and VO2, oxygen volume.
Data Supplement 17. Diuretics Versus Ultrafiltration in Acute Decompensated HF (Section 7.3.2.1) Study Name, Aim of Study Study Study Patient Population Endpoints Statistical Analysis (Results) Study Findings/ Author, Year Type Size Limitations Comments Diuretic Inclusion Criteria Exclusion Criteria Primary Endpoint Secondary studies Endpoint DOSE-AHF, To compare high and RCT 308 Prior clinical BNP <250 mg/mL or NT-proBNP Pt well-being, as Weight loss; Comparison of bolus vs. continuous N/A N/A Felker, 2011 low doses of diuretics diagnosis of HF <1000 mg/mL; IV vasoactive determined by VAS; Proportion of pt infusion: no significant difference in 21366472 administered over that was treated treatment or ultrafiltration therapy change in SCr free of congestion; either (144) longer and shorter with daily oral loop since initial presentation; treatment change in the pts' global assessment of symptoms periods of time to diuretics for at plan includes IV vasoactive bivariate (mean AUC, 4236±1440 in the bolus vs determine the safest least 1 mo; treatment or ultra-filtration; relationship of 4373±1404 in the infusion group, and most effective current diagnosis substantial diuretic response to creatinine vs. p=0.47) combination. of HF, as defined prerandomization diuretic dosing weight loss; Mean change in creatinine level by the presence of such that higher doses of diuretics dyspnea, as (0.05±0.3 mg/dL in the bolus vs at least 1 symptom would be medically inadvisable; determined by 0.07±0.3 mg/dL in the infusion group, (dyspnea, SBP <90 mm Hg; SCr >3.0 mg/dL VAS; pt global p=0.45) orthopnea, or at baseline or currently undergoing assessment, as Secondary Endpoints: No significant edema) and 1 sign renal replacement therapy; determined by differences, including SCr and cystatin (rales on hemodynamically significant VAS; change in C levels during index hospitalization and auscultation, arrhythmias; ACS within 4 wk prior SCr; Change in at 60 d. Comparison of high-dose vs. peripheral edema, to study entry; active myocarditis; cystatin C; low-dose strategy: no significant ascites, pulmonary hypertrophic obstructive worsening or difference in pts' global assessment of vascular cardiomyopathy; severe stenotic persistent HF, symptoms, although there was a congestion on valvular disease; restrictive or defined as a need nonsignificant trend toward greater chest constrictive cardiomyopathy; for rescue therapy; improvement in the high-dose group radiography); complex congenital heart disease; development of (mean AUC, 4430±1401 vs. daily oral dose of constrictive pericarditis;. non- cardio-renal 4171±1436; p=0.06; mean change in furosemide 80 mg- cardiac pulmonary edema; clinical syndrome, defined creatinine level (0.08±0.3 mg/dL with 240 mg (or evidence of digoxin toxicity; need as an increase in the high-dose strategy and 0.04±0.3 equivalent); for mechanical hemodynamic the SCr level >0.3 mg/dL with the low-dose strategy, identified within 24 support; sepsis; terminal illness mg/dL; net fluid p=0.21). Secondary h of hospital (other than HF) with expected loss; time from endpoints: The high-dose strategy was admission; survival time of <1 y; history of study entry to associated with greater diuresis (net current treatment adverse reaction to the study discharge during fluid loss and weight loss) and greater plan includes IV drugs; use of IV iodinated index relief from dyspnea but also with loop diuretics for at radiocontrast material within 72 h hospitalization; transient worsening of renal function least 48 h prior to study entry or planned death or total days (occured in 23% of pts in the high-dose during hospitalization; enrollment hospitalized for vs 14% in the low-dose group, p=0.04) © American College of Cardiology Foundation and American Heart Association, Inc. 60
or planned enrollment in another HF; death or re- Clinical composite endpoint of death, clinical trial during hospitalization; hospitalization rehospitalization, or ED visit during the inability to comply with planned 60-d follow-up period: HR with study procedures continuous infusion: 1.15; 95% CI: 0.83- 1.60; p=0.41, HR with high-dose strategy, 0.83; 95% CI: 0.60-1.16; p=0.28 PROTECT, Rolofylline, an RCT 2,033 Persistent dyspnea Pregnant or breast feeding; acute Primary end point was Two secondary Rolofylline did not provide a benefit with Post hoc Rolofylline did Massie, 2010 adenosine A1-receptor at rest or with contrast induced nephropathy, treatment success, outcomes were respect to the primary endpoint (OR: selection of the not have a 20925544 antagonist, would minimal activity, sepsis, serum potassium treatment failure, or no prespecified: death 0.92; 95% CI: 0.78-1.09; p=0.35). best of 3 dose favorable effect (145) improve dyspnea, impaired renal <3.5mEq/L; ongoing or planned IV change in the pt's condition. from any cause or Persistent renal impairment developed groups from the with respect to reduce the risk of function (an therapy for acute HF with positive Success defined as pt- rehospitalization in 15% of pts in the rolofylline group and pilot trial with the primary WRF, and lead to a estimated CrCl of inotropic agents, vasopressors, reported moderate or for cardiovascular in 13.7% of pts in the placebo group multiple small clinical more favorable clinical 20-80 mL/min with vasodilators, or mechanical marked improvement in or renal causes (OR: 1.11; 95% CI: 0.85-1.46; p=0.44). treatment groups composite end course in pt with acute the use of the support, with the exception of IV dyspnea both 24 and 48 h through d 60 and By 60 d, death or readmission for carries the risk point, nor did it HF Cockcroft−Gault nitrates, BNP<500; ongoing or after administration of the the proportion of cardiovascular or renal causes had that an apparent improve renal equation), a BNP planned UF, hemofiltration or study drug, in the absence pts with persistent occurred in similar proportions of pts superiority may function or 60- level of ≥500 dialysis; severe pulmonary of any criterion for failure. renal impairment, assigned to rolofylline, 386 of 1356 pts be the play of d outcomes. It pg/mL or more or disease; significant stenotic Failure defined as the defined as an (Kaplan–Meier estimate, 30.7%; 95% chance and may does not show an NT-pBNP level valvular disease, heart transplant occurrence of any of the increase in the SCr CI: 27.8-33.6) as compared with 195 of have resulted in promise in the ≥2000 pg/mL, recipient or admitted for cardiac following: death or level ≥0.3 mg/dL 677 pts assigned to placebo (Kaplan– the inability to treatment of ongoing IV loop- transplantation readmission for HF through by d 7, confirmed Meier estimate: 31.9%; 95% CI: 27.4- replicate pilot acute HF with diuretic therapy, d 7, worsening symptoms at d 14; the 36.4) (HR: 0.98; 95% CI: 0.83-1.17; study findings in renal and enrollment and signs of HF occurring initiation of p=0.86). AE rates were similar overall; this more dysfunction within 24 h after >24 h after the initiation of hemofiltration or however, only pts in the rolofylline group definitive, larger admission. the study drug requiring dialysis through d had seizures, a known potential adverse study. Also, intervention by d 7 or 7; or death by d 7. effect of A1-receptor antagonists1. clinical relevance discharge (if earlier), or of endpoints has persistent WRF, defined as been questioned an increase in the SCr level ≥0.3 mg/dL (26.5 μmolL) from randomization to d 7, confirmed at d 14, or the initiation of hemofiltration or dialysis during the period from initiation of the study drug through d 7. Pts were classified as having unchanged treatment status if they met neither the criteria for treatment success nor the criteria for treatment failure.
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DAD-HF, Evaluate the effect of RCT 60 Age >18 y; history Acute de novo HF; severe renal Incidence of WRF during Changes in SCr, Mean hourly excreted urine volume Relatively small This study Giamouzis, low-dose dopamine of HF; failure (admission SCr >215 the first 24 h from urea, potassium, (272±149mL in high-dose furosemide study, 2 groups shows that 2010 and furosemide on deterioration of HF, mmol/L [2.5 mg/dL] or eGFR <30 randomization. 2 and eGFR during vs 278±186mL in LDFD plus low-dose did not receive LDFD infusions 21111980 diuresis and renal symptoms of mL min 1 1.73 m2); admission SBP definitions were used for the first 24 h from dopamine group; p=.965) and changes the same dose of are as effective (146) function in pts with recent onset (<6 <90 mm Hg; severe valvular WRF: 1) >0.3 mg/dL rise in randomization; in dyspnea score (Borg index: 4.4±2.1 furosemide and as high-dose acute decompensated h), dyspnea at disease; known adverse reactions SCr level from baseline to incidence of WRF in high-dose furosemide group vs did not include a furosemide HF rest, orthopnea, to furosemide or dopamine; HF 24 h; and 2) >20% over the course of 4.7±2.0 in LDFD group; p=.575) during low-dose infusions in and paroxysmal secondary to congenital heart decrease in eGFR from hospitalization; the 8 h of protocol treatment were furosemide only terms of clinical nocturnal dyspnea, disease; a scheduled procedure baseline to 24 h total length of stay; similar in the two groups. WRF was group. and diuretic accompanied by with a need for IV contrast dye in and 60-d mortality more frequent in the high-dose response in pts signs of the present hospitalization; and a or rehospitalization furosemide (n=9; 30%) than in the hospitalized for congestion (third scheduled cardiac surgery within 2 rate (all-cause, LDFD group (n=2; 6.7%; p=.042). acute heart sound, mo. cardiovascular, Serum potassium changed from decompensate jugular venous and worsening of 4.3±0.5 to 3.9±0.4mEq/L at 24 h d HF. distension, HF). (p=.003) in the high-dose furosemide Moreover, pulmonary rales) group and from4.4±0.5 to LDFD infusion on physical 4.2±0.5mEq/L at 24 hours (p=.07) in the was associated examination; levels LDFD group. Length of stay and 60-d with of serum BNP mortality or rehospitalization rates (all- significantly >400 pg/mL or NT cause, cardiovascular, and worsening lower rates of pBNP >1,500 HF). WRF than pg/mL; and oxygen high-dose saturation <90% furosemide, on admission. suggesting a renoprotective effect in this pt population.
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Pilot Pilot study of RCT 41 Primary diagnosis End-stage renal disease or Change in SCr from Cumulative urine None of the outcomes showed a Smaller study No statistically continuous furosemide by of acute anticipated need for renal admission to hospital d 3 or output and other statistically significant difference significant vs bolus continuous infusion vs decompensated replacement therapy; were not hospital discharge electrolyte between bolus and continuous dosing differences infusion twice-d bolus injection. HF; evidence of expected to survive hospitalization; changes from from admission to hospital d 3. noted between (Duke), L Hypothesis that volume overload; pregnant admission to Nonsignificant trend toward bolus and Allen, 2010 continuous dosing of could be hospital d 3 as well improvement in the bolus dosing arm. continuous 20538132 IV furosemide randomized <24 h as hospital length Decreases in serum potassium, serum infusion (147) provides gradual from hospital of stay sodium, and SBP showed nonsignificant diuresis with less presentation trends in favor of continuous infusion neurohormonal activation, which would manifest as less renal dysfunction, compared to bolus dosing in the treatment of acute decompensated HF with volume overload Pilot Pilot study comparing RCT 56 Admission Pts who had received >2 doses of Net daily urine output Net daily urine Mean urine output in 24 h was Smaller study LOS shorter continuous the effectiveness of diagnosis of acute IV fruosemide before output normalized 2,098±1,132 mL in pt receiving and mean vs bolus continuous IV with decompensated randomization for amount of continuous vs 1,575±1100 mL in the urine output infusion intermittent IV infusion HF furosemide bolus group (p=0.086). Total urine greater in the (MUSC), of furosemide in pt received, total output was 3726±1121 mL/24 h in the continuous Thomson, with acute daily urine output continuous group vs 2,955±1,267 infusion group 2010 decompensated HF normalized for mL/24 h in bolus group (p=0.019). vs bolus group 20206891 amount of Length of hospital stay was 6.9±3.7 d in (148) furosemide the continuous group vs 10.9±8.3 d in received, weight the bolus group (p=0.006) loss during the study, need for additional HF therapy, duration of study drug dministration, length of hospitalization ADHERE, To determine the Registry 82,540 Pts in the Pts receiving vasoactive drugs or Increase from baseline to Inhospital Both before and after risk and ADHERE registry Among pts in Peacock, clinical and renal ADHERE registry dialysis. Those who received last available SCr > 0.5 mortality, ICU propensity adjustments, an increase in data were the ADHERE 2008 outcomes associated who received IV multiple types of diuretics. Pts with mg/dL; admission, ICU SCr >0.5 mg/dL occurred less retrospective and registry, After 18480204 with lower vs higher IV diuretics during a SCr values >6 mg/dL or decrease in GFR >10 LOS >3 d, and frequently in LDD admissions than in observational so covariate and (149) loop diuretic dose in hospitalization for hospitalizations with LOS <4 h mL/min from baseline to hospital LOS >4 d HDD admissions (both p<0.0001). The should be propensity pts hospitalized with acute were excluded from the analysis of discharge; initiation of prevalence of a >10 mL/min decrease in regarded as adjustments, acute decompensated decompensated change in SCr and dialysis dialysis during GFR from baseline to discharge was hypothesis the inhospital © American College of Cardiology Foundation and American Heart Association, Inc. 63
HF. This study HF. initiation. Pt with SCr values >6 hospitalization. significantly lower in LDD vs HDD generating. mortality risk of analyzed data from the mg/dL, GFR values >200 mL/min, admissions (p <0.0001). Significant Clinical reasons pts who ADHERE registry to or hospitalizations with LOS <24 h differences between cohorts present for initiation of IV received LDD look at the impact of were excluded from the analysis of after risk and propensity adjustments. diuretics was not was diuretic dosing. 62,866 change in GFR. LDD treatment was associated with collected and significantly pt receiving <160 mg lower prevalence of prolonged ICU LOS therefore not lower and 19,674 pts ≥160 (nonsignificant differences). considered in compared to mg of furosemide were After covariate and propensity analysis. those receiving analyzed. adjustments: in-hospital mortality risk of HDD. LDD was significantly lower compared to HDD. AUC for adjusted model was 0.78. Unadjusted mortality OR 0.875; 95% CI: 0.787–0.973; p =0.01. After adjustment for covariates known to be associated with mortality – age, BUN, SBP, DBP, sodium, creatinine, heart rate and dyspnea at rest – adjusted OR was 0.888: 95% CI: 0.795– 0.993; p =0.0364 Cohort study This study was a Cohort 183 Eligible pts had to Pts were excluded if they required All pts were followed for 1 Secondary Compared with pts taking LDD (113 pts Smaller study, HDD may be high vs. low prospective have a primary renal replacement therapy, had a y. The primary outcome for outcomes included [62%]), pts taking HDD (70 pts[38%]) observational, more of a dose observational analysis diagnosis of concurrent noncardiac diagnosis the analysis was time to individual had more markers of increased single-center marker than a (Brigham and of pts in an advanced chronic HF and be expected to limit life expectancy to first HF event of HF components of the cardiovascular risk (older, ischemic cause of Women's) HF clinic stratified at followed by a less than 1 y, or were unable to admission, cardiac HF composite and cardiomyopathy, DM and HTN) and instability. A Mielniczuk, baseline by diuretic specialist in a participate in repeat clinical transplant, MCS, or death WRF, which was were more likely to have a history of history of HF 2008 dose (low dose ≤80 tertiary care HF assessments defined as an recent instability (33% vs 4.4% in low stability during 18514930 mg, high dose >80 mg clinic. Pts with increase in SCr dose, p< .001). SCr significantly higher the past 6 mo (150) furosemide equivalent) either preserved or >0.3 mg/dL from in pts receiving HDD vs. LDD (1.4 ± 0.5 is associated to evaluate the effect reduced systolic baseline mg/dL vs 1.1 ± 0.5 mg/dL, respectively, with an 80% of high/low (or no) function were p < .001). lower risk of an diuretic doses on included 1 y cumulative HF event rates HF event outcomes. significantly greater in pts taking HDD during the next when to low-dose/no diuretics (HF y, composite, 29% vs 4.5%, p<.01; HF independently hospitalization, 26% vs 4.5%, p< .01; of baseline MCS or transplant, 7.1% vs 2.7%, P = diuretic dose. .02; death, 2.9% vs 0.9%, p= .4; high vs low dose for all). Among pts taking HDD, those with a history of instability had significantly greater HF event rates during a 1-y period compared with pts with recent
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clinical stability (HF composite, 47% vs 18%, p =.013) Independently of diuretic dose, pts with a history of clinical stability had an 80% lower risk of developing an HF event . HDD were a strong univariate predictor of subsequent HF events (HR: 3.83, 95% CI: 1.82-8.54); however, after adjustment for clinical stability, diuretic dose no longer remained significant (HR: 1.53, 95% CI: 0.58-4.03). PROTECT Pilot study was RCT 301 Hospitalized for SBP <95 or >160 mm Hg; fever The prespecified primary Composite of Pts treated with rolofylline more likely to Limited by the The pilot, Cotter, designed to identify an acute HF with an >38°C; acute contrast-induced analysis for this pilot phase death or all-cause achieve success, as evidenced by study size and preservation of 2008 efficacious dose while estimated CrCl of nephropathy; resistant was a trichotomous readmission within improved dyspnea (52.7% vs 37.2%), number of renal function 18926433 refining inclusion 20-80 mL/min and hypokalemia; ongoing or planned classification of pts as 60 d and less likely to experience failure treatment groups. associated with (151) criteria and endpoints elevated natriuretic IV therapy with positive inotropic ”success,” “unchanged,” or (manifested by worsening HF, death, or Study was not rolofylline, a peptide levels agents, vasopressors, vasodilators ”failure” based on their renal impairment) compared with pts powered to selective renal were enrolled with the exception of IV nitrates, or changes in symptoms and treated with placebo (16.2% vs 28.2%). quantitatively vasodilator, is within 24 h of mechanical support (intra-aortic renal function. This pilot By comparing rolofylline 30 mg with distinguish the first presentation balloon pump, endotracheal phase was not powered to placebo, the OR estimated from the between the 3 evidence that intubation, or ventricular assist demonstrate statistically proportional odds model was 0.51 (95% active doses, an intervention device); severe pulmonary significant changes. The CI: 0.28–0.94). In the prespecified although trends to prevent disease; significant stenotic major objective was to subgroup of pts with higher natriuretic emerged renal valvular disease; previous heart evaluate the performance peptide levels, pretreatment BNP level suggesting a impairment transplant or admission for cardiac of this novel endpoint and ≥500, or NT pro-BNP ≥2000 pg/mL, dose-related may positively transplantation; clinical evidence of refine it on the basis of real- most likely representing more severe preservation of affect acute ACS <2 wk before screening; and world experience. acute HF, the OR from the proportional renal function and symptoms and acute HF caused by significant Treatment success was odds model was 0.59 (95% CI 0.30– increase in 60-d outcome arrhythmias; pts at high risk of defined as an improvement 1.17). SCr increased in pts receiving diuresis, as well in pts with seizures in dyspnea (reported by the placebo and remained stable or tended as a greater acute HF; pt using a 7-point Likert to decrease in those receiving effect on the however, scale as moderately or rolofylline. On d 14 the absolute composite results were markedly better compared differences between placebo and endpoint at the 30 not confirmed with study start) determined rolofylline for change in creatinine mg dose. in the phase III at 24 and 48 h after the increased with increasing rolofylline trial. start of study drug (d 2 and dose, reflecting the lesser increase in 3) or d of discharge if creatinine in rolofylline-treated pt (r = - earlier, as long as the pt did 0.12, p=.030). Treatment with 30 mg, not meet any of the criteria the dose selected for the pivotal trials, for treatment failure. was associated with a trend toward Treatment failure was reduced 60-d mortality or readmission defined as death, early HF for cardiovascular or renal cause (HR: readmission (occurring 0.55; 95% CI: 0.28-1.04).
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within 7 d of study drug initiation), worsening HF as defined daily by the physician assessment by d 7, or persistent renal impairment as defined above. Unchanged pts were classified as unchanged if neither criteria for success or failure were met. DIG, Ahmed, The objective of this Registry 7,788 Pts who were at Age <21 yrs; baseline EF not All-cause mortality and all- Mortality and All-cause mortality occurred in 173 pts Beta blockers Diuretic use 2008 propensity-matched ≥21 y of age were available; MI, cardiac surgery or cause hospitalization during hospitalizations not receiving diuretics and 208 pts were not associated with 17532064 study was to eligible for the PTCA within 4 wk; unstable or 36.7 mo of median follow- due to receiving diuretics respectively during approved for HF increased (152) determine the effect of main trial if they refractory angina <1 month; II-III up cardiovascular 2,056 and 1,943 person-y of follow-up during the DIG mortality diuretics on mortality had HF, a LVEF AV block without pacemaker; AF or causes and HF (HR:1.36; 95% CI: 1.08-1.71; p=0.009). trial and data on among elderly and hospitalizations in ≤45%, were in flutter; cor pulmonale; constrictive All-cause hospitalizations occurred in beta blocker use in the DIG trial HF pts ≥65 y. normal sinus pericarditis; acute myocarditis; 413 pts not receiving and 438 pts were not rhythm, and did hypertrophic cardiomyopathy; receiving diuretics respectively during collected not meet any of 20 amyloid cardiomyopathy; complex 1,255 and 1,144 person-y of follow-up easily determined, CHD; tx with IV inotropic agents; (HR: 1.18; 95% CI: 0.99-1.39; p=0.063). not overly K+ < 3.2 mmol/L or >5.5 mmol/L; Diuretic use was associated with restrictive on heart transplant list; noncardiac significant increased risk of exclusion criteria cause of HF; Creatinine >3.0 cardiovascular mortality (HR:1.50; 95% mg/dL or severe liver disease; CI:1.15-1.96; p=0.003) and HF unlikely to comply hospitalization (HR:1.48; 95% 95% CI: 1.13-1.94; p=0.005). EVEREST, To evaluate short-term RCT 2,048 Age ≥18 y with a Cardiac surgery within 60 d of Composite of changes in Dyspnea (d 1), Rank sum analysis of the composite N/A In pts Gheorghiade, effects of tolvaptan (trial A) history of chronic enrollment, cardiac mechanical global clinical status based global clinical primary endpoint showed greater hospitalized 2007 when added to and HF (requiring support, biventricular pacemaker on a visual analog scale status (d 7 or improvement with tolvaptan vs placebo with HF, oral 17384438 standard therapy in pts 2,085 treatment for a placement within the last 60 d, and body weight at d 7 or discharge), body (trial A, mean [+SD], 1.06 [0.43] vs 0.99 tolvaptan in (153) hospitalized with HF (trial B) minimum of 30 d comorbid conditions with an discharge if earlier weight (d 1 and 7 [0.44]; and trial B, 1.07 [0.42] vs 0.97 addition to before expected survival of less than 6 or discharge), and [0.43]; both trials p<.001). Mean (+SD) standard hospitalization) mo, acute MI at the time of peripheral edema body weight reduction was greater with therapy who had been hospitalization, hemodynamically (d 7 or discharge). tolvaptan on d 1 (trial A, 1.71 [1.80] vs including hospitalized significant uncorrected primary 0.99 [1.83] kg; p<.001; and trial B, 1.82 diuretics primarily for cardiac valvular disease, refractory [2.01] vs 0.95 [1.85] kg; p<.001) and improved worsening CHF end-stage HF, hemofiltration or day 7 or discharge (trial A, 3.35 [3.27] many, though and had a LVEF dialysis, supine systolic arterial vs 2.73 [3.34] kg; p<.001; and trial B, not all, HF ≤40% (measured blood pressure of less than 90 mm 3.77 [3.59] vs 2.79 [3.46] kg; p<.001). signs and at any point within Hg, SCr concentration >3.5 mg/dL Improvements in global clinical status symptoms, 1 y of admission). (>309.4 μmol/L), serum potassium were not different between groups. without serious Entry required HF concentration > 5.5 mEq/L, and More pts receiving tolvaptan (684 AE.
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symptoms at rest hgb of less than 9 g/dL [76.7%] and 678 [72.1%] for trial A and or minimal exertion trial B, respectively) vs pts receiving and signs of placebo (646 [70.6%] and 597 [65.3%], congestion (≥2 of respectively) reported improvement in the following: dyspnea at d 1 (both trials p<.001). dyspnea, jugular Edema at d 7 or discharge improved venous distention, significantly with tolvaptan in trial B (p or peripheral =0.02) but did not reach significance in edema) at time of trial A (p=0.07). Serious AE frequencies randomization. were similar between groups, without excess renal failure or hypotension EVEREST, To investigate the RCT 4,133 Pts age ≥18 y with Cardiac surgery within 60 d of Dual primary endpoints Composite of During a median follow-up of 9.9 mo, N/A Tolvaptan Konstam, effects of tolvaptan reduced LVEF enrollment, cardiac mechanical were all-cause mortality cardiovascular 537 pts (25.9%) in tolvaptan group and initiated for 2007 initiated in pts ≤40%, signs of support, biventricular pacemaker (superiority and mortality or 543 (26.3%) in placebo group died HR acute 17384437 hospitalized with HF volume expansion, placement within the last 60 d, noninferiority) and cardiovascular for mortality: 0.98; 95% CI, 0.87-1.11; treatment of (154) NYHA class III/IV comorbid conditions with an cardiovascular death or hospitalization; p=.68). Kaplan-Meier estimates of pts hospitalized symptoms, and expected survival of <6 mo, acute hospitalization for HF incidence of mortality at 1 y were 25.0% in the with HF had no hospitalization for MI at the time of hospitalization, (superiority only) cardiovascular tolvaptan group and 26.0% in the effect on long- exacerbation of hemodynamically significant mortality; and placebo group. term mortality chronic HF no uncorrected primary cardiac incidence of Composite cardiovascular death or or HF-related more than 48 h valvular disease, refractory end- clinical worsening hospitalization for HF: 871 tolvaptan morbidity. earlier were stage HF, hemofiltration or dialysis, of HF (death, group (42.0%) and 829 placebo group eligible for the supine systolic arterial bp < 90 mm hospitalization for (40.2%) HR: 1.04; 95% CI: 0.95-1.14; study Hg, SCr >3.5 mg/dL (309 μmol/L), HF, or p=.55). K+ level greater than 5.5 mEq/L, unscheduled visit Secondary endpoints of CV mortality, and hgb <9 g/dL. for HF). Additional CV death or hospitalization, and secondary worsening HF were also not different. endpoints included Tolvaptan significantly improved changes from secondary endpoints of d 1 pt-assessed baseline in body dyspnea (p<.001), with 74.3% of the weight at d 1, tolvaptan group and 68.0% of the serum sodium placebo group demonstrating an level at d 7 or improvement in dyspnea score, as well discharge in pts as d 1 body weight, and d 7 edema. In with a baseline pts with hyponatremia, serum sodium serum sodium levels significantly increased. The <134 mEq/L, KCCQ overall summary score was not edema score at d improved at outpt wk 1, but body weight 7 or discharge for and serum sodium effects persisted those with edema long after discharge. at baseline, pt- assessed dyspnea at d 1 for those
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with dyspnea at baseline, and KCCQ overall summary score at outpt wk 1.
DIG, Ahmed Non-potassium- Registry 2,782 The DIG trial Age <21 y; baseline EF All-cause mortality Mortality from Propensity scores for diuretic use were Based on non- Chronic (UAB), 2006 sparing diuretics are enrolled 7,788 unavailable; MI, cardiac surgery or worsening HF, and calculated for each of the 7,788 DIG randomized diuretic use 16709595 commonly used in HF. ambulatory chronic PTCA within 4 wk; unstable or hospitalizations participants using a non-parsimonious findings, was associated (155) They activate the systolic (LVEF refractory angina <1 mo; II-III AV due to all causes multivariable logistic regression model, retrospective. with increased neurohormonal ≤45%; n=6800) block without pacemaker; AF or and worsening HF and were used to match 1,391 (81%) Beta-blockers long-term system, and are and diastolic flutter; cor pulmonale; constrictive no-diuretic pts with 1,391 diuretic pts. were not mortality and potentially harmful. (LVEF >45%; pericarditis; acute myocarditis; Mean survival times for diuretic vs. no- approved for HF hospitalizations Yet, the long-term n=988) HF pts in hypertrophic cardiomyopathy; diuretic pts: 47 (95% CI: 46–48) and 50 during the DIG in a wide effects of chronic normal sinus amyloid cardiomyopathy; complex (95% CI: 49–51) mo. trial and data on spectrum of diuretic use in HF are rhythm, of whom CHD; tx with IV inotropic agents; All-cause mortality was 21% for no- beta-blocker use ambulatory largely unknown. This 6,076 (78%) were K+ < 3.2 mmol/L or > 5.5 mmol/L; diuretic pts and 29% for diuretic pts were not chronic systolic study retrospectively receiving diuretics on heart transplant list; noncardiac (HR: 1.31; 95% CI: 1.11-1.55; p=0.002). collected and diastolic analysed the DIG data cause of HF; Creatinine > 3.0 HF hospitalizations occurred in 18% of HF pts to determine the mg/dL or severe liver disease; no-diuretic pts and 23% of diuretic pts effects of diuretics on unlikely to comply (HR: 1.37; 95% CI: 1.13-1.65; p=0.001). HF outcomes. Effects Mortality due to HF occurred in 6% of of diuretics on pts in the no-diuretic group and 9% of mortality and those in the diuretic group (HR: 1.36; hospitalization at 40 95% CI 0.99–1.87; p=0.056). mo of median follow- Compared with 8% deaths among pts up were assessed never receiving diuretics during the first using matched Cox 24 mo of follow-up, 19% of those who
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regression models always received diuretics during the same time died from all causes (multivariable adjusted HR: 1.81; 95% CI 1.38–2.38; p<0.0001).
DIG, Investigate the Registry 6,797 HF and LVEF Age <21 y; baseline EF not All-cause death, N/A For death from HF or SCD, the incident Post-hoc study Among pts in Domanski, associations between ≤45% enrolled in available; MI, cardiac surgery or cardiovascular death, death rates were not significantly different and doses of the DIG trial, 2006 death, cardiovascular the DIG trial. The PTCA within 4 wk; unstable or from progressive HF, SCD, between the pts taking the PSD only diuretics were not compared with 16762792 death, death from DIG randomly refractory angina <1 mo; II-III AV and HF hospitalization versus no-diuretic group (p=.06, and available for pts not taking (156) worsening HF, SCD, assigned 6800 pts block without pacemaker; AF or p=.7, respectively); for the other 4 analysis. Also, did any diuretic or and HF hospitalization with HF and LVEF flutter; cor pulmonale; constrictive events (hosp for HF, death from CVD, not analyze taking a PSD, among those taking a ≤45% to digoxin or pericarditis; acute myocarditis; death from all causes, hosp or death effects of pts taking non- PSD, NPSD, or no placebo in a hypertrophic cardiomyopathy; from HF), the incidence rates were all treatment over PSD had a diuretic in the DIG trial double-blinded amyloid cardiomyopathy; complex significantly lower in the no-diuretic time. Beta- higher RR of controlled trial CHD; tx with IV inotropic agents; group than in the PSD-only group blockers were not death. K+ < 3.2 mmol/L or > 5.5 mmol/L; (p≤.01). For all 6 approved for HF on heart transplant list; noncardiac events, the incidence rates for the during the DIG cause of HF; Creatinine > 3.0 NPSD only group were significantly trial and data on mg/dL or severe liver disease; higher than the PSD-only group (p≤.02). beta blocker use unlikely to comply The incidence rates for the NPSD-only were not group and both-diuretic groups were collected comparable and not significantly different with the p- values ranging from .07 to .6 (date not shown). After multivariate analysis, the risks of all 6 endpoints were increased in pts taking a NPSD, whether or not they were taking a PSD after adjusting for known covariates. There was no significant difference in the risk of any of these events for pts taking only PSD and those taking no diuretics. Compared with not taking diuretic, risk of death (RR: 1.36, 95% CI: 1.17–1.59, p<.0001), cardiovascular death (RR: 1.38, 95% CI: 1.17–1.63; p=.0001), progressive HF death (RR: 1.41, 95% CI: 1.06–1.89, p= .02), SCD (RR: 1.67, 95% CI 1.23–2.27, p=.001), and HF hospitalization (RR: 1.68, 95% CI: 1.41–
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1.99, p< .0001) were increased with NPSD. There was no significant difference in any endpoint for pts taking only PSD compared to no diuretic. PSD only subjects were less likely than NPSD subjects to be hospitalized for HF (RR: 0.71, 95% CI: 0.52–0.96, p=.02). Cohort study This study sought to Cohort 1,354 Study population Pts with LVEF >40%, those with All-cause mortality The composite Pts with HF in the highest diuretic dose Possible selection This study low vs. high determine the dose- consisted of 1,354 HF due to valvular disease, and endpoint of death quartile were found to have significantly bias. Diuretic suggests that dose (Cedars dependent relation consecutive pts those aged <18 y were excluded or urgent impaired survival compared with pts in dose was in pts with Sinai/ UCLA), between loop diuretic with advanced from the analysis transplant (status the lowest quartile. examined at only advanced Eshaghian, use and HF prognosis systolic HF IA) was analyzed Survival estimates at 1 y were 91%, a single point in systolic HF, the 2006 referred to a single as a secondary 88%, 80%, and 69% for quartiles 1, 2, time, without use of higher 16765130 university medical endpoint 3, and 4, respectively (p <0.0001). considering doses of loop (157) center for HF Survival estimates at 2 y were 83%, chnages in doses diuretics is management 81%, 68%, and 53%, respectively (p over time. associated with and/or transplant <0.0001). Death from any cause: HR: Baseline significantly evaluation from 3.4, 95% CI: 2.4-4.7 characteristics increased all- 1985 to 2004 death and urgent transplantation: HR and other HF cause 2.7, 95% CI 2.0-3.5 treatments mortality. death from progressive HF: HR: 3.8; different among Although it may 95% CI 2.1-6.8 the diuretic dose appear obvious sudden death: HR: 3.6; 95% CI: 1.9-6.8 quartiles. With that pts with Univariate analysis- compared with the adjustment for HF requiring lowest quartile, increasing loop diuretic multiple higher loop dose quartiles were associated with a covariates, larger diuretic doses progressive increase in mortality loop diuretic to prevent fluid (second quartile, HR: 1.2; 95% CI: 0.8- doses could still retention and 1.7; third quartile, HR: 2.1, 95% CI 1.5- be a surrogate for control 2.9; and fourth quartile, HR: 3.4; 95% CI other measured symptoms 2.4-4.7). Diuretic dose quartiles were and unmeasured might be sicker associated with increased mortality variables that than pts independent of other covariates. After reflect more receiving lower adjustment the highest diuretic quartile severe HF. doses, the remained a significant predictor of Serum potassium powerful and increased mortality at 1 y (HR: 4.2; 95% and magnesium independent CI: 1.5-11.3) and at 2 y (HR: 4.0; 95% level information association CI 1.9-8.4) was unavailable. with mortality Propensity warrants matching was not further performed. So the consideration. relation between
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loop diuretic dose and increased mortality is causative.
Cochrane To compare the Meta- 254 RCTs comparing N/A (7 studies) urine output, N/A Urine output: the output (as measured Available data Based on small review, 2005 effects and adverse analysis the efficacy of cc/24 h; in cc/24 h) was noted to be greater in were insufficient and relatively 16034890 effects of continuous continuous IV Electrolyte disturbances pts given continuous infusion with a to confidently heterogeneous (158) IV infusion of loop infusion versus (hypokalemia, WMD of 271 cc/24 h (95%CI: 93.1-449; assess the merits studies, this diuretics with those of bolus IV hypomagnesemia); adverse p<0.01). Electrolyte of the 2 methods review showed bolus IV administration administration of effects (tinnitus and hearing disturbances were not significantly of giving IV greater diuresis among pts with HF loop diuretics in HF loss); (single different in the two diuretics. The and a better class III-IV in a total of 8 study) duration of hospital treatment groups : RR 1.47; 95%CI: existing data did safety profile RCTs. stay and cardiac 0.52-4.15; p=0.5. not allow when loop mortality; (2 studies) all Less adverse effects (tinnitus and definitive diuretics were cause mortality hearing loss) were noted with recommendations given as continuous infusion: RR 0.06; 95%CI: for clinical continuous 0.01- 0.44; p=0.005. practice infusion. Duration of hospital stay was significantly shortened by 3.1 d with continuous infusion WMD -3.1; 95%CI - 4.06 to -2.20; p<0.0001; while cardiac mortality was significantly different in the two treatment groups, RR: 0.47; 95% CI: 0.33 to 0.69; p<0.0001. All-cause mortality was significantly different in the two treatment groups, RR: 0.52; 95% CI: 0.38- 0.71; p<0.0001. SOLVD, Study sought to Registry 6,797 Symptomatic and Only drug class was ascertained; Rates of hospitalization for N/A The risk of hospitalization from This study is This study Domanski, determine whether asymptomatic pts specific medications were not HF, death from worsening HF in those taking a PSD retrospective and, shows that in 2003 NPSDs in the absence with a LVEF recorded. cardiovascular disease, relative to those taking only a non-PSD therefore, not pts with 12932605 of a PSD may result in fraction <0.36 were death from all causes, and was 0.74; 95% CI 0.55-0.99; p= 0.047. definitive proof moderate or (159) progressive HF. randomly assigned either hospitalization or The RR for cardiovascular death was that NPSDs severe LV to double-blinded death due to worsening HF 0.74; 95% CI 0.59-0.93; p=0.011), for cause dysfunction, treatment with death from all causes 0.73; 95% CI: progressive HF. the use of a enalapril or 0.59-0.90; p=0.004), and for Because the PSD is placebo. hospitalization for, or death from, HF diuretic dosage associated with 0.75; 95% CI: 0.58-0.97; p=0.030). was not available, a reduced risk Compared with pts not taking any we cannot draw of death or diuretic, the risk of hospitalization or conclusions about hospitalization death due to worsening HF in pts taking a dose-response due to
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non-PSDs alone was significantly relationship. Also, progressive increased (RR:1.31: 95% CI: 1.09-1.57; baseline data HF, relative to p=0.0004); this was not observed in pts were used, and pts taking only taking PSDs with or without a NPSD diuretic treatment a non-PSD. (RR: 0.99; 95% CI: 0.76- 1.30; p=0.95). status may have changed over time
PRAISE, The prognostic Registry 1,153 LVEF <30% and Pts were excluded if their serum Death or cardiac N/A HDD were independently associated Retrospectiveolde Found that Neuberg, importance of diuretic NYHA functional potassium level was <3.5 or >5.5 transplantation with mortality, sudden death, and pump r study as pts high doses of 2002 resistance (as class IIIb/IV HF mmol/L and if their SCr level was failure death (aHR: 1.37 (p=.004), aHR: enrolled in loop diuretic 12094185 evidenced by a high- despite mandatory >3.0 mg/dL (270 >mol/L), and/or if 1.39 (p=.042), and aHR: 1.51 (p=.034), PRAISE were not (>80mg of (152) dose requirement) was background they met other standard exclusion respectively. on beta blockers. furosemide or retrospectively treatment with criteria Use of metolazone was an independent >2mg of evaluated in pts with digoxin, diuretics, predictor of total mortality (aHR: 1.37; buetanide advanced HF who and ACE inhibitors. p=.016) but not of cause-specific daily) were were enrolled in the mortality. In quartiles of loop diuretic independently PRAISE. dose, total mortality increased associated with progressively without a clear risk mortality in pts threshold, more than doubling from the with advanced lowest-dose group to the highest-dose HF. When group (p=.001). Unadjusted mortality degree of rates were 20.7% (n=152), 30.7% congestion was (n=313), 36.8% (n=304), and 44.8% considered (n=84) for increasing dose of together with furosemide (40 mg, 40-80 mg, 80-120 its treatment, mg, and 120 mg daily) or bumetanide the associated (1 mg, 1-2 mg, 2-3 mg, and 3 mg daily), risks were respectively. By proportional hazard additive, regression, high diuretic dose was an suggesting that independent predictor of total mortality diuretic (aHR: 1.37; p=0.004), sudden death (a resistance HR: 1.39, p=0.042), and pump failure should be death (aHR: 1.51, p=0.034). considered an indicatior of prognosis in chronic HF. However, retrospective analysis does not establish harm, nor rule out a long-term
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benefit of diuretic therapy. Ultrafiltration UNLOAD This study was RCT 19 Pts hospitalized for acute Pts with ACS, SCr >3.0 Urine output, GFR N/A 19 pts (59 +/- 16 y, 68% were male) Small single During a 48-h substudy designed to evaluate decompensated HF with mg/dL, SBP ≤ 90 mm Hg, (as measured by were randomized to receive UF (n= 9) center study. period, UF did not (Maryland), the consequences of an EF <40% and ≥2 hematocrit >45%, inability to iothalamate), and or IV diuretics (n= 10). The change in Pts receiving cause any Rogers, UF and standard IV signs of hypervolemia obtain venous access, or renal plasma flow (as GFR (-3.4 +/- 7.7 mL/min vs -3.6 +/- UF tended to significant 2008 diuretic (furosemide) based on at least 2 of the clinical instability likely to measured by para- 11.5 mL/min; p= .966), renal plasma have worse differences in renal 18226766 therapy on GFR and following findings: ≥2+ require IV nitroprusside or IV aminohippurate) flow (26.6 +/- 62.7 mL/min vs 16.1 +/- GFR at hemodynamics (160) renal plasma flow in pts pitting edema of the pressors, history of were assessed 42.0 mL/min; p= .669), and filtration baseline. compared with the with acute lower extremities, jugular administration of IV diuretics before fluid removal fraction (-6.9 +/- 13.6 mL/min vs -3.9 +/- Renal standard treatment decompensated HF. venous pressure ≥10 cm and/or vasoactive drugs and after 48 h. 13.6 mL/min; p= .644) after treatment hemodynamic of IV diuretics H2O, pulmonary edema during the present were not significantly different between outcomes or pleural effusion on hospitalization (except for a the UF and furosemide treatment were chest radiograph single dose of IV diuretics groups. No significant measured consistent with administered in the ED difference in net 48-h fluid removal during acute decompensated before hospitalization), use between the groups (-3211 +/- 2345 mL fluid removal congestive HF, ascites, of iodinated radiocontrast for UF and -2725 +/- 2330 mL for (48 h). paroxysmal nocturnal material, contraindication to furosemide, p= .682). UF removed 3666 Unknown as dyspnea, or ≥2 pillow the use of anticoagulation, +/- 2402 mL. to when orthopnea. systemic infection, or Urine output during 48 h was changes in hemodialysis were excluded significantly greater in the furosemide GFR or RPF from the substudy. group (5786 +/- 2587 mL) compared occur. The with the UF group (2286 +/- 915 mL, p< present study .001). does not assess any chronic effects of UF or diuresis.
UNLOAD, To compare the safety RCT 200 Pts hospitalized with ACS; creatinine >3.0; SBP Total weight loss Change in global Primary efficacy endpoints: Population While weight loss MR and efficacy of primary diagnosis of <90 mmHg; hematocrit during first 48 h; assessment; change in Weight loss was greater in the UF than not was greater and Costanzo, venovenous UF and acute decompensated >45%; prior administration of change in dyspnea QoL (living with HF); in the standard-care group (5.0 ± 3.1 kg representative rehospitalization at 2007 standard IV diruetic congestive HF; evidence IV vasoactive drugs in the score during first 48 changes in BNP; vs. 3.1 ± 3.5 kg; p=0.0001) of HF pts 90 d was lower in 17291932 therapy for of fluid overload as ED; clinical instability h. changes in 6 min walk Dyspnea scores were similarly (better renal the UF arm, data (161) hypervolemic HF pts indicated by: pitting requiring pressors during test; total fluid loss during improved in the UF and standard-care function, and not available on edema (2+) of lower hospitalization; recent use of first 48 h; changes in group at both 8 and 48 h. excluded pts long-term effects extremities; jugular iodinated contrast material; BUN and creatinine; Primary safety endpoints: with on renal function venous distension; severe concomitant disease changes in renin and Changes in SCr were similar in the 2 hypotention); or resource pulmonary edema or expected to prolong aldosterone; rate of groups throughout the study and % of industry utilization. The pts pleural effusion; ascites; hospitalization; sepsis; on or hospitalizations and pts with rise in SCr >0.3 mg/dL were sponsored; in trial represented
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paroxysmal nocturnal requires renal dialysis; unscheduled clinic and similar in both groups at 24 h, 48 h and small trial; hemodynamically dyspnea or 2-pillow history of cardiac transplant; ED visits in the wk after at discharge usual care stable/congested orthopnea heparin allergy. inpt treatment Serum potassium <3.5 mEq/l occurred group not HF pts that in 1% of the UF group and 12% of very respond very well diuretics group (p=0.018) aggressively to diuretics and treated have better outcomes vs. HF population in general. Case-series Present data on UF Case- 11 HF pts admitted to Mayo Contraindication to UF Change in creatinine; N/A 5 pts had significant rise in creatinine, Small study; In high risk (Mayo from a series of pts series clinic who have failed at fluid loss; 5 required dialysis, overall 6-mo single populations, (mean clinic), treated at the Mayo least 1 IV diuresis complications from mortality 55%, bleeding and institution; pts GFR of 38 mL/min) Liang, 2006 clinic who were treatment UF complications related to positional flow with much UF may not be the 17174232 generally sicker and were common. worse most appropriate (162) had failed at least 1 IV prognosis vs choice. treatment general HF population RAPID-CHF, Pilot study which RCT 40 Hospitalized with primary Severe stenotic valvular 24-h weight loss Total volume removal at No difference in 24-h weight loss Small study, UF group had Bart, 2005 compared a single 8-h diagnosis of HF; at least disease; ACS; SBP <90; 24 and 48 h; global HF (p=0.240), significantly more fluid pilot more fluid 16325039 UF intervention to usual 2+ edema of the lower hematocrit >40% and dyspnea removal with UF (4,650 mL in UF group removed, with no (163) care in pts admitted extremities and at least 5. poor peripheral venous assessments; serum vs. 2,838 mL in usual care group, significant change with decompensated either JVP >10, access; hemodynamic electrolytes; and length (p=0.001) and improved dyspnea in creatinine, HF pulmonary edema or instability; use of iodinated of hospital stay scores (p=0.039) and no change in however no pleural effusion on CXR, radiocontrast within 72 h of creatinine. Trend toward greater weight difference in 24 h pulmonary rales, consent or anticipated use; loss at 24 h in the UF group weight loss. pulmonary wedge or severe concomitant disease LVEDP >20, ascites, or pre-sacral edema EUPHORIA, Compared UF to Observat 20 Volume overload; Hematocrit >40%;. end- Weight loss; hospital Increase in creatinine An average of 8,367 ± 4,232 mL were Small Concluded that UF Costanzo, historical controls in ional modest degree of renal stage renal disease requiring length of stay >25%, hypotension; BNP removed with 2.6 ± 1.2, 8 h UF courses. observational decreases length 2005 order to determine if study dysfunction or diuretic dialysis; Hypercoagulability; levels Of the 19 pts 12 (68%) were discharged study; Single- of stay and 16325040 use of UF before any IV resistance (chronic daily SBP <85 mm Hg; in ≤3 d center series readmissions. (164) diuretics in pts with PO furosemide ≥80 mg, Requirement for IV compared the decompensated HF and or torsemide ≥ 40mg, or inotropes; Participation in treatment period modest renal bumetamide ≥ 2mg and another research study or with the pre- dysfunction SCr ≥1.5 mg/dl), previously in this trial treatment period, reestablishes euvolemia relatively high diuretic rather than with a and permits hospital requirement at baseline; randomized control discharge in ≤3 d, <12 h since cohort. without hypotension, a hospitalization, given no ≥25% increase in SCr. vasoactive drugs and <1 or other AEs. dose IV diuretic
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Agostoni, Investigated the RCT 16 Treated with a Pts with acute MI (<1 y), Scores of lung water; 3 mo after UF or IV diuretic, the Small older After UF, improved 1994 mechanisms involved in combination of angina pectoris, primary exercise test hemodynamic variables examined at study functional capacity 8154506 the regulation of salt digoxin, oral furosemide, valvular disease, intermittent parameters; plasma rest had returned to the control values continued for 3 mo (165) and water metabolism and ACE inhibitor claudication, fibrotic or renin, aldosterone in the diuretic group, but not the UF after the procedure in pt with HF. (captopril primary vascular lung and norepinephrine group. In the UF group, right atrial Extracorporeal UF was or enalapril) for chronic; diseases, sinus or pressure, pulmonary artery pressure utilized as a sinus rhythm; NYHA II-III atrioventricular node and wedge pressure were still as nonpharmacologic dysfunction, effort-induced reduced as they had been 24 h after method for withdrawal severe ventricular UF. (p<0.01, only figures displayed). of body fluid. arrhythmias or an artificial pacemaker Pepi, 1993 To investigate the RCT 24 NYHA functional class II- Severe tricuspid or mitral LVSF (from UF decreased radiological score of Small older Pathophysiological 8038023 pathophysiological III HF and clinically silent regurgitation; pleural, ultrasonography); extravascular lung water (from 15(1)- study; single study involving UF (166) (cardiac function and by radiologically evident pericardial or abdominal Doppler evaluation of 9(1)) and of right (from 7.1 (2.3)-2.3 institution and hemodynamic physical performance) increased lung water; effusion mitral, tricuspid, and (1.7) mm Hg) and left (from 17.6 (8.8)- outcomes. significance of clinically sinus rhythm and EF aortic flow and echo- 9.5 (6.4) mm Hg) ventricular filling silent interstitial lung <35% Doppler pressures; an increase in oxygen water accumulation in determination of consumption at peak exercise (from pts with moderate HF; cardiac output; 15.8 (3.3) to 17.6 (2) mL/min/kg) and of to use isolated UF as a radiological score of tolerance time (from 444 (138) to 508 means of extravascular extravascular lung (134) s); decrease in atrial and fluid reabsorption water; R/LV filling ventricular dimensions; no changes in pressures; oxygen the systolic function of the left ventricle; consumption at peak a reduction of the early to late filling exercise and ratio in both ventricles (mitral valve from exercise tolerance 2 (2) to 1.1 (1.1)); (tricuspid valve from time in 1.3 (1.3) to 0.69 (0.18)) and an increase cardiopulmonary in the deceleration time of mitral and tests. tricuspid flow, reflecting a redistribution of filling to late diastole. Variations in the ventricular filling pattern, lung water content, and functional performance persisted for 3mo in all cases. None of these changes was detected in the control group. Agostoni, The aim of this study RCT 36 NYHA functional classes Pts with acute MI (<1 y), Functional Plasma norepinephrine Significant reductions in UF group right Small older Pathophysiological 1993 was to evaluate II and III; stable clinical angina pectoris, primary performance was levels atrial pressure (from 8 ± 1 - 3.4 ± 0.7 study study involving UF 8426008 whether UF is beneficial condition; receiving drug valvular disease, intermittent assessed with mm Hg, pulmonary wedge pressure and hemodynamic (167) in pts with moderate treatment (stable over claudication, fibrotic or cardiopulmonary (from 18 ± 2.5 - 10 ± 1.9 mm Hg) and outcomes. congestive HF. last 6 mo) optimized to primary vascular lung exercise tests cardiac index (from 2.8 ± 0.2 -2.3± 0.2 prevent development of diseases, sinus or L/min). During the follow-up period, edema and maintain a atrioventricular node lung function improved, extravascular stable body weight (+/- 1 dysfunction, effort-induced lung water (X-ray score) decreased and
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kg in last 6 mo); severe ventricular peak oxygen consumption (mL/min per therapeutic digoxin level arrhythmias or an artificial kg) increased from 15.5 ± 1 (d -1) to (if on digoxin) pacemaker 17.6 ± 0.9 (d 4), to 17.8 ±0.9 (d 30), to 18.9 ±1 (d 90) and to 19.1 ±1 (d 180). Oxygen consumption at anaerobic threshold (mL/min per kg) also increased from 11.6 ±0.8 (d -1) to 13 ±0.7 (d 4), to 13.7 ± 0.5 (d 30), to 15.5 ± 0.8 (d 90) and to 15.2 ± 0.8 (d 180). These changes were associated with increased ventilation, tidal volume and dead space/tidal volume ratio at peak exercise. Improvement in exercise performance was associated with a decrease in norepinephrine at rest, a downward shift of norepinephrine kinetics at submaximal exercise and an increase in norepinephrine during orthostatic tilt. None of these changes were recorded in group B. ACS indicates acute coronary syndrome; ADHERE, Acute Decompensated Heart Failure National Registry; AE, adverse event; AUC, area under the curve; BNP, B-Type natriuretic peptide; BUN, blood urea nitrogen; CHD, chronic heart disease; CHF, congestive heart failure; CrCl, creatinine clearance; CV, cardiovascular; DAD-HF, Dopamine in Acute Decompensated Heart Failure; DBP, diastolic blood pressure; DIG, Digitalis Investigation Group; DM, diabetes mellitus; ED, emergency department; eGFR, glomerular filtration rate; EUPHORIA, Early Ultrafiltration Therapy in Patients with Decompensated Heart Failure and Observed Resistance to Intervention with Diuretic Agents; EVEREST, Efficacy of Vasopressin Antagonism in hEart failuRE: Outcome Study With Tolvaptan; HDD, high dose diuretics; HF, heart failure; Hgb, hemoglobin; HTN, hypertension; ICU, intensive care unit; IV, intravenous; KCCQ, Kansas City Cardiomyopathy Questionnaire; LDD, low dose diuretics; LDFD, low-dose furosemide; LOS, length of stay; LVEF, left ventricular ejection fraction; MCS, mechanical cardiac support; N/A, not applicable; NPSD, nonpotassium-sparing diuretics; NT-pBNP, N-terminal pro-B-Type natriuretic peptide; PO, per oral; PRAISE, Prospective Randomized Amlodipine Survival Evaluation; PROTECT, Placebo-controlled Randomized study of the selective A(1) adenosine receptor antagonist rolofylline for patients hospitalized with acute heart failure and volume Overload to assess Treatment Effect on Congestion and renal function; PTCA, percutaneous transluminal coronary angioplasty; PSD, potassium-sparing diuretics; pts, patients; RAPID-HF, Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure; RCT, randomized control trial; SBP, systolic blood pressure; SCD, sudden cardiac death; SCr, serum creatinine; SOLVD, Studies of left ventricular dysfunction; Tx, treatment; UF, ultrafiltration; UNLOAD, Ultrafiltration Versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure; VAS, visual analog scale, WMD, weighted mean difference; and WRF, worsening renal function.
Data Supplement 18. ACE Inhibitors (Section 7.3.2.2) Study Name, Aim of Study Study Type Background Study Size Etiology Patient Population Endpoints Mortality Trial Absolute P Values & 95% CI: Author, Year Therapy Duration Benefit (Years) Pre-trial N (Total) Ischemic/ Inclusion Exclusion Primary Secondary 1st Year standard n (Experimental) Non-Ischemic Criteria Criteria Endpoint Endpoint Mortality treatment. n (Control)
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CONSENSUS To Evaluate RCT Diuretics 253; 127;126 CAD 73% Severe APE; Mortality Change in NYHA- 52% placebo 0.51 y N/A Crude mortality at end of 1987 influence of (spironolactone HF/symptoms at hemodynamicall FC, LV size, Cr group and 6 mo (primary endpoint), 2883575 (168) enalapril on 53%, mean dose rest/NYHA class y import level 36% enalapril 26% in enalapril group prognosis of 80mg), digitalis lV; aortic/MV group (6 mo and 44% in placebo NYHA class lV (93%), other Increased heart stenosis; mortality: group—40% reduction (p HF vasodilators, size >600 ml; MI w/in prior 2 26% in =0.002). except ACEI (ie BP: 120/75; mo enalpril group Mortality was reduced by nitrates 46%) HR: 80; AF Unstable and 44% in 31% at 1 y (p=0.001) 50% angina; planned placebo cardiac surgery; group) right HF b/c of pulm disease; Cr>300 umol/L 10 y FU of Report on the 10-y open- All pts were 315; 77; 58 253 randomized Mortality 10 y 5 pts, all in the enalapril CONSENSUS survival at the label follow-up offered open- pts included in group, were long-term 1999 10-y follow up study (via label enalapril analysis of time survivors (p=0.004). 10099910 of the pts completion of a therapy from Averaged over the trial (169) randomized in questionnaire) randomization to (double-blind plus open- CONSENSUS. on the survival death; label extension) risk (1st study to status of pts in Survivors (135) reduction was 30% show CONSENSUS of the double- (p=0.008), 95% CI: 11% prognostic -a RCT. blind period - 46%. improvement included in At end of double-blind by an ACEI. analysis of the study period, mortality Pts in NYHA time from end of considerably higher class IV HF double-blind among pts not receiving treated with period to death; open ACEI therapy enalapril or Severe, NYHA placebo. After lV study completion all pts were offered open- label enalapril therapy).
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SOLVD 1991 Study the effect RCT Diuretics + 2569; 1285; 1284 Ischemic heart LVEF <35%; Age >80 y; Mortality Hospitalizations; 15.70% 3.45 y Treating Reduced mortality by 2057034 (170) of enalapril on Digoxin disease 72% Mild to severe Unstable Incidence of MI; 1000 16%; (95% CI, 5-26%; mortality and (11% class angina; MI w/in Mortality by SOLVD+ p=0.0036) hospitalization l/<2% class lV); past mo; Cr>2.0 specific causes; pts with in pts with LVEF 25%; BP: mg/dL Combined enalapril chronic HF and 125/77; HR: mortality and for ~3 y EF <35% 80; AF: 8-12% morbidity from would both save ~50 SOLVD+/SOLVD- premature deaths and 350 hospitaliz ations.
SOLVD 1992 Study effect of RCT No drug 4228; 2111; 2117 History of EF <35%; As per SOLVD+ Mortality; Incidence of HF 3.12 y Reduced mortality: 1463530 (90) ACEIs on total treatment for HF ischemic heart Asymptomatic; Combined and rate of p=0.30; 95% CI: -8-21% mortality and disease 85% NYHA class I mortality and hospitalization for mortality from (67%) + ll; the HF CV causes, the EF: 28%; BP: incidence of development of 126/78; HR: HF and rate HF, and 75; AF: 4% of hospitalization hospitalizatio for HF in pts n for HF with EF <35% SOLVD F/U 12-y FU of 12 y f/u of N/A 6784; 3391; 3393 N/A Participation in N/A Mortality N/A N/A N/A Enalapril In the prevention trial, 2003 SOLVD to RCTs SOLVD+ and extended 50.9% of the enalapril 12788569 (91) establish if the [SOLVD+ and SOLVD- median group had died c/w mortality SOLVD-] Asymptomatic to survival 56.4% of the placebo reduction with severe; by 9.4 mo group (p=0.001). enalapril NYHA l-lV in the In the treatment trial, among pts with combined 79.8% of the enalapril HF was trials group had died c/w sustained, and (95% CI: 80.8% of the placebo whether a 2.8–16.5, group (p=0.01). subsequent p=0.004). Combined prevention reduction in and treatment trials: HR mortality would for death was 0.90 for emerge among the enalapril group c/w those with placebo group (95% CI: asymptomatic 0.84–0.95, p=0.0003). ventricular dysfunction.
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ATLAS To compare RCT N/A 3164; CAD 65% LVEF <=30%; Acute coronary Mortality Combined risk of 5 y High-dose group had 8% 1999 the efficacy 1596 to the low- NYHA class II, ischemic event from all all-cause lower risk of all-cause 10587334 and safety of dose strategy and III, or IV, despite or causes mortality and mortality (p=0.128) and (171) low and high 1568 to the high- treatment with revascularizatio hospitalization for 10% lower risk of CV doses of ACEI dose strategy. diuretics for ≥2 n procedure any reason; mortality (p=0.073) than on the risk of mo within 2 mo; CV mortality, CV low-dose group. death and (Treatment for History of hospitalizations; Death or hospitalization hospitalization HF in ED or sustained or All-cause for any reason, high- in chronic HF. hospital within 6 symptomatic mortality dose group had 12% than the large mo required for ventricular combined with lower risk than low-dose doses that pts in class II); tachycardia; CV group, p=0.002. have been Prior use of Intolerant of hospitalizations; Total number of shown to digitalis, ACEIs, ACEIs; CV mortality hospitalizations: high- reduce or vasodilators SCr >2.5 mg/dL combined with dose group 13% fewer morbidity and allowed but not CV hospitalizations for any mortality in pts mandated; hospitalizations; reason (p=0.021), 16% with HF. NYHA ll-lV Combined risk of fewer hospitalizations for AIM: (mainly class ll); fatal and nonfatal CV reason (p=0.05), and Investigate if LVEF 23%; MI plus 24% fewer low doses and SBP 126 mmHg; hospitalization for hospitalizations for HF high doses of HR 80; NYHA unstable angina (p=0.002). ACEIs have class: lll (few ll similar benefits. and lV) Post-MI ACEI Use
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SAVE, 1992 To test the RCT Beta-blockers 2231; 1115; 1116 Ischemic Alive 3 d after Failure to Mortality from Mortality from 3.5 y Mortality from all causes 1386652 (89) hypothesis that 36%; 100% MI; undergo all causes CV causes; was significantly reduced the long-term Digitalis 26%; LVEF <40%; randomization Mortality in the captopril group administration Nitrates 51% >21 y of age, within 16 d after combined with a (228 deaths, or 20%) as of captopril to but <80; the MI; decrease in the c/w the placebo group survivors of Killip class I — Relative EF of at least 9 (275 deaths, or 25%); the acute MI who 60% contraindication units in surviving RR:19% (95% CI, 3- had baseline (60% of the ps to the use of an pts; 32%; p= 0.019). LV dysfunction did not have ACEIs or the CV morbidity RR:21% (95% CI, 5 - but did not even transient need for such an (development of 35%; p = 0.014) for have overt HF pulmonary agent; severe CHF or death from CV causes, requiring congestion at SCr > 2.5 mg/dl the recurrence 37% (95% CI, 20-50%; vasodilator baseline/the of MI); p<0.001) for the therapy would time of their Combination of development of severe reduce acute MI; CV mortality and HF, 22% (95% CI, 4- mortality, EF 31%; morbidity; 37%; p= 0.019) for CHF lessen BP 113/70; 2 endpoints of requiring hospitalization, deterioration in HR 78; severe HF and 25% (95% CI, 5- cardiac (treatment 40%; p= 0.015) for performance, failure): 1st, recurrent MI. and improve development of clinical overt HF outcome. necessitating treatment with ACEI and 2nd, hospitalization to treat CHD.
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AIRE 1993 Investigated RCT 2006; 1014; 992 Aged ≥18 y, Use of an ACEI Mortality from 1.3 y Mortality from all causes 8104270 (172) the effect of with a definite considered to be all causes was significantly lower therapy with acute MI 3-10 d mandatory for pts on ramipril ACEI ramipril, before compared to pts on on survival in randomization; placebo. RR: 27%; 95% pts who had Clinical Cl: 11-40%; p = 0.002. shown clinical evidence of HF Prespecified secondary evidence of HF at any time outcomes: risk reduction at any time since acute MI of 19% for the 1st after an acute validated outcome— MI. Also, to namely, death, compare the severe/resistant HF, MI, incidences of or stroke (95% CI: 5% - progression to 31%; p=0.008). severe or resistant HF, nonfatal re- infarction and stroke between the 2 groups.
TRACE 1995 To determine RCT Beta blocker 16%; 1749; 876; 873 Ischemic Consecutive pts Contraindication Death from Death from a CV The mortality 24 lives During the study period, 7477219 (173) whether pts Calcium antagonist 100% >18 y to ACEI or a any cause cause, sudden from all causes were 304 pts in the trandolapril who LV 28%; Diuretic hospitalized with definite need for death; at 1 y was saved group died (34.7%), as dysfunction 66%; Nitrates MI; them; Progression to 24%. after one did 369 in the placebo soon after MI 53%; Digoxin Criteria for MI: Severe, severe HF mo of group (42.3%). RR: 0.78 benefit from 28%. chest pain or uncontrolled DM; (hospital treating (95% CI, 0.67 - 0.91; long-term oral electrocardiogra Hyponatremia admission for 1000 pts p=0.001). ACE inhibition. phic changes, (<125 mmol/L); HF, death due to In every subgroup, accompanied by Elevated SCr progressive HF, treatment with >2X increase in level (2.3 mg/dL) or HF trandolapril was one or more necessitating associated with a cardiac open-label reduction in risk. enzymes; ACEI); LV dysfunction Recurrent (EF <35%); infarction (fatal NYHA class 1 - or nonfatal); 41%; Change in the BP 121/76; HR wall-motion 81 index (EF) ACEI indicates angiotensin-converting-enzyme inhibitor; AF, atrial fibrillation; AIRE, Acute Infarction Ramipril Efficacy; APE, acute pulmonary embolism; ATLAS, Assessment of Treatment with Lisinopril and Survival; BP, blood pressure; CAD, coronary artery disease; CHD, chronic heart disease; CHF, congestive heart failure; CONSENSUS Cooperative North Scandinavian Enalapril Survival Study; Cr, creatinine; CV, cardiovascular; C/W, compared with; DM, diabetes mellitus; ED, emergency department; FU, follow-up; HF, heart
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failure; HR, heart rate; LV, left ventricular; MI, myocardial infarction; MV, mitral valve; N/A, not applicable; NYHA, New York Heart Association; pts, patients; SAVE, survival and ventricular enlargement trial; SBP, systolic blood pressure; SOLVD, Studies Of Left Ventricular Dysfunction; RCT, randomized control trial; SCr, serum creatinine; and TRACE, Trandolapril Cardiac Evaluation. Data Supplement 19. ARBs (Section 7.3.2.3) Study Name, Trial Author, Aim of Study Background Duration Year Study Type Therapy Study Size Etiology Patient Population Severity Endpoints Mortality (Y) Statistical Results Pre-trial N (Total) standard n (Experimental) Ischemic/ Inclusion Exclusion Primary Secondary treatment. n (Control) Non-Ischemic Criteria Criteria Endpoint Endpoint 1st Y Mortality CHARM Discover RCT Diuretics, 2028; 1013; Ischemic 67-70% Symptomatic NYHA ll-lV; mild to Composite of CV death, 2.8 y Absolute reduction of 7 major Alternative; whether Beta-blockers 1015 HF, EF <40%, severe (<4% class CV death or hospital events per 100 pts threated - Granger et ARB could (55%), no ACEI (b/c lV); EF: 30%; BP: hospital admission for NNT 14 pts to prevent 1 CV al; (2003) improve spironolacton of intolerance) 130/70; HR: 74- admission for CHF or non-fatal death or hospitalization. 13678870 outcome in e 24%, 75; AF: 25-26% CHF MI; CV death, HR: 0.77 (95% CI: 0.67-0.89); (174) pts not Digoxin 45- CHF admission, p=0.0004 taking an 46% non-fatal MI, non- ACEI fatal stroke; CV (intolerant) death, CHF admission, non- fatal MI, non-fatal stroke, coronary revascularization; Death (any cause); New DM CHARM- To RCT Beta blocker- 2548; 1276; Ischemic 62-63% Symptomatic NYHA class ll-lV; Composite of CV death, 3.4 y Absolute reduction of 4.4 pts ADDED; investigate 55%; 1272 HF; EF <40%; mild to severe CV death or hospital with events per 100 pts McMurray if ARB + spironolacton Treatment with (<3% class lV) ; hospital admission for treated- NNT of 23 to prevent et al; ACEI in pts e 17%; ACEI; Age >18 EF 28%; BP admission for CHF or non-fatal 1 first event of CV death or (2003) with chronic Digoxin 58- y 125/75; HR 74; CHF MI; CV death, CHF hospitalization. 13678869 HF improve 59% AF 27% CHF admission, RR: 0.85 (95% CI: 0.75-0.96); (175) clincal nonfatal MI, non- p=0.011 outcomes fatal stroke; CV death, CHF admission, non- fatal MI, non-fatal stroke, coronary revascularization; Death (any cause); New DM
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VALIANT; Compare Random Beta- 14,703 Ischemic 100% Age >18 y; Prior NYHA l-lV; Death from 12.5% VAL 2.1 y VAL and CAP: 1.0 (97.5% CI- Pfeffer et the effect of ized blockers; ASA Valsartan:4909 (MI inclusion Acute MI intolerance asymptomatic- any cause 12.3% VAL--CAP - 0.90-1.11); p= 0.98 ; al; (2003) an ARB, double Captopril-: 4909 criteria) complicated by or contra- severe, 13.2% CAP VAL+CAP and CAP: 0.98 14610160 ACEI and blind VAL + CAP: HF; indication to EF 35%; BP: (97.5% CI-- 0.89-1.09); p= (176) the multicen 4885 LV systolic ACEI/ 123/72; HR: 76 0.73 combination ter trial dysfunct (EF ARB of the 2on <35%), (<40% mortality on radionuclide ventriculograp hy); SBP > 100 mmHg; Cr < 2.5 mg/dL Val-HeFT; Evaluate RCT Diuretics; 5010; 2511; Ischemic 57% Age>18 y; NYHA ll-lll, lV Mortality; Change in EF; 1.92 y Mortality similar for the 2 Cohn et al; long term Digoxin 67%; 2499 NYHA ll, ll, lV; (only ~2% class Combined • NYHA class, treatment groups. (2001) effects of Beta blocker At least 2 wk lV); Mild to end point of QoL scores; For the combined endpoint: 11759645 adding ARB 35%; ACEI of background severe; mortality and Signs and RR: 0.87; 97.5% CI, 0.77- (177) to standard 93% meds including EF 27%; BP morbidity symptoms of HF 0.97; p=0.009 therapy for ACEIs; 123/76; AF 12% HF EF <40% and LVID >2.9 cm/BSA HEAAL Compared RCT Diuretic drugs 3846 IHD 64% >18 y; Pregnancy NYHA ll-lV (70% Death or Composite 4.7 y Treating pts with 150 mg dose study; the effects (77%), beta losartan 150 mg NYHA class II– or lactation; ll); EF: 33%; BP: admission for endpoint of death median instead of 50 mg dose would Lancet of high- blockers (n=1927) or 50 IV; LVEF known 124/77; HR: 71; HF or CV admission. f/u result in 1 additional pt w/out 2009; 374: dose vs (72%), and mg daily <40%, with intolerance AF; 28% Additional the primary event at 4 y for 1840-48. low-dose ARBs (38%). (n=1919). stable CV to ARBs; prespecified every 31 pts treated. 19922995 losartan on medical Systolic outcomes Composite: 828 (43%) pts in (178) clinical therapy for at arterial included: death, 150 mg group vs. 889 (46%) outcomes in least 2 wk; blood death or all-cause in 50 mg group died or pts with HF. Intolerance to pressure admission, CV admitted for HF (HR: 0.90; ACEI; <90 mm Hg; death, all-cause 95% CI: 0.82-0.99; p=0.027) Investigators Significant admission, CV • Components: 635 pts in 150 encouraged to stenotic admission, mg group vs. 665 in 50 mg start beta valvular admission for HF, group died (HR: 0.94, 95% CI: blocker and heart and changes in 0.84-1.04; p=0.24), and 450 titrate to a disease; the severity of vs. 503 pts admitted for HF maximum, Active heart disease (0.87, 0.76–0.98; p=0.025) whenever myocarditis; possible active pericarditis; Planned
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heart transplantati on w/in 6 mo; coronary angioplasty, CABG, acute MI, UA pectoris, cerebrovasc ular accident, or TIA within the previous 12 wk; Suspected significant renal artery stenosis CHARM- Aimed to RCT- Diuretics 83% 7601 pts >18 y; SCr > 265 NYHA ll-lV The primary The annual CV 3.1 y 886 (23%) pts in candesartan Overall find out parallel, Beta blockers (7599 with data) NYHA class II– μmol/L, NYHA ll-lV outcome of death rate among and 945 (25%) in placebo 13678868 whether the randomi 55% 3803 IV for at least 4 serum Only 3% class lV the overall the placebo group group died (unadjusted HR: (179) use of an zed, ACEI 43% 3796 wk; potassium program: all- who had reduced 0.91; 95% Cl: 0.83–1.00; ARB could double- Spironolacton 3 distinct >5.5 mmol/L cause LVEF was around p=0.055; covariate aHR: 0.90 reduce blind, e 17% populations: Bilateral mortality; 9% and was only 95% CU: 0.82–0.99; p=0.032) mortality Digoxin 43% pts with LVEF renal artery For all the 4% in the placebo • Fewer CV deaths (691 [18%] and <40% who stenosis; component group of CHARM- vs 769 [20%], unadjusted HR: morbidity. were not symptomatic trials: CV Preserved. 0.88; 95% Cl: 0.79–0.97; receiving hypotension death or p=0.012; covariate aHR: 0.87; ACEIs Women of hospital 95% Cl: 0.78–0.96; p=0.006) (previous childbearing admission for • Hospital admissions for CHF intolerance) or potential not CHF. (757 [20%] vs 918 [24%], who were using p<0.0001) currently adequate receiving ACE, contraceptio and pts with n; Critical LVEF >40% aortic or mitral stenosis; MI, stroke, or open- heart surgery in
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the previous 4 wk; Use of an ARB in the previous 2 wk ACEI indicates angiotensin-converting-enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blockers; ASA, aspirin; BP, blood pressure; BSA, body surface area; CABG, coronary artery bypass graft; CHARM, Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity; CHD, chronic heart disease; CHF, congestive heart failure; Cr, creatinine; CV, cardiovascular; DM, diabetes mellitus; EF, ejection fraction; FU, follow-up; HEAAL study, effects of high-dose versus low-dose losartan on clinical outcomes in patients with heart failure; HF, heart failure; HR, heart rate; IHD, ischemic heart disease; LV, left ventricular; LVD, left ventricular dilatation; MI, myocardial infarction; MV, mitral valve; N/A, not applicable; NNT, number needed to treat; NYHA, New York Heart Association; QoL, quality of life; pts, patients; SBP, systolic blood pressure; RCT, randomized control trial; SCr, serum creatinine; TIA, transient ischemic attack; UA, unstable angina; Val-HeFT, Valsartan Heart Failure Trial; and VALIANT, Valsartan in Acute Myocardial Infarction.
Data Supplement 20. Beta Blockers (Section 7.3.2.4)
Study Name, Aim of Study Background Trial Statistical Author, Year Study Type Therapy Study Size Etiology Patient Population Severity Endpoints Mortality Duration Results N (Total) n (Experimental) Inclusion Primary Secondary Annualized 1st Y n (Control) Criteria Exclusion Criteria Endpoint Endpoint Mortality Mortality CIBIS ll CIBIS Investigate RCT- Diuretics + 2647; 1327; Documented NYHA class lll Uncontrolled HTN; Moderate to All-cause All-cause 13.2% N/A 1.3 y HR: 0.66 (95% ll investigators the efficacy multicent ACEI; 1320 Ischemic or lV MI/UA w/in previous 3 severe. mortality hospital Placebo CI: 0.54-0.81); and committee of bisoprolol er [amiodarone 50% EF: <35% mo; Mean BP: admissions group p<0.0001 members in double- allowed--14- 18-80 y old PTCA/CABG w/in 130/80; Mean All CV deaths 8.8% (1999) decreasing blind l6%] previous 6 mo; HR: 80; Mean Combined Treatm't 10023943 all-cause randiomi AV-block >1st degree EF: 28%; Mean endpoints group (180) mortality in sed w/o PPM; LVEDD: 6.7 cm; Permanent chronic HF placebo Heart rate < 60bpm; AF: 20% treatment controlle resting SBP withdrawal d trial <100mmHg; renal (Europe) failure; Reversible obstruct lung disease; Use of beta blocker MERIT-HF; Investigate RCT-- Diuretics + 3991; 1991; Ischemic NYHA ll-lV; MI/UA w/in 28 d; Mild to severe. All-cause N/A 11.0% N/A 1 y Treatment of 27 MERIT study whether multicent ACEI 2001 65% 40-80 y old; Contra-indication or Mean BP: mortality Placebo pt for 1 y can Group; (1999) Metoprolol er [Amiodarone LVEF <40% current use of beta 130/78; Mean All-cause group prevent 1 death. 10376614 CR/XL double- NOT allowed] (36-40 if 6-min blocker; HR: 78; Mean mortality in 7.2% 0.66 (95% CI: (181) lowered blind walk <450m); PTCA/CABG w/in 4 mo EF 28%; AF 16- combination Treatm't 0.53-0.81); mortality in randiomi HR >68 bpm Planned transplant or 17% with all-cause group p=0.00009 pts with sed ICD; admission to decreased placebo Heart block > 1st hospital EF and controlle degree w/o PPM;
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symptoms of d trial SBP<100mmHg HF (Europe + USA) COPERNICUS Investigate RCT-- Diuretics (PO 2289; 1156; Ischemic Euvolumic Pt requiring Severe All-cause Combined risk 19.7% 18.5% in 10.4 mo Treating 1000 pt ; Packer et al; whether double or IV) + ACEI 1133 67% NYHA class lV; hospitalized intensive Mean BP: mortality of death or placebo placebo for 1 y led to (2002) Carvadiolo is blind (or ARB); LVEF <25%; care; 123/76; hospitalization- [24.0% in pts group savings of 70 12390947 beneficial in [Amiodarone No positive Use of positive Mean HR: 83; any reason; with recent 11.4% in premature deaths (182) severe HF allowed 17- inotropes or inotropes or IV; Mean EF 20%; Combined risk or recurrent Carvedil p=0.0014 18%] vasodilators vasodilators w/in 4-d; of death or cardiac ol group w/in 4 d Coronary hospitalization- decompensa revascularization/MI/C -CV reason; tions] VA/sign VT or VF w/in Combined risk 2 mo; of death or SBP < 85 mmHg, hospitalization- Heart rate <68, Cr >2.8 -HF reason; mg/dL Pt global assessment SENIORS; Assess RCT Diuretics + 2128; 1067; Prior h/o Age >70 New HF therapy w/in 6 Mild to severe Composite of All-cause N/A N/A 1.75 y Absolute risk Flather et al; effects of the ACEI 1061 CAD in 69% Chronic HF wk or change in drug Mean BP: all-cause mortality reduction 4.2%; (2005) beta blocker (+aldosterone with one of the therapy w/in 2 wk 139/81; mortality or Composite of 24 pts would need 15642700 Nebivolol in antagonist in following: Contra-indication to Mean HR: 79; CV hospital all-cause to be treated for (183) pts >70 y 29%) hospitalization beta blockers, current Mean EF 36% admission mortality or all- 21 mo to avoid regardless of with CHF w/in use of beta blockers (1/3 with EF cause hospital one event EF. a year or EF Significant renal >35%); admissions RR: 0.86; 95% CI: <35% w/in the dysfunction All cause 0.74-0.99; past 6 months CVA w/in 3 mo. hospital p=0.039 admissions CV hospital admissions CV mortality Composite of CV mortality or CV hospital admissions NYHA class assessment; 6 MWT
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A Trial of the Designed to RCT ACEIs (if 2708; 1354; Ischemic NYHA class III Reversible cause of HF NYHA lll or lV Death from Death from CV For pt in N/A ~2 y 449 pt in placebo Beta-Blocker determine tolerated) 1354 59% or IV HF present (92% class lll) any cause causes (death NYHA group (33%) died, Bucindolol in Pt whether [91% ACE; LVEF <35% Candidates for heart EF 23%; due to pump functional 411 in the with Advanced bucindolol 7% ARB], for >18 y transplantation HR 82; failure or an class III, the bucindolol group Chronic HF hydrochlorid at least 1 mo. Cardiac BP 117/71; ischemic event annual (30%; HR: 0.90; The Beta- e, a Before the revascularization AF 12% or sudden mortality rate 95% CI, 0.78- Blocker nonselective publication of procedure within the death) was 16% in 1.02; unadjusted Evaluation of beta- the results of previous 60 d Hospitalization the placebo p=0.10; adjusted Survival Trial adrenergic the DIG trial, UA for any reason group; For pt p=0.13) Investigators blocker and 12 digoxin Heart rate <50 beats Hospitalization with NYHA 11386264 mild therapies per minute, SBP because of HF class IV, the (184) vasodilator, were <80mmHg Composite of annual would required, but Decompensated HF. death or heart mortality rate reduce the thereafter its tansplantation in the rate of death use became LVEF at 3 and placebo from any discretionary 12 mo group was cause [DIG 94%]. MI; QoL; and 28% among pt any change in Overall: with the need for annual advanced concomitant mortality of HF and to therapy 17% in assess its placebo effect in group c/w various 15% in the subgroups bucindolol defined by group. ethnic background and demographic criteria — specifically women and members of minority groups.
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COMET; To compare RCT Diuretics, 3029; N/A NYHA class ll- N/A Mild to severe All-cause N/A N/A N/A 4.8 y All-cause Poole-Wilson the effects of ACEIs 1511 carvedilol; lV mortality mortality 34% et al; (2003) carvedilol 1518 metoprolol EF <35% Composite carvedilol and 12853193 and tartrate Previous CV endpoint of 40% metoprolol (185) metoprolol admission all-cause (HR: 0.83; 95% CI on clinical mortality, or 0.74-0.93; outcome in all-cause p=0.0017) pts with HF admission (CIBIS) III; Sufficient Multicent Diuretics 1010 CAD 62% >65 y, NYHA Treatment with an NYHA ll or lll; The primary Combined end N/A N/A Mean of In the ITT sample, 2005 data do not er, 84%; Digoxin Bisoprolol 505; class II or III, ACEI, an ARB, or a mild to moderate endpoint was point at the end 1.22±0.4 178 pt (35.2%) 16143696 currently prospecti 32% Enalapril 505 and LVEF beta blocker for >7 d CHF time-to-the- of the 2 y with a primary (186) exist to ve, <35% (By echo during the 3 mo before LVEF 29%; first-event of monotherapy (maximu end point in the establish the randomiz within the 3 randomization Heart rate 79; combined all- phase and the m of 2.10 bisoprolol-first optimum ed, mo) Heart rate at rest <60 SBP 134 cause individual y). group, and 186 order of open- Clinically stable beats/min without a mortality or components of (36.8%) in the initiating label, HF (without functioning pacemaker all-cause the primary enalapril-first chronic HF blinded clinically Supine SBP <100 mm hospitalization end point, at group (absolute therapy end point relevant fluid Hg at rest study end and difference -1.6%; (ACEI vs. evaluatio retention or SCr≥220 µmol/L at the end of 95% CI -7.6 to beta n diuretic AV block greater than the 4.4%; HR: 0.94; blocker). (PROBE) adjustment first degree without a monotherapy 95% CI 0.77 to This was the trial,24 within 7 d) functioning pacemaker phase. 1.16; objective of with 2 Obstructive lung CV death noninferiority for the CIBIS III parallel disease CV bisoprolol-first trial-- it groups. contraindicating hospitalization versus enalapril- compared bisoprolol treatment first treatment, the effect on p=0.019) mortality and hospitalizatio n of initial monotherap y with either bisoprolol or enalapril for 6 mo, followed by their combination for 6 to 24 mo. ACEI indicates angiotensin-converting-enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; AV, atrioventricular; BP, blood pressure; CABG, coronary artery bypass graft; CHF, congestive heart failure; CIBIS II, Cardiac Insufficiency Bisoprolol Study II; COMET, Carvedilol Or Metoprolol European Trial; COPERNICUS, carvedilol prospective randomized cumulative survival; Cr, creatinine; CR/XL, controlled release/extended release; CV, cardiovascular; CVA, cerebrovascular accident; c/w, compared with; DIG, Digitalis Investigation Group; EF, ejection fraction; HF, heart failure; h/o, history of; HR, hazard ratio; ICD, ICD, implantable cardioverter defibrillator; ITT, intent to treat; MERIT-HF, Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure;
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MI, myocardial infarction; MWT, minute walk test; NYHA, New York Heart Association; PPM, permanent pacemaker; PTCA, percutaneous transluminal coronary angioplasty; Pts, patients; QoL, quality of life; RCT, randomized control trial; RR, relative risk; SBP, systolic blood pressure; SCr, serum creatinine; UA, unstable angina; USA, United States of America; VF, ventricular fibrillation; VT, ventricular tachycardia; and w/o, without.
Data Supplement 21. Anticoagulation (Section 7.3.2.8.1) Study Size Study Name, (HF Author, Year Aim of Study Study Type Study Size Subpopulation) Patient Population Endpoints Statistical Analysis (Results) Inclusion Criteria Exclusion Criteria Primary Endpoint Secondary Endpoint WARCEF Pullicino Compare efficacy RCT, double N=2305, mean N/A EF≤35%,NYHA I- Contraindication to Efficacy: time to first of Efficacy: primary Primary Efficacy: 7.47 events (warfarin) 2006, 16500579; of warfarin (INR blind/double f/u 3.5 y; (69% IV, sinus rhytm, or absolute indication (death+ischemic endpoint+MI+HF vs. 7.93 events (aspirin) /100 person-y. Homma 2012, 2.75) vs aspirin dummy, power to detect taking ACEI/ARB for 1 treatment; stroke+intracerebral hospitalization; components Secondary: ischemic stroke – warfarin, 22551105 (325 mg/d) in HF multicenter, parallel ~18% or H/N, planned MI/PCI/cardiac hemorrhage); Safety: of primary composite; HR: 0.52; Safety major hemorrhage: (187) pt in sinus rhythm group reduction treatment with surgery <3 mo; major hemorrhage Safety: Warafin 1.78 vs aspirin 0.87/100 person- primary beta blocker decompensated HF, intracerebral+intracranial y. endpoint) life expectancy hemorrhage Primary Endpoint: p=0.40: 95% CI: 0.79 - otherwise <5 y, HF 1.10; ischemic stroke p=0.0005, 95% CI: admission or CEA or 0.33 - 0.82; major hemorrhage p<0.001 PPM insertion <1 mo HELAS Determine if RCT, multicenter, N=194, mean N/A NYHA II-IV; EF MI <2 mo; "reversible Efficacy: composite Need for coronary Primary Efficacy (events/100 person-y): Cokkinos 2006 warfarin(INR 2.0- double-blind, f/u 22 mo; <35%; ischemia", mitral [nonfatal stroke + revascularization; Isch/aspirin (14.9), Isch/warfarin (15.7); 16737850 3.0) or aspirin (325 placebo-controlled; Ischemic Prespecified disease, HoCM, AF, arterial TEE or PE + MI readmission for ischemia DCM/warfarin (6); DCM/placebo (10); (188) mg/d) reduces (converted to pilot (aspirin vs subgroups: LV thrombus, + rehospitalization + Safety: Isch/ warfarin (4), DCM/ warfarin thromboemboli in study due to warfarin), Ischemic vs DCM pregnancy, uncontr worsened HF + all- (3), others (0). 2.2 events/100 person-y (5 HF inadequate N=114; DCM HTN, contra-ind to cause mortality]; Safety: stroke, 2 MI, no arterial TEE or PE). enrollment) (warfarin vs. either study drug, ICH + "bleeding" on placebo), N=80 otherwise <2 y treatment (stopped at 4% expected survival target due to poor recruitment) WASH Pilot Study: Prospective N=279 pts, N/A Required diuretics; "Definite" indication Time to first event (on Prespecified: death or CV Both ITT an AT: "no difference" Cleland 2004 feasibility of study multicenter mean f/u 27 mo LVEDD >55 mm or for warfarin or treatment or within 10 d hospitalization; death or all- PRIMARY ITT: Placebo: 26% (HR: 0.96; 15215806 comparing warfarin placebo-controlled >30 mm/m2 or EF aspirin, MI < 4 wk, of stopping treatment): cause hospitalization; total 95% CI: 0.60-1.54); Aspirin: 32% (HR: (189) (INR 2.5) to aspirin RCT, 3-arm, open- ≤35%; inpt status, contr-ind composite [death + hospitalizations; death or 1.16; 95% CI: 0.74-1.85); Warfarin: 26% (300 mg/d) to label, blinded Prespecified to either drug nonfatal MI + nonfatal CV hospitalization or need (HR: 0.88; 95% CI 0.54-1.43), p=0.22; placebo endpoint subgroups: stroke] for increased diuretic dose; AT: Placebo: 20% (HR: 1.08 95% CI: ischemic vs. DCM worsening HF; MI; stroke; 0.65-1.89); Aspirin: 22% (HR: 1.02 95% major hemorrhage. CI: 0.59-1.75); Warfarin: 18% (HR: 0.89
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95% CI: 0.50-1.16); Secondar ITT: all- cause hospitalizations (Placebo 48% vs. Aspirin 64% vs. Warfarin 47%); Major hemorrhage "no difference"; minor hemorrhage (Placebo 5% vs. Aspirin 13% vs. Warfarin 17%), p=0.033 WATCH Hypotheses: Prospective, N=1587; N/A NYHA II-IV, EF Reversible HF; Efficacy: time to first Death; nonfatal MI; nonfatal Efficacy ITT: Primary - No difference Massie 2009 warfarin superior to multicenter RCT, treatment for 1 ≤35%; sinus contraindicated to event of composite stroke; hospitalization for warfarin vs. aspirin vs clopidogrel; 19289640 aspirin and open label y; mean f/u 1.9 rhythm on entry; any study drug; [death + nonfatal MI + HF Secondary - A group with more total and (190) clopidogrel (warfarin) or double y (stopped on diuretics and imminent procedure nonfatal stroke]; Safety: HF hospital admissions; Safety ITT: superior to aspirin blind APT group early due to ACE-I /ARB or or surgery; other major bleeding warfarin=aspirin, both with more major for HF pt with comparing aspirin poor H/N survival-limiting bleeding than clopidogrel reduced LVEF in (162 mg) vs. recruitment) disease Efficacy PRIMARY: ITT: warfarin vs. sinus rhythm clopidogrel (75 mg aspirin: HR: 0.98; 95% CI: 0.86-1.12; no load) vs warfarin p=0.77. clopidogrel vs. aspirin: HR: 1.08 (target INR 2.5) 95% CI: 0.83-1.40; p=0.57. warfarin vs. clopidogrel: HR: 0.89; 95% CI: 0.68-1.16; p=0.39. AT: warfarin superior to aspirin (p=0.0095), warfarin superior to clopidogrel (p=0.0031). SECONDARY endpoints: HF hospitalizations aspirin (22.2%) vs. warfarin (16.5%), p=0.019; Total HF admissions aspirin (218) vs. warfarin (155), p <0.001. Safety PRIMARY: major bleeding warfarin (5.2%) vs. clopidogrel (2.1%), p=0.007; warfarin vs. aspirin (p=NS). POST HOC Ischemic group (N=1163): Strokes warfarin (0) vs. aspirin (1.6), p=0.01; warfarin (0) vs. clopidogrel (2.7%), p=0.0009; Nonischemic group (N=424) Major bleed clopidogrel (0.7%) vs. warfarin (6.3%), p=0.0093. AT analysis (not prespecified): warfarin superior to aspirin (p=0.0095); warfarin superior to clopidogrel (p=0.0031).
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EPICAL Compare warfarin Prospective N=417 with N/A ≥ 1 hospitalization Failure to meet Survival 1 y and 5 y None Both warfarin (RR=0.60) and aspirin Echemann 2002 vs. aspirin vs. both observational complete data, for HF, NYHA II- inclusion criteria from index (RR=0.70) associated with improved 12413509 on survival in CHF population-based, mean f/u= 5 y; IV, EF ≤30% or (systematic hospitalization; stratified survival (191) nonrandomized, aspirin (30.9%) CTR ≥ 0.60, plus enrollment) by LVEF Univariate survival: AC (1 y 77.7%; 95% consecutive vs. OAT hypotension or CI: 71.7-82.4), 3 y 55.1%; 95% CI: 48.7- hospital survivors (28.3%) vs. systemic or 61.5), 5 y 40.4% [95% CI: 34.1-46.8] vs. of hospitalization, both (2.4%) pulmonary edema no AC (1 y 71.5% [95% CI: 64.9-78.1], 3 y aspirin vs. warfarin 47.0% [95% CI: 39.6-54.3], 5 y 31.0% at hospital [95% CI 24.0-38.0; p=0.01] for AC vs no discharge AC; Multivariate: OAT RR:0.60 [95% CI 0.4-0.8], aspirin RR: 0.7 [95% CI 0.5-0.9] Wojnicz 2006 Pilot Study: LMWH Prospective, N=102 (52 N/A Stable NYHA II-IV, Contraindicated to Composite [mortality + Total survival, BNP, LVEF, Primary: no difference 16996844 effects on clinical randomized, active treatment, 50 EF ≤40%; cath to any heparin, T1DM, urgent heart transplant echo chamber parameters, Primary: enoxaparin 4 vs. control 8, (192) endpoints in treatment control, control) exclude CAD, valvular HD, recent + hospital admission for NYHA class change, VO2 p=NS; mortality: p=NS; Secondary: BNP chronic HF open label enrolled, data Biopsy heparin exposure, worsening HF] at 6 and max, QoL reduction enoxaparin (1125-489) p<0.001 secondary to DCM comparing on N=85 for CAD 12 mo vs. no change in control; LVEF enoxaparin 1.5 analysis; f/u=1 improvement: enoxaparin increase 6.5%, mg/kg BID x 14 d, y p=0.023; 95% CI: 1.01-8.17. then 1 daily x 3 mos RE-LY Compare Noninferiority, Total HF n=5793 AF + ≥1 additional Excessive bleeding Efficacy: composite Stroke, systemic embolism, ITT, noninferiority with Cox prop hazards. Connolly 2009 dabigatran vs. multicenter, N=18,113; (32%): HF on risk factor for risk, severe valve [stroke or systemic death, MI, PE, TIA, Subsequent analyses for superiority 19717844 warfarin effects on prospective RCT, median f/u=2.0 dab 110 mg stroke (median disease, stroke <14 embolism]; Safety: hospitalization Symptomatic HF: multivariate HR for dab (193) stroke/arterial blinded dab (110 or y (n=1937/6015); CHADS2 score d/severe stroke <60 Major hemorrhage (2 y) 150 vs warfarin, p=0.33; 150 mg dab vs emboli in pts with 150 mg BID) or HF on dab 150 2.1). HF as mo, creat clear <30 warfarin: stroke 0.64; 95% CI: 0.51-0.81; AF unblinded warfarin (n=1934/6076); qualifying criteria mL/min p<0.001 (p<0.05 for all stroke subgroups). (INR 2.0-3.0) HF on warfarin req'd LVEF <40% MI: RR: 1.38; 95% CI1.00-1.91; p=0.048 (n=1922/6022). or NYHA Class ≥ II ACTIVE-W Combination Prospective open Total N=6706 HF N=2031 AF, LVEF <45% Other need for Efficacy: First event of Efficacy: components of KM log-rank (time to event) 2006 clopidogrel + label noninferiority (30%) warfarin, excessive [stroke or arterial TEE primary; Safety: Minor Total Study: Primary Efficacy: clopidogrel 16765759 aspirin vs warfarin RCT of [clopidogrel bleeding risk, prev or MI or vascular death]; hemorrhage +aspirin: 5.60 events/y vs. warfarin 3.93 (194) in reducing 75 mg + aspirin 75- ICH, platelets <50 K, Safety: Major events/y; RR: 1.44; 95% CI 1.18-1.76; vascular events in 100 mg] vs warfarin mitral stenosis hemorrhage p=0.0003; stroke RR: 1.72; 95% CI: 1.24- AF (INR 2.0-3.0) 2.37; p=0.001 ARISTOTLE Compare apixaban Prospective Total N=18,201 HF n=6451 ≥2 episodes AF or Reversible AF, mitral Noninferiority: Superiority: EFFICACY: PRIMARY: ITT Efficacy: apixaban Granger 2011 to warfarin in double-blind, , median (35.5%), flutter, CHADS2 stenosis, orther EFFICACY: stroke stroke (ischemic or 1.27%/y vs warfarin 1.60%/y) 21870978 preventing stroke double-dummy F/u=1.8 y apixaban=3235, ≥2 (HF criteria: indication for (ischemic or hemmorhagic) + systemic Modified ITT Safety: apixaban 2.13% vs (195) in pt with AF noninferiority + warfarin=3216 symptomatic HF anticoagulation, hemmorhagic) + embolism; all-cause warfarin 3.09%; mortality apixaban 3.52% superiority RCT of within 3 mo or recent stroke, need systemic embolism; mortality; SAFETY: major + vs warfarin 3.94%. AP 5 mg BID to LVEF ≤ 40% for antiplatelet SAFETY: major clinical nonmajor bleeding HF subgroup results not different (p for warfarin INR 2-3 therapy (beyond low- bleeding interaction 0.50) dose aspirin), creat Efficacy: apixaban: HR: 0.79; 95% CI:
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>2.5 mg/dL 0.66-0.9;, p<0.001 for noninferiority, p=0.01 for superiority; Mortality apixaban: HR: 0.89: 95% CI: 0.80-0.99; p=0.047. Safety: apixaban: HR: 0.69; 95% CI: 0.60- 0.80; p<0.001 (apixaban RRR: 27%) ROCKET AF Compare Prospective N=14,264 8909 (rivaroxaban Nonvalvular AF, Mitral stenosis, Primary efficacy: Secondary efficacy: Active treatment analysis (by design): Patel 2011 rivaroxaban to multicenter double- randomized, 4467, warfarin CHADS2 ≥2; HF absolute non-AF composite [ischemic or composite stroke + rivaroxaban (1.7% per year events) 21830957 warfarin in blind double- median f/u=707 4441) (62.5%) (clinical dx or indication for AC, hemorragic stroke + systemic embolism + CV noninferior to warfarin (2.2% per year (196) preventing dummy event- d LVEF ≤ 35%) high risk for systemic embolism]; mortality]; composite [stroke events) for primary outcome; no ischemic strokes in driven noninferiority anticoagulation Primary safety: + systemic embolism + CV difference in safety endpoints; fewer CHN pt with nonvalvular RCT of rivaroxaban composite [major + mortality + MI]; individual hemorrhage and fatal bleeding in AF 20 mg/d (15 mg if nonmajor clinically components of primary rivaroxaban group. Findings consistent for Cr Cl 30-49 relevant bleeding] composite. Secondary all subgroups. mL/min) vs. safety Efficacy: Per protocol, rivaroxaban HR: warfarin (INR 2-3) 0.79; 95% CI: 0.66 - 0.96; p<0.001 for noninferiority; HF subgroup ITT p=0.419. Safety superiority of rivaroxaban p=0.02 Belch 1981 Effect of low-dose Prospective, Total N=100 HF subset n=38 HF NYHA II-IV, "Definite" risk of DVT diagnosed by I-125 Clinical evidence of H reduced demonstrable DVT 7291971 SQ H on lower randomized, open (21 treatment, 17 clinical signs of bleeding, DVT or PE fribrinogen scanning bleeding Total group: DVT (Ctl 26% vs H 4% of (197) extremity DVT in label, controlled control) volume overload on admission, >2 d every 2 d or until treated, p<0.01); 20% had minor bleeding pts with HF and pts study SQ H 5000 u bed rest prior to discharge (bruising at injection site), no major with chest q8h x 14 d or until admission bleeding infections discharge ARTEMIS Safety and efficacy Double-blind, N=849 medical HF n=160 CHF (NYHA III-IV) High bleeding risk" or Efficacy: DVT Efficacy: composite [Total ITT (efficacy): all pt with ≥1 dose of drug Cohen 2006 of fondaparinux in placebo-controlled, inpt, mean (fondaparinux 78, or acute contraindicated to diagnosed by contrast VTE + bleeding + death at 1 (safety); HF pts=predefined subgroup. 16439370 reducing VTE in block randomized, f/u=1 mo placebo 82) respiratory illness; anticoagulation, venogray (d 5-15), mo]; Safety: composite Fishers Exact and log-rank (198) older, moderate- multicenter RCT of expected bed rest Creat >2.0 mg/dL, symptomatic VTE (inc [death or minor bleeding] HF subgroup: Primary: fondaparinux high risk medical SQ fondaparinux >4 d; age >60 contrast allergy, PE by imaging or fatal) 7/78 (9%) vs placebo 10/82 (12.2%), inpt 2.5 mg/d for 6-14 d mechanical vent >24 through d 15; Safety: p=NS; Primary safety: p=NS (1 bleed in started within 48 h h (total), indication major bleeding each group) of admission for AC prophylaxis or therapy, life expectancy otherwise <1 mo
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CERTIFY Compare LMWH to Prospective, Total N=3239, HF n=470; 238 age ≥70, clinical Contraindicated to Efficacy: composite Prox DVT, nonfatal PE, Active treatment only. No difference in Tebbe 2011 heparin on VTE double-blind, mean pts (cert) vs 232 diagnosis of HF on anticoagulation, [prox DVT (compression fatal VTE, distal DVT, efficacy or safety endpoints in HF pt 21315215 incidence in elderly double dummy, hospitalization pts (H), admission (no History of DVT, PE USG d 8-20) + nonfatal symptomatic DVT, all-cause based on treatment arm. Primary: cert (199) HF pt active control, 12.2 +/-5.1 d, further details) or HIT2, stroke <3 PE + VTE-related mortality, documented 3.78% vs heparin 4.74%, OR: 0.79; 95% randomized mean mo, >3 d death]; Safety: symtpomatic VTE, CI 0.32-1.94; p=NS; multivariate: noninferiority study treatment immobilization before composite [major composite [nonfatal PE + insufficient to confirm noninferiority in HF of certoparin 3000 period = 9 d randomization, cast bleeding + minor prox DVT + all-cause pt. u/d vs H 5000 u or fracture, surgery bleeding + HIT] mortality] TID SQ (HF <3 wk, severe predefined sepsis, mechanical subgroup) ventilation, any heparin <5 d THE PRINCE Compare safety Prospective, Total N=665 HF n=333 for NYHA III-IV Contraindicated to Efficacy: Comfirmed Efficacy: composite [TEE No differences in primary, secondary or Kleber 2003 and efficacy of randomized, active safety endpoint, heparin or TEE (DVT by or death] safety endpoints 12679756 enoxaparin with control/parallel n=206 for efficacy anticoagulation, venography or autopsy, 12.6% HF pt had events. Primary: (200) UFH in preventing group open label, contrast allergy, DVT PE by V/Q, CXR/Q enoxaparin (9.7%) vs heparin (16.1%) [CI VTE in pts with HF noninferiority or PE on admission, scan [plus confirmatory -1.4 - +14.2], p=0.139. Secondary: or severe comparison immobilized >24 h venogram if +], mortality: enoxaparin 5.3% vs heparin respiratory disease enoxaparin 40 prior to admission, angiogram or autopsy) 6.4% (no statistical comparison); Saftey: mg/d vs heparin taking warfarin or within 1 d of completing no difference (1 bleed in entire study 5000 u TID for 10 >low dose aspirin on treatment; Safety: Major population) +/- 2 d. 1-sided admission bleeding equivalence, upper limit = 9% or 4% difference in efficacy. MEDENOX Compare safety Prospective, Total N=855; HF n=290 (34%) NYHA III-IV Contraindicated to VTE (DVT [contrast VTE d 1-110; Major or Enoxaparin 20 mg = Placebo (excluded Samama 1999 and efficacy of 2 randomized, f/u = 110 d anticoagulation or venograpy or minor hemorrhage, from final analysis); lower incidence of 10477777; doses of double-blind, heparin, contrast compression USG day mortality, radiographic DVT in enoxaparin 40 mg vs Turpie 2000 enoxaparin vs parallel arm of allergy, thrombophilic 6-14 or earlier with thrombocytopenia, any placebo. No difference in mortality or AEs 11206019; placebo to prevent placebo vs disease or symptoms], PE [high adverse event, lab among treatment groups. Alikhan 2003 VTE in medical pt enoxaparin 20 coagulopathy, Creat prob V/Q, CTA or angio] abnormalities (multiple) Primary: All HF pts: enoxaparin 4.0% vs 12945875 hospitalized ≤14 d mg/d vs enoxaparin >1.7, mechanical or both) d 1-14 placebo 14.6%, (RR: 0.29; 95% CI: 0.10- (201) 40 mg/d ventilation, any AC 0.84; p-0.02); Class III HF pts: enoxaparin for >48 h prior to 5.1% vs. placebo 12.3% (RR: 0.42; 95% enrollment CI: 0.13-1.29; p=0.20); Class IV HF pts: enoxaparin 0% vs. placebo 21.7%, (p=0.05); History of chronic HF as risk (regardless of admission diagnosis): enoxaparin 2.2% vs. placebo 12.1% (RR: 0.26; 95% CI: 0.08-0.92; p=0.04) AC indicates anticoagulant; ACEI, angiotensin-converting-enzyme inhibitor; ACT, active control parallel; AE, adverse event; AP, apixaban; APT, antiplatelet therapy; AF, atrial fibrillation; ARB, angiotensin receptor blockers; AT, as treated; BID, twice a day; BNP, brain natriuretic peptide; CAD, coronary artery disease; CHF, congestive heart failure; CrCl, creatinine clearance; CTA, computed tomography angiography; CTR, cardiothoracic ratio; CV, cardiovascular; CXR, chest x-ray; Dab, dabigitran; DCM, dilated
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cardiomyopathy; DVT, deep venous thrombosis; EF, ejection fraction; f/u, follow-up; H, heparin; HD, heart disease; HF, heart failure; HIT2, heparin-induced thrombocytopenia; H/N, hydralazine and nitrates; HTN, hypertension; ICH, ischemia; INR, international normalized ratio; ITT, intent to treat; KM, kaplan-meier; LMWH, low moleduclar weight heparin; LV, left ventricular; LVEDD, left ventricular end diastolic diameter; LVEF, left ventricular ejection fraction; MI, myocardial infarction; N/A, not applicable; NS, not significant; NYHA, New York Heart Association; OAT, oral anticoagulant therapy; PCI, percutaneous coronary intervention; PE, pulmonary embolism; PPM, pacemaker; pt, patient; QoL; quality of life; RCT, randomized control trial; SQ, subcutaneous; TEE, thromboembolic event; TIA, transient ischemic attack; TID, three times a day; UFH, unfractionated heparin; USG, ultrasonography ; VO2, oxygen volume; V/Q, ventilation/perfusion scan; and VTE, venous thromboembolic disease.
Data Supplement 22. Statin Therapy (Section 7.3.2.8.2) Study Name, Author, Aim of Study Background Trial Absolute Statistical Study Year Study Type Therapy Study Size Etiology Patient Population Severity Endpoints Mortality Duration Benefit Results Limitations N (Total) Ischemic/ Severity of Pretrial standard n (Experimental) Non- Inclusion Exclusion HF Primary Secondary Annualized 1st Year treatment n (Control) Ischemic Criteria Criteria Symptoms Endpoint Endpoint Mortality Mortality Horwich et To Cohort ACEI/ARB, beta- 551; 248; 303 45% Pts referred LVEF NYHA 3-4 Death or N/A N/A 75% 2 y 14% HR 0.44; Single-center, al, 2004 investigate study blockers,spironolac for >40%, urgent 95% CI non- 14975476 the impact tone, diuretics transplant baseline transplant 0.30-0.67; randomized, (202) of statin evaluation data p<0.0001 reason for therapy in between incomplete drug use pts with 2000-2 unclear, bias advanced HF referred for transplant evaluation at UCLA. Mozaffaria To evaluate Cohort ACEI/ARB, 1,153; 1,019; 134 63% Dyspnea or N/A NYHA 3b-4 All-cause Cause- 29 N/A Mean 1.5 N/A HR: 0.38; Post-hoc n et al, the relation study diuretics, digoxin fatigue on mortality specific deaths/100 y 95% CI: analysis from 2004 of statin exertion mortality person-y 0.23-0.65; clinical trial 15110204 therapy (NYHA 3b- (SCD, Propensity- (203) with clinical 4), LVEF pump matched outcomes ≥30% failure HR: 0.46. in severe death, fatal 95% CI: HF enrolled MI) 0.26–0.75 in the PRAISE study
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Ray et al, To Cohort ACEI/ARB, beta- 28,828; 1,146; 11.3% Adults aged Pts N/A Death N/A 9.9% per N/A 16.6 mo 8.2% per HR: 0.62; Retrospective 2005 determine study blockers,spironolac 27,682 history of 66 to 85 y in hospitalize from any 100 person- in the 100 95% CI: cohort study, 15642876 whether tone, diuretics, MI Ontario d within 36 cause, y vs 19.1% statin person-y 0.53-0.69; non- (204) statin use is nitrates Canada mo for HF nonfatal per 100 group aHR: 0.72; randomized, associated newly or having acute MI, person-y and 24.4 95% CI: reason for with hospitalized diagnosis or mo in the 0.63-0.83. drug use a lower risk with primary of cancer nonfatal nonstatin unclear, bias of death diagnosis of within past stroke group and major HF between 365 d prior CVD April 1, to index HF among 1995, and hospitalizati adults December on newly 31, 2001 discharge diagnosed and survived date; as having at least 90 d dispensed HF in after the statin 365 d Ontario index prior to registry HF hospital hospitalizatio discharge, n length of stay >60 d, direct transfer to chronic care hospital, cancer within 90 d following index HF hospitalizati on Foody et To evaluate Cohort ACEI/ARB, beta- 54,960; 9,163; 30% history Sampling of <65 y of NYHA 2-4 All-cause N/A 20% N/A 3 y N/A HR: 0.62; Retrospective al, 2006 the study blockers,spironolac 45,797 of MI Medicare age, HF mortality 95%CI: cohort study, 16490817 association tone, diuretics, fee-for- readmissio 0.59–0.65; sampling, (205) between nitrates service ns, p<0.001 non- statin use beneficiaries transferred aHR: 0.80; randomized, and hospitalized out of the 95%CI: reason for survival with a hospital, 0.76–0.84; drug use among a principal left AMA, or p<0.001 unclear, bias national diagnosis of had sample of HF by ICD-9 unknown elderly code discharge
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Medicare between disposition, beneficiarie 4/98-3/99 died during s and 7/00- hospitalizati hospitalized 6/01. on, had no with HF date of from death National information Heart Care available, Project. hospitalize d outside the US, discharged to hospice, contraindic ations to statin therapy, including statin allergy or liver dysfunction , or no medication s recorded on discharge Anker et al, To assess Cohort ACEI or ARB (as in 5,200; 1,103; 67% ELITE-II: pts NR NYHA 2-4 All-cause N/A NR 12% mean 1.5 NR ELITE-II: Retrospective 2006 the study ELITE-2), diuretics, 4,097 age ≥60 y; mortality y aHR 0.61; cohort study 16846656 relationship digoxin NYHA 2-4, (ELITE- 95% CI: and post-hoc (206) between LVEF ≥40%. 2); 0.44-0.84; analysis, statin use European 2 y p<0.0028 sampling, and registry: (Europea European non- survival in diagnosis of n registry: randomized, ELITE-II as HF followed registry) aHR 0.58; reason for well as a 5- by HF clinic 95%CI drug use center adjusted unclear, bias registry 0.44-0.77; p<0.0001;
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Folkeringa Investigate Case- ACEI/ARB, 524; 262; 262 50% Pts admitted NR NYHA 3-4 All-cause N/A NR NR Mean 2.6 4% OR: 0.42; Retrospective et al, 2006 the effects control diuretics, digoxin for HF with mortality y 95% CI: cohort study, 16520262 of statins study an 0.26–0.69 sampling, (207) on survival uncomplicat non- in CHF pts ed survival randomized, using a for at least 1 reason for matched mo after drug use case- hospital unclear, bias controlled discharge, study in pts group-wise admitted to matched hospital between because of survivors severe and non- CHF from survivors on the means of MARCH age, LVEF, study renal function, and sex. Go et al, To evaluate Cohort ACEI/ARB, 24,598; 12,648; 54% Adults (age Pts who NYHA 2-4 Death N/A 13.90% NR Median NR aHR: 0.76; Retrospective 2006 the study diuretics, digoxin 11,950 ≥20 y) were from any 2.4 y 95%CI: cohort study, 17077375 association diagnosed receiving cause and 0.72-0.80 sampling, (208) between with HF statin hospitaliz non- initiation of 1/96-12/04 therapy at ation for randomized, statin with ≥1 the study at HF reason for therapy and hospitalizatio entry date; drug use risks for ns with a who were unclear, bias death and principal not eligible hospitalizati diagnosis of for on among HF; ≥2 treatment adults with hospitalizatio based on chronic HF ns with a national in the secondary guidelines Kaiser diagnosis of Permanent HF in which e Chronic the principal HF cohort diagnosis is cardiac- related; ≥3 hospitalizatio ns with secondary
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diagnosis of HF; ≥2 outpatient diagnoses; ≥3 ED visit diagnoses; or ≥2 inpatient secondary diagnoses plus 1 outpatient diagnosis. Krum et al, To examine Cohort ACEIs/ARB, beta- 2,647; 220; 2,421 59% Pts enrolled N/A NYHA 2-4 Death CV deaths 11.10% NR Mean 1.3 NR HR 0.57; Retrospective 2007 statin/beta study blockers,spironolac in CIBIS-II included y 95% CI: cohort study, 16960445 blocker tone, diuretics study the 0.37–0.94; sampling, (209) interactions following aHR 0.60; non- within the specific 95% CI: randomized, context of a causes: 0.39–0.94 reason for large-scale sudden drug use clinical trial death, unclear, bias of pts with pump systolic failure, MI CHF in and any CIBIS-II other CV condition not listed above which led to the pt's death. Worsening HF only was counted as an outcome endpoint in CIBIS II when this (critical) event led to the hospitalizati
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on of the pt.
Krum et al, To assess Cohort ACEI/ARB, beta- 5,010; 1,602; 57% Pts enrolled N/A NYHA 2-4 All-cause Mortality 7.90% NR Mean 1.9 7.20% HR 0.81: Retrospective 2007 the study blockers,spironolac 3,408 in Val-HeFT mortality and y 95%CI 0.70– cohort study, 17049646 outcome of tone, diuretics study morbidity 0.94; sampling, (209) pts enrolled (cardiac p=0.005 non- in Val- arrest with randomized, HeFT resuscitatio reason for according n, drug use to statin hospitalizati unclear, bias use at the on for HF, time of or randomizati administrati on to on of valsartan or IVinotropic placebo. or vasodilator drugs for 4 h or more without hospitalizati on) Dickinson To examine Cohort ACEI/ARB, beta- 2,521; 965; 1,556 52% Ischemic N/A NYHA 2-3 All-cause N/A 6.80% NR Mean 3.8 NR aHR 0.7; Retrospective et al, 2007 the effects study blockers,spironolac and non- mortality y 95% CI: cohort study, 17383296 of statin in tone, diuretics ischemic 0.57-0.83 sampling, (210) reducing cardiomyopa non- mortality in thy, NYHA randomized, SCD-HeFT 2-3 HF, reason for LVEF 35% drug use or less unclear, bias
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CORONA, To RCT ACEI/ARB, beta- 5,011; 2,497; 100% Age ≥18, Myopathy NYHA 2-4 Composit Death from 11% NR Median 0.9% per HR: 0.92; N/A Kjekshus et investigate blockers,spironolac 2,514 symptomatic or e of death any cause, 2.7 y 100 95% CI: al, 2007 the tone, diuretics HF NYHA 2- hypersensti from any patient-y 0.83-1.02; 17984166 beneficial 4, IHD, vity to cardiovas coronary p=0.12 (211) effects of LVEF <40%, statin, ACS cular event rosuvastati does not or causes, (sudden n on need statin revasculari nonfatal death, fatal improving therapy, zation <1 MI, and or nonfatal survival, optimal mo, nonfatal MI, PCI or reducing medical reduced life stroke CABG, morbidity, therapy >2 expectancy ventricular and wk , planned defibrillatio increasing surgery <3 n by an well-being mo, Cr >2.5 ICD, in pts with mg/dL, ,CK resuscitatio chronic, >2x ULN, n after symptomati LFTs >1.5x cardiac c, systolic, ULN, arrest, or ischemic uncorrecte hospitalizati HF. d valve or on for UA), HCM death from CV causes (with an additional analysis of cause- specific death from a CV cause), and the number of hospitalizati ons for CV causes, unstable angina, or worsening HF GISSI-HF, To RCT ACEI/ARB, beta- 4,574; 2,285; 42% history ≥18, Hypersenst NYHA 2-4 Co- Death for a 7.90% NR Median -1% HR: 1.02 N/A Tavazzi et investigate blockers,spironolac 2,289 of MI symptomatic ivity to primary CV cause; 3.9 y 99% CI: al, 2008 the effi tone, diuretics HF NYHA 2- statin, endpoint: first 0.923-1.130; 18757089 cacy and 4, if LVEF investigatio time to hospital p=0.594
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(212) safety of >40% (10%) nal drug <1 death; admission aHR: 1.01; the statin requires HF month, MI time to for any, 99% CI rosuvastati hospitalizatio <6 mo, death CV, or HF 0.908-1.112, n in pts with n within 12 ACS or or cause; and p=0.903; HF. mo revasculari admission the zation <3 for combined mo, cardiovas outcome reduced life cular measure of expectancy reasons CV death , planned or surgery/dev admission ice <3 mo, to hospital Cr >2.5 for any mg/dL, cause LFTs >1.5x ULN, pregnant ACEI indicates angiotensin-converting-enzyme inhibitor; ACS, acute coronary syndrome; AMA, against medical advice; ARB, angiotensin receptor blocker; CABG, coronary artery bypass surgery; CHF, congestive heart failure; CIBIS-II, The Cardiac Insufficiency Bisoprolol Study II; CORONA, Controlled Rosuvastatin Multinational Trial in HF; CV, cardiovascular; ELITE-II, Losartan Heart Failure Survival Study; HF, heart failure; GISSI-HF, Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico; ICD, implantable cardioverter defibrillator; ICD-9, international classification of diseases 9th edition; IHD, ischemic heart disease; LVEF, left ventricular ejection fraction; MARCH, Maastricht Registry of Congestive HF; MI, myocardial infarction; N/A, not applicable, NR, not reported; NYHA, New York Heart Association; PCI, Percutaneous coronary intervention; PRAISE, Prospective Randomized Amlodipine Survival Evaluation; SCD, sudden cardiac death; SCD-HeFT , Sudden Cardiac Death in Heart Failure Trial;UA, unstable angina; UCLA, University of California Los Angelos; and Val-HeFT, Valsartan Heart Failure Trial.
Data Supplement 23. Omega 3 Fatty Acids (Section 7.3.2.8.3) Study Name, Trial Author, Aim of Study Background Duratio Statistical Anaylsis Study Complications/ Year Study Type Therapy Study Size Etiology Patient Population Severity Endpoints Mortality n (Results) Limitations Adverse Events Study Severit Entry N (Total) y of HF Sverity n (Experimental) Inclusion Exclusion Sympt Criteri Primary Secondary Annualized 1st Year n (Control) Criteria Criteria oms a Endpoint Endpoint Mortality Mortality GISSI-HF, To Randomis All treatments 7,046; 3494; 49.6% ≥18 y, Specific Class II NYHA 2 co- Cardiovasc 7% 7.0% 4.5 y, 1.8% absolute mortality By the end The rate of pts Lancet investigate ed, of proven 3,481 (placebo) ischemic/5 clinical indication or 63%, III Class primary ular (estimate median reduction (95% CI 0·3– of the study, who had 2008 whether double- efficacy for 0.4% non- evidence of contraindicati 34%, IV II-IV endpoints mortality, d from KM f/u 3.9 y 3·9%). Absolute benefit 1004 (29%) permanently 18757090 omega-3 blind, chronic HF ischemic- HF of any on to n-3 3% HF : time to cardiovasc curves) for mortality or of pts in the discontinued (213) fatty acid placebo- (eg, ACEIs, other cause PUFA; known death, ular admission for omega 3 FA taking the study supplement controlled beta blockers, classified as hypersensitivi and time mortality or cardiovascular reasons group and drug because of ation could trial (2x2, diuretic drugs, the ESC GL ty to study to death admission was 2·3% (95% CI 0·0– 1029 (30%) adverse reactions improve factorial italis, NYHA class treatments; or for any 4·6%). NNT for benefit in the was much the morbidity design, spironolacton II–IV, presence of admissio reason, is 56 pts need to be placebo same in the and rosuvastat e) were provided that any non- n to sudden treated to avoid 1death group were omega 3 FA and mortality in in) positively LVEF was cardiac hospital cardiac and 44 pts treated to no longer in the placebo a large recommende measured comorbidity for death, avoid 1event like death taking study groups (102 [3%] © American College of Cardiology Foundation and American Heart Association, Inc. 101
population d. within 3 mo (eg, cancer) cardiovas admission or admission drug for vs 104 [3%], of pts with Background before incompatible cular for any for cardiovascular various p=0·87). Very well symptomati treatment enrollment. with a long reasons. reason, reason for nearly 4 y. reasons. tolerated. No c HF of any rates of When LVEF f/u; treatment admission Mortality: aHR: 0·91; Only safety issues other cause. ACEI/ARB was >40%, with any other for 95·5% CI 0·833–0·998; evaluated a than a slight 93%, beta the pt had to investigationa cardiovasc p=0·041. Mortality or single dose. excess of blockers 65%, have been l agent within ular were admitted to Study cerebrovascular aldosterone admitted at 1 mo before reasons, hospital for conducted in events, which was antagonists least 1 randomisatio admission cardiovascular reasons Italy where a similar finding to 40%, loop hospital for n; ACS or for HF, MI, (aHR: 0·92; 99% CI there is that reported in the durietics 90% HF in the revascularisat and stroke. 0·849–0·999; p=0·009). relatively GISSI- preceding y ion procedure Mortality: aHR 0.91 high amount Prevenzione trial. to meet the within the Mortality of CV of dietary This excess was inclusion preceding 1 Hospitalization aHR intake of distributed fairly criteria. mo; planned 0.92 omega 3 evenly between cardiac fatty acids. ischaemic and surgery, (p=0·45; haemorrhagic expected to table 5). cases. No drug be done interactions noted. within 3 mo with after gastrointestinal dis randomisatio turbance being the n; significant most frequent liver disease; cause in both and groups (table 5). pregnant or lactating women or women of childbearing potential who were not adequately protected against becoming pregnant. GISSI- To evaluate Randomiz Standard 11323 pts ; 4324 100% Patient with Contraindicati No HF Time to Sudden 4% per y 4% 3.5 y Treatment with n-3 Open label. Well tolerated. Preventio the effect of ed, background (with LVEF ischemic AMI in prior ons to the or death, death PUFA reduced total Excluded pts n, omega 3 multicente therapy for ≤50%) 3 mo. dietary NYHA and time mortality in pts with and with over Macchia A fatty acid r, open- pts who are Irrespective supplements Class I, to death without systolic HF. et al. supplement label, post AMI of LV (ie, known subgrou or dysfunction, 24% (40%- EJHF ation in clinical function. No allergy to p admissio 4%, p =0.02) and 19% 2005 post MI pts trial age limits. omega-3 fatty analysis n to (41% to +10%, p (subgroup with LVD. with acids). in pts hospital =0.17), respectively analysis) blinded Unfavorable with for (heterogeneity test 16087142 validation short-term LVEF cardiovas p=0.55). (214) of events. outlook (eg, ≤50% cular The effect on SD
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Subgroup overt CHF, reasons reduction was analysis cancers, etc). asymmetrical, with a of those greater effect in pts with pts with LVSD (RRR: 58%; 95% post MI CI: 74%-33%; p LVD =0.0003) as compared to pts with preserved systolic function (RRR: 11%; 95% CI: 54% - 69%; p =0.71), although the heterogeneity test was not statistically significant (p=0.07). LVD subgroup (0.60– 0.96) p=0.02) RR 0.76 (subgroup with LVD) Omega 3 This study Randomiz Evidence 133; 100% non- Pts aged 18- presence of Mild, Mild Change Peak V02, 0% 0% 12 mo LVEF increased by Single None fatty acids was ed, single based HF 67 experimental; ischemic 75 y with a symptoms or Class I, severit in LVEF hospitalizat 10.4% n-3 PUFA and center, in DCM, designed to center therapy 66 control diagnosis of evidence of 15%, y on ions decreased by 5.0% with small, no Nodari, test the double ACE/ARB NICM, LVSD CAD Class II medica placebo, p<.0001, deaths. JACC, effects of 3 blind, 100%, beta (defined as diagnosed 85%. l peak VO2 (increased 201 PUFAs on clinical blockers an EF through therapy by 6.2% and decreased 21215550 (LV) trial 100%, <45%), and noninvasive by 4.5%, respectively); (215) systolic with aldosterone stable tests, PAD, exercise duration function in blinded antagonists clinical presence of increased by 7.5% and chronic HF validation 60%, loop conditions congenital or decreased by 4.8%; due to of events. diuretics with minimal primary VHD, and mean NYHA class NICM Subgroup 100% or no persistent AF, decreased from 1.88 +/- analysis symptoms inability to 0.33 to 1.61 +/- 0.49 of those for at least 3 perform and increased from pts with mo on bicycle 1.83 +/- 0.38 to 2.14 +/- post MI evidence- ergometry for 0.65. The LVD based noncardiac hospitalization rates for medical causes, HF were 6% in the n-3 treatment at moderately PUFAs and 30% in the maximum severely placebo group (p = tolerated reduced 0.0002). target doses functional for at least 6 capacity, mo. NYHA class IV, poor acoustic windows limiting the ability to assess echo
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measurement s, chronic lung disease, advanced renal disease (eGFR <30 ml/min/1.73 m2), advanced liver disease; any disease limiting life expectancy to <1 y, contraindicati ons to study drugs, and concomitant participation in other research studies. ACEI indicates angiotensin-converting-enzyme inhibitor; ACS, acute coronary syndrome; AMI, acute myocardial infarction; ARB, angiotensin receptor blocker; CAD, coronary artery disease; CV, cardiovascular; EF, ejection fraction; eGFR, estimated glomerular filtration rate; ESC GL, European Society for Cardiology guidelines; f/u, follow-up; GISSI-HF, Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico; HF, heart failure; KM, Kaplan-Meier; LVD, left ventricular dysfunction; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; MI, myocardial infarction; NICM, nonischemic cardiomyopathy; NNT, number needed to treat; NYHA, New York Heart Association; PAD, peripheral arterial disease; PUFA, polyunsaturated fatty acids; SD, sudden death
Data Supplement 24. Antiarrhythmic Agents to Avoid in HF (7.3.2.9.2) Study Study Drug Effect Trials Functional QoL Other Comments Design Drug Control Patients Mortality CV events Capacity Class I Na Channel Blocker CAST RCT Encainide/ P Post-MI ↑ N/A N/A N/A Study terminated early. 2473403 Flecainide/ NSVT with (216) Moricizine encainide, flecainide RR 2.5 Class III K Channel Blockers SWORD RCT d-Sotalol P Post-MI ↑ N/A N/A N/A Study terminated early. 8691967 LVEF<40% RR 1.65 (217)
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Dronedarone Study Group RCT Dronedarone P NYHA II-IV ↑ ↑ N/A N/A No difference in primary 18565860 LVEF<35% HR 2.13 first CV composite endpoint. (218) hospitalized hospitalizations
CAST indicates Cardiac Arrhythmia Suppression Trial; CV, cardiovascular; K, potassium; LVEF, left ventricular ejection fraction; MI, myocardial infarction; Na, sodium; NSVT, nonsustained ventricular tachycardia; N/A, not applicable; NYHA, New York Heart Association; P, placebo; QoL, quality of life; RCT, randomized control trial; and SWORD, Survival With Oral d-Sotalol.
Data Supplement 25. Calcium Channel Blockers to Avoid in HF (Section 7.3.2.9.3) Study Study Drug Effect Trials Functional Other Comments Design Drug Control Patients Mortality CV events QoL Capacity Nondihydropyridine MDPIT RCT Diltiazem P Post-MI NS ↑ N/A N/A None 2899840 In pts with (219) LVEF<40% or pulm congestion on CXR HR 1.41 MDPIT Retro Diltiazem P Post-MI ↑ N/A N/A None 1984898 HF in pts with (220) EF<40%, pulm congestion, or anterolateral Q wave MI DiDi RCT Diltiazem P Idiopathic NS N/A N/A N/A 18% of pts did not finish study. 8759075 DCM No difference in transplant-free (221) NYHA II-III survival (85.2% vs. 80.4%, p=0.44). DAVIT-II RCT Verapamil P Hospitalized for NS N/A N/A N/A HF pts had worse outcomes 2220572 AMI (222) Dihydropyridine Elkayam U Circulation RCT Nifedipine ISDN NYHA II-III N/A ↑ NS N/A None 1990 LVEF <40% HF hospitalization 2242521 (nifedipine vs ISDN) (223) ↑ worsening HF (nifedipine+ISDN vs either alone) Felodipine UK Study RCT Felodipine P NYHA II-III N/A ↑ NS N/A None Group LVEF <40% worsening HF 7786657 76% ICM © American College of Cardiology Foundation and American Heart Association, Inc. 105
(224) V-HeFT III RCT Felodipine P NYHA II-III NS NS NS NS More edema AE with felodipine. 9264493 LVEF <45% Not powered to study mortality. (225) 55% ICM PRAISE-2* RCT Amlodipine P NICM NS NS N/A N/A None 15921795 NYHA III-IV (226) LVEF<30% Amlodipine Exercise Trial RCT Amlodipine P NYHA II-IV N/A N/A NS NS None 10689266 LVEF <35% (227) 53% ICM AE indicates adverse event; AMI, acute myocardial infarction; CV, cardiovascular; CXR, chest x-ray; DAVIT-II, Danish Verapamil Infarction Trial II; DCM, dilated cardiomyopathy; DiDi, Diltiazem in Dilated Cardiomyopathy Trial; EF, ejection fraction; HF, heart failure; HR, hazard ratio; ICM, ischemic cardiomyopathy; ISDN, isosorbide dinitrate; LVEF, left ventricular ejection fraction; MDPIT, Multicenter Diltiazem Postinfarction Trial; MI, myocardial infarction; NICM, nonishemic cardiomyopathy; N/A, not applicable; NS, no statistically significant difference; NYHA, New York Heart Association; P, placebo; PRAISE-II, second Prospective Randomized Amlodipine Survival Evaluation; pts, patients; QoL, quality of life; RCT, randomized control trial; Retro, retrospective analysis; UK, United Kingdom; and V-HeFT, Vasodilator-Heart Failure Trial.
Data Supplement 26. NSAIDs Use in HF (Section 7.3.2.9.4) Study Results Cohort Populations Experimental Control Other Comments Design Patients Mortality CV events (n) (n) Netherlands PHARMO Obs NSAID plus Diuretics Age >55 y N/A ↑ HF hospitalization Data presented in pt-y 9605782 Diuretics alone aRR 1.8 (228) New South Whales Case- HF admission (365) Non-HF Mean age 76 y N/A ↑ HF admission None 10737277 controlled admission with non-ASA NSAID use (229) cohort (658) OR 2.1 ↑1st HF admission in pts with h/o heart disease and NSAID use vs no h/o heart disease and NSAID use Rotterdam Study Cohort No history of HF None Age >55 y N/A ↑ HF readmission None 11822918 admission (7277) FS>30% during concurrent use of NSAID (230) aRR 9.9 Ontario Drug Benefit Retro Rofecoxib (14,583) No NSAID Age >66 y N/A ↑ HF hospitalization No increased risk seen with Program Cohort Celecoxib (18,908) (100,000) 12% IHD relative to non-NSAID users celecoxib relative to non-NSAID 15172772 Non-selective Rofecoxib aRR 1.8 users (231) NSAID (5,391) NS NSAID aRR 1.4 Quebec Retro Rofecoxib (869) Celecoxib Age >66 y ↑ ↑Recurrent HF ER visit or hospitalization Combined endpoint significant 15947399 Cohort Non-selective (717) Index HF NS NSAID HR 1.54 NS NSAID HR 1.21 (0.92-1.6) risk with NS NSAID and rofecoxib (232) NSAID (280) admission Rofecoxib HR 1.44 Rofecoxib HR 1.17 (0.96-1.42)
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Danish National Patient Retro Rofecoxib (6116) No NSAID Age >30 y ↑ ↑HF hospitalization Increased risk with higher doses Registry Cohort Celecoxib (5734) (70738) Index HF Rofecoxib HR 1.7 Rofecoxib HR 1.4 of NSAIDs for all types 19171810 Ibuprofen (16875) admission Celecoxib HR 1.75 Celecoxib HR 1.24 (233) Diclofenac (9377) 13% h/o MI Ibuprofen HR 1.31 Ibuprofen HR 1.16 Naproxen(2176) Diclofenac HR 2.08 Diclofenac HR 1.35 Other NSAID Naproxen HR 1.22 Naproxen HR 1.18 (11488) Other HR 1.28 Other NSAID HR 1.27 aRR indicates adjusted relative risk; ASA, aspirin; ER, emergency room; FS, fractional shortening; HF, heart failure; h/o, history of; IHD, HR, hazard ratio; ischemic heart disease; MI, myocardial infarction; N/A, not applicable; NS, not statistically significant; NSAID, non-selective nonsteroidal anti-inflammatory drug; Obs, observational study; OR, odds ratio; pt-y, patient years; and Retro, retrospective analysis.
Data Supplement 27. Thiazolidinediones in HF (Section 7.3.2.9.5) Study Results Cohort /Trial Experimental Control Design Patients Mortality CV events (n) (n) Pharmetrics Retro TZD No TZD No HF N/A ↑ incidence of HF Integrated Outcomes Cohort (5441) (28,103) Age >18 y TZD HR 1.7 Database DM II 14578227 (234) oral hypoglycemic agent PROactive RCT Pioglitazone (2065) Placebo (2633) NYHA I HF NS ↓ 16214598 Age 35-75 y Composite all-cause mortality, non-fatal MI, and CVA HR 0.84 (235) DM II 95% CI 0.72-0.98; p=0.27 Macrovascular disease ↑ HF events 11% Pioglitazone vs 8% placebo, P<0.0001 Dargie HJ JACC 2007 RCT Rosiglitazone (110) Placebo NYHA I-II HF NS N.S. 17448371 (114) LVEF <45% (236) DM II oral hypoglycemic agent Lipscombe LL JAMA Retro TZD Other oral Age > 66 y ↑ ↑ 2007 Cohort hypoglycemic DMII RR 1.29 HF adjusted RR 1.60 18073359 oral hypoglycemic agent 95% CI 1.02-1.62; 95% CI 1.21-2.10; p<.001 (237) p=0.03 ↑ AMI RR 1.40 95% CI, 1.05-1.86; p=.02 RECORD RCT Rosiglitazone add- MET and SU No HF NS ↑ 19501900, 20118174 on (2227) DMII HF HR 2.1 (238,239) (2220) oral MET or SU 95% CI 1.35-3.27, p=0.001 ↔ AMI HR 1.14 95% CI 0.8-1.63, p=0.47
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Giles TD Congestive RCT Pioglitazone (151) Glyburide NYHA I NS NS Heart Failure 2010 (149) Mild cardiac disease exercise capacity, HbA1c 20557330 DM II (240) AMI, acute myocardial infarction; CVA, cerebral vascular accident; DM II, type 2 diabetes mellitus; HbA1c, hemoglobin A1c; HF, heart failure; HR, hazard ratio; LVEF, left ventricular ejection fraction; MET, metformin; MI, myocardial infarction; N/A, not applicable; NS, no statistically significant difference; NYHA, New York Heart Association; PROactive, Prospective pioglitazone Clinical Trial In Macrovascular Events;RCT, randomized control trial; RECORD, Rosiglitazone evaluated for cardiovascular outcomes in oral agent combination therapy for type 2 diabetes; Retro, retrospective analysis; RR, relative risk; SU, sulfonylurea; and TZD, thiazolidinediones.
Data Supplement 28. Device-Based Management (Section 7.3.4)
Study Name, Study Author, Year Aim of Study Study Type Size Patient Population Endpoints Statistical Analysis (Results) Study Limitations
Primary Secondary Endpoint Endpoint COMPASS, Bourge et Determine impact of Single blind RCT 274 Class III-IV with HF events HF hospitalization Failed primary, with 21% reduction (p=0.33). Both groups high clinical contact al. 2008 JACC clinician knowing hospitalization/6 mo, all (post hoc) HF hospilization 36% reduction (HR: 0.64: (0.95/wk). No protocol for response to 18342224 continuous EF p=0.03) information. (241) ambulatory right heart pressures COMPASS –Diastolic Determine impact of RCT 70 Class III-IV, EF ≥50% HF events N/A 20% reduction (p=0.66). HF hopsitlization Both groups high clinical contact HF, substudy. Zile, clinician knowing 29% reduction (p=0.43) (0.95/wk). No protocol for response to 2008 J Cardiac Fail continuous information. Small subgroup. 19041044 ambulatory right (242) heart pressures REDUCE-HF Determine impact of Single blind RCT 400 of Class II/III HF events N/A No trend for benefit Trial stopped for anticipated lead Adamson,Congestive clinician knowing and 1200 problems Heart Failure 2011 acting on home (target) 21906250 pressures (243) SENSE-HF Determine predictive Observational, 501 N/A Predictive value N/A PPV for HF hosp increased from 4.7 to 38% N/A Conraads 2011 Eur J value of impedance Doubleblinded of impendance during study Echo changes Phase I, changes 21362703 unblinded Phase (244) II FAST Compare impedance RCT (Pts and 156 Class III-IV Number of N/A Greater sensitivity for impedance than daily Weight changes defined as 3 lbs/1 d or Abraham 2011 Changes to daily study team With ICD or CRT, threshold weights: 5 lbs in 3 d. Unknown relationship of Cong H Fail weights for blinded to LVEF ≤35% changes 76% vs 23% (p=0.001) weight changes to therapy change 21449992 monitoring impedance data) associated with Unexplained change rate (245) HF event within 1.9 vs 4.3/pt-y. 30 d 1 in 7 impedance changes associated with
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event (p=0.0001) CHAMPION Determine impact of Single blind RCT 550 Class III HF and HF AUC 6 mo PAP, 39% reduction in HF hospitalizations (HR: 7 procedure-related SAEs Abraham PAP information hospitalized in past y hospitilizations % admitted 0.7; p=0.0001), Lancet 2011 from wireless DAOH, More reduction in PAP (p=0.008), 21315441 monitor MLHF Lower % pts with HF hospitalizations (HR: (246) 0.7; p=0.02), DAOH, (p=0.02), Better MLHF (p=0.02) CHAMPION Determine impact of Single blind RCT 119 Class III HF and HF N/A HF hosp reduced from 0.33 to 0.16 Subgroup small, same trend EF ≥40% PAP information hospitalized in past y hospitilizations (p=0.0001) 21315441 from wireless (246) monitor HOMEOSTASIS Feasibility study of Open-label 40 Class III-IV; N/A N/A LAP declined 17.6 to 14.8 (p=0.0003); Pilot observational, no controls. Ritzema, Circulation daily LAP monitoring Registry, hospitalized in past y % over 15 declined 67% (p=0.001) key concepts: physiology 2011 to inform pt-directed uncontrolled all EF Beta blocker/ACE-I doses increased 40/37% reduce diuretics. 20176990 therapy (p=0.001) Pt responsibility (247) Loop doses decreased 27% (p=0.15) DOT-HF trial, Determine impact of Single blind RCT N/A N/A N/A N/A Monitoring increased hospilizations, N/A 21931078 knowing impedance clinic visits, [5816 /id} information No decrease in mortality
AUC, area under the curve; CHAMPION, CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients; COMPASS-HF, Chronicle Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure; CRT, cardiac resynchronization therapy; DOT-HF, Diagnostic Outcome Trial in Heart Failure; EF, ejection fraction; FAST, Fluid Accumulation Status Trial; HF, heart failure; HOMEOSTASIS; Hemodynamically Guided Home Self-Therapy in Severe Heart Failure Patients; ICD; implantable cardioverter-defibrillator; LAP, left atrial pressure; lbs, pounds; LVEF, left ventricular ejection fraction; MLHF, Minnesota Living with Heart Failure Questionnaire; N/A, not applicable; PAP, pulmonary artery pressure; PPV, positive predictive value; pt, patient; pt-y, patient years; RCT, randomized control trial; REDUCE-HF, Reducing Decompensation Events Utilizing Intracardiac Pressures in Patients With Chronic Heart Failure; SAE, serious adverse event; SENSE-HF, Sensitivity of the InSync Sentry feature for the Prediction of Heart Failure.
Data Supplement 29. CRT (Section 7.3.4.2) Patient Population - QRS QRS Composite N (total) durati Subgroups Endpoint (for Study Name, Study n (experimental) Follow-Up Baseline on by duration QRS Author, Year Aim of Study Type n (control) (mo) Treatment NYHA Class EF (%) (ms) Exclusion Criteria (ms) subgroups) Results COMPANION Aim of trial was to RCT 1520; 617; 16.2 (CRT), ACE-Is, beta 3 or 4 < 35 > 120 • non- randomized 120-147 (n All cause CRT with a pacemaker decreased N Engl J Med compare optimal medical therapy*: 11.9 (medical) blockers, and • no-CRT control group 324); 148- mortality or the risk of the primary end point 2004;350:214 pharmacologic 308; spironolactone • enabled ICD *168 (n 314); hospitalizations (HR: 0-50. therapy plus CRT pacemaker- implantation only in one >168 (n 287) 0.81; p=0.014), 15152059 with a pacemaker, defibrillator: 595 study arm only CRT with a pacemaker–defibrillator (248) optimal • cross-over study design decreased the risk of the primary pharmacologic • did not report the endpoint (HR: 0.80; p=0.01) therapy plus CRT clinical outcomes of
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with a pacemaker– interest Risk of the combined endpoint of defibrillator, and • reported clinical death from or hospitalization for optimal outcomes without any HFwas reduced by 34% in the pharmacologic relation to specific limited pacemaker group (p<0.002) and by therapy alone in a QRS ranges 40 % in the pacemaker–defibrillator population with group (p<0.001 for the comparison advanced HF and with the pharmacologic-therapy intraventricular group). conduction delays. Pacemaker reduced the risk of the secondary endpoint of death from any cause by 24% (p=0.059), and a pacemaker–defibrillator reduced the risk by 36% (p=0.003). CARE-HF To analyze the RCT 813; 409; 29.4 ACE-Is, beta- 3 or 4 <35 >120 • not randomized 120-159 (n All cause Primary endpoint was reached by N Engl J Med effects of cardiac medical therapy*: blockers, and • lacked non-CRT control 290); >159 (n mortality or 159 pts in the cardiac- 2005;352:153 resynchronization 404 spironolactone group 505) hospitalizations resynchronization group, as 9-49. on the risk of • enabled ICD for major CV compared with 224 pts in the 15753115 complications and implantation only in one event including medical-therapy group (39 % vs. (249) death among pts study arm HF 55%; HR: 0.63; 95 % CI: 0.51-0.77; who were receiving • had cross-over study hospitalization p<0.001). standard medical design therapy for • did not report the There were 82 deaths in the moderate or clinical outcomes of cardiac-resynchronization group, severe HF and interest such as compared with 120 in the cardiac • reported clinical medical-therapy group (20% vs. dyssynchrony. outcomes without any 30%; HR: 0.64; 95 %CI: 0.48-0.85; relation to specific limited p<0.002). QRS ranges. As compared with medical therapy, cardiac resynchronization reduced the interventricular mechanical delay, the end-systolic volume index, and the area of the mitral regurgitant jet; increased the LVEF; and improved symptoms and the QoL (p<0.01 for all comparisons).
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REVERSE To determine the RCT 610; 419; 12 ACE-Is, beta 1 or 2 <40 >120 • not randomized 120-151 (n All cause The HF clinical composite 19038680 effects of CRT in CRT-off : 191 blockers, and • lacked non-CRT control 303); mortality or HF response endpoint, which (223) NYHA functional spironolactone group >151 (n 307) hospitalization compared only the percent class II HF and • enabled ICD or worsened HF worsened, indicated 16% NYHA functional implantation only in one resulting in worsened in CRT-ON compared class I (ACC/AHA study arm cross-over or with 21% in CRT-OFF (p =0.10). stage C) pts with • had cross-over study drop-out Pts assigned to CRT-ON previous HF design worsened experienced a greater symptoms. • did not report the NYHA class or improvement in LV end-systolic clinical outcomes of moderately or volume index (-18.4 + 29.5 ml/m2 interest such markedly vs. -1.3 +23.4 ml/m2, p < 0.0001) • reported clinical worsened HF and other measures of LV outcomes without any symptoms remodeling. Time-to-first HF relation to specific limited hospitalization was significantly QRS ranges. delayed in CRT-ON (HR: 0.47; p=0.03).
MADIT-CRT Aim of trial was to RCT 1800 28.8 ACE-Is, beta- 1 or 2 <30 >130 • not randomized 130-149 (n All cause Primary end point occurred in 19723701 determine whether 1089 blockers, and • lacked non-CRT control 645); >149 (n mortality or HF 17.2% of the CRT–ICD group and (250) CRT medical therapy*: spironolactone group 1175) event (HF in 25.3% of the ICD-only group. with biventricular 731 • enabled ICD hospitalization CRT–ICD group HR: 0.66; 95% CI: pacing would implantation only in one or outpatient 0.52-0.84; p=0.001. reduce the risk of study arm intravenous The benefit did not differ death or HF events • had cross-over study diuretic therapy) significantly between pts with in design ischemic cardiomyopathy and pts with mild • did not report the those with nonischemic cardiac symptoms, clinical outcomes of cardiomyopathy. CRT superiority a reduced EF, and interest such was driven by a 41% reduction in a wide QRS • reported clinical the risk of HF events evident complex. outcomes without any primarily in a prespecified relation to specific limited subgroup of pts with a QRS QRS ranges. duration ≥150 msec. CRT was associated with a significant reduction in LV volumes and improvement in the EF. There was no significant difference between the two groups in the overall risk of death, with a 3% annual mortality rate in each treatment group. SAEs were infrequent in the 2 groups.
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RAFT Aim of trial was to RCT 1800; 894; 40 ACE, beta- 2 or 3 <30 >120 • not randomized 120-149 (n All casue Primary outcome occurred in 21073365 evaluate whether No CRT: 904 blockers, and • lacked non-CRT control 627); >149 (n mortality or HF 33.2% in the ICD–CRT group and (251) adding spironolactone group 1036) hospitalization 40.3% in the ICD group; ICD–CRT CRT to an ICD and • enabled ICD group HR: 0.75; 95% CI: 0.64- optimal medical implantation only in one 0.87; p<0.001. therapy might study arm In the ICD–CRT group, 186 pts reduce mortality • had cross-over study died, as compared with 236 in the and morbidity design ICD group (HR: 0.75; 95% CI: among such pts. • did not report the 0.62-0.91; p=0.003), and 174 pts clinical outcomes of were hospitalized for HF, as interest such compared with 236 in the ICD • reported clinical group (HR: 0.68; 95% CI: 0.56- outcomes without any 0.83; p<0.001). 30 d after device relation to specific limited implantation, AEs had occurred in QRS ranges. 124 pts in the ICD-CRT group, as compared with 58 in the ICD group (p<0.001). PROSPECT Aim of trial was to prospecti 498-enrolled; 6 Medical therapy, 3 or 4 <35 >130 N/A N/A 12 Clinical composite score was Circulation. evaluate selected, ve, 467-implanted; unless echocardiograp improved in 69% of 426 pts, 2008;117: predefined multicent Not applicable contraindicated, hic parameters whereas 2608-2616. baseline er, was to include an of LV end-systolic volume decreased 18458170 echocardiographic nonrand ACE-I or ARB for dyssynchrony, >15% in 56% of 286 pts with (252) parameters for omized at least 1 mo based on both paired data. The ability of the 12 their ability to study before enrollment conventional echo parameters to predict clinical predict clinical and (observat and a and tissue composite score response varied echocardiographic ional) beta blocker Doppler-based widely, with sensitivity ranging from response to CRT. started at least 3 methods, were 6%- 74% and specificity ranging mo before and evaluated after from 35%- 91%; for predicting unchanged for at site training in LVESV response, sensitivity least 1 mo before acquisition ranged from 9%-77% and enrollment methods and specificity from 31%-93%. For all blinded core the parameters, the area under the laboratory ROC curve for positive clinical or analysis. volume response to CRT was <0.62. There was large variability in the analysis of the dyssynchrony parameters.
CONNECT To determine if multicent 1,997 15 N/A Inclusion N/A N/A permanent AF N/A N/A The median time from clinical J Am Coll wireless remote er, REMOTE ARM: criteria: 1) chronic warfarin therapy event to clinical decision per pt was Cardiol monitoring with prospecti 1014 being able previous ICD, CRT reduced from 22 d in the in-office 2011;57:1181 automatic clinician ve, All automatic and willing to device, or pacemaker arm to 4.6 d in the remote arm –9 alerts reduces the randomiz clinician alerts replace age <18 y (p<0.001). The health care
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21255955 time from a clinical ed were enabled for regularly having a life expectancy utilization data revealed a (252) event to a clinical evaluatio pts in the remote scheduled <15 mo decrease in mean length of stay decision in n arm. Audible pt in-office per CV hospitalization visit from 4.0 response to alerts were follow-ups d in the in-office arm to 3.3 d in the arrhythmias, CV disabled with the with remote remote arm disease exception of followups; (p=0.002). progression, those related to and 2) being and device issues lead and able to compared to pts device integrity. attend all receiving standard IN-OFFICE ARM: required in-office care. A 983 follow-up secondary Only audible pt visits. objective was to alerts associated No HF as compare the rates with lead and well as of CV health care device integrity NYHA 1-4 utilization between were enabled for were pts in the remote pts in the included in and in-office arms. in-office arm study because they are nominal settings and considered standard of care SMART AV Aim of trial was to randomiz 1014; 332 SD; 6 Diuretics, beta 3 or 4 <35%, >120 • Complete heart block, N/A The primary The medians (quartiles 1 and 3) for Circulation. compare 3 ed, 323-Echo; 325 blockers, and or who otherwise are endpoint was change in LV end-systolic volume 2010;122:266 alternative multicent Fixed nominal AV angiotensin- unable to tolerate pacing LV end-systolic at 6 mo for the SmartDelay, 0-2668 techniques and to er, delay converting at VVI-40-RV for up to 14 volume. echocardiography, and fixed arms 21098426 assess the double- enzyme inhibitors d Secondary were 21 mL (45 and 6 mL), 19 mL (253) hypotheses that blinded, or angiotensin • Previously received endpoints (45 and 6 mL), and 15 mL (41 and systematic AV 3-armed receptor CRT included NYHA 6 mL), respectively. No difference delay optimization trial blockers, • Upgrade of a class, QoL in improvement in left ventricular with pacemaker or ICD and score, 6-min end-systolic volume at 6 months echocardiography unable to tolerate pacing walk distance, was observed between the and/or the SD at VVI-40-RV for up to 14 LV end-diastolic SmartDelay and echocardiography algorithm is d volume, and arms (p=0.52) or the SmartDelay superior to a fixed • Heart transplant during LVEF. and fixed nominal AV delay the course of the study arms (p=0.66). Secondary end as demonstrated • Cardiac surgeries or points, including structural (LV end- by improved LV procedures planned diastolic volume and LVEF) and geometry after 6 during the study functional (6-min walk, QoL, and mo and that • Have or are likely to NYHA classification) programming receive a tricuspid valve measures, were not significantly according to SD is prosthesis (mechanical different between arms. noninferior to using right valve)
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echocardiography- • Neuromuscular, determined AV orthopedic, or other delay noncardiac condition that optimization. prevents normal, unsupported walking • Pregnant or planning to become pregnant • Enrolled in another investigational study or registry that would directly impact the current study
*diuretics, ACEIs, beta-blockers, and spironolactone ACEI indicates angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; AV, atrioventricular;CARE-HF, Cardiac resynchronization in heart failure; COMPANION, comparisons of medical therapy, pacing, and defibrillation in heart failure; CONNECT, Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision; CRT, cardiac resynchronization therapy; EF, Ejection Fraction; HCU; Health Care Utilization; HF, heart failure; HM, home monitoring; ICD, implantable cardioverter defibrillator; LVES left ventricular end-systolic; LVESV, left ventricular end-systolic volume; MADIT-CRT, multicenter automatic defibrillator implantation trial-cardiac resynchronization therapy; N/A, not applicable; NYHA, New York Heart Association; PROSPECT, Predictors of Response to CRT; Pt, patient; REVERSE, resynchronization reverses remodeling in systolic left ventricular dysfunction, RAFT, resynchronation-defibrillation for ambulatoryheart failure trial; ROC curve, receiver-operating characteristics curve; SMART-AV, SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy; SD, SmartDelay™, TRUST, The Lumos-T Safely Reduces Routine Office Device Follow-Up;
Data Supplement 30. Therapies, Important Considerations (Section 7.4.2) Study Name, Author, P Values & Study Yearl Aim of Study Study Type Study Size Patient Population Results 95% CI: OR: HR: RR: Limitations Inclusion Criteria Exclusion Criteria Hemodynamic Assessment of Hospitalized Patient Binanay C, Califf RM, To determine RCT 433 Pts with severe Exclusion criteria to PAC did not significantly affect the primary endpoint of d p=0.35 1.26 Use of inotropes, Hasselblad V et al. whether PAC use symptomatic HF despite minimize confounding alive and out of the hospital during the first 6 mo (133 d vs variability Evaluation study of is safe and recommended therapies. 1) comorbidities or urgent 135 d; HR: 1.00; 95% CI: 0.82-1.21; p=.99), mortality (43 between centers, congestive HF and improves clinical hospitalization for HF within crossover included pts [10%] vs 38 pts [9%]; OR: 1.26; 95% CI: 0.78-2.03; generalizabiity of pulmonary artery outcomes in pts the past y; (2) urgent visit to Crlevel >3.5 mg/dL p=.35), or the number of d hospitalized (8.7 vs 8.3; HR: stringent catheterization hospitalized with the ED; or (3) treatment (309.4 μmol/ L), or 1.04; 95% CI: 0.86-1.27; p=.67). HR: 1.0 d alive outside hemodynamic effectiveness: the severe during the preceding mo prior use of hospital, HR: 1.26 for mortality (p=0.35), h 1.04 For d targets ESCAPE trial. JAMA symptomatic and with >160 mg of furosemide dobutamine or hospitalized.19 % mortality at 6 mo (dead at 180 d= 43 in ,individualized 2005 October recurrent HF daily (or equivalent). LVEF dopamine >3 PAC, 38 in CAG). Annualized mortality 36%. Inhospital AEs targets not 5;294(13):1625-33. ≤30%, SBP ≤125mmHg, μg/kg/min, or any prior were more common among pts in the PAC group (47 applied 16204662 (254) and at least 1 sign and 1 use of milrinone during [21.9%] vs 25 [11.5%]; p=.04). There were no deaths symptom of congestion. the current related to PAC use, and no difference for in-hospital plus hospitalization. 30-d mortality (10 [4.7%] vs 11 [5.0%]; OR: 0.97; 95% CI, 0.38-2.22; p=.97
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Drazner MH, Hellkamp To determine Retrospective 194 Compared H&P estimates Crlevel >3.5 mg/dL RAP was <8 mm Hg in 82% of pts with RAP estimated from p<0.05 Estimated RAP posthoc, small AS, Leier CV et al. whether analysis of filling pressures and (309.4 μmol/L), or prior jugular veins as <8 mm Hg, and was >12 mm Hg in 70% of OR: 4.6, sample Value of clinician estimated cardiac index with invasive use of dobutamine or pts when estimated as >12 mm Hg. From the H&P, only orthopnea OR: assessment of hemodynamics measurements in 194 pts in dopamine >3 estimated RAP ≥12 mm Hg (OR: 4.6; p<0.001) and 3.6 hemodynamics in from history and the ESCAPE trial. H&P μg/kg/min, or any prior orthopnea ≥2 pillows (OR: 3.6; p<0.05) were associated advanced HF: the physical estimates were compared use of milrinone during with PCWP ≥30 mm Hg. Estimated cardiac index did not ESCAPE trial. Circ examination with 6-mo outcomes in 388 the current reliably reflect measured cardiac index (p=0.09), but "cold" Heart Fail 2008 reflect invasive pts enrolled in ESCAPE. hospitalization. versus "warm" profile was associated with lower median September;1(3):170-7. measurements measured cardiac index (1.75 vs. 2.0 L/min/m(2); p=0.004). 19675681 (31) and predict In Cox regression analysis, discharge "cold" or "wet" profile outcomes in conveyed a 50% increased risk of death or advanced HF rehospitalization. In advanced HF, the presence of orthopnea and elevated jugular venous pressure are useful to detect elevated PCWP, and a global assessment of inadequate perfusion ("cold" profile) is useful to detect reduced cardiac index. Hemodynamic profiles estimated from the discharge H&P identify pts at increased risk of early events. Shah MR, Hasselblad V, To estimate the Meta-analysis 5051 MEDLINE (1985-2005), the N/A HR for mortality 1.04. In critically ill pts, use of the PAC p=0.53 The combined heterogenity of Stevenson LW et al. impact of the Cochrane Controlled Trials neither increased overall mortality or d in hospital nor OR for studies Impact of the pulmonary PAC device in Registry (1988-2005), the conferred benefit. Despite almost 20 y of RCTs, a clear mortality was artery catheter in critically ill pts. National Institutes of Health strategy leading to improved survival with the PAC has not 1.04 (95% CI: critically ill pts: meta- ClinicalTrials.gov database, been devised. The neutrality of the PAC for clinical 0.90-1.20; analysis of randomized and the US Food and Drug outcomes may result from the absence of effective p=.59). The clinical trials. JAMA Administration Web site for evidence-based treatments to use in combination with PAC difference in 2005 October RCTs in which pts were information across the spectrum of critically ill pts.Use of the the mean 5;294(13):1664-70 randomly assigned to PAC PAC was associated with a higher use of inotropes (OR: number of d 16204666 (255) or no PAC were searched. 1.58; 95% CI: 1.19-2.12; p= .002) and IV vasodilators (OR: hospitalized for Results from the ESCAPE 2.35; 95% CI: 1.75-3.15; p<.001). PAC minus the trial of pts with severe HF mean for no were also included. Search PAC was 0.11 terms included pulmonary (95% CI: -0.51- artery catheter, right heart 0.74; p=.73). catheter, catheter, and Swan-Ganz.
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Allen LA, Rogers JG, To characterize Registry 439 ESCAPE sites enrolled 439 N/A Registry pts had longer hospitalization (13 vs 6 d, p<.001) p<0.05 N/A N/A Warnica JW et al. High pts enrolled in pts receiving PAC without and higher 6-mo mortality (34% vs 20%, p<.001) than trial mortality without ESCAPE randomization in a pts. On average, registry pts had lower blood pressure, ESCAPE: the registry of Registry prospective registry. worse renal function, less neurohormonal antagonist HF pts receiving Baseline characteristics, therapy, and higher use of IV inotropes compared with trial pulmonary artery pertinent trial exclusion pts. Although clinical assessment anticipated less volume catheters without criteria, reasons for PAC overload and greater hypoperfusion among the registry randomization. J Card use, hemodynamics, and population, measured filling pressures were similarly Fail 2008 complications were elevated in the registry and trial pts, whereas measured October;14(8):661-9 collected. Survival was perfusion was slightly higher among registry pts. 6 mo 18926438 (256) determined from the mortality 34% National Death Index and the Alberta Registry. Much sicker pts than ESCAPE Positive Pressure Ventilation Studies Gray A, Goodacre S, Noninvasive RCT 1069 Age > 16 y, clinical N/A There was no significant difference in 7-d mortality between p=0.87 N/A N/A Newby DE, Masson M, ventilation CPAP (trandomize diagnosis of acute pts receiving standard oxygen therapy (9.8%) and those Sampson F, Nicholl J. or NIPPV d to cardiogenic PE, PE on undergoing noninvasive ventilation (9.5%, P=0.87). There Noninvasive ventilation appears to be of standard chest radiograph, was no significant difference in the combined endpoint of in acute cardiogenic benefit in the oxygen respiratory rate >20 death or intubation within 7 d between the two groups of pts pulmonary edema. N immediate therapy, (n- breaths/min, and arterial undergoing noninvasive ventilation (11.7% for CPAP and Engl J Med 2008 July treatment of pts 367) versus hydrogen ion 11.1% for NIPPV, p=0.81). In pts with acute cardiogenic 10;359(2):142-51. with acute CPAP (5 to concentration >45 nmol/L PE, noninvasive ventilation induces a more rapid 18614781 (257) cardiogenic 15 cm of (pH <7.35). improvement in respiratory distress and metabolic pulmonary water) disturbance than does standard oxygen therapy but has no edema and may (n=346) OR effect on short-term mortality. CPAP or NIPPV MAY be reduce mortality. NIPPV considered as adjunctive therapy in pts with severe acute To determine (inspiratory cardiogenic pulmonary oedema in the presence of severe whether pressure, 8 respiratory distress or when there is a failure to improve noninvasive to 20 cm of with pharmacological therapy.As compared with standard ventilation water; oxygen therapy, noninvasive ventilation was associated with reduces mortality expiratory greater mean improvements at 1 h after the beginning of and whether pressure, 4 treatment in pt-reported dyspnea (treatment difference, 0.7 there are to 10 cm of on a visual-analogue scale ranging from 1 to 10; 95% CI: important water) 0.2-1.3; p=0.008), heart rate (treatment difference, 4 differences in (n=356). beats/min; 95% CI; 1-6; p=0.004), acidosis (treatment outcome difference, pH 0.03; 95% CI: 0.02-0.04; p<0.001), and associated with hypercapnia (treatment difference, 0.7 kPa [5.2 mm Hg]; the method of 95% CI: 0.4-0.9; p<0.001). treatment (CPAP or NIPPV).
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Masip J, Roque M, To systematically Meta-analysis 15 trials Acute PE, relevant N/A Overall, noninvasive ventilation significantly reduced the p<0.05 for RR: 0.55 N/A Sanchez B, Fernandez review and comparing randomized controlled mortality rate by nearly 45% compared with conventional mortality R, Subirana M, Exposito quantitatively noninvasive trials and systematic therapy (RR: 0.55; 95% CI; 0.40-0.78; p=.72 for reduction with JA. Noninvasive synthesize the ventilation reviews published from heterogeneity). The results were significant for CPAP (RR: noninvasive ventilation in acute short-term effect to to 1988-2005. Included 0.53; 95% CI: 0.35-0.81; p= .44 for heterogeneity) but not ventilation cardiogenic pulmonary of noninvasive convention trials were all parallel for NIPSV (RR: 0.60; 95% CI, 0.34-1.05; p=.76 for edema: systematic ventilation on al oxygen studies comparing heterogeneity), although there were fewer studies in the review and meta- major clinical noninvasive ventilation to latter. Both modalities showed a significant decrease in the analysis. JAMA 2005 outcomes. conventional oxygen "need to intubate" rate compared with conventional therapy: December therapy in pts with acute CPAP (RR: 0.40; 95% CI: 0.27-0.58; p=.21 for 28;294(24):3124-30 PE. Comparisons of heterogeneity), NIPSV (RR, 0.48; 95% CI: 0.30-0.76; p=.24 16380593 (258) different techniques, for heterogeneity), and together (RR: 0.43; 95% CI: 0.32- either CPAP or bilevel 0.57; p=.20 for heterogeneity). There were no differences in NIPSV, were also intubation or mortality rates in the analysis of studies included comparing CPAP and NIPSV.Noninvasive ventilation reduces the need for intubation and mortality in pts with acute cardiogenic pulmonary edema. Although the level of evidence is higher for CPAP, there are no significant differences in clinical outcomes when comparing CPAP vs. NIPSV. Severe Cardiogenic Shock Patient, Role of PVADs to Bridge to Recovery or Bridge/Transplant Kar B, Gregoric ID, To determine the Prospective 117 Cardiogenic shock pts N/A 56 (47.9%) of the 117 pts (41 of 80 [51.2%] with ICM; 15 of N/A N/A N/A Basra SS, Idelchik GM, efficacy and Cohort with a SBP of 90 mm 37 [40.5%] with NICM) were undergoing CPR during pVAD Loyalka P. The safety of the Hg, a cardiac index of placement.The average time from CPR onset to percutaneous pVAD in pts in 2.0 l/(min·m2) and TandemHeart implantation was 65.6+/-41.3 min. 80 pts had ventricular assist device SRCS despite evidence of end-organ ischemic and 37 pts had nonischemic cardiomyopathy. The in severe refractory intra-aortic failure despite average duration of support was 5.8 d. After implantation, cardiogenic shock. J Am balloon pump IABP/pressor support.A the cardiac index improved from median 0.52 (interquartile Coll Cardiol 2011 and/or high-dose total of 117 pts with range [IQR]: 0.8) l/(min·m2) to 3.0 (IQR: 0.9) l/(min·m2) February 8;57(6):688- vasopressor SRCS implanted with (p=0.001). The SBP and mixed venous oxygen saturation 696. support. TandemHeart pVAD increased from 75 (IQR: 15) mm Hg to 100 (IQR: 15)mm Hg 20950980 (259) were studied, of whom (p 0.001) and 49 (IQR: 11.5) to 69.3 (IQR: 10) (p 0.001), 56 pts (47.9%) respectively. The PCWP, lactic acid level, and Crlevel underwent active decreased, respectively, from 31.53 to 10.2 mm Hg to 17.29 cardiopulmonary 10.82 mm Hg (p 0.001), 24.5 (IQR: 74.25) mg/dl to 11 resuscitation immediately (IQR: 92) mg/dl (p=0.001), and 1.5 (IQR: 0.95) mg/dl to 1.2 before or at the time of (IQR: 0.9) mg/dl (p 0.009). The mortality rates at 30 d and implantation 6 mo were 40.2% and 45.3%, respectively.
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Thiele H, Lauer B, To characterize Case Series 18 VADs were implanted in N/A Mean duration of cardiac assistance was 4+/-3 d. Mean flow N/A N/A N/A Hambrecht R, Boudriot whether PVAD 18 consecutive pts who of the VAD was 3.2+/-0.6 L/min. Before support, cardiac E, Cohen HA, Schuler may offer had cardiogenic shock index was 1.7+/-0.3 L/min per m(2) and improved to 2.4+/- G. Reversal of effective after MI. 0.6 L/min per m(2) (p<0.001). Mean blood pressure cardiogenic shock by treatment for increased from 63+/-8 mm Hg to 80+/-9 mm Hg (p<0.001). percutaneous left atrial- cardiogenic PCWP, central venous pressure, and pulmonary artery to-femoral arterial shock pressure were reduced from 21+/-4, 13+/-4, and 31+/-8 mm bypass assistance. Hg to 14+/-4, 9+/-3, and 23+/-6 mm Hg (all p<0.001), Circulation 2001 respectively. Overall 30-d mortality rate was 44%. December 11;104(24):2917-2922. 11739306 (260) Idelchik GM, Simpson L, To evaluate the Case Series 18 18 pts in SRCS received N/A The mean duration of PVAD support was 4.2 +/- 2.5 d. N/A N/A N/A Civitello AB, Loyalka P, efficacy of a a PVAD as a bridge to During this time, the cardiac index improved from 0.86 +/- Gregoric ID, Delgado R, PVAD as a bridge LVAD placement or 0.66 to 2.50 +/- 0.93 liters/min/m2 (p < 0.001), SBP III, Kar B. Use of the to LVAD orthotopic heart improved from 72 +/- 11 to 98 +/- 15 mm Hg (p=0.001), and percutaneous left implantation in transplantation. 6 pts had systemic mixed venous oxygenation improved from 37 +/- 7 ventricular assist device pts in cardiogenic ischemic to 62 +/- 6 mm Hg (p < 0.001). We terminated life support in in pts with severe shock refractory cardiomyopathy, and 12 4 of the 18 pts before LVAD placement; 14 were refractory cardiogenic to IABP and had nonischemic successfully bridged to LVAD or heart transplantation. The shock as a bridge to pressor support. cardiomyopathy. At the mortality rate was 27% at 30 d and 33% at 6 mo. There long-term left ventricular time of PVAD placement, were no PVAD-associated deaths. CONCLUSION: In pts assist device 17 were receiving IABP with terminal hemodynamic collapse, PVAD support is an implantation. J Heart support, and 10 were effective bridging therapy to LVAD and appears to be a Lung Transplant 2008 undergoing viable alternative to other invasive methods of support January;27(1):106-111. cardiopulmonary 18187095 (261) resuscitation Cheng JM, den Uil CA, A meta-analysis Meta-Analysis 2 trials evaluated the N/A After device implantation, percutaneous LVAD pts had N/A N/A N/A Hoeks SE, van der EM, of controlled trials TandemHeart and a higher CI (MD 0.35 L/min/m(2), 95% CI: 0.09-0.61), higher Jewbali LS, van of PVADs vs. recent trial used the MAP (MD 12.8 mmHg, 95% CI: 3.6-22.0), and lower PCWP Domburg RT, Serruys intra-aortic Impella device (MD -5.3 mm Hg, 95% CI: -9.4 to -1.2) compared with IABP PW. Percutaneous left balloon pump pts. Similar 30-day mortality (RR: 1.06; 95% CI: 0.68-1.66) ventricular assist counterpulsation was observed using percutaneous LVAD compared with devices vs. intra-aortic for treatment of IABP. No significant difference was observed in incidence of balloon pump cardiogenic leg ischaemia (RR: 2.59, 95% CI: 0.75-8.97) in counterpulsation for shock for 30 d percutaneous LVAD pts compared with IABP pts. Bleeding treatment of cardiogenic mortality (RR: 2.35, 95% CI: 1.40-3.93) was significantly more shock: a meta-analysis observed in TandemHeart pts compared with pts treated of controlled trials. Eur with IABP.Although percutaneous LVAD provides superior Heart J 2009 haemodynamic support in pts with cardiogenic shock September;30(17):2102- compared with IABP, the use of these more powerful 2108 devices did not improve early survival. These results do not 19617601 (262) yet support percutaneous LVAD as first-choice approach in
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the mechanical management of cardiogenic shock.
Seyfarth M, Sibbing D, To test whether RCT (ISAR- 26 Cardiogenic shock post N/A In 25 pts the allocated device (n=13 IABP, n=12 Impella mortality p= N/A N/A Bauer I, Frohlich G, the LVAD Impella SHOCK Trial) AMI LP2.5) could be safely placed. 1 pt died before implantation. ns Bott-Flugel L, Byrne R, LP2.5 provides The CI after 30 min of support was significantly increased in Dirschinger J, Kastrati superior pts with the Impella LP2.5 compared with pts with IABP A, Schomig A. A hemodynamic (Impella: DeltaCI = 0.49 +/- 0.46 l/min/m(2); IABP: DeltaCI = randomized clinical trial support 0.11 +/- 0.31 l/min/m(2); p = 0.02). Overall 30-d mortality to evaluate the safety compared with was 46% in both groups.percutaneously placed LVAD and efficacy of a the IABP. (Impella LP 2.5) is feasible and safe, and provides superior percutaneous left hemodynamic support compared with standard treatment ventricular assist device using an IABP. versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction. J Am Coll Cardiol 2008 November 4;52(19):1584-1588 19007597 (263) Burkhoff D, Cohen H, To test the RCT (Tandem 42 Pts from 12 centers N/A Cardiogenic shock was due to MI in 70% of the pts and Mortality =ns N/A N/A Brunckhorst C, O'Neill hypothesis that vs IABP) presenting within 24 h of decompensated HF in most of the remaining pts. The mean WW. A randomized the TandemHeart developing cardiogenic duration of support was 2.5 d. Compared with IABP, the multicenter clinical study (PVAD) provides shock.randomized to TandemHeart PVAD achieved significantly greater to evaluate the safety superior treatment with IABP increases in cardiac index and mean arterial blood pressure and efficacy of the hemodynamic (n=14) or TandemHeart and significantly greater decreases in PCWP. Overall 30- TandemHeart support PVAD (n=19). Thirty pts dsurvival and SAEs were not significantly different between percutaneous compared with (71%) had persistent the 2 groups ventricular assist device IABP. shock despite having an versus conventional IABP in place at the time therapy with intraaortic of study enrollment. balloon pumping for treatment of cardiogenic shock. Am Heart J 2006
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September;152(3):469-8 16923414 (264)
AMI indicates, acute myocardial infarction; CPAP, continuous positive airway pressure; IABP, intra-aortic balloon pump; LVAD, left ventricular assist device; N/A, not applicable; NIPPV, noninvasive intermittent positive-pressure ventilation; NIPSV noninvasive pressure support ventilation; PAC, pulmonary artery catheter; PCWP, pulmonary capillary wedge pressure; PE, pulmonary edema; PVAD; percutaneous ventricular assist device; RAP, right atrial pressure; SBP, systolic blood pressure; SRCS, severe refractory cardiogenic shock;
Data Supplement 31. Sildenafil (Section Section 7.4.2)
Study Name, Study Study Trial Duration P Values & Author, Year Aim of study Type Size Etiology Patient Population Severity Endpoints (Years) Absolute Benefit 95% CI: Severity of Ischemic/Non- HF Ischemic Inclusion Criteria Exclusion Criteria Symptoms Primary Endpoint PDE5 Inhibition To test the effects of RCT 45 50% ICM NYHA II-III HF with clinical Unable to complete a maximal 100% NYHA LV diastolic 1 y D Mitral E/A @ 1yr p<0.01 for all With Sildenafil PDE5 inhibition stable conditions defined exercise test; Resting SBP <110 II-III function, chamber placebo 0 vs SIL -0.19 parameters Improves LVDF, (sildenafil) on LVEF, as no changes in HF mm Hg; therapy with nitrate (42% NYHA dimensions, and D IVRT @ 1y Cardiac LVDF, cardiac regimens or hospitalization preparations; LVADs; II/58% NYHA mass placebo +1.4 vs SIL - Geometry, and geometry, and clinical since 6 mo before study History of sildenafil intolerance; III) 6.0 D E/E', lat @ 1yr Clinical Status in status entry; significant lung or valvular peak VO2 placebo -0.8 vs. SIL Pts With Stable Negative exercise stress diseases, neuromuscular 12.8 +3.7 D LVEDD (mm)@ Systolic HF, test before study; disorders, or peripheral vascular ml/min/kg 1y placebo +0.9 vs SIL - Guazzi M, 2011 FEV1/FVC >70%; disease; Diabetic pt VE/VCO2 4.2d D LVMI @ 1yr 21036891 (265) LVEF <40% slope 35.3 placebo no change, SIL Presence of LV diastolic decrease (value not dysfunction determined by provided) Doppler analysis with D peak VO2 @ 1y documen- tation of a mitral placebo +0.3 vs SIL inflow early (E) velocity to +2.7 D VE/VCO2 mitral annulus early Slope at 1y placebo +0.4 velocity (E') >10. vs SIL -6.0; D QOL (breathlessness, fatige, emotional function)
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PDE5A inhibitor To test the hypothesis Open 58 56% ICM Advanced LV dysfunction, Combined LVAD and RVAD; Pts N/A The primary Enrollment 1999- Lowering of PVR from Change in treatment of that when PH persists label treatment with LVAD receiving chronic inotrope endpoint of the 12 2007; 12-15 wk 5.87+1.93 to 2.96+0.92 PVR, p<0.001 persistent after adequate LV clinical implantation, and therapy to 15 wk change in of sildenafil Wood Units (mm Hg/ for LVAD pulmonary unloading via recent trial persistent PH (defined by PVR treatment/follow- L/min;) after 2- 4 wk of +sildenafil hypertension after LVAD therapy, a PVR >3 Wood Units 7 to andcontractility up; sildenafil therapy; vs. no group mechanical phosphodiesterase 14 d after LVAD index (dP/dtmax/IP) change in PVR in LVAD Change in RV circulatory type 5A inhibition implantation) despite only group. Also, contractility support, Tedford would decrease PH in normalization of their marked improvement in index for RJ, 2008 this population. PCWP to a value <15 RV systolic and diastolic LVAD+sildefanil 19808294 (266) mmHg were consented for function, as measured group, and received treatment by RV contractility index p<0.0001 with sildenafil in an attempt (dP/dtmax/IP; 8.69+1.78 to reduce PVR before to 13.1+3.3) in LVAD + cardiac transplantation sildenafil group Sildenafil To test the hypothesis RCT 34 50% ICM >18 y of age, Pts with a noncardiac limitation 100% NYHA No predefinied 12 wk trial Peak VO2 increased Improves that sildenafil, an LVEF<40%,NYHA II-IV to exercise, provocable II-IV primary endpoints; from 12.2+0.7 to Exercise Capacity effective therapy for chronic HF despite ischemia, hemodynamic (53% NYHA measured exercise 13.9+1.0 mL/ kg/min in and Quality of Life pulmonary arterial standard HF therapies instability, or ongoing nitrate II / 38% capacity, invasive the sildenafil group in Pts With hypertension, would Pts were required to have therapy were excluded. NYHA III/ hemodyanamic (p=0.02) and did not Systolic HF and lower pulmonary secondary PH as defined Additional exclusion criteria 9% NYHA IV) parameters, QoL, change in the placebo Secondary vascular resistance by a mean pulmonary included concentric LV peak VO2 and biomarkers group. Pulmonary and improve exercise arterial pressure >25 mm hypertrophy, critical aortic 11.1 Change in peak VO2 Hypertension, capacity in pts with HF Hg stenosis, or long-term use of ml/kg/min from baseline among pts Lewis GD, 2007 complicated by PH medications that inhibit treated with sildenafil 17785618 (267) cytochrome P450 3A4. (1.8+0.7 mL/· kg/min) was greater than the change in the placebo group (-0.27 mL/kg/min; p=0.02). Sildenafil treated pts had improvement in RVEF at rest and with exercise; control group had no improvement in RVEF. Mean MLHFQ score decreased (reflecting improvement) by 13+5 and 16+5 at wk 6 and 12, respectively, among pts receiving sildenafil (p=0.007) and did not change in pts receiving placebo.
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Long-term use of To test the functional RCT 46 ICM 46% Stable NHYA II-III CHF ; Unable to complete a maximal NYHA II-III No predefined 6 mo f/u In the sildenafil group p<0.01 for all sildenafil in the exercise capacity and negative exercise stress exercise test; SBP >140 or <110 peak VO2 15 primary endpoint; only, at 3 and 6 mo, changes therapeutic endothelial function in test prior to study; mm Hg; DM; Therapy with ml/min/kg assessments (at 3 systolic PAP decreased management of a cohort of CHF pts FEV1/FVC >70%; nitrate; History of sildenafil and 6 mo) of from 33.7 to 25.2 mm HF, Guazzi M, treated with chronic LVEF <45%, determined intolerance; Significant lung or endothelial function Hg and then 23.9 mm 2007 type 5 by echocardiography. valvular diseases, by brachial artery Hg, ergoreflex effect on 18036451 (268) phosphodiesterase neuromuscular disorders, AF, FMD, ventilation decreased (PDE5) inhibitor claudication, or peripheral cardiopulmonary from 6.9 to 2.3/min and vascular disease exercise testing, 1.9L/min, VE/VCO2 ergoreflex decreased from 35.5 to response, and 32.1 and 29.8, and QOL questionnaire breathlessness (score) (CHF) were from 23.6 to 16.6 and performed 17.2, FMD increased from 8.5% to 13.4% and 14.2%, peak VO2 from 14.8 to 18.5 ml/min/kg and 18.7 ml/min/kg, and ratio of VO2 to work rate changes from 7.7 to 9.3 and 10. Sildenafil Effects To investigate the RCT 23 ICM 22% CHF outpatients who were ED considered secondary to NYHA II-IV First phase: 6MWT, 1 mo Peak VO2 (ml/kg/min) p=0.025 on Exercise, acute effects of referred for ED treatment causes other than CHF; exercise test placebo 16.6+3.4 vs p=0.027 Neurohormonal sildenafil on exercise, (ED was defined as the Previous therapy for ED, Second phase: sildenafil 17.7+3.4 Activation, neurohormonal inability to achieve or Recent use of PDE inhibitors; efficacy of sildenafil Ve/VCO2 slope and Erectile activation, and clinical maintain an erection Severe systemic disease, visual in ED was placebo 33+8 Dysfunction in status of CHF pts with sufficient to permit disturbances, psychiatric or evaluated by the 15 sildenafil 31+5 Congestive HF, (ED). To evaluate the satisfactory sexual psychological disorder; questions of the Bocci EA, 2002 efficacy and safety of intercourse); UA or MI within the previous 3 IIEF; adverse side 12196335 (94) sildenafil for ED History of ED x > 4 mo, mo;, effects treatment in a 1-mo present interest in sex and Syncope, follow-up in a stable relationship; Angina, Concomitant new HR <55 bpm, high-risk symptoms of CHF, arrhythmias, new atrial worsening of HF clinical tachycardia/fibrillation/flutter or status, or a change in uncontrolled high ventricular specific medication for response, new or high degree of CHF; AV block All pts were in stable HCM clinical condition without Valvular disease, required changes in Symptomatic hypotension or treatment within the last 3 SBP <85 mm Hg mo. Unstable CHF, low systemic
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perfusion, or venous or pulmonary congestion.
6MWT indicates 6 minute walk test; AF, atrial fibrillation; AV, atrioventricular; CHF, congestive heart failure; D, Doppler; DM, diabetes mellitus; ED, erectile dysfunction; EF, ejection fraction; FEV, forced expiratory volume; FMD, flow-mediated dilatation; FVC, forced vital capacity; HCM, hypertrophic cardiomyopathy; HF, heart failure; HR, heart rate; ICM, ischemic cardiomyopathy; IIEF, International Index of Erectile Function; LVAD, left ventricular assist device; LVDF, left ventricular diastolic function; LVEDD, left ventricular end diastolic diameter; LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; Mitral E/A, Mitral early-to-late velocity; MLHFQ, Minnesota Living with Heart Failure Questionaire; MI, myocardial infarction; NYHA, New York Heart Association; PAP, pulmonary artery pressure; PCWP, pulmonary capillary wedge pressure; PDE5A, phosphodiesterase type 5A; PH, pulmonary hypertension; pts, patients; PVR; pulmonary vascular resistance; QoL, quality of life; RCT, randomized control trial; RVAD, right ventricular assist device; RVEF, right ventricular ejection fraction; SBP, systolic blood pressure; SIL, sildenafil; UA, unstable angina; VE/VCO2, ventilation efficiency ventilation to CO2 production slope; VO2, oxygen volume.
Data Supplement 32. Inotropes (Section 7.4.4) Study Aim of Stud Backgrou Study Size Etiology Patient Population Severity Endpoints Mortality Trial Absolute Statistical Study Complicatio Name, study y nd Duratio Benefit or Analysis Limitatio ns/Adverse Author, Type Therapy n Major (Results) ns Events Year (Years) Finding Pretrial N (Total) Ischemic/ Inclusion Exclusion Severity of Study Primary Secondary Annualized 1st Year standard n Non- Criteria Criteria HF Entry Endpoint Endpoint Mortality Mortality treatment (Experiment) Ischemic Symptoms Sverity n (Control) Criteria
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Intermittent To reduce RCT ACEI 82% 38; 19 47% ICM Age >18 y; History of 100% NYHA III- Reduction of Changes in N/A N/A Enrollmen No benefit in Time to first CV death Small N/A 6-mo low- hospitalizat Digoxin 95% (dobutamine); NYHA III-IV documented NYHA III-IV IV hospitalizatio NYHA t 18 mo hospitalization, or hospitalization for sample size dose ions for Furosemide 19 (control) CHF ; malignant 6MWTD symptom ns for functional class, (7/94- functional status, any cause, p=0.91 dobutamine worsening 95% Hospitalized arrhythmias 298m s, worsening of 6-min walking 12/95); 6 or mortality rate. infusion in of CHF by Nitrates 63% for CHF and without an CI CHF test, and mo f/u severe HF: administeri Amiodarone administratio automatic <2.2L/mi mortality rates. DICE ng 39% n of IV defibrillator n/m2 Multicenter intermittent inotropes in in place; Trial, Oliva low-dose the 6 mo Neoplastic F, 1999 dobutamin before the or systemic 10426835 e (2.5- evaluation; disease (269) 5mg/kg/min > 48 h of affecting for 48- clinical short-term 72hrs/wk) stability on prognosis oral therapy. UA, CI <2.2 angiographi L/min/m2 cally 6. LVEF < documented 30%. effective coronary stenosis Surgically curable valvular heart disease Levosimen To RCT Digoxin 75%, 203; 48% Hospitalized Age <21 y Severity CI < 2.5 Proportion of Changes from N/A N/A Enrollmen The primary Primary endpoint: No placebo Angina, chest dan compared Diuretics 103 Ischemic with low- Childbearing determined L/min/m2 pts with baseline in t 1/97- haemodynamic HR; 1.9; 95% CI 1.1- control pain, or Infusion the effects 53%, levosimendan; output HF, potential by invasive Mean haemodyna haemo-dynamic 11/98 endpoint was 3.3; p=0.022; Small study myocardia versus of ACEI 89%, 100 requiring HF due to hemodyna PCWP > mic variables other (23mo); achieved in 28% Secondary endpoint: size ischaemia (7% Dobutamin levosimend bblockers dobutamine haemodyna restrictive or mic 15 mm improvement than CO and study levosimendan- HR 0.57; p=0.029 No dobutamine vs e Study an and 38%, mic monitor- hypertrophic monitoring, Hg (defined as PCWP (eg, CI, drug group pts and information 0% (LIDO), dobutamin oral nitrates ing and cardiomyop not an increase stroke volume, infusion 15% in the on the levosimendan, Follath F, e on 41%, treatment athy or to symptomat of 30% or PADP, mean up to 24 dobutamine duration of p=0.013); 2002 haemodyn anticoagulant with IV uncorrected ology more in CO RAP, BP, HR hrs, follow group. infusion of Arrhythmias 12133653 amic s 43%, inotropic stenotic and a and total peri- up out to Secondary end levosimenda (13% (270) performanc Class III agent. a) valvular decrease of pheral 180 d point: n needed for dobutamine vs e antiarrhthmic deterioration disease; 25% or more resistance) at At 180 d, 26% optimum 4% and clinical agents 15%, of severe Chest pain in PCWP) at 24 h; levosimendan benefit or on levosimendan, outcome in CCB 4%, chronic HF at the time 24 h. Changes from group pts had how often it p=0.023 pts with antiplatelet despite of baseline to 24 h died, compared may be low-output agents 1% optimum randomisati in HF symptoms with 38% in the repeated in HF oral therapy on; (dyspnoea and dobutamine pts who do with Sustained fatigue) on a 4- group not respond vasodilators VT/VF within grade scale initially or and prior 2 wk; (much better, who relapse diuretics, AVB of 2nd slightly better, after an including or 3rd no change, initial those degree; worse); response. awaiting HR >120 Proportion of Exclusion of cardiac bpm at rest; pts needing IV pts with transplantati SBP< 85 rescue therapy cardiogenic on; b) mm Hg; with positive shock. severe Severe renal inotropic Short-term
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HF after failure (SCr drugs, hemodynami cardiac >450 vasodilators, or c surgery; or mol/L); diuretics during assessment c) acute HF Hepatic the infusion of Not powered related to a failure study drug; to assess cardiac or Cardiac No. of d alive mortality non-cardiac tamponade; and out of disorder of ARDS; hospital and not recent Septic receiving IV onset. shock. drugs during the LVEF<35% 1st mo; (by echo or Time to radio-nuclide development of ventriculogra worsening HF phy w/in 1 or death. mo of study Safety enrolment) endpoints: a) CI < 2.5 AEs, b) L/min/m2 laboratory Mean safety tests PCWP >15 (blood and mm Hg. urine), and c) all-cause mortality at 31 d and 180 d after randomization. OPTIME- To RCT ACEI 70%, 949; 477 ICM 51% Age >18 y If treating 100% NYHA II- Total number Main secondary N/A N/A Recruitm No difference in p=0.71, d of Did not Sustained CHF, Cuffe prospective ARB 12%, (milrinone); LVEF <40% physician NYHA II-IV IV of d outcome ent 7/97- primary efficacy hospitalization for CV directly hypotension, MS, 2002 ly test bblocker 472 (placebo) within the judged that 7% NYHA symptom hospitalized included the 11/99 (29 end point causes within 60 d address (SBP< 80 mm 11911756\ whether a 22%, past y. IV inotrope II s for CV proportion of mo); Milrinone was p=0.92, death or pts with Hg for more (271) strategy Diuretic 90%, Known was 46% NYHA causes (or d cases failing Study associated with readmission within 60 d ADHF for than 30 min, that Digoxin 73%, systolic essential III deceased) therapy drug higher rate of p<0.001 for treatment whom requiring includes CCB 11% chronic HF (eg, for 47% NYHA within the 60 because of AE treatment treatment failure failure due to AE inotropic intervention); short-term placebo v Hospitalized shock, IV d after or worsening for up to at 48 h due to AE therapy was 10.7% with use of 16% for metabolic randomizatio HF 48 h after 72 h with (12.6% vs 2.1%) felt to be milrinone, 3.2% milrinone in milrinone exacerbation acidosis, or n. Hospital d initiation of 60 day essential with placebo, addition to ASA 46% of chronic severe were defined therapy. follow-up (eg, low p<0.001 standard Amiodarone HF <48 h hypotension as Other period cardiac Significant atrial therapy 15% earlier. ). inpt d and secondary from time output state arrhythmias can Active ED outcomes of with tissue during index improve myocardial visit d. included the randomiz hypoperfusio hospitalization; clinical ischemia proportion of pts ation n), Not 4.6% milrinone, outcomes within the achieving target structured to 1.5% placebo, of pts past 3 mo doses of ACEI assess pts p=0.004 hospitalize Atrial therapy and for NSVT, a d with an fibrillation time to achieve known exacerbatio with poor target dose, adverse n of chronic ventricular symptoms, effect of HF rate control improvement in milrinone. (>110/min) HF score, Inadequately Sustained length of initial powered to ventricular hospitalization, evaluate tachycardia d of mortality. or hospitalization
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ventricular for CV events fibrillation. from initial Baseline hospital SBP< 80 discharge to 60 mm Hg d, d of SCr level > hospitalization 3.0mg/dL for CV events within 30 d after randomization, all-cause hospitaliz-ation, and mortality. HF Etiology To assess Post- ACEI 70%, 949 (total); 485 ICM Age >18 y If treating 100% NYHA II- D Main secondary N/A N/A Recruitm D hospitalized for Primary endpoint, p=0.2 Retrospectiv In pts with and the hoc bblocker 477 (51% of LVEF < 40% physician NYHA II-IV IV hospitalized outcome ent 7/97- CV causes or 60d mortality, P=0.03 e study; ischemic HF, Response interaction analysi 23%, (randomized total) within the judged that 7% NYHA symptom for CV included the 11/99 death w/in 60d Combined endpoint, No data milrinone tended to Milrinone between s Amiodarone to milrinone); 464 NICM past year. IV inotrope II s causes or proportion of (29mo); after p=0,02 collected on to be associated in HF etiology 15%, 242 (ICM, (49% of Known was 46% NYHA death within cases failing Study randomization Able to reach target the level of with prolonged Decompen and Digoxin 73%, milrinone) ; total) systolic essential III 60 d after therapy drug was 13.0+14.2d ACEI dose, p=0.001 care that pts hospitalization sated HF response 235 (NICM, chronic HF (eg, for 47% NYHA randomizatio because of treatment for ischemic HF Treatment failure on received and higher (subanalysi to milrinone milrinone); Hospitalized shock, IV n adverse events for up to pts, 11.7+13.9d study drug, p=0.7 (i.e., ICU vs. mortality. s of in 243 (ICM, for metabolic or worsening 72 h with for nonischemic monitored Composite of OPTIME- decompens placebo); 229 exacerbation acidosis, or HF 48 hr after 60 d f/u HF pts bed), which death or CHF), ated HF (NICM, of chronic severe initiation of period 60 d mortality potentially rehospitalization Felker GM, placebo) HF < 48 h hypotension therapy. from time was greater for could have at 60 d was 42% 2003 earlier. ). Other of ischemic (11.6%) affected the for ischemic pts 12651048 Active secondary randomiz than for non- results of treated with (272) myocardial outcomes ation ischemic pts study; milrinone and ischemia included the (7.5%). Imbalanced 36% for those within the proportion of pts Combined end follow up treated past 3 mo achieving target point of death or btwn w/placebo Atrial doses of ACEI rehospitalization etiologic (p=0.01 for fibrillation therapy and at 60 d was groups (4 pts etiology- with poor time to achieve 38.7% in in ischemic treatment ventricular target dose, ischemic pts and group vs. 8 interaction). In- rate control symptoms, 31.5% in the pts in hospital (>110/min) improvement in nonischemic pts. nonischemic mortality for Sustained HF score, More pts with group lost to milrinone- ventricular length of initial nonischemic HF follow-up) treated pts with tachycardia hospitalization, were able to ischemic HF or d of reach target was 5.0% vs. ventricular hospitalization dosing of ACEI at 1.6% for fibrillation. for CV events hospital placebo (p Baseline from initial discharge (49%) =0.04 for SBP< 80 hospital compared etiology- mm Hg discharge to 60 w/ischemic HF treatment SCr level > d, d of pts (36%). interaction), and 3.0mg/dL hospitalization Treatment failure 60 d mortality for CV events while on the was 13.3% for within 30 d after study drug was milrinone vs randomization, similar btwn the 2 10% for placebo all-cause groups (14.2% for (p= 0.21 hospitaliz-ation, ischemic vs. for etiology- and mortality. 15.2% for treatment nonischemic pts). interaction).
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Baseline QoL data did not differ between the 2groups. Inhospital To Regist Beta blocker 65180; 6549 56% ICM admitted to HF is not the NYHA IV N/A Inhospital Total LOS, ICU N/A Inpatient 10/01- Worse inpatient Inhospital Mortality Dob Observation N/A mortality in compare in ry 50% (NTG); 5220 ; a principal 45% mortality LOS mortality 7/03 mortality and vs Milrinone: OR: 1.24; al analysis pts with hospital ACEI 43% (nesiritide) ; participating focus of (dyspneic Milrinone: longer LOS with 95% CI: 1.03-1.55: Retrospectiv acute mortality in ARB 12% 2021 acute care diagnosis or at rest) 12.3% IV inotropes p=0.027 e analysis decompens pts with Spironolacto (milrinone) ; hospital and treatment Dobutami compared to IV NTG vs Dobutamine: Clinician ated HF acute ne 15% 4226 given a during the ne: 13.9% vasodilators or OR: 0.46; 95% CI:.37- judgement requiring decompens (varied (dobutamine) ; discharge admission or NTG: neither. 0.57, p<0.005 for medical intravenous ated HF amongst 49950 (all diagnosis of if their 4.7% NTG vs Milrinone: OR: management vasoactive receiving subgroups 7- others) HF medical Nesiritide: 0.69; 95% CI:0.53-0.89; /choice of IV medication treatment 24%) record 7.1% p<0.005 med s: an with 1 of 4 cannot be All others: Non- analysis vasoactive accessed for 3.1% randomized from the meds administrativ Differences Acute (NTG, e reasons in clinical Decompen nesiritide, severity sated HF milrinone, between National dobutamin subgroups Registry e) (ADHERE), Abraham WR, JACC 2005 15992636 (273) Survival of To assess RCT Beta blocker 1327; 664 76% Age >18 y Severe 86% NYHA Low- All-cause All-cause N/A N/A Enrollmen During the 180 d Primary endpoint: Short Hypokalemia Pts with the effect 51% (levosimendan Hospitalized ventricular IV output mortality mortality during t 3/03- after study drug HR 0.91; 95% CI 0.74- duration of (9.4% Acute HF in of a short- ACEI/ARB ); 663 with ADHF. outflow ADHF during the 31 d, change in 12/04 infusion, there 1.13; p=0.40 treatment. levosimedan vs Need of term IV 69% (dobutamine) LVEF <30% obstruction; 180 d BNP level from (22mo), were 173 deaths Secondary endpoint Detail of 5.9% Intravenous infusion of Aldosterone within prior SBP following baseline to 24 study (26%) in the (DBNP): p<0.001 duration of dobutamine, Inotropic levosimend antagonist 12 mo persistently randomizatio h; No. of d alive drug levosimendan infusion and p=0.02) Support an 53% Required IV <85 mm Hg n. and out of the infusion group and 185 dose of AF (9.1% (SURVIVE) or IV diuretics inotropic HR hospital during for deaths in the study drug levosimedan vs , Mebazaa dobutamin 79% support, persistently the 180 d; minimum dobutamine used is not 6.1% A, 2007 e on long- IV nitrates as > 130 bpm; change in pt of 24 h group (28%). provided. dobutamine, 17473298 term 37% evidenced IV inotrope assessed and total No difference in No p=0.05), (274) survival IV dopamine by an use during dyspnea at 24 duration secondary information Headache 6% insufficient the index h; Pt assessed of endpoints, except regarding (8.3% response to hospitalizati global unknown in mean change clinical levosimedan vs IV diuretics on (except assessment at period, in BNP at 24 h symptomatol 4.7% and/or dopamine 2 24 h; CV follow up from baseline (- ogy at dobutamine, vasodilators, μg/kg/min or mortality at 180 d, 631 baseline. p=0.01) and >1 of digitalis); through levosimendan vs PVCs (6.1% the following History of 180 d. -397 dobutamine) levosimedan vs at screening: torsade de 3.6% (a) dyspnea pointes; dobutamine, at rest or SCr> 5.1 p=0.05) mechanical mg/dL (450 Agitation (1.1% ventilation μmol/L) or levosimedan vs for ADHF; on dialysis. 0% dobutamine, (b) oliguria p=0.02) © American College of Cardiology Foundation and American Heart Association, Inc. 127
not as a result of hypovolemia ; or (c) PCWP >18 mm Hg and/or CI < 2.2 L/min/m2. Enoximone To RCT Diuretic 88%, 201; 101 61% ICM Age > 18 y Received a 100% Low- Ability to Time to N/A N/A Enrollmen 30 d after Unadjusted primary end Small Exacerbation of in determine ACEI 62%, (enoximone); NYHA III or positive NYHA III-IV output wean reinitiation of IV t 7/00- weaning, 51% of point p=0.14, adjusted sample size. CHF in 54% Intravenous whether ARB 18%, 100 (placebo) IV CHF inotropic (56% ADHF subjects from inotrope 2/04 placebo pts and for etiology p= 0.17 Not designed enoximone vs Inotrope- low-dose bblocker Ongoing agent other NYHA IV) IV inotropic Total number of (44mo); 61.4% 60d wean rate or powered 52% placebo, Dependent oral 40%, need for > 5 than digoxin, support. d on IV inotrope 26 wk trial enoximone pts unadjusted p=0.016 as mortality NS Subjects enoximone digoxin 70%, d of dobutamine, Assessed Total number of were alive and Time to death/ study Dyspnea, 5% Study could wean antiarrhythmi continuous or milrinone using the hospitalization d free of IV reinitiation of IV enoximone vs (EMOTE), pts with c 37%, IV inotropic within 12 h prespecified for all cause, inotropic therapy inotrope: 95% CI 0.55- 0% placebo, Feldman ultra- ICD 42%, therapy or of CMH test, CV, and At 60 d, the wean 1.04 P<0.05 AM, 2007 advanced Milrinone the need for randomizati adjusted for CV/vascular rate was 30% in Reduction at 60d, 95% 17967591 HF (UA- 62%, intermittent on cardiomyopa events; placebo group CI 0.43-0.89, p = 0.009 (275) HF) from dobutamine IV inotropic Trough thy etiology. Measurements and 46.5% in Reduction @ 90d, 95% intravenous 36%, therapy with digoxin The primary of symptoms enoximone group CI 0.49-0.97, P = .031 (IV) both either levels were efficacy (SAS scale, Kaplan-Meier Time to death/ inotropic dobutamine dobutamine >1.0 ng/mL. variable was NYHA) and pt curves reinitiation of IV support and milrinone (≥2 ICD firing also well-being demonstrated a inotrope: HR 0.76 3% μg/kg/min) within 90 d. assessed as (Visual Analog trend toward a Reduction @60d HR Continuous or milrinone a protocol Scale, global decrease in the 0.62 IV inotrope (≥0.125 and assessments) time to death or Reduction @90d HR 74% μg/kg/min) statistical at 4 and 26 wk. reinitiation of IV 0.69 for ≥6 h at a analysis inotropic therapy frequency of plan– over the 182-day >1x/ wk, and prespecified study for ≥4 wk. secondary period and a LVEF of end point reduction at 60 d ≤25% by using time- and 90 d after radionuclide to-event weaning in the ventriculogra (Kaplan- enoximone phy or ≤30% Meier) group. by 2- curves and dimensional the log-rank echocardiog statistic, over raphy the entire Cardiac 182 d study dilatation period. (LVEDD ≥2.7 cm/m2 or ≥5.4 cm as measured by 2- dimensional echocardiog raphy within 26 wk
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of the baseline visit). Ongoing and stable (>30 d) therapy with optimal and stable doses of conventional medications Use and To Post- ACEI 79% 433; 75 50% ICM Hospitalized N/A Mean peak N/A All- cause Combined end N/A 6 mo N/A Worse 6 mo 6 mo mortality Severe N/A impact of determine hoc Diuretics (vasodilator); for severe VO2 10.0 mortality point of all- mortality outcomes (adjusted), p, 95% CI ADHF inotropes 6-mo risks analysi 98% 133 (IV ADHF mean cause mortality (mortality and Inotrope 1.10-4.15, Conducted and of all-cause s of bBlocker inotrope); 47 Age>18 y; 6MWTD plus either p=0.024 by HF vasodilator mortality RCT 62% (both); 178 Hx of HF for 414 ft rehospitalization mortality/rehospit Both ino & vasodilator specialists at therapy and all- IV inotrope (neither >3 mo; alization) with 2.34-9.90, p<0.001 academic in cause 42% inotrope/vaso On ACEI inotropes 6mo mortality or rehosp medical hospitalize mortality IV dilator) and diuretics (whether alone or (adjusted) centers d pts with plus vasodilator for z3 mo;. with vasodilator) Inotrope 1.37-2.82, Small study severe HF rehospitaliz 28% LVEF<30% p<0.001 size (ESCAPE), ation in the 12 mo Both ino & vasodilator Non- Elkayam U, associated before 1.88-4.48, p<0.001 randomized Am Heart J with the randomizatio 6 mo mortality HR Retrospectiv 2007 use of n; adjusted e analysis 17174645 vasodilator SBP <125 Inotrope 2.14 (276) s, mm Hg; Both inotrope and inotropes, elevated LV vasodilator 4.81 and their filling 6 mo mortality or combinatio pressure as rehosp HR (adjusted) n indicated by Inotrope 1.96 at least 1 Both ino & vasodilator physical 2.90 sign and 1 symptom; At least 1 prior admission for ADHF during the previous 12 mo or aggressive outpatient therapy for at least the previous mo. Prospective To RCT Nitrates 58% 1088; 561 54% ICM NYHA III-IV Obstructive 100% NYHA III- All cause CV mortality, N/A N/A Enrollmen Increased All-cause mortality: Background Stopped study Randomize determine Antiarrhythmi (milrinone); CHF x >3mo valvular NYHA III-IV IV mortality No. of t 22mo mortality with nominal P=0.038, 95% medical drug due to d Milrinone the effect cs 25% 527 (placebo) LVEF < 35% disease 58% NYHA hospitalizations, (1/89- milrinone (30% CI 0.01-0.61; adjusted management worsening HF, Survival of oral Digoxin level Medical Active III /42% Addition of 10/90); milrinone vs 24% P=0.06, is outdated 1.8% milrinone v Evaluation milrinone 1.5nmol/l regimen of myocarditis NYHA IV vasodilators for stopped placebo); CV mortality: 95% CI and 0.9% placebo (PROMISE on the digoxin, HCM or treatment of early Log-rank test, 0.06-0.69, nominal suboptimal ), Packer mortality of diuretics, cardiac worsening hf, because milrinone P=0.016; adjusted
© American College of Cardiology Foundation and American Heart Association, Inc. 129
M, 1991 pts with and ACEI for amyloid Symptoms, of associated with P=0.037 1944425 severe > 4wk Uncorrected Adverse adverse 28% increase in (277) chronic HF thyroid reactions effect of mortality; who disease milrinone; Log-rank test, remained Malfunctioni median milrinone symptomati ng artificial duration associated with c despite heart valve of follow- 34% increase in convention up, 6.1mo CV mortality al therapy Continuous To Post- N/A 471; 80 67% NYHA IIIB or SBP<80 mm No NYHA Occurrence QoL meaures N/A N/A N/A The dobutamine Primary endpt 1st Observation At 6 mo intravenous evaluate hoc (dobutamine); Ischemic IV HF for >1 Hg; dobutamine IIIB-IV of clinical group had a event p=0.0006 al analysis First event dobutamine clinical analysi 391 (no mo while Significant : events from higher mortality p=0.0001 No details 85.3% is characterist s dobutamine) receiving a valvular 47% NYHA the FIRST occurrence of first provided dobutamine vs associated ics and regimen stenosis; III trial, event (85.3% vs regarding 64.5% no with an outcomes including a Anticipated 53% NYHA including 64.5%) and a duration and dobutamine , increased of pts with loop diuretic, revasculariz IV worsening higher mortality dose of p=0.0006 risk of advanced digitalis ation or Dobutamin HF, need for rate (70.5% vs dobutamine Death 70.5% death in pts HF glycoside, valvular e: mechanical 37.1%) compared dobutamine vs with receiving and an surgery; 11% NYHA assist with the no 37.1% no advanced intravenous ACEI, MI within 3 III device, dobutamine dobutamine, HF: continuous unless mo; 89% NYHA resuscitation group. p=0.0001 Insights dobutamin contraindicat Uncontrolled IV from sudden No difference in from the e in the ed. tachyarrhyth cardiac QOL between Flolan FIRST Trial LVEF <25% mias; death, MI, groups. Internation (Flolan by a Unstable or and death al Internation multigated symptom- Randomize al angiocardiog limiting d Survival Randomize ram within 3 angina; Trial d Survival mo of Requiremen (FIRST), Trial). enrollment, t for a O'Connor unless the pt mechanical CM, 1999 was assist 10385768 being device to (278) treated with maintain life; an IV Major inotropic change in IV agent, in vasoactive which case medicat-ions LVEF <30% within 12 hr was of accepted. randomizati Pts receiving on; IV CHF caused vasoactive by medications uncontrolled were thyroid required to disease, have not myocarditis, responded high output to an failure, or attempt to infiltrative wean from cardio- the myopathy; medicines Significant
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within 1 wk congenital of heart enrollment. disease with Ineligibility shunts, for cardiac valvular or transplant- vascular ation and obstruction; eligibility for Substance long-term or alcohol oral abuse w/in anticoagulati 1year; on therapy Moderate or were also severe lung required. disease; Other comorbid conditions likely to shorten survival; Current use of another investigation al drug or device. Care To assess Cohort ACEI/ARB 36 47% ICM Hospitalized N/A N/A N/A Survival after Total N/A 1 y N/A >2 N/A Lack of QOL Line processes the Study 72% advanced presumably hospital hospitalizations, mortality rehospitalizations assessment infection/sepsis and clinical outcomes Dobutamine end-stage NYHA IIIb- discharge causes for 94% : 36% Lack of cost (15% of outcomes of chronic 100% HF pts IV rehospitalization 6 mo 0-1 evaluation rehospitalization of home Dopamine Declined , cause of death mortality rehospitalization: Small study s) continuous inotropic 22% cardiac 74% 64% size outpatient support in Milrinone transplantati 30% of Retrospectiv support Stage D 11% on or rehospitalizations e with HF pts ineligible for 2/2 worse HF inotropes cardiac Cause of death (COSI) in transplantati Worsening HF pts with on 80% refractory SCD 14% endstage Unknown 6% HF, Hershberge r RE, J Cardiac Failure 2003 12815567 (279)
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Prognosis To Case- ASA 39% 112; 56 41% ICM Stage D HF N/A N/A Inotrope Survival N/A N/A 6 mo N/A No difference in Propensity matched Retrospectiv N/A on chronic investigate control beta blocker (dobutamine); pts deemed presumably depende mortality mortality between mortality, e analysis dobutamine the led 5% (dob) v 56 (milrinone) inotrope NYHA IIIb- nt (propensit inotrope type log-rank p= 0.74 Single center or milrinone relationship 34% (mil) dependent IV y (multivariate study infusions between ACEI 43% matched) analysis) Small study for stage D choice of ARB 5% Dobutami size HF, dobutamin Aldosterone ne 60% Lack of QOL Gorodeski e or blocker 52% Milrinone assessment EZ, Circ HF milrinone Amiodarone 54% 2009 and 50% 1yr 19808355 mortality in Furosemide mortality (280) inotrope- 78% Dobutami dependent Other diuretic ne 69% stage D HF 17% Milrinone pts 63% The To RCT ESSENTIAL- ESSENTIAL-I: ESSENTI Age >18 y Acute MI in 91% NYHA NYHA III- First co- N/A N/A N/A Enrollmen No difference in All-cause mortality, Crude global 1Worsening HF, Studies of investigate I 904 AL-I 52% HF caused previous 90 III IV x > 2 primary t 2/02- first co-primary p=0.73, 95% CI: 0.80- assessment 39% enoximone Oral the effects beta blockers ESSENTIAL- ICM by d, 8% NYHA mo endpoint 5/04 endpoint: all- 1.17 for QOL; vs 39% placebo, Enoximone of low 83%, II: 950 ESSENTI ischaemic or CV surgery IV (time to all- (28mo); cause mortality, All-cause mortality and 6MWT may p=0.88 Therapy in doses of ACEI/ARBs enoximone AL-II 59% nonischaemi in prior 60 d, 6MWT cause Median all-cause CV hospitalizations, not be Diarrhea, 12% Advanced the positive 94%, ESSENTIAL-I ICM c Symptomati 274m mortality or follow-up mortality and CV p=0.71, 95% CI 0.86- sensitive enoximone vs HF inotrope Aldosterone 454 cardiomyopa c ventricular (ESSENTI CV duration hospitalizations 1.11 enough to 7% placebo, (ESSENTI enoximone antagonist ESSENTIAL-II thy arrhythmias AL-I) hospitalizatio 16.6 mo No difference in Change in 6MWTD, detect p=0.0001, AL), Metra on 62% 472 LVEF < or ICD firing 6MWT ns) and for change in p=0.16 (ESSENTIAL-I), improvement Palpitations 8% M, 2009 symptoms, Diuretics placebo 30%, in prior 90 d 293m safety (all- 6MWTD p=0.57 (ESSENTIAL-II) s in exercise enoximone vs 19700774 exercise 95%, ESSENTIAL-I LVEDD > Serum (ESSENTI cause No difference in Change in PGA, p=0.79 capacity/func 5% placebo, (281) capacity, DIgitalis 450 3.2 cm/m2 potassium AL-II) mortality) PGA changes (ESSENTIAL-I), p=0,11 tional status p=0.01 and major glycosides ESSENTIAL-II or 6.0 cm; <4.0 or >5.5 (ESSENTIAL (ESSENTIAL-II) clinical 69% 478 NYHA III–IV mEq/L, -I and II, All cause mortality, HR outcomes Warfarin for >2 mo Digoxin combined) 0.97 in pts with 31% >1 levels >1.2 Co-primary All-cause mortality and advanced Amiodarone hospitalizati ng/mL endpoint CV hospitalizations, HR HF who 22% on or 2 Magnesium 6MWTD 0.98 were also ICD 21% outpatient levels <1.0 (ESSENTIAL treated with ESSENTIAL- visits mEq/L -I,-II beta II requiring IV SCr> 2.0 separately) blockers bblocker diuretic or mg/dL Co-primary and other 90% vasodilator Serum endpoint guideline- ACEI/ARBs therapy w/in bilirubin > Patient recommen 99% 12 mo 3.0 mg/dL. Global ded Aldosterone before Assessment, backgroun antagonist screening; (ESSENTIAL d therapy 54% Optimal -I and -II, Digitalis medical separately) glycosides therapy 46% including Warfarin 8% diuretics, Amiodarone beta- 14% blockers, ICD 5% and ACEIs or ARBs unless intolerant or contraindicat
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ed
A To Cohort Digoxin 60; 60 66.6% Milrinone Uncontrolled NYHA II-III NYHA II- Survival to Hospitalizations N/A N/A 43 mo f/u 88.3% of pts QOL/MLHFQ score Not 8% hospitalized Prospective determine study 96.6% (milrinone); ICM dose <0.5 arrhythmia; Peak VO2 III transplant , underwent OHT change from baseline, randomized; for IV line Sutdy of the Loop diuretic none mg/kg/min; SBP<80 mm 11.4 QoL measures 3.2% died before p=0.0061 No control; infection Continuous feasibility 88.3% Stable dose Hg; ml/kg/min cost transplant Limited cost 65% Intravenous and safety Warfarin of diuretic to Recurrent 1.6% LVAD data; rehospitalized Milrinone of 83.3% maintain dry electrolyte 3.2% BIVAD Small study for ADHF during Therapy for continuous Beta-blocker weight; abnormality; QoL improved size study period Status IB IV 73.3% Long-term Infection (MLHFQ score Pts milrinone ACE-I 66.6% venous requiring IV decreased by - Awaiting therapy Statin access; antibiotic; 13.3+3.4 points) Heart administere therapy AICD; Requiremen Transplant d at home 63.3% Adequate t for >1 at Home, in pts listed Aspirin social inotropic Brozena as Status 63.3% support agent; SC, 2003 IB for heart Spironolacto system as Acute renal 15454175 transplant ne 41.6% assessed by failure; (282) Amiodarone a transplant Hepatic 28.3% social transaminas ARB 25.0% worker; es >2x Hydralazine/ Functional normal nitrate 13.3% class
tion LVAD), and ations from Normal LV need for continuous filling additional inotrope (e.g. pressures vasodilator line (mean or inotropic infections, PCWP < 15 therapy etc) mm Hg), (nitroprussid Developmen e or t of dopamine). noncardiac medical illness sufficient to remove pts from the cardiac transplant waiting list LVAD as To analyze Post- Diuretic 95% 91 (on N/A LVEF <25% Advanced NYHA IV Peak All-cause QoL at 1 y N/A N/A Enrollmen In pts undergoing p=0.0014 Did not N/A Destination outcomes hoc >1 Diuretic inotrope at NYHA IV age, VO2 <14 mortality t 5/98- inotropic therapy capture for pts in pts analysi 52% randomization symptoms diabetes mL/kg/mi during the 7/01; at randomization, inotropic undergoing undergoing s bblocker ); for 60 of 90 with end- n 180 d 1 y survival with dependency intravenous inotropic 20% 45 (LVAD); d despite organ following LVAD was 49% status in all inotropic infusions at ACE-I 55% 46 (OMM) attempted damage, randomizatio vs. 24% for OMM pts. therapy: a randomizati therapy with SCr>2.5 n. and by 2 y, 28% Post-hoc, subset on for ACEIs, mg/dL for were alive with subgroup analysis LVAD diuretics, >90 d, LVAD group analysis. from destination and digoxin. compared with Outdated REMATCH, therapy Peak VO2 11% in OMM LVAD model. Stevenson <12-14 group LW, 2004 mL/kg/min 15313942 with (284) evidence of anaerobic metabolism, Dependence on IV inotropic agents supported by completion of a weaning failure form. ACEI indicates angiotensin-converting-enzyme inhibitor; ADHF, acute decompensated heart failure; AE, adverse event; AICD, automated implantable cardioverter defibrillator; ARDS, acute respiratory distress syndrome; ASA, aspirin; AVB, atrioventricular block; BIVAD, biventricular assist device; BNP, B-type natriuretic peptide; BP, blood pressure; CCB, calcium channel blockers; CHF, congestive heart failure; CMH, Cochran-Mantel-Haenszel; CO, cardiac output; CrCl, creatinine clearance; CV, cardiovascular; ED, emergency department; F/U, follow-up; HCM, hypertrophic cardiomyopathy; HF, heart failure; HR, heart rate; IABP, intra- aortic balloon pump; ICD, implantable cardioverter defibrillator; ICM, ischemic cardiomyopathy; ICU, intensive care unit; IV, intravenous; LOS, length of stay; LVAD, left ventricular assist device; LVEDD, left ventricular end diastolic diameter; LVEF, left ventricular ejection fraction; MLHFQ, Minnesota Living with Heart Failure Questionaire; MWTD, minute walk test distance; N/A, not applicable; NSVT, non-sustained ventricular tachycardia; NTG, nitroglycerin; NYHA, New York Heart Association; OHT, orthotopic heart transplantation; OMM, optimal medical management; OPTIME_CHF, the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure study; PADP, pulmonary artery diastolic pressure; PCWP, pulmonary capillary wedge pressure; PGA, polyglycolide; pts, patients; PVC, premature ventricular contraction; QoL, quality of life; RAP, right atrial pressure; RCT, randomized control trial; SAE, serious adverse event; SAS, specific activity scale; SBP, systolic blood pressure; SCD, sudden cardiac death; SCr, serum creatinine; UA, unstable angina; UAHF, ultra-advanced; VF, ventricular fibrillation; VT, ventricular tachycardia.
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Data Supplement 33. Inotropic Agents in HF (Section 7.4.4) Study Study Results
Design Drug Support Patients Hemo- Functional QoL Hospitalization Survival Duration dynamics Capacity
PROMISE RCT M vs. P Chronic NYHA III-IV N/A N/A N/A N/A ↓ 1944425 (277) LVEF <35%
Aranda JM 2003* RCT M, D Chronic Txplt-C M ≅ D N/A N/A N/A M ≅ D 12595851 (283) FIRST RCT D vs. none Chronic NYHA III-IV N/A N/A N/A N/A ↓ 10385768 (278) (post-hoc) LVEF <25-30%
Txplt-IE
COSI Cohort M, D Chronic Hospitalized N/A N/A NS N/A 6% @ 1 y 12815567 (279) Txplt-IE 26% @ 6 mo
Brozena SC 2004* Cohort M Chronic Txplt-C (1B) N/A N/A ↑ N/A N/A 15454175 (282) Gorodeski EZ 2009 Case M vs. D Chronic stage D N/A N/A N/A 65% M ≅ D 19808355 (280) Control ino-dpdt 31%-37% @ 1 y
OPTIME-CHF RCT M vs. P Short-term Hospitalized for N/A N/A NS NS NS 11911756 (271) HF, NYHA II-IV, (<72 h) LVEF <40%
ESCAPE RCT M,D Short-term Hospitalized for N/A N/A N/A ↑ ↓ 17174645 (276) HF, LVEF <30% (post-hoc)
ADHERE Retro M, D Short-term Hospitalized for N/A N/A N/A ↑ ↓ 15992636 (273) HF Obs LOS in-hosp
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DICE RCT D Intermittent Hospitalized N/A NS N/A NS NS 10426835 (269) (48-72 h/wk x 6 mo) NYHA III-IV
LVEF <30%, prior h/o ino
*Study limited to patients awaiting cardiac transplantation. 1B indicates UNOS Status 1B; ADHERE, Acute Decompensated HF National Registry; ADHF, acute decompensated heart failure; COSI, continuous outpatient support with inotropes; D, dobutamine; DICE, Dobutamina nell’Insufficienza Cardiaca Estrema; ESCAPE, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; FIRST, Flolan International Randomized Survival Trial; in-hosp, in-hospital mortality; ino-dpdt, inotrope-dependent; LOS, length of stay; LVEF, left ventricular ejection fraction; M, milrinone; N/A, not applicable; NS, no significant benefit; NYHA, New York Heart Association; OPTIME-CHF, the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure study; P, placebo; Post-hoc (RCT), post-hoc analysis of an RCT; PROMISE, PROspective Imaging Study for Evaluation of Chest Pain; RCT, randomized, controlled clinical trial; RetroObs, retrospective observational study; QoL, quality of life; Txplt-C, cardiac transplantation candidate; and Txplt-IE, transplantation ineligible.
Data Supplement 34. Mechanical Circulatory Support (Section 7.4.5) Study Study Evidence of Benefit Adverse Events Comments
Design Device Control Patients DOS Survival HD Support Function QoL (n) (n) REMATCH RCT HM XVE (68) OMM (61) Txplt-IE P + N/A + Bleeding Neuro 1 y Mortality RR 0.52 11794191, 15313942 74% ICM N/A SVT No benefit at 2 y (284,285) 71% ino Sepsis INTrEPID pNRCT NovaCor (37) OMM (18) Txplt-IE P + N/A N/A N/A Neuro 1 y Survival 27% (NovaCor) 17707178 (286) 38% ICM 100% ino Infxn vs. 11% (OMM) HMII-DT RCT HMII (134) HM XVE (66) Txplt-IE P + N/A + + PumpRplt Sepsis RespFail 2 y Survival 58% (HMII) vs. 19920051 (287) 67% ICM +21 +21 RenalFail RV Fail Rehosp 24% (HM XVE) Lower AE rate with HMII HMII-BTT Cohort HMII (281) None Txplt-C T + N/A +8, 21 +8, 21 Bleeding RespFail Infxn (NV) Mortality 17761592, 19608028 43% ICM VT 12mo: 27%; 18mo: 28% (288,289) Sepsis RV Fail EuroHMII Registry HMII (411) None 21% Txplt-IE 21% P + N/A N/A N/A MOF 1 y mortality 28.5% 19616963 (290) 73% Txplt-C 79% T Infxn 70% ICM RV Fail 100% ino Bleeding VT Neuro INTERMACS pNRCT HMII (169) HM XVE (135) Th- Txplt-C T + N/A N/A N/A Infxn 1 y Survival 21545946 (291,292) IVAD (34) 80-89% ino Bleeding 85% (HMII) vs 70% (comp) © American College of Cardiology Foundation and American Heart Association, Inc. 136
Lower rate of infxns with HMII
Grady K, pNRCT HM XVE (78) None Txplt-C T N/A +/- +/- n/a N/A Ann Thorac Surg 2004 15063260 (293) ADVANCE pNRCT Heart Ware (137) INTER MACS (499) Txplt-C T + N/A + + Infxn HeartWare is NON-INFERIOR 41% ICM Bleeding to control 82% ino Neuro Lower AE rate for bleeding, infxn Elhenawy A, ObsRS BTC (22) BTT (15) 41% Txplt-C T + N/A N/A N/A Infxn/ Sepsis No difference in BTC vs. BTT J Card Surg 2011 59% Txplt-IE RVAD Post-OHT survival 21883463 (294) NovaCor 6, HMXVE NovaCor 1, HMXVE 27% ICM MOF 1 y: 67% vs. 100% 11, HMII 5 7, HMII 7, 2 y: 67% vs. 90% and 3 y: 64% vs. 87% Alba A, Obs Fixed pHTN (22) No pHTN (32) Txplt-C T +/- N/A N/A N/A n/a Comparable post-OHT JHLT 2010 NovaCor 2, HMXVE NovaCor 4, HMXVE 22% ICM survival 1 y: 93% vs. 96% 20620083 (295) 14, HMII 6 19, HMII 9 5 y: 77% vs. 86% Higher peri-OHT mortality in fixed pHTN: 18% vs. 0% Nair P, Obs pHTN (14) No pHTN (44) Txplt-C T + + N/A N/A Infxn Comparable post-VAD and JHLT 2010 NovaCor, Th-LVAD, 100% ino post-OHT survival 20113910 (296) NovaCor, Th-LVAD, Th-IVAD, HM XVE 40% ICM Early ↓TPG with VAD, Th-IVAD, HM XVE sustained ↓mPAP with ongoing MCS MOMENTUM RCT Orqis Cancion (109) OMM (59) ADHF T N.S NS N/A NS Bleeding 65d mortality 33.9% (pVAD) 18765394 (297) 100% ino or vasodilator Infxn vs. 32.2% (OMM) 47% ICM Seyfarth M, RCT Impella (12) IABP (13) Post-MI CS T N/A + N/A N/A n/a No difference in MOF or JACC 2008 sepsis 19007597 (263) Burkhoff D, AHJ 2006 RCT TandemHeart (19) IABP (14) CS T N/A + N/A N/A Arrhythmia Not powered to fully assess 16923414 (264) Bleeding hemodynamic effects or Neuro clinical outcomes (NS) Thiele H, RCT Tandem Heart (21) IABP (20) Post-MI CS T NS + N/A N/A Infxn/Sepsis Not powered to detect EHJ 2005 DIC (VAD) mortality benefit 15734771 (298) + indicates survival benefit; ADHF, hospitalized for acute decompensated heart failure; AE, adverse event; BTC, bridge to candidacy; BTT, bridge to transplantation; DOS, duration of support; Expt, Experimental group; HMII, HeartMate II; HIMI-BTT, HeartMate II bridge to transplant; HIMI-DT, HeartMate II destination therapy; HM XVE, HeartMate XVE; IABP, intra-aortic balloon pump; ICM, ischemic cardiomyopathy; ino, inotrope-dependent at time of randomization/implantation; Infx, infection; Infxn (NV), non-VAD related infection; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; INTREPID, Investigation of Nontransplant-Eligible Patients Who Are Inotrope Dependent; MCS, mechanical circulatory support; MOF, multi-organ failure; MOMENTUM, Multicenter Trial of the Orqis Medical Cancion System for the Enhanced Treatment of Heart Failure Unresponsive to Medical Therapy; mPAP, mean pulmonary artery pressure; N/A, not applicable; Neuro, neurological complication (e.g. stroke); NS, no significant difference; Obs, Observational study; OHT, orthotopic heart transplantation; OMM, optimal medical management; P, permanent; pNRCT, prospective non-randomized clinical trial; post-MI CS, post-myocardial infarction cardiogenic shock; PumpRplt, pump replacement; RCT, randomized clinical trial; Rehosp, rehospitalization; REMATCH, Randomized Evaluation of © American College of Cardiology Foundation and American Heart Association, Inc. 137
Mechanical Assistance in Treatment of Chronic Heart Failure; RenalFail, renal failure; RespFail, respiratory failure; RV Fail, right ventricular failure requiring inotropic support; RVAD, need for right ventricular assist device; RR, relative risk; SVT, supraventricular tachycardia; T, temporary; Th-IVAD, Thoratec implantable ventricular assist device; Th-LVAD, extracorporeal VAD; TPG, transpulmonary gradient; Txplt-C, transplant candidate; Txplt-IE, transplant ineligible; and VT, ventricular tachycardia.
Data Supplement 35. LVADs (Section 7.4.5)
Trial Study Name, Study Study Duration Absolute Benefit or Complications/ Author, Year Aim of Study Type Size Patient Population Endpoints Mortality (Years) Major Study Findings Adverse Events N (Total Primary Secondary Study Size) Inclusion Criteria Exclusion Criteria Endpoint Endpoint 1st Year Mortality SELECTION OF VAD CANDIDATES Clinical To compare Case- 101 Pts implanted with an N/A Survival to N/A N/A ~2 y Actuarial survival N/A outcomes for post-implant controlle LVAD prior to 8/27/07 at discharge, Group 3: 95.8%, continuous-flow outcomes across d University of Minnesota, LOS after Group 2: 68.8%, LVAD pts different University of Pittsburgh, VAD p=0.065 vs Group 3 stratified by pre- INTERMACS and Columbia University implantation, Group 1: 51.1%, operative classification with either a VentraAssist actuarial p=0.011 vs Group 3 INTERMACS levels. or HM II, classified by survival while survival to discharge classification, INTERMACS level at time on MCS Group 3: 95.8%, Boyle AJ, JHLT of implant (Goup 1: p=0.02 vs Group 1 2011 INTERMACS profile 1; Group 2: 93.8%, 21168346 (299) Group 2: INTERMACS p=0.009 vs Group 1 profiles 2-3; Group 3: Group 1: 70.4% INTERMACS profiles 4-7) VAD AS DT Randomized To evaluate the RCT 129 Adults with chronic end- HF due to thyroid disease, The primary Secondary 1 y Mortality: Enrollment Reduction of 48 % in Sepsis (Rate Ratio 2.03) Evaluation of suitability of stage HF obstructive end point was endpoints LVAD 48% 5/98-7/01 the risk of Non-neurologic bleeding (Rate Mechanical implantable and contraindications to cardiomyopathy,pericardial death from included the OMM 75% (39mo); death from any cause Ratio 9.47) Assistance for LVAD for their transplantation. NYHA IV disease, amyloidosis, or any cause incidence of p=0.002 — the primary endpoint Neurologic dysfunction (Rate the Treatment ultimate intended HF for >60 of 90 d active myocarditis and was SAEs, the no. 2yr Mortality: — in LVAD group, as Ratio 4.35) SVT of CHF use as a long- despite attempted therapy Technical obstacles that compared of d of LVAD 77% compared with medical- (Rate Ratio 3.92) REMATCH, term myocardial- with ACEI, diuretics, and pose an inordinately high between hospitalizatio OMM 92% therapy group (OMM) Suspected malfunction of Rose E, 2001 replacement digoxin; surgical risk groups with n, the QoL, p=0.09 QoL suggested greater LVAD (0.75 rate/pt-y) 11794191 (285) therapy for pts LVEF < 25% INR >1.3 or PT >15 sec the use of the symptoms of improvement in LVAD who are ineligible Peak VO2 <12- BSA <1.5 m2 log-rank depression, group, though not all for cardiac 14ml/kg/min or a BMI >40 kg/m2 statistic. and functional measures reached transplantation continued need for IV Severe COPD (FEV<1.5 status. statistical significance. inotropic therapy owing to L/min) (RR 0.52; 95% CI: symptomatic hypotension, Positive serum pregnancy 0.34-0.78; p=0.001) decreasing renal function, test or worsening pulmonary Fixed pHTN with PVR> 8 © American College of Cardiology Foundation and American Heart Association, Inc. 138
congestion. Wood units NYHA III-IV for > 28 d Candidate for CABG, and who had received at valvular repair, LV least 14 d of support with reduction, or IABP or with a cardiomyoplasty dependence on IV Hx of cardiac inotropic agents, with 2 transplantation, LV failed weaning reduction or attempts. cardiomyoplasty Mechanical AV that will not be converted to bioprosthesis AST, ALT, TBili > 5x normal or biopsy-proved liver cirrhosis Stroke w/in 90d or cerebrovascular dz with > 80% extracranial stenosis Impaired cognitive function, Alzheimer’s disease and/or other irreversible dementia, Untreated AAA >5 cm Suspected or active systemic infection Platelet count <50x103/mm3 SCr >3.5 mg/dL or dialysis Peripheral vascular disease with rest claudication or leg ulceration CCB (except amlodipine) or type I or type III antiarrhythmic agent. Abdominal operation planned Psychiatric disease /Substance abuse Participating in another clinical study Other condition with survival < 3 y
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LVAD as To analyze Post- 91 (on LVEF <25% Advanced age, All-cause QoL at 1 y 1 y Mortality: Enrollment In pts undergoing N/A Destination for outcomes in pts hoc inotrope at NYHA IV symptoms for Diabetes with end-organ mortality LVAD 51% 5/98-7/01; inotropic therapy at pts undergoing undergoing analysis randomizat 60 of 90 d despite damage, during the OMM 76% randomization, 1 y intravenous inotropic ion) attempted therapy with SCr >2.5 mg/dL for >90 d 180 d p=0.0014 survival with LVAD was inotropic infusions at ACEI, diuretics, and following 2yr Mortality: 49% vs 24% for OMM therapy: a randomization for digoxin. Peak randomization LVAD 72% and by 2 y, 28% were subset analysis LVAD destination VO2 <12-14 mL/kg/min . OMM 89% alive with LVAD group from therapy with evidence of compared with 11% in REMATCH, anaerobic metabolism, OMM group Stevenson LW, Dependence on IV (p=0.0014). 2004 inotropic agents 15313942 (284) supported by completion of a weaning failure form. Investigation of To evaluate the Prospec 55 Adults with inotrope- BSA <1.5 m2 All-cause AEs, 1st y mortality Enrollment 6 mo survival CVA 34.5% Nontransplant- impact of LVAD tivenonr dependent stage D HF; Contraindication to chronic mortality at 6 functional 73% (LVAD) vs 39 mo (3/00- 46% (LVAD) vs 22% Infection 24% Eligible Pts Who support on andomiz LVEF < 25%, anticoagulation mo capacity 89% (OMT) 5/03); 12 mo (OMT) Are Inotrope survival and QoL ed NYHA IV symptoms for > Presence of a mechanical HRQoL 6mo mortality: follow-up (HR 0.47; 95% CI 0.23- Dependent in inotrope- clinical 3 mo before enrollment aortic valve constituted an 54% (LVAD) vs 0.93; p=0.03) (INTrEPID dependent HF trial and were not candidates exclusion criterion for LVAD 78% (OMT) 1 y survival Trial), Rogers pts ineligible for for cardiac transplantation support 27% (LVAD) vs 11% JG, 2007 cardiac Treated with maximally CVA or TIA within 6 mo (OMT) 17707178 (286) transplantation tolerated doses of ACEI, before enrollment, a 70% Absolute reduction of 1 beta-blockers, digoxin, carotid stenosis, or an y mortality by 16% with diuretics, and/or other ulcerated carotid plaque. LVAD vasodilators. Unresolved drug or alcohol (HR: 0.48; 95% CI: dependency 0.25-0.85; p=0.02) Active systemic infection SCr >5.0 mg/dL, Tbilli >5.0 mg/dL Mechanical ventilatory support for >48 h at the time of enrollment Comorbid medical condition limiting life expectancy < 2 y Advanced HF To compare the RCT 200 Age >18 y HF is due to uncorrected The primary Secondary 1st y mortality: Enrollment The primary composite Higher complication rate with treated with outcomes of pts BSA > 1.5m2 for a pt to thyroid disease, obstructive composite endpoints 32% (continuous 5/05-5/07 (2 endpoint was achieved pulsatile LVAD (p<0.001) continuous-flow ineligible for be randomized HM XVE - cardiomyopathy, pericardial endpoint was, included flow LVAD) vs y) in more pts assigned to Pump replacement LVAD, cardiac HM II. If BSA < 1.5 disease, amyloidosis, active at 2 y, survival, 42% (pulsatile Follow-up >2 receive a continuous- Sepsis (HeartMateII transplantation m2and > 1.2 m2, the pt myocarditis or RCM. survival free frequency of flow LVAD) y or until flow LVAD than in Respiratory failure DT), Slaughter with pulsatile must meet the remaining Technical obstacles, which from disabling AE, the QoL, death, those assigned to Renal failure MS, 2009 versus criteria and can be pose an inordinately high stroke and and functional cardiac receive a pulsatile-flow RV failure requiring extended 19920051 (287) continuous flow enrolled in the Small Size surgical risk, in the reoperation to capacity. transplant, or LVAD (46% vs. 11%) inotrope Rehospitalization
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LVAD destination Cohort. judgment of the investigator. repair or explant of On the basis of the as- therapy NYHA IIIB or IV HF and 1 Ongoing mechanical replace the LVAD treated analysis, the of following: circulatory support other device. Kaplan–Meier estimate i. On OMM, including than IABP. of actuarial survival was dietary salt restriction, BMI >40 kg/m2. significantly better for diuretics, digitalis, beta Positive pregnancy test pts who had a blockers, spironolactone Presence of mechanical AV continuous- flow LVAD and ACE-I, for > 45 out of that will not be converted to as compared with those the last 60 d and failing a bioprosthesis with a pulsatile-flow to respond; History of cardiac transplant LVAD ii. NYHA III-IV HF for >14 or cardiomyoplasty. Improvements in d and dependent on IABP Platelet count < 50,000 functional status by for 7 d and/or inotropes Untreated aortic aneurysm > NYHA Class and for >14 d 5cm. 6MWT did not differ iii. Treated with ACE-I or Psychiatric disease, between the two beta blockers for > 30 d irreversible cognitive groups. and found to be dysfunction, psychosocial intolerant. issues that are likely to Primary composite Female pts of impair compliance endpoint: childbearing potential Active, uncontrolled HR 0.38; 95%CI: 0.27 must agree to use infection. to 0.54; p<0.001 adequate contraception Intolerance to anticoagulant Actuarial survival, RR: Ineligible for cardiac or antiplatelet therapies or 0.54 transplant. any other peri/post 95% CI, 0.34 to 0.86; VO2max < 14 mL/kg/min operative therapy that may p=0.008 or <50% of predicted be required VO2max with attainment INR > 2.5, not due to anti- of anaerobic threshold, if coagulant therapy, or Plavix not contraindicated due to within 5 days IV inotropes, angina or AST, ALT, or total bilirubin physical disability. > 5x normal or biopsy LVEF is < 25%. proven liver cirrhosis Severe COPD or restrictive lung disease. Fixed pHTN with a PVR >8 Wood units Stroke w/in 90 d, or cerebral vascular disease with >80% extra cranial stenosis. SCr >3.5 mg/dl or on dialysis Significant peripheral vascular disease with rest
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pain or ulceration. Moderate to severe AIy without plans for correction Participation in any other clinical investigation CCB (except amlodipine), or Type I /III antiarrhythmic (except amiodarone) within 28 d prior to enrollment. Any condition that could limit survival to <3 y. BTT Use of a To assess the Cohort 133 Transplant listed. HF due to uncorrected The principal Secondary 1 y mortality Enrollment 75% reached principal Bleeding requiring pRBCs continuous-flow efficacy of BSA > 1.2 m2. thyroid disease, outcomes outcomes 32% 3/05-5/06 outcomes Local infection, non-LVAD device in pts continuous-flow NYHA IV HF symptoms. obstructive/restrictive were the included (15mo); 18.8% died before Ventricular arrhythmias awaiting heart LVAD for Female pts of childbearing cardiomyopathy, pericardial proportions of overall follow-up 180d of support Sepsis transplantation providing potential must agree to disease, or amyloidosis. pts who, at survival, through 180d Right HF (HMII BTT), hemodynamic use adequate Technical obstacles, which 180 d, had survival while Miller LW, 2007 support of at contraception pose an inordinately high undergone receiving 17761592 (289) least 6 mo to pts On inotropic support, if surgical risk. transplantatio device awaiting heart tolerated. Ongoing mechanical n, had support, transplantation Despite medical therapy, circulatory support other undergone survival after the pt must meet one of than IABP explantation transplantatio the following criteria: BMI > 40 kg/m2. of the device n, a. No contraindication for Positive pregnancy test because of frequency of Status 1A listing Mechanical aortic valve that recovery of AEs, b. No contraindication for will not be converted to a ventricular assessment Status 1B listing bioprosthesis function, of functional PCWP or PAD > 20 Hx of cardiac transplant. or had class by a 6- mmHg, Platelet count <50,000/mL. ongoing min walk test, CI < 2.2 L/min/m2 or SBP Untreated aortic aneurysm mechanical independent < 90 mmHg > 5cm. support and evaluation of Psychiatric dz irreversible remained NYHA cognitive dysfunction, eligible for functional psychosocial issue transplantatio class by a Active uncontrolled n (i.e., were physician, infection. not removed and QoL. Intolerance to anticoagulant from the or antiplatelet therapies or waiting list any other peri/post owing to operative therapy that may irreversible be required complications Any one of the following or clinical © American College of Cardiology Foundation and American Heart Association, Inc. 142
risk factors for and deterioration) indicators of severe end- organ dysfunction or failure: a) INR >2.5 not due to anticoagulant therapy or Plavix within 5 d. b) Total bilirubin > 5mg/dl, or shock liver (AST, ALT >2,000), or biopsy proven liver cirrhosis. c) Severe COPD or severe restrictive lung disease. d) Fixed pulmonary hypertension, with a recent PVR >6 Wood units, e) Unresolved stroke or uncorrectable cerebrovascular disease. f) SCr >3.5 mg/dL or the need for chronic dialysis. g) Significant peripheral vascular disease with rest pain or ulceration Moderate to severe aortic insufficiency without plans for AVR Participation in any other clinical investigation Extended To evaluate the Cohort 281 Same as above (HMII Same as above (HMII Survival and Pts were 6 mo Mortality Enrollment 79% of LVAD pts Bleeding requiring pRBCs Mechanical use of a Study Study) Study) transplantatio assessed for 18% (95% CI: 3/05-4/08 (38 reached primary Respiratory failure Circulatory continuous-flow n rates were AEs 77-87%) mo); 18 mo outcome measure, Local infection, non-LVAD Support with a rotary LVAD as a assessed at throughout 1 y Mortality follow-up either received Ventricular arrhythmias Continuous- bridge to heart 18 mo. the study and 27% (95% CI: a transplant, Sepsis Flow Rotary transplantation for 66-80%) 18 Mo recovered cardiac Right HF requiring extended LVAD (HMII over an extended QoL, Mortality 28% function and inotropic support BTT), Pagani period, up to 18 functional (95% CI: 65- underwent device FD, 2009 mo status, and 79%) explantation, or 19608028 (288) organ remained alive with function for 6 ongoing LVAD mo. support at 18-mo follow-up
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Evaluate the To test whether RCT 26 Pts with acute MI within Age <18 y; The Hemodynami n/a N/A; follow-up The CI after 30 min of No difference in adverse Safety and the percutaneous 48 h and cardiogenic Prolonged resuscitation hemodynamic c and of 30d support was effects between pLVAD and Efficacy of a LVAD Impella shock within 24 h (>30 min) improvement metabolic significantly increased IABP Percutaneous LP2.5 provides CI < 2.2 l/min/m2 and HCM; at 30 min parameters; in pts with LVAD vs. IABP superior PCWP >15 mm Hg or an LV thrombus; after All-cause the Impella LP2.5 for Treatment of hemodynamic angiographically Treatment with intra-aortic implantation mortality at 30 compared with pts Cardiogenic support measured LVEF <30% balloon pump; defined as the d; with IABP Shock Caused compared with and LVEDP >20 mm Hg Severe valvular disease or change in CI Device- (Impella:DCI=0.49+0.4 by Myocardial IABP mechanical heart valve; from baseline. related 6 l/min/m2; IABP: Infarction, Cardiogenic shock caused complications DCI=0.11+ 0.31 Seyfarth M, by mechanical including l/min/m2). 2008 complications of AMI such hemolysis, p= 0.02 19007597 (263) as ventricular septal defect, major acute mitral regurgitation bleeding, greater than second cerebrovasc- degree, or rupture of the ular events, ventricle; limb Predominant RV failure or ischemia, and the need for a RVAD; multiple- Sepsis; organ Known cerebral disease; dysfunction bleeding with a need for scores at 30 d surgical intervention; using MODS Allergy to heparin or any and SOFA known coagulopathy; criteria. Moderate to severe AI; Pregnancy; Inclusion in another study or trial Impact of To examine the Registry 351 NYHA IV symptoms for > Not specifically outlined; 1 y survival 1 y Mortality Enrollment: High volume center Sepsis Center Volume impact of LVAD ; 60 d despite maximized similar to REMATCH with DT low volume: 5/98-12/05 compared with low Multiorgan failure on Outcomes of center volume on Retrosp oral therapy or 52.2% (92 mo); total volume center has an Stroke LVAD the outcomes of ective requirement of inotropic medium duration of absolute benefit of Right HF Implantation as DT analysis support LVEF < volume:42.8% observation: 19.6% reduction in LVAD failure/complications DT: Analysis of 25% high volume: 102 mo; mortality at 1 y (1y the Thoratec Peak VO2 <12 mL/kg/min 32.6% median mortality of 32.6% vs HeartMate or documented failure to follow-up 52.2%) Registry, 1998 wean IV inotropic therapy; period 9.5mo OR 0.4; 95% CI 0.2- to 2005, Lietz K, Contraindication to HT 0.7; p=0.006; 2009 attributable to age >65 y, 19808309 (300) insulin-dependent DM with end organ damage, chronic renal failure, or
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other comorbidities.
Predictors of To identify Registry 420 Pt underwent implantation Not specifically stated 1 y survival AEs 1 y Mortality 19 mo, 12 mo Risk factors for death CNS events death and predictors for of mechanical circulatory post LVAD DT: 37% follow-up 1. INTERMACS level Infection transplant in pts death and support device implantation BTT: 24% 1 (p=0.02) with a transplantation (INTERMACS registry) 2. Older age (> 60yr) mechanical based on initial (p<0.01) circulatory results from 3. Presence of ascites support device: INTERMACS (p=0.003) a multi- 4. Elevated total institutional bilirubin study (p=0.05) (INTERMACS), 5. BiVAD (p=0.002) Holman WL, 6. Total artificial heart 2009 (p=0.03) 19134530 (301)
European To report on the Registry 411 NYHA IIIB-IV CHF on Not specifically stated 6 mo and 1 y AEs 6 mo mortality: 52mo (3/04- Overall survival to Multiorgan failure results with a European maximum medical survival 26% 8/08) transplantation, Infections (sepsis, local non- continuous-flow experience with treatment including IV 1st y mortality: recovery of natural VAD related, drive line) VAD for the Heart Mate II inotropic support 8.5% heart function with Right heart failure advanced HF LVAD At least LVAD evice removal, or Bleeding pts, Lahpor J, implantation took place at ongoing device Ventricular arrhythmias 2010 least 6 mo prior to closing support at end of Neurologic complications 19616963 (290) date of study study: 69%
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Post–cardiac To determine Registry 468 Adult pts with end-stage Severe renal, pulmonary, or 1 mo and 1 y Overall 1 y Enrollment 38 Post-transplant Bleeding requiring pRBCs transplant factors related to HF and listed for heart hepatic dysfunction, survival; mortality: 13% mo (3/05- survival at 1y: survival after posttransplant transplantation Active uncontrolled survival after 4/08); follow- <30 d LVAD support: support with a survival in pts (SAME AS HMII BTT infection transplantatio up for 1 y 94% continuous-flow supported with STUDIES) Mechanical aortic valve or n post- 30-89 d LVAD LVAD: Impact of continuous-flow aortic insufficiency, transplant support: 93% duration of LVADs Aortic aneurysm, and for 18 mo 90-179 d LVAD LVAD support Other MCS (other than post-LVAD if support: 84% and other IABP) not >180 d LVAD support: variables, John Technical obstacles thought transplanted 81% R, 2010 to pose an increased (p=0.18) 20447659 (302) surgical risk
Results of the To determine Registry 338 INTERMACS registry, Survival 30 d mortality, 12 mo mortality Enrollment 12 mo survival: Bleeding event rate/pt-y Post-U.S. FDA- whether results LVAD for BTT (transplant or inhospital 13% HMII vs. 9/07-2/09; at 85% HMII vs 70% 1.44 HMII v 1.79 COMP, Approval Study with the HMII death) mortality, 22%COMP least 12 mo COMP p=0.19 With a LVAD in a LOS, QOL, follow-up post no difference between Infection event rate/pt-y Continuous commercial AE VAD INTERMACS profiles 1.0 HMII v 2.12 COMP, Flow LVAD as a setting are within each group p<0.0001 Bridge to Heart comparable to 12 mo survival: Transplantation other available log rank p<0.001 (INTERMACS), devices for the Starling RC, same indication JACC 2011 21545946 (291) BIVAD Survival after To identify the Registry 1852 INTERMACS registry, N/A Survival AEs 6 mo mortality 15 mo (6/06- Risk factors for death Bleeding biventricular underlying pre- LVAD or BiVAD BiVAD: 44% 9/09) with BiVAD Infection assist device implant implantation LVAD: 14% Older age implantation: An characteristics of p<0.0001 Higher BSA analysis of the population Presence of Ascites INTERMACS requiring BiVAD Elevated creatinine database, support that Elevated total bilirubin Cleveland JC, contribute to Elevated INR 2011 reduced survival, History of valve surgery 21621423 (303) and to identify Failure to wean from differences in bypass postoperative outcomes with respect to AEs compared with pts supported with LVAD alone. © American College of Cardiology Foundation and American Heart Association, Inc. 146
PERCUTANEOUS VAD Multicenter Trial To compare RCT 168 LVEF<35% Recent Q-wave MI or Overall success Change in SCr 65 d mortality Enrollment Primary efficacy Any bleed (40.4% device vs of the Orqis percutaneous Persistent clinical, cardaic composite based at d 3 Change pVAD 33.9% 9/04-8/07 endpoint success 13.6% control, p=0.0004) Medical continuous aortic hemodynamic, revascularization; on technical in body weight control 32.2% (3y), out to 64 (hemodynamic and Cancion System flow and renal derangement Severe lung disease; (device group at d 4 (HR:1.05; d since clinical success for both for the augmentation despite standard oral Primary liver disease; only), Change in CI p=0.87) randomization groups plus technical Enhanced (flow<.5 L/min for medication and treatment SCr >4.0 mg/dL or on hemodynamic, and (72- 96 h success in Treatment of HF up to 96 h) plus for > 24 h with >1 of the dialysis; clinical success average), the device group) was Unresponsive to medical therapy following drugs at CRT device defined as follows: Change in NT- seen in 13.6% of the Medical vs. medical minimum dosage (stable implanted within 14 d; technical success proBNP at d 3; control group and 17.4% Therapy therapy alone for >6 h): SBP <80 mm Hg; (device group Change in of the device group pts (MOMENTUM), a) dobutamine 2.5 Need for cardiac only), insertion and KCCQ Overall (p=0.45) Greenberg B, mg/kg/min mechanical support; attainment of flow Summary No significant difference 2008 b) milrinone 0.3mg/kg/min Platelet count >1 L/min for >24 h; score at 2 wk was found in SCr, NT- 18765394 (297) c) dopamine 5 mg/kg/min , <50 000/ L; hemodynamic and 35 d. proBNP, or body weight. d) nesiritide INR > 1.5 in the success, mean KCCQ Overall Summary 0.01mg/kg/min absence of PCWP decrease and e) nitroprusside anticoagulation; from baseline of 5 Clinical Summary scores 0.25mg/kg/min , or Systemic infection; mmHg calculated increased more in the f) nitroglycerine CVA or TIA within 3 as the average of device group (p=0.10) 0.25mg/kg/min mo; values at 72-96 h; than in the control group PCWP >18 mm Hg Active status on the and clinical (p=0.095), but treatment continuously for 12 h and cardiac success, from d 1- differences were not >20 mm Hg at time of transplantation list 35 after significant randomization; unless transplant was randomization, any CI < 2.4 L/min/m 2; considered unlikely of the following: SCr >1.2 mg/dL or IV within 65 d; >10 consecutive d furosemide dose >120 Peripheral vascular alive out of mg/d or equivalent. disease with absent hospital, no pedal pulse or alternative evidence of mechanical limb ischemia; support, absence Significant of death, and uncorrected primary absence of valvular disease. readmission for HF QOL
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Longitudinal To describe Cohort 78 Received either N/A QOL N/A N/A N/A QoL outcomes were N/A Change in QoL change with time Study HeartMate VE LVAD or questionnaires: fairly good and stable and Impact on (from 1mo to 1 y) Heart Mate implantatble QOL Index, Rating from 1 mo to 1 y after Survival After in pts who pneumatic LVAD between Question Form, HF LVAD implantation. LVAD received a Heart 8/1/94 and 8/31/99 at 1 of Symptom Overall QoL was Implantation, Mate vented 9 medical centers in US Checklist, and unchanged, however Grady KL, 2004 elecric LVAD as and one medical center in Sickness Impact both positive and 15063260 (293) BTT and to Australia as BTT Profile negative changes in identify QOL Age > 18 y subareas of QoL were (predictors of Able to read and write noted. Pt satisfaction survival after English with life improved in LVAD Physically able to area of implantation) participate health/functioning but worsened in satisfaction with significant others. Cardiopulmonary, neurologic, psychological, and physical symptom distress improved. Functional disability with respect to work, sleep/rest, self-care, and physical disability improved over time. However, functional disability with respect to home management and social interaction worsened. Continuous To assess the Cohort 655 Pts enrolled in either HM II N/A NYHA Functional N/A N/A N/A LVAD pts demonstrated N/A Flow LVAD impact of Study BTT or DT clinical trials Class assess by early and sustained Improves continuous flow clinician improvements in Functional LVADs on Pt reported activity functional status and Capacity and functional levels (METS) and QOL. NYHA functional QoL of capacity and HF- 6MWT class improved from Advanced HF related QoL Heart failure- class IV to class I or II in Pts, Rogers JG, related QOL by majority of pts (about 2010 MLWHF and 80%). Improved 6MWT 20413033 (304) KCCQ distance as well as MLWHF and KCCQ scores.
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QOL and To review QoL in Retrosp 30 Pts who underwent HMII Pt transplanted or 6MWT distance, Hospital N/A LVAD pts spend the 90% of pts experienced functional status pt on LVAD ective or HMI LVAD implantation died before 365 d of MET tolerance, readmissions, majority of time outside hospital readmissions, with in pts surviving support for >1 y analysis between 2000-2008 at MCS MLHFQ, NYHA infectious the hospital enjoying a mean no. of readmissions 12 mo after Johns Hopkins Hospital functional class complications good QoL per year of 2.9 with mean LVAD length of stay of 13.8 d. 43% implantation, of readmissions were for Allen JG, 2010 infectious complications. 77% 19837607 (305) of LVAD pts required additional operations for various indications. AAA indicates abdominal aortic aneurysm; ACEI, angiotensin-converting-enzyme inhibitor; AE, adverse event; ALT, alanine aminotransferase; AST, aspartate aminotransferase; AV, atrioventricular; AVR, aortic valve replacement; BMI, body mass index; BSA, body surface area; BTT, bridge to transplantation; CABG, coronary artery bypass surgery; CCB, calcium channel blocker; CHF, congestive heart failure; Cl, clearance; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; DM, diabetes mellitus; DT, destination therapy; dz, disease; FEV, forced expiratory volume; HCM, hypertrophic cardiomyopathy; HF, heart failure; HM II, HeartMate II; HM XVE, HeartMate XVE; HT, heart transplantation; hx, history; IABP, intra-aortic balloon pump; INR, international normalized ratio; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; IV, intravenous; KCCQ, Kansas City Cardiomyopathy Questionnaire; LOS, length of stay; LV, left ventricle; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MCS, mechanical circulatory support; METS, metabolic equivalents; MLWHF, Minnesota Living with Heart Failure; MWT, minute walk test; MODS, multiple organ dysfunction scores; N/A, not applicable; NT-proBNP, N-terminal pro-B-Type natriuretic peptide; NYHA, New York Heart Association; OMM, optimal medical management; PAD, peripheral arterial disease; pRBC, packed red blood cells; PCWP, pulmonary capillary wedge pressure; pHTN, pulmonary hypertension; pts, patients; PVR, peripheral vascular resistance; QoL, quality of life; RCM, Restrictive cardiomyopathy; RCT, randomized control trial; RV, right ventricule; SAE, serious adverse event; SBP, systolic blood pressure; SCr, serum creatinine; SOFA, sequential organ failure assessment; SVT, supraventricular tachycardia; Tbilli, total bilirubin; TIA, transient ischaemic attack; VAD, ventricular assist device; and VO2, oxygen volume.
Data Supplement 36. Transplantation (Section 7.4.6) Study Name, Aim of study Study Type Background Therapy Study Patient Population Severity Endpoints Mortality Trial Absolute Benefit P Values & Author, Year Size Duratio or Major Finding 95% CI: n (Years) Pretrial standard N (Total Inclusion Exclusion Severity of Primary 1st Year treatment. Study Criteria Criteria HF Endpoint Mortality Size) Symptoms PATIENT SELECTION Value of peak To determine Case-control ACEI 95% 122 Ambulatory HF Dependent on NYHA II Death 1 y mortality 3 Pts with preserved N/A exercise oxygen whether Diuretics 100% pt referred for inotrope or 13% peak VO2 <14, exercise capacity consumption for measurement of Digoxin 100% cardiac mechanical NYHA III accepted for despite severe resting optimal timing of peak VO2 during Vasodilators 98% transplantation support; 70% transplant: 30% hemodynamic cardiac maximal exercise PDE3 inhibitors 13% evaluation Unable to NYHA IV peak VO2 >14: impairment have transplantation in testing can be Antiarrhythmics 10% achieve 17% 6% survival and ambulatory pts with used to identify ICD 1% anaerobic peak VO2 <14, functional capacity HF, Mancini DM, pts in whom threshold on rejected for equal to those afforded Circulation, 1991 transplantation CPX transplant: 53% by cardiac 1999029 (27) can be safely transplantation deferred
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Predicting Survival To examine the Case-control Beta blockers 65% 221 Ambulatory HF N/A N/A Outcome events: 1 y event-free 6 No difference in 1 y Survival by in Ambulatory Pts predictive value pts referred for death before survival: event-free survival HFSS, With Severe HF on of peak VO2 and heart transplant transplant, LVAD beta blocker amongst beta blocker p<0.0002 Beta Blocker the HFSS in pts evaluation implantation, 75% users by peak VO2 (total Therapy, Lund LH, referred for inotrope- no beta blocker statum; cohort), Am J Cardiol 2003 cardiac dependent 56% however, significant p<0.02 (beta 14636921 (306) transplantation in transplantation difference by HFSS blocker pts) the beta blocker statum Survival by era VO2, p=0.3 (total cohort), p=0.29 (beta blocker pts) Selection of Pts for To assess the Case-control ACEI 92% 507 HF pts with On inotrope; NYHA III- 1 y event-free Overal 1-y N/A No difference in 1 y N/A Heart relationship Diuretic 96% LVEF <40%; Angina or IV 84% survival (without survival event-free survival in Transplantation in between Digoxin 94% Underwent CPX orthopedic issue need for LVAD or Transplanted: current era by initial the Current Era of survival, peak beta blocker 10% in 1994-1997 restricting urgent- Status 88% peak VO2; trend HF Therapy, Butler exercise oxygen (past) vs. 72% (past era) or exercise 1A- Current era HF: towards difference in J, JACC 2004 consumption (current) 1999-2001; capacity; transplantation) 88% survival when stratified 14998618 (307) (VO2), and HF Spironolactone 2% (current era) Significant for HF pts; Past era HF: by HFSS survival score (past) vs. 41% Underwent OHT valvular stenosis; Overall 1-y 78% (HFSS) in the (current) in 1993-2000 Exertional survival for current era of HF Antiarrhythmic 13% oxygen transplanted pts (HF) therapy AICD 11% (past) v desaturation 19% (current) Peak VO2 and To examine the Retrospectiv ACEI 70% 213 HF diagnosis; N/A Cardiac-related 1 year mortality 8 y, 7 Peak VO2 (<14 1 y cardiac VE/VCO2 slope in ability of peak e analysis Digitalis 57% Evidence of LV mortality and VE/VCO2 < 34: mo ml/kg/min) was mortality pts with HF: a VO2 and Diuretic 63% systolic hospitalization 1- 0.8% (CPX revealed by VE/VCO2 prognostic VE/VCO2 slope Oral nitrate 29% dysfunction by y after exercise VE/VCO2 >34: from multivariate Cox slope >34, p comparison, Arena to predict beta blocker 42% echocardiogram testing via 16.9% 4/93- regression analysis to <0.0001 R, Am Heart J, cardiac-related CCB 15% or cardiac medical chart 10/01), add significantly to the 2004 mortality and anticoagulant 35% catheterization review and the plus 1 y VE/VCO2 slope (>34) 14760336 (308) hospitalization Antiarrhythmic 15% Social Security f/u in predicting 1-y Death Index cardiac-related hospitalization (residual X2 =6.5; p=0.01). The addition of peak VO2 did not provide additional value to the VE/VCO2 slope in predicting overall cardiac-related mortality (residual
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X2 = 0.2; p=0.89) or 1-year cardiac-related mortality (residual X2= 1.5; p=0.29).
Prognostic To develop a Case-control Beta blocker 86% (no 874 Chronic HF with N/A NYHA III- Major cardiac- 2 y event-free 11 y Pts without a No VT vs usefulness of the prognostic model VT) vs 75% (VT) stable HF IV related events survival based (CPX detectable VT had VT: functional aerobic using FAR as a ACEI 76% symptoms and 89% (no (heart upon CPX between worse prognosis. p<0.001, reserve in pts with continuous CCB 7% medications for VT) vs. transplantation, responses--- 5/97- VE/VCO2 slope (>36) 95% CI 2.3- HF, Chase P, Am H variable that Diuretic 90% (no VT) at least 1 mo 45% (VT) LVAD favorable 5/08); 2 is the strongest overall 4.8 J, 2010 incorporates pts vs 70% (VT) before exercise implantation, and responses yfollow- univariate and Prognostic 21095281 (309) with an testing, cardiac-related defined as up multivariate predictor; classification undetectable VT. LVEF<45% death) for 2 y VE/VCO2 <36, FAR (<3 ml O2/kg/min) p<0.001 Secondarily, to after CPX testing VO2pk > 10 mL and peak VO2 (<10ml determine the O2/kg/min, FAR O2/kg/min) are prognostic power > 3ml O2/kg/ additive to the of the FAR with min) VE/VCO2 slope that of VO2pk All favorable and the responses: VE/VCO2 slope 95% in pts with HF 1 unfavorable: 83.1% 2 unfavorable: 76.0% All unfavorable: 58.3% Ventilatory To assess Case-control N/A 663 HF pts who Primary valve NYHA II-IV Death or heart During follow-up Median Ve/VCO2 slope <43, Ve/VCO2 Efficiency and the whether underwent disease; transplant period, f/u 26 1y survival 97% slope <43, Selection of Pts for Ve/VCO2 slope cardiopulmonary Congenital heart 15.2% mo 3y survival 89.4% 1y survival: Heart would identify testing at 4 disease; underwent Ve/VCO2 slope >43 95% CI: Transplantation, individuals likely laboratories; Planned transplant 1y survival 77.8% 95.4-98.6, y Ferreira AM, to benefit from NYHA II-IV; coronary; 13,7% died 3y survival 55.1% survival: Circulation HF, heart transplant LVEF <40% revascularization; 95% CI: 2010 more accurately Planned cardiac 85.8-93.0 20176714 (310) than current surgery; p<0.001 exercise criteria Age <18 y; Ve/VCO2 for listing Primary slope >43 pulmonary 1 y survival: disease; 95% CI: Previous cardiac 71.3-84.3%, transplantation; 3 y survival: Submaximal 95% CI: CPX (peak RER 45.2-65.0
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ratio <1.05).
The HF Survival To evaluate peak Case-control ACEI/ARB 80% 715 Systolic HF pt Excluded pts mean Outcome events 1 y event-free N/A HFSS significantly 1y event- Score outperforms VO2 and HFSS b-blocker 64% (no referred for unable to NYHA were defined as survival with discriminates between free survival, the peak oxygen as prognostic device) v 76% (any heart transplant exercise for any class 2.82 death, urgent peak VO2 10.1- the 3 risk strata across amongst consumption for tools in pts with device) evaluation reason (total), 2.7 transplantation 14 all device groups, CRT+/-ICD heart and without (no device) (UNOS Status 1), Total cohort: whereas peak VO2 pts transplantation CRT-D referred vs 2.9 (any or implantation 77% <10 only discriminates low risk selection in the era for heart device) of LVAD. Pts CRT+/-ICD: high risk from HFSS 90%, of device therapy, transplant who underwent 84% low/medium risk. medium risk Goda A, JHLT evaluation transplant as ICD +/- CRT: HFSS 72%, 2011 non-urgent 80% high risk 21093299 (311) (UNOS status 2) Any device: 80% HFSS 56% were censored 1 year event- alive on the date free survival with of the transplant. peak VO2 < 10 Total cohort: 65% CRT+/-ICD: 52% ICD +/- CRT: 59% Any device: 58% FUNCTIONAL/QOL OUTCOME Improvement in To compare QoL Cohort Post-transplant 148 Underwent N/A N/A Symptoms, N/A N/A Total symptom N/A QoL in Pts with HF of pts with HF at maintanence cardiac health distress decreased who Undergo time of loisting immunosuppression transplantation perception, after heart Transplantation, for a heart included cyclosporine, at Loyola functional status, transplantation. Grady KL, 1996 transplant with prednisone and University of stress, coping, Overall level of 8878757 (312) that 1 y after azathioprine. Some Chicago Medical life satisfaction, functional disability transplantation received induction anti- Center or and overall QoL improved after heart T-cell therapy. University of as measured by transplantation, though Alabama at 6 point- remained low. Birmingham completed instruments. Demographic and clinical data from chart review.
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A Controlled Trial To assess the RCT All pts were treated 27 Underwent Multiple medical N/A Differences in N/A Enrollme 6 mo D peak VO2: p=0.01 of Exercise effects of with triple-drug cardiac issues limiting results of nt 11 +4.4 L/min/kg Rehabilitation After structured 6 mo immunosuppression-- transplantation ability to cardiopulmonary mo; 6 (exercise) Heart training cyclosporine, participate in exercise stress mo +1.9 L/min/kg (control) Transplantation, (cardiopulmonary azathioprine, and exercise training testing at 1- and followup Kobashigawa JA, rehabilitation) on prednisone. 6- mo after (total 1999 the capacity for transplantation 17mo) 9920951 (313) exercise early after cardiac transplantation Predictors of QoL To describe QoL, Cohort study Some pt receieved 232 Pts who N/A N/A QoL domains N/A Recruite Predictors of better p<0.00001 in Pts at 1 y After examine induction anti-T celll survived to 1 y and multiple d pts QoL at 1 y post-OHT for all Heart relationships therapy with HATG or post-cardiac subscales within listed for were: less total stress, Transplantation, between quality OKT3, some did not. transplant and these domains: OHT more helpfulness of Grady KL, 1999 of life and All pts were on completed the somatic from information, better 10328145 (314) demographic, maintenance study booklet sensation, 3/88- health perception, physical, and immmunosuppression psychological 8/96 better compliance with psychosocial consisting of state, physical transplant regimen, variables, and cyclosporine, and occupational more effective coping, identify prednisone, and function, social more functional ability, predictors of Q0L azathioprine. interaction less symptom distress, in pts 1 y post- Prednisone was rapidly older age, fewer transplant tapered to 0.1mg/kg/d complications by 1 y post-OH. Predictors of POOR outcome were primarily psychological Lifestyle and QoL To describe Cross- N/A 93 Cardiac N/A N/A Self-report N/A Mean Despite having N/A in Long- Term long-term (>1 y) sectional transplant questionnaire time multiple co-morbidities, Cardiac Transplant cardiac study recipients who incorporating: (1) since heart transplant Recipients, Salyer transplant were: (1) >18 y pt characteristics; transpla recipients evaluate J, 2003 recipients’ of age at the (2) barriers to nt was their health as good. 12633699 (315) perceptions of time of health promotion, 101.4 QoL in recipients who barriers to transplant; (2) perceived health mo (SD are, on average, 8.5 y health-promoting could read and competence and 49.44 post-transplant and behaviors; ability write English; health-promoting mo, demonstrate that, to manage their and (3) had the lifestyle; (3) range overall, they are health, health- visual acuity to perceived health 12-188 moderately satisfied promoting read and status; and (4) mo) with their lives lifestyle, health respond to QoL. Predictors of better status and QoL; written perceptions of QoL and determine questionnaires. included less predictors of education, longer time QoL. since transplant,
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ischemic etiology of HF, fewer barriers, higher perceived health competence and a health- promoting lifestyle (R2 =0.51; F=14.77; p=0.001). Changes in To prospectively Case control In txplt pts 125 Underwent N/A N/A Peak VO2, N/A N/A Ve/VCO2 slope Ve/VCO2, exercise capacity, examine Immunosuppression: cardiac Ve/VCO2 slope improved (decreased) p<0.001 vs. ventilation, and changes in peak cyclosporine/tacrolimus transplantation at 6 mo and remained baseline, body weight VO2 and 100% between 9/97 improved at 12, 24 mo p=0.12 vs following heart ventilatory prenisolone 100% and 1/02 at post-txplt compared matched transplantation, efficiency azathioprine/MMF German Heart with pre-txplt value normals Habedank D, 2007 (VE/VCO2 slope) 100% Institute, Berlin; and no different than Peak VO2, 17023206 (316) over 24 mo ACE-I/ARB 99% Healthy matched normal at 6 p<0.01 vs following heart CCB 93% volunteers mo. baseline, transplantation Diuretics 92% Peak VO2 improved at p<0.0001 vs and evaluate the alpha blocker 17% 6 mo and remained matched potentially beta blocker 12% improved at 12, 24 mo normals confounding post-txplt compared to effects of weight pre-txplt baseline but gain remained lower than normal matched controls. Patterns and To describe QoL Cohort N/A 555 Transplanted N/A N/A N/A N/A N/A QoL is positive and N/A Predictors of QoL over time and between 7/1990 stable at 5 to 10 y after at 5 to 10 Y After identify and 6/1999; heart transplantation. Heart predictors of QoL Survived 5-10 y Bio-psychosocial Transplantation, longitudinally post-transplant variables predicted Grady KL, 2007 from 5-10 y after Completed pt satisfaction with 18022086 (317) heart survey overall QoL and transplantation pamphlet; HRQoL. Age >21y; Literate in English SURVIVAL OUTCOMES Long-term Results To examine the Case-control N/A 527 NYHA IV HF Severe pHTN NYHA IV Survival after 6 y mortality 9 y 18% worse 6-y of Cardiac long-term results unremedial to (PVR >6 Wood transplant >60y/o: 46% survival/higher mortality: Transplantation in of cardiac surgical units, <60y/o: 28% mortality at 6 y post- p<0.05 Pts Older than 60 transplantation in treatment other irreversible) transplant for pts Death from Y, pts >60 y than cardiac Severe transplanted at age > infection: Bull DA, 1996 replacement, irreversible 60 y. p<0.003 © American College of Cardiology Foundation and American Heart Association, Inc. 154
8583816 (318) Limited life hepatic, renal or Older transplant Death from expectancy, 1-y pulmonary recipient (>60y/o) cancer: mortality >50% disease, more likely to die of an p=0.015 Age <65 y; Active systemic infectious complication Rejection No systemic or pulmonary after transplantation. episodes: illness other infection, Older transplant p=0.009 than Recent recipient (>60y/o) abnormalities pulmonary more likely to die of related to HF, infarction, malignant disease Emotional Uncontrollable after transplantation. stability, HTN, Older pts (>60y/o) had Strong family Uncorrectable significantly fewer support system. peripheral rejection episodes per vascular disease, pt than those < 60 Active peptic years at ulcer disease, transplantation History of (1.9+1.3 vs 2.6 +1.8) substance abuse (including alcohol) or behavior problem that would interfere with medical compliance Comparative To determine Prospective N/A 889 Age >16 y, N/A NYHA IV Mortality, 1 y mortality N/A For the total cohort p=0.04 Outcome and whether there is observational listed for cardiac stratified by HF after listing: there was no survival (mortality Clinical Profiles in a survival benefit cohort transplantation severity. high risk: 51% benefit from risk Transplantation associated with medium risk: transplantation. reduction for (COCPIT) Study, cardiac 32% However, for high risk high risk pts) Deng MC, 2000 transplantation in low risk: 29% pts, a mortality risk 10968814 (319) Germany. p <0.0001 reduction was 1y mortality observed within 2 wk while waiting on of transplantation (RR transplant list: <1.0). This benefit high risk: 32% disappeared after eight medium risk: months. 20% low risk: 19% p <0.0003 for high risk compared with low/medium
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1y mortality s/p transplant high risk: 64% medium risk: 76% low risk: 75% p=0.2 Reversible To assess the Case-control ACEI 81% 151 Referred for Pts with NYHA IIIB- 1 y post- 1y post-txplt >3 y Non-wait list, wait list, N/A pulmonary HTN in value of Digitalis 74% heart transplant implanted MADs; IV transplant mortality and 1y post-txplt heart transplant prostaglandin E1 Diuretics 75% evaluation at clinical Mortality Non-pHTN: mortality rates are candidates— (PG-E1) for beta blockers 38% Munster decompensation 14.8% similar for pts with pretransplant reduction of PHT University or inotropic- Reversible reversible pHTN as evaluation and and to predict between 3/98- support at initial pHTN: 22% those without pHTN. outcome after the postoperative 4/01 evaluation Wait list OHT, Klotz S, 2003 outcome, mortality 14607204 (320) compared to pts Non-pHTN: without PHT 17% Reversible pHTN: 17% Non-wait list Mortality Non-pHTN: 7% Reversible pHTN: 13%, p= 0.39 Irreversible pHTN: 50%, p<0.05 Evolving trends in To examine Cohort, N/A 7290 7290 pts N/A N/A The primary end 1y post-txplt 10 y Later transplantation N/A risk profiles and differences in Registry undergoing point of this study mortality 1990- registry date reduced late post- causes of death risk-adjusted cardiac trans- was death from 1992: 16% + 3 y transplant mortality, after heart expected versus plantation at 42 all causes. 1993-1995: 15% follow- particularly that due to transplantation: A observed institutions over 1996-1999: 15% up, 13 y rejection and graft 10 y multi- actuarial a 10-y period 3 y post-txplt observat vasculopathy, institutional study, outcomes of (1990-2000) mortality ion refelcting increasing Kirklin JK, 2003 cardiac 1990-1992: 24% period institutional expertise, 12698152 (321) transplantation 1993-1995: 21% changing over time at a 1996-1999: 21% immunosuppression single institution regimens.
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Retransplantation To determine Cohort, N/A 7290 Pts in CTRD NYHA IIIB- Freedom from 1 y 10 y Major indications for Improved in 7,290 Primary subsets of pts for Registry that underwent IV events retransplantation cardiac survival Transplant Pts: A whom cardiac a second (retransplantation rate: 0.8% retransplantation: post-retxplt 10-Y retransplantation cardiac and 10 y 1. Acute rejection if done for Multi-Institutional is appropriate transplantation subsequent retransplantation 2. Early graft failure CAV, Study (Cardiac therapy between death, rejection, rate: 3.2% 3. Allograft p=0.02 Transplant January 1990 and infection) 1y mortality vasculopathy Post-retxplt Research and December 15% after first Improved survival post survival for Database Group), 1999 transplant re-txplt if primary CAV no Radovancevic B, 46% after 2nd reason is allograft different 2003 transplant vasculopathy, not than that for 12909465 (322) 1y mortality acute rejection or early primary txplt post-2nd txplt by graft failure; survival of any indication for re- similar to that of pts cause, txplt undergoing primary p=0.67 68% acute OHT rejection 50% early graft failure Outcome in To evaluate the Case-control Cyclosporine 58% 157 Pts transplanted Pediatric pts, N/A Incidence of Overall mortality N/A Donor heart Increased Cardiac Recipients outcome in Tacrolimus 41% between 1/01 multiple organ cardiac recipient (mean 3 y f/u) LVWT>1.4cm mortality of Donor Hearts recipients of Sirolimus 31% and 12/04 at recipients, death or cardiac donor LVH increases post- with donor With Increased LV donor hearts with Mycophenolate 69% Stanford recipients who retransplantation (>1.2): 21.3% transplant mortality LVWT>1.4, WT, Kuppahally increased LVWT University died within 3 d donor normal and risk of allograft p=0.003, SS, 2007 >1.2 Medical Center after LVWT: 20% vasculopathy 95% CI 1.8- 17845572 (323) and the affiliated transplantation donor LVH 21.5 Northern (>1.4): 50% VAD BTT, California Kaiser total: 20.4% p=0.04, 95% Permanente CI 1.02-6.85 heart transplant programs Long-term To assess Registry Induction cytolytic rx 671 1. Age <40 y at N/A N/A Rejection, N/A 15 y PPCM recipients had Overall outcomes of outcomes in a 31% time of cardiac infection, cardiac registry similar long-term survival cardiac relatively large Steroids (at 1y): 88% transplant allograft survival as male IDCM PPM vs transplantation for group of PPCM 2. Etiology of vasculopathy, recipients; PPCM male IDCM, PPCM: a allograft HF: PPCM or and survival recipients trended p=0.9 multiinstitutional recipients with IDCM towards better survival PPM vs +P, analysis (CTRDG), long-term follow- compared with female P=0.05 Rasmusson KD, up IDCM, +h/o pregnancy PPM vs -P, 2007 recipients; p=0.07 18022074 (324) PPCM recipients appeared to have better survival than
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femail idiopathic DCM, never pregnancy recipients but not statistically significant.
Clinical outcomes To investigate Case- Calcineurin inhibitors 304 Muscular N/A N/A Survival after 1y post-txplt 15 y N/A p=0.5 (post- after cardiac the clinical out- controlled Cyclosporine 87% dystrophy pts transplant mortality: registry txplt transplantation in comes of cardiac Tacrolimus 9% who underwent Muscular mortality) muscular dystrophy transplantation in Unknown 4% cardiac dystrophy 11% pts (CTRDG), Wu muscular Azathioprine 61% transplantation Matched-control RS, 2010 dystrophy pts Mycophenolate 33% and matched- 9% 19864165 (325) with an extended Uknown 6% control cohort of 5 y post-txplt follow-up period Steroids (@1yr) 25% IDCM pts mortality: and to assess (matched by Muscular the outcomes in age, BMI, dystrophy 17% comparison with gender, and Matched-control an age-matched race) 21% control cohort p=0.5 The effect of To elucidate the Case-control N/A 147 Data from the N/A N/A 1 y mortality 1st y post- 5.5 y Low-, medium, and p<0.001 for transplant center effect of transplant Scientific transplant registry high-volume transplant each group volume on survival transplant center centers/ Registry of mortality centers have lower 1y compared after heart volume on 1-y 13230 Transplant significantly post-transplant with very- transplantation: A mortality heart Recipients of higher at very mortality than very-low low volume multicenter study, transplants heart low-volume volume transplant center Shuhaiber JH, transplantations transplant centers. group, 2010 between 1/1/99 centers 95% CI: 20138635 (326) and 5/31/05 compared with Low volume low to high 0.62-0.82 volume Med volume transplant 0.56-0.74 centers. High volume 0.48-0.65 ACEI indicates angiotensin-converting-enzyme inhibitor; AICD, automatic internal cardiac defibrillator; BMI, body mass index; BTT, bridge to transplant; CAV, cardiac allograft vasculopathy; CCB, calcium channel blocker; COCPIT, Comparative Outcome and Clinical Profiles in Transplantation; CPX, cardiopulmonary stress testing; CRT, cardiac resynchronization therapy; CRT-D, cardiac resynchronization therapy defibrillator; CTRD, Cardiac Transplant Research Database; DCM, dilated cardiomyopathy; FAR, functional aerobic reserve; f/u, follow-up; HATG, anti-T cell therapy; HF, heart failure; HFSS, heart failure survival score; h/o, history of; HTN, hypertension; ICD, implantable cardioverter defibrillator; IDCM, idiopathic dilated cardiomyopathy; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; LVWT, left ventricular wall thickness; MAD, mechanical assist device; N/A, not applicable; NYHA, New York Heart Association; OH, organ harvest; OHT, orthotopic heart transplantation; OKT3, Othoclone; PG-E1, prostaglandin E1; PDE3, phosphodiesterase enzyme; pHTN, pulmonary hypertension; PPCM, peripartum cardiomyopathy; PVR, pulmonary vascular resistance; QoL, quality of life; RCT, randomized controlled trial; RER, espiratory exchange ratio; SD, standard deviation; txplt, transplant; UNOS, United Network for Organ Sharing; VAD, ventricular assist device; VE/VCO2, carbon dioxide production; VO2, oxygen consumption; and VT, ventricular tachychardia.
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Data Supplement 37. Comorbidities in the Hospitalized Patient (Section 8.1) Study Name, Author, Aim of Study Study Background Study Size Etiology Patient Population Endpoints Absolute P Values & OR: HR: RR: Year Type Therapy Benefit 95% CI:
Pretrial standard N (Total Ischemic/Non- Inclusion Criteria Exclusion Criteria Primary treatment. Study Size) Ischemic Endpoint Diabetes and Hyperglycemia Intensive vs. Conventional Randomization of RCT Tight glucose 6104 N/A Hospitalized pts N/A Death -2.60% 95% CI: 1.02 - OR:1.02 death at 90 Glucose Control in Critically ICU pts to control 1.28 (p=0.02) d Ill Pts: The NICE-SUGAR intensive vs. recommended by Investigators. NEJM 2009; conventional some 360: 1283-97 (327) glucose control 19318384 Elevated Admission To investigate the Cohort Tight glucose 50,532 59.7% ischemic Hospitalized pts N/A Death N/A p=0.64 0.998 fully adjusted Glucose and Mortality in association control model per 10 mg/dL Elderly Pts Hospitalized between recommended by increase in admission with HF. Kosiborod M, admission some glucose Inzucchi SE, Spertus JA, glucose and Wang Y, Masoudi FA, mortality in Havranek EP, Krumholz elderly pts HM. Circulation 2009; 119: hospitalized with 1899-1907. (328) HF 19332465 Seven-Year mortality in HF To assess the Cohort N/A 400 43% ischemic Acute HF Lost to follow-up Total N/A 95% CI: 1.17 - aHR unknown DM pts with undiagnosed DM: prognosis of admission mortality 2.46 (p=0.006); 1.69 (ACM); HR an observational study. hyperglycemia 95% CI: 1.10 - clinical DM 1.48 Flores-LeRoux JA et al. (previously 1.99 (p=0.009) (ACM) Cardiovasc Diabetol 2011; undiagnosed DM) 10:39 (329) in pts admitted to 21569580 the hospital with HF Berry C, Brett M, Stevenson To investigate the Cohort N/A 454 N/A N/A N/A Inhospital N/A p=0.0023; (95% 1.08, aHR per 2 K, McMurray JJV, Norrie J. nature and mortality CI: 1.03-1.13) mmol/L increase in Nature and prognostic importance of glucose importance of abnormal blood glucose glucose tolerance and abnormalities in diabetes in acute HF. Heart an unselected HF 2008;94:296-304. (330) population 17664189
Anemia
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Blood Transfusions for To assess the Propensity Unknown 2335 ~85% ischemic ADHF Chronic HF Mortality; N/A In hosp 0.08 aOR for BT: 0.48; Acute Decompensated HF: impact of blood score admitted for another 39.6 vs. (95% CI: 0.21- 0.29; 0.74; 0.86 Friend or Foe? Garty et al. transfusion analysis, reason 28.5% in BT 1.11); 30 d 0.02 Am Heart J 2009;158:653- among pts with national HF vs. no BT pts (95% CI: 0.13- 8. (331) 19781427 ADHF survey 0.64); 1 y 0.12 (95% CI: 0.50- 1.09); 4 y 0.29 (95% CI: 0.64- 1.14) COPD Bronchodilator Therapy in The association Registry (AD N/A 10,978 N/A ED discharge N/A Mortality N/A For pts without 1.02; 1.69 ADHF in Pts without a between inhaled HF National diagnosis of (inhospital) COPD History of Chronic bronchodilators Registry ADHF as a bronchodilator Obstructive Pulmonary and HF pts with Emergency primary use associated Disease. Singer AJ et al. and without Module condition, adult with mortality Ann Emerg Med. 2008;51: COPD registry) (95% CI: 0.67– 25-34. (332) 17949853 1.56); mechanical ventilation (95% CI: 1.21–2.37) [adjusted, propensity- scored model]. For pts with COPD, no significant difference Should acute treatment with To determine the Review; N/A N/A N/A N/A N/A N/A N/A N/A N/A inhaled beta agonists be safety and evidence withheld from patients with efficacy of acute synthesis dyspnea who may have administration of from heart failure? Maak CA et inhaled beta-2 MEDLINE al. J Emerg Med. 2011 agonists to pts and Feb;40(2):135-45. (333) with HF EMBASE 18572345 searches ACM indicates all cause mortality; ADHF, acute decompensated heart failure; BT, blood transfusion; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; ED, emergency department; EMBASE, Excerpta Medica Database; HF, heart failure; ICU, intensive care unit; MEDLINE, Medical Literature Analysis and Retrieval System Online; N/A, not applicable; NICE-SUGAR, Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation; pt, patient; and RCT, randomized control trial.
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Data Supplement 38. Worsening Renal Function, Mortality and Readmission in Acute HF (Section 8.5) Study Name, Aim of Study Study Type Study Size Patient Population Endpoints Statistical Analysis (Results) Author, Year Inclusion Criteria Exclusion Criteria Primary Endpoint Secondary Endpoint Damien Study prevalence, Observational 416 pts admitted for Pts hospitalized for acute Chronic and severe renal Combined death; first N/A WRF occurred in 152 cases (37%), 5±3 d after Logeart, causes and acute HF HF failure (admission SCr >230 unscheduled readmission for admission. Old age, DM, HTN and acute coronary 2008 (334) consequences of μmol/lol/L); cardiogenic HF Outcome during the 6 mo syndromes increased the risk of WRF. Inhospital 17651843 WRF during shock or severe low output after discharge was furosemide doses as well as discharge treatment hospitalization for requiring inotropic agents determined by contacting the were similar in WRF and no-WRF pts. Serum acute HF during the hospitalization; pts or their general Crelevation was the strongest independent inhospital death practitioners by telephone. determinant of a longer hospital stay (p=0.001). AEs occurred in 158 pts (38%) during follow-up, with 23 deaths and 135 readmissions. Cox analysis showed that WRF, transient or not, was an independent predictor of the risk of death or readmission (HR: 1.74 95%CI: 1.14–2.68; p=0.01). Grace L. Estimate Meta-analysis 80,098 hospitalized Cohort studies and Studies with <6 mo follow-up All-cause mortality risks Cardiovascular mortality (all A total of 63% of pts had any renal impairment, and Smith, prevalence of renal and non- secondary analyses of and a study that defined associated with any renal cardiovascular mortality and 29% had moderate to severe impairment. After 2006 (335) impairment in HF hospitalized HF pts. several RCTs. renal impairment using ICD- impairment (Cr>1.0 mg/dL, HF or pump failure mortality) follow-up ≥1 y, 38% of pts with any renal 16697315 pts and the 9 code but no direct serum CrCl or estimated eGFR <90 and functional decline by impairment and 51% with moderate to severe magnitude of measures mL/min, or cystatin- validated functional status impairment died vs 24% without. Adjusted all- associated clopidogrel >1.03 mg/dL) scales such as NYHA cause mortality was increased with any impairment mortality risk using and moderate to severe functional class or activities of (aHR: 1.56; 95% CI: 1.53-1.60, p <0.001) and a systematic impairment (Cr≥1.5, CrCl or daily living assessment moderate to severe impairment (aHR: 2.31; 95% review of published eGFR <53, or cystatin- CI: 2.18-2.44, p<0.001). Mortality worsened studies. clopidogrel ≥1.56) incrementally across the range of renal function, with 15% (95% CI: 14%-17%) increased risk for every 0.5 mg/dL increase in Crand 7% (95% CI: 4%-10%) increased risk for every 10 mL/min decrease in eGFR. Marco Association Observational 318 consecutive pts Diagnosis of acute HF, Inability to give informed Cardiac death and urgent, N/A 53 pts (17%) died and 132 (41%) were Metra, between admitted for acute as established by the consent and those with unplanned hospitalizations rehospitalized for HF. WRF-Abs-% occurred in 107 2008 (336) hospitalizations for HF. ESC guidelines; evidence of ACS, acute (34%) pts. In multivariable survival analysis, WRF- 18279773 acute HF and WRF treatment with an IV arrhythmia, myocarditis, Abs-% was an independent predictor of death or agent, which in all cases valve stenosis, cardiac HF rehospitalization (aHR: 1.47; 95%CI: 1.13–1.81; included furosemide with tamponade, aortic p=0.024). The independent predictors of WRF-Abs- or without other dissection, pulmonary %, evaluated using multivariable logistic vasoactive medications. embolism, high output regression, were history of chronic kidney disease syndrome or evidence of (p=0.002), LVEF (p=0.012), furosemide daily dose non-cardiovascular factors (p=0.03) and NYHA class (p=0.05) on admission.
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as main cause of symptoms development of complications or undergoing procedures which may cause a rise in Cr during the hospitalization
Cowie MR, To determine the Observational 299 Age >20 y, documented Pts with a planned discharge All-cause mortality during the N/A 1/3 of pts [72 of 248 pts, 29% (95% CI: 26-32%)] 2006 prevalence and risk history of chronic HF within 24 h of admission; an initial hospitalization and developed WRF during hospitalization. The risk of 16624834 factors for WRF defined according to the investigator-defined history within WRF was independently associated with SCr levels (337) among pts ESC criteria; of ACS or cardiogenic shock 30+7 d and 180+7 d of the on admission (OR: 3.02, 95% CI: 1.58-5.76), hospitalized for documented evidence of within 1 mo prior to the index index hospitalization; date pulmonary edema OR: 3.35, 95% CI: 1.79-6.27, decompensated impaired LVSF, as admission; receiving a new and cause of subsequent and a history of AF: OR 0.35: 95% CI: 0.18-0.67. HF and the demonstrated by an EF prescription for potentially hospital re-admissions Although the mortality of WRF pts was not association with 40% on TTE or other nephrotoxic drugs within 2 d were also recorded. increased significantly, the length of stay was 2 d subsequent imaging technique on the prior to admission; severe longer [median 11 d (90% range (4-41) vs 9 d (4- rehospitalization index admission or within aortic stenosis, valvular 34), p=0.006]. The rehospitalization rate was and mortality. the preceding 6 mo disease anticipated to similar in both groups. require surgery within 6 mo, ‘high output’ cardiac failure, or those undergoing chronic renal replacement therapy or cancer chemotherapy Komukai To investigate Observational 109 pts Pts with CHF who had HF complicated by acute MI, Rehospitalization for HF N/A Pts with decreased renal function (estimated GFR K, 2008 whether renal been admitted and undergoing or starting after discharge on admission <45ml Emin.1 E1.73m2) were 18577827 dysfunction is followed up after dialysis during the follow-up rehospitalized more frequently than were pts with (338) associated with discharge at the period, or undergoning preserved renal function (estimated GFR on rehospitalization for outpatient clinic were cardiac surgery during the admission .45). Pts with decreased renal function CHF after reviewed. CHF was follow-up period were older and had higher rates of anemia, WRF successful diagnosed by ≥2 during hospitalization, and previous HF discharge cardiologists on the basis hospitalization. Independent predictors of of the Framingham rehospitalization for HF identified with multivariate criteria analysis were age, previous hospitalization for HF, decreased renal function, and non-use of an ACEI or ARB. Akhter Evaluate the Secondary 481 (215 had RI and Patients with dyspnea at N/A Length of hospitalization, 30 N/A Elevated baseline Cr was associated with length of MW, 2004 relation between analysis of the 266 did not) rest caused by acute HF d readmission rate as well as hospital stay (median 6 vs 7 d, p=0.003). RI was 15464689 elevated SCr at VMAC trial 30-d and 6-mo mortality associated with a 59% increase in 30-d (339) baseline, as well as readmissions (17% vs 27%, p=0.016). Higher Cr WRF during on admission was associated with both morbidity hospitalization, and and mortality. All-cause mortality at 6 mo increased
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outcomes pts (37.4% vs 12.3%, p <0.0001). Baseline RI was an hospitalized for independent predictor of 6-mo mortality with a RR: decompensated 2.72; 95% CI 1.76-4.21; p=0.0001. HF in the VMAC trial
Nohria A, Examine the Secondary A total of 433 pts LVEF ≤30%, recent Creatinine >3.5 mg/dL, the D alive and out of the 30-d mortality and length of Baseline and discharge RI, but not WRF, were 2008 ESCAPE analysis of the were enrolled at 26 hospitalization or use of dobutamine/dopamine hospital for 6 mo after stay associated with an increased risk of death and 18371557 database to assess ESCAPE trial sites escalation of outpatient >3 μg/kg/min or milrinone randomization death or rehospitalization. Among the (340) the impact of renal diuretic therapy, and before randomization, and hemodynamic parameters measured in pts dysfunction in SBP ≤125 mm Hg who requirement for early right randomized to the PAC arm (n=194), only right patients with acute were admitted to the heart catheterization. atrial pressure correlated weakly with baseline SCr HF hospital with at least 1 (r=0.165; p=0.03). There was no correlation sign and 1 symptom of between baseline hemodynamics or change in HF, despite adequate hemodynamics and WRF. A PAC-guided strategy treatment with ACEIs was associated with less average increase in Cr, and diuretics but did not decrease the incidence of defined WRF during hospitalization or affect renal function after discharge relative to clinical assessment alone. Owan et Whether the Observational 6440 All consecutive HF pts N/A Change in the incidence of N/A The incidence of WRF, defined as an increase in al., 2006 severity of renal admitted to Mayo Clinic WRF or outcomes over time Crof >0.3 mg/dL increased slightly over the study 16679257 dysfunction, the hospitals in Rochester, period (p=0.01). Renal dysfunction and incidence of WRF MN, between January 1, development of WRF were associated with or outcomes has 1987, and December 31, mortality. When adjusted for the changes in changed over time 2002 baseline characteristics, later admission year was (secular trends) in associated with lower 3-mo (aOR: 0.98 per y; 95% pts hospitalized for CI: 0.96–0.99; p=0.008) and overall mortality (HR: HF therapy. 0.99 per y; 95% CI 0.98–1.00; p 0.002). Krumholz, To determine the Retrospecrive 1,681 pts from 18 Age ≥65 y; discharge Pts <65 y of age; pts whose The outcome variable for the N/A WRF occurred in 28% of the cohort and was 2000 incidence and Connecticut with HF without having diagnosis could not be first phase of the study was associated with male gender, HTN, rales > basilar, 10781761 identify factors hospitals clear precipitants for validated by medical record worsening renal function, pulse >100 beats/min, SBP >200 mm Hg, and (341) associated with the renal dysfunction review, pts with severe aortic defined as in the ELITE admission Cr>1.5 mg/dL. Based on the number of development of stenosis, severe mitral study as an increase in SCr these factors, a pt’s risk for developing WRF worsening renal stenosis, or HF secondary to level during hospitalization of ranged between 16% (≤1 factor) and 53% (≥5 function in elderly a medical illness (e.g., >0.3 mg/dL from admission. factors). After adjusting for confounding effects, patients with acute sepsis); major complications The principal endpoints for WRF was associated with a significantly longer HF and to examine (stroke, acute MI shock, the 2nd phase of the study length of stay by 2.3 d, higher inhospital cost by the impact of WRF heart arrest, hypotension, were inhospital mortality, $1,758, and an increased risk of inhospital mortality on clinical and pneumonia, and infection) or length of stay and cost, 30-d (aOR:2.72; 95% CI:1.62-4.58) economic underwent a cardiac mortality and readmission, outcomes. procedure requiring contrast and 6-mo mortality and (cardiac catheterization or readmission angioplasty) or bypass © American College of Cardiology Foundation and American Heart Association, Inc. 163
surgery during hospitalization
Forman , To determine the Cohort 1,004 HF pts hospitalized Pts were excluded if their The principal outcome was N/A Among 1,004 HF pts studied, WRF developed in 2004 prevalence of WRF (retrospective) between July 1, 1997, hospitalizations were for an WRF, defined as an increase 27%. In the majority of cases, WRF occurred within 14715185 among hospitalized and June 30, 1998, at 11 elective procedure (e.g., in SCr of >0.3 mg/dL (26.5 3 d of admission. History of HF or DM, admission (342) HF pts, clinical academic medical percutaneous transluminal μmol/L) from admission, Cr≥1.5 mg/dL (132.6 μmol/L), and SBP >160 mm predictors of WRF, centers. coronary angioplasty, consistent with several Hg were independently associated with higher risk and hospital pacemaker, or cardioversion) previous investigations; of WRF. A point score based on these outcomes or if their hospital length of hospital length of stay, characteristics and their RR ratios predicted those associated with stay was <2 d. Other inhospital mortality, and at risk for WRF. Hospital deaths aRR: 7.5; 95% CI: WRF. exclusion criteria included complications occurring after 2.9-19.3), complications (aRR: 2.1; 95% CI: 1.5- severe aortic stenosis, the rise in creatinine. 3.0), and length of hospitalizations >10 d (aRR: 3.2, anticipated cardiac Complications were defined 95% CI: 2.2-4.9) were greater among pts with WRF transplantation, transfer from as shock, MI, stroke, major another inhospital setting, infection/sepsis, clinically chronic dialysis, use of a LV significant hypotension, and assist device, high-output new onset AF with HF, age <20 y, concomitant ventricular rates >100 use of an investigational beats/min. product or device, and patients receiving chemotherapy. Subjects were also excluded if Crvalues were not documented at admission.
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Klein, To investigate the Retrospective 949 Pts >18 y who had Active myocardial ischemia Total no. of d hospitalized for N/A Although both lower admission eGFR and higher 2008 relation between analysis of known systolic HF and within the past 3 mo, AF with cardiovascular causes within admission BUN were associated with higher risk of 19808267 admission values OPTIME-CHF had been hospitalized for poor ventricular rate control 60 d of randomization. D lost death by 60 d after discharge, multivariable (343) and changes in (multicenter, exacerbation of no more (>110/min), sustained to follow-up and d deceased proportional-hazards analysis showed that BUN BUN and eGFR randomized, than 48 h earlier ventricular tachycardia or were prospectively included was a stronger predictor of death by 60 d than was and rate of death double-blind, ventricular fibrillation, in the primary endpoint to eGFR (χ2 =11.6 and 0.6 for BUN and eGFR, by 60 d after placebo- baseline SBP <80 mm Hg or avoid bias toward a therapy respectively). Independently of admission values, discharge controlled trial) SCr level >3.0 mg/dL (265 with an increased death rate. an increase of ≥10 mg/dL in BUN during µmol/L) hospitalization was associated with worse 60-d survival rate: BUN (per 5-mg/dL increase) had a HR: 1.08; 95% CI: 1.01-1.16). Although milrinone treatment led to a minor improvement in renal function by discharge, the 60-d death and readmission rates were similar between the milrinone and placebo groups ACEI indicates angiotensin-converting-enzyme inhibitor; ACS, acute coronary syndrome; AE, adverse event; AF, atrial fibrillation; BUN, blood urea nitrogen; CHF, congestive heart failure; Cr, creatinine; CrCL, creatinine clearance; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate; ELITE, Evaluation of Losartan in the Elderly; ESC, European Society of Cardiology; ESCAPE, Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness; HTN, hypertension; ICD-9, international classification of diseases – 9th edition; IV, intravenous; LVSF, left ventricular systolic function; MI, myocardial infarction; NYHA, New York Heart Association; OPTIME-CHF, the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure study ; Pts, patients; RCT, randomized clinical trial; RI, renal insufficiency; SBP, systolic blood pressure; SCr, serum creatinine; TTE, transthoracic echocardiography; VMAC, Vasodilation in the Management of Acute Congestive Heart Failure; and WRF, worsening renal function.
Data Supplement 39. Nesiritide (Section 8.7) Study Name, Backgrou Trial Statistical Author, Aim of Study nd Duration Analysis Study Complications Year study Type Therapy Study Size Etiology Pt Population Severity Endpoints Mortality (Years) (Results) Limitations /AEs Study Pre-trial N (Total) Ischemic/ Severity of Entry Secondar standard n (Experimental) Non- Inclusion Exclusion HF Sverity Primary y 1st Year treatment. n (Control) Ischemic Criteria Criteria Symptoms Criteria Endpoint Endpoint Mortality Nesiritide Determine RCT Chronic Efficacy trial: 127 Efficacy Symptomatic MI/UA within Efficacy Symptomat Efficacy: Efficacy N/A <1y (10 Efficacy trial: Subjective Asymptomatic/ Study efficacy/clinic medication Comparative trial: trial: 46% HF prior 48 h. trial: 98% ic ADHF change from trial: mo PCWP - measureme mildly Group al use of regimen 305. ICM, warranting Clinically NYHA III-IV requiring baseline Global enrollme 6.0±7.2mm nts of global symptomatic (NSGT), nesiritide for N/A; any IV Comparativ hospitalizatio important mean >1 PCWP @ 6 clinical nt 10/96- Hg (@ 0.015 clinical hypotension. Colucci WS, short term medication NESIRITIDE e trial: 54% n for >1 IV valvular PCWP 28 intravenou h after status. 7/97); g/kg/min) vs. status and NSVT 2000. treatment of (dobutamin Efficacy trial: ICM. medication in stenosis, HCM mmHg, s treatment Clinical Compara - clinical (Comparative 10911006 ADHF. e, 43 (0.015 addition to or RCM, mean CI medication Comparativ symptoms tive trial: 9.6±6.2mm symptoms. trial). (344) milrinone, g/kg/min), 42 diuretics. constrictive 1.9 in addition e: . 68-73% Hg (@ 0.03 Background dopamine, (0.03 mg/kg/min) Efficacy trial: pericarditis, L/min/m2, to Global Other rx with g/kg/min) vs. medical or Comparative trial: PCWP >18 primary pHTN, mean SBP diuretics. clinical hemodyn nesiritide +2.0±7.2mm therapy not vasodilator) 103 mmHg, CI, or active 116 mmHg. status amic x 1-2 d Hg (placebo) reported. was (0.015mg/kg/min) <2.7L/min/m, myocarditis. Comparativ (independen measure 14-21% Comparative 3. Change in
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discontinue , 100 (0.03 2, SBP, >90 e: 92% t ments. x 3-5d, trial: none. PCWP is a d; diuretics mg/kg/min). mmHg. NYHA III- assessment 9-14% x surrogate were held 4 IV. by pt and 5d. Efficacy trial: outcome. h before, Efficacy trial: 42 investigator, p<0.001 during, and placebo, 5-point (pairwise 6 h after Comparative scale: with study drug Trial: 102 markedly placebo). infusion in standard rx better, Efficacy (investigator better, no trial. choice of up to 2 change, IV agents--- worse, or milrinone, markedly dobutamine, worse). nitroglycerin, or Clinical nitroprusside, symptoms along with (dyspnea diuretics and and fatigue, other oral HF jointly pt medications). and investigator assessment , 3 point scale: improved, no change, or worse).
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Vasodilation To compare RCT Diuretics 489 Ischemic Dyspena at SBP <90 mm 100% NYHA IV PCWP Comparis N/A Enrollme PCWP at 3 h Subjective Generalized in the the efficacy 86%, 55% rest due to Hg, NYHA IV at at Pt self- ons nt (mean (SD)) measureme headache (8% Managemen and safety of ACEI 60%, 204(nesiritide) decompensat cardiogenic time of presentatio assessment between October Nesiritide: nts of global nesiritide group t of Acute intravenous ARB 11%, ed CHF shock or presentatio n (dyspnea of dyspnea nesiritide 1999 and −5.8 (6.5) clinical vs. 20% CHF nesiritide, beta 143 Severe volume n/entry or at at rest). @ 3 h of and July mmHg* status and nitroglycerin (VMAC), intravenous blockers (nitroglycerin) enough depletion, any least study drug nitroglyce 2000 (10 Nitroglycerin clinical group) 2002. nitroglycerin, 33%, oral 142 (placebo) dyspnea to condition that dyspneic at infusion (3 rin: mo); : −3.8 (5.3) symptoms. Asymptomatic 11911755 and placebo. nitrates require would rest, 84% point scale: Onset of study mmHg Change in (8%) and (345) 35%, CCB hospitalizatio contraindicate chronic improved, effect on drug Placebo: −2 PCWP is a symptomatic 14%, n & IV an IV NYHA III-IV no change, PCWP. infusion, (4.2) mmHg surrogate (4%) digoxin therapy. vasodilator, (prior to worse). Effect on median ABSOLUTE outcome. hypotension in 60%, A cardiac acutely decompens PCWP @ time 24- BENEFIT IN nesiritide warfarin etiology for unstable ation), 19% 24 hr after 25 h. PCWP group. 33%, ASA dyspnea was clinical status SBP start of Nesiritde vs. 45%, established that would not <100mmHg study Placebo : - statins by estimated permit a 3 h . drug. 3.8 mmHg. 25%. or measured placebo Self- elevation of period, use of assessed *p<0.05 cardiac filling IV dyspnea (compared pressures nitroglycerin and with (PCWP >20 that could not global placebo, mm Hg in be withheld, clinical compared catheterized mechanical status. with pts) and > 2 ventilation, Overall nitroglycerin) of the and safety . following: (a) anticipated profile. JVD, (b) survival of Use of N/A PND or 2- <30-35 d. other IV pillow vasoactiv orthopnea e within 72 h agents or before study diuretics. entry, (c) Effects on abdominal other discomfort hemodyn due to amic mesenteric variables. congestion, or (d) a CXR consistent with decompensat ed CHF.
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Prospective To evaluate RCT Diuretics 237 N/A 1. Pt 1. Pt not a 61% NYHA Dyspnea at No pre- N/A N/A 11 mo Total No pre- Asymptomatic Randomize the safety 77%, presented to candidate for III-IV at rest or with defined enrollme hospital LOS defined hypotension d Outcomes and efficacy ACEI 58%, 120 ED with a observation baseline. <20 feet primary nt period through primary end- (10% with Study of of a standard ARB 14%, medical Hx (e.g., ambulation endpoints. (3/01- study Day points; nesiritide vs Acutely care beta 117 with HF, presented with . Efficacy 1/02); 30 excluding 49% of pts 3% with Decompens treatment blockers along with any condition measures mean index visit were NYHA placebo, ated regimen with 46%, fluid overload that obviously included study (days) I-II or p=0.03). Congestive the addition aldosteron or elevated mandated admission drug Mean + SD: without any HF Treated of either e cardiac filling hospital to the infusion 7.1 + 4.25 Hx of HF. Initially as nesiritide or antagonist pressures by admission, hospital time ~20 (placebo + Outpts With placebo in 14%, CCB clinical such as acute after the h (same standard Nesiritide ED/OU pts 22%, assessment, MI, or index visit, for both care) vs. 3.1 (PROACTIO with digoxin dyspnea at requirement readmission groups); + 2.20 N), Peacock decompensa 48% rest or with for invasive within 30 d 30d (nesiritide + IV WF, ted HF. placebo vs. minimal monitoring or for any follow-up standard 2005. 34% exertion mechanical reason, period. care); 2. 16183441 nesiritide, (defined as ventilation, length of Subjects (346) nitrates walking 20 including stay in the readmitted 45%, ft), and BPAP); hospital, after index statins judged to 2. SBP <90 assessment hospitalizatio 29%, require >12 h mmHg; of dyspnea, n, excluding ASA 46%. of hospital 3. Admitted to and those who therapy for the ED resource died or were HF. primarily for a utilization. lost to 2. Evidence diagnostic Safety follow- up: of HF as evaluation measures 23% primary (e.g., rule out included: (placebo + etiology of ACS); vital signs, standard the dyspnea 4. Receiving AEs care) vs. 9% required >2 chronic (defined as (nesiritide + of the dialysis; any pre- standard following: a) 5. Had cardiac existing care). PND or 2- markers medical pillow indicative of event that 1. p=0.032 orthopnea myocardial worsened or 2. p=0.049 within 72 h necrosis; any new before the 6. Medical medical N/A start of study condition so event that drug; b) JVD; severe that 30 occurred c) abdominal d survival was during symptoms, unlikely; administrati as manifest 7. Medical on of study by condition drug,
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discomfort, (such as whether or decreased cardiogenic not related appetite, or shock or to study nausea volume drug), and attributed by depletion) that SAEs the contraindicate (defined as investigator d use of IV AEs that to be due to vasodilatators. were life- hepatosplanc 8. If within 2 h threatening, hnic before the resulted in congestion; start of study hospitalizati d) >5lb drug on, or weight gain administration death). in the pt received IV previous vasodilatators month; e) or oral ACEI; CXR with or they were findings anticipated to indicative of require either HF; or f) IV vasodilators pulmonary during the first rales. 3 h after the start of study drug or oral ACEI during the first 30 min after the start of study drug. Risk of To Meta- Variable 1269 N/A (see Five RCTs N/A See original See Studies N/A N/A N/A WRF: Meta- N/A Worsening investigated analy (see original (1288 pts RCTs original were 21% analysis Renal the renal sis original 797 RCTs) were enrolled RCTs reviewed for (nesiritide) Inability to Function effects of RCTs and the vs. 15% adjust With nesiritide as included in 472 randomized, incidence of (control). statistically Nesiritide in treatment for meta- 1269 worsening WRF for Pts With ADHF. analysis). underwent renal requiring differences Acutely assessment function medical in other Decompens of renal (increase in intervention: factors ated HF, function) SCr >0.5 11% beyond Sackner- reported the mg/dL (nesiritide) treatment Bernstein effects of recorded at vs. 4% group JD, 2005. nesiritide on any time (control) assignment 15781736 renal function during the WRF that could (347) as measured input portion requiring have
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by the of the trial). hemodialysis influenced frequency of : 2% vs 2%. the increased developmen (SCr) >0.5 1) p=0.001 t of renal mg/dL 2) p=0.03 dysfunction. forming the 3) p=0.71 WRF is a basis of surrogate meta- 1) RRMH: marker for analyses. 1.54; 95% clinical CI: 1.19 to outcome. 1.98; 2) RRMH: 2.29; 95% CI: 1.07-4.89; 3) 95% CI: 0.50- 2.76; Short-term To Meta- Variable 862 N/A (see Randomized N/A Variable: See 30 d N/A N/A N/A 1) 30 d 1) The Risk of investigate analy (see original double-blind 60-98% original survival was mortality: NSGET, Death the safety of sis original 485 RCTs) study of pts NYHA III- RCTs assessed by 7.2% VMAC, and After nesiritide RCTs with acutely IV, overall meta- (nesiritide) PROACTIO Treatment relative to included in 377 decompensat 79% NYHA analysis vs. 4.0% N studies With noninotrope- meta- ed HF, III-IV. using a (control). were not de- Nesiritide based con analysis). therapy fixed-effects signed to for trol administered model and 1) p=0.059. definitively Decompens therapies, as single time- determine ated HF primarily infusion (>6 dependent 1) RR: 1.74; whether A Pooled consisting of h), inotrope risk by 95% CI: nesiritide is Analysis of diuretics or not Kaplan- 0.97-3.12. associated RCTs, vasodilators. mandated as Meier with risk of Sackner- control, and analysis death, Bernstein reported 30 d with Cox although JD, 2005. mortality proportional each 15840865 (NSGET, hazards prospectivel (348) VMAC, regression y monitored PROACTION modeling. for deaths ). following therapy. 2) None of the 3 studies collected complete information on the use
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of additional medications or procedures through the 30 d follow- up period. (possible confounders ). 3) It is possible that these results are due to chance. BNP- To evaluate RCT Beta 75 CAD: 77% Newly Baseline SBP N/A N/A A significant Net N/A 30 mo No Small # of 13% CARDS, the impact of blocker (nesiritide) admitted with <90 mm Hg. decline in negative (3/04 - significant participants discontinued Witteles nesiritide on 65%, 39 vs. 56% primary dx of renal diuresis 8/06); up differences still could infusion d/t RM, 2007. renal ACEI/ARB (control) ADHF. Hemodynamic function >1 l/day to 30 d in the allow for a hypotension; 17980248 function in 49%, 36 Calculated ally significant (defined as while on follow incidence of type II error. 10% (349) pts with aldosteron GFR (using aortic a peak SCr the up. a 20% Exclusion of transferred to acute e the stenosis. increase of infusion. creatinine important ICU; 10% 30 d decompensa antagonist Cockcroft- Need for IV >20% at Change in rise (23% subgroups mortality; 33% ted HF and 13%, Gault vasodilator any time weight nesiritide vs. of ADHF 30 d baseline digoxin formula) therapy. during the during the 25% pts, mortality/readm renal (26%), between 15 Admission to first 7 d of infusion. placebo). including ission (of note: dysfunction. amiodaron to 60 ml/min ICU. hospitalizati Need to No those no difference in e (21% (changed Hx of cardiac on discontinu significant needing these nesiritide from 15 to 50 transplantation compared e the difference in intensive SAE/complicati vs. 6% ml/min in Allergy to with the infusion the change care and ons compared placebo), December nesiritide. admission due to in SCr (-0.05 those with placebo CCB 24%, 2004 to be Prior creatinine). hypoten- vs. +0.05 requiring IV control). hydralazine consistent enrollment in Change in sion. mg/dl). vasodilator (5% with the the trial. SCr from Total No therapy; the nesiritide published the diuretic significant results of vs. 25% definition of admission use while differences this trial placebo). “moderate value to receiving in the certainly do renal discharge the secondary not exclude impairment”). and/or Day infusion. end points of a potentially Age >18 y. 7 of Median 3a) weight (- important hospitalizati length of 2.19 vs. - effect of on, stay. 1.58 kg), nesiritide whichever Death or 3b) IV (positive or
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was sooner. rehospitali furosemide negative) on zation (125 vs. 107 renal within 30 mg), 3c) function in d. discontinuati those pts. Resource on of Although utilization infusion due trial was not —defined to powered to by need hypotension evaluate for (13% vs. mortality dialysis, 6%), 3d) and hospital intensive 30 d readmission, care death/hospit there were monitorin al nonsignifica g, readmission nt trends pulmonar (33% vs. observed in y artery 25%) favor of catheteriz placebo. ation, and 1) p=0.85 Due to the intubation 2) p=0.46 relatively . 3a) p=0.26 small 3b) p=0.53 sample size, 3c) p=0.28 the lack of 3d) p=0.43 statistical significance does not rule out differences in these outcomes. Follow-Up To test the RCT Diuretics 138 65% ICM Adults (aged SBP<90 mm 100% N/A Safety, as N/A N/A Enrollme The The study AEs related to Serial feasibility of 100%, beta >18 y). Hg. NYHA III-IV predetermin nt period frequency of was not renal function Infusions of nesiritide as blockers 49 (0.005 NYHA III or Recipient of or ed by the N/A; 12 all-cause powered to (i.e., abnormal Nesiritide, adjunctive 75%, ACEI g/kg/min) 46 IV HF for >60 listed for ability to wk hospitalizatio assess renal function, FUSION I, therapy for 56%, ARB (0.010 g/kg/min) d before cardiac tolerate out- follow- n through wk outcomes. acute renal Yancy CW, pts with 17%, oral randomizatio transplantation pt infusions up. 12 was failure, 2006. advanced HF nitrates 43 (standard n. Placement of of nesiritide lower in pts increased 16828598 and a Hx of 49%, care) >2 hospital a BiV PM without receiving SC blood urea (350) recurrent aldosteron admissions within evidence of plus either nitrogen, hospitalizatio e or previous 60 d an nesiritide increased SCr, ns. antagonist unscheduled or AICDd increased 0.005 and oliguria, as 36%, IV outpt visits within AE rate g/kg/min or defined in milrinone requiring IV previous 30 d. compared nesiritide Coding 28%, IV vasoactive Currently with SC. 0.010 Symbols for a
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dobutamin treatment for receiving long- g/kg/min Thesaurus of e 10%, IV ADHF within term dialysis than in those Adverse dopamine the 12 mo or likely to receiving SC Reaction 11%. preceding require only. Also, Terms), randomizatio dialysis during pts in the occurred in n. the study nesiritide 22% of all pts. 4. >1 period. groups were An increase in admission in Inability to alive and out SCr to >0.5 the complete a 6 of the mg/dl higher preceding 5 m walk test. hospital for than baseline to 30 d. Evidence of more days occurred at 5. 6MWT acute MI (median 84 some time <400 m. within d for the 2 during the 6. Currently previous 30 d. groups) than study in 18 of receiving those in the 41 pts (44%) in optimal HF SC-only the standard treatment group care-only with long- (median 77 group, 17 of 49 term oral d). pts (35%) in medications. the nesiritide All cause 0.005 g/kg/min hospitalizatio group, and 16 n: p=0.037 of 46 pts (35%) (nesiritide in the nesiritide 0,005 0.010 g/kg/min mg/kg/min group vs. standard (p=0.614). care alone), The most p=0.011 frequently (nesiritide reported AEs 0,010 among all pts mg/kg/min with RI were vs. standard worsening HF care alone). (42%), Days alive asymptomatic and out of hypotension hospital: (16%), p=0.005 dyspnea (nesiritide (13%), and vs. standard symptomatic care only). hypotension (12%).
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Second To evaluate RCT Loop 911 64% >2 HF SBP <90 100% N/A Time to all- No. of N/A Enrollme All-cause "Because of SCr >0.5 mg/dl Follow-Up the potential diuretics Ischemic hospitalizatio mmHg. NYHA III-IV cause death cardiovas nt 4/04- mortality or the much in 32.1% Serial clinical utility 75%, ACEI 605 ns or the Dependence or the first cular and 6/06. cardiovascul lower than (nesiritide) vs. Infusions of of outpt, 43%, ARB equivalent on (or inability hospitalizati renal Follow- ar and renal expected 38.8% Nesiritide, intermittent 14%, beta 306 within 12 mo, to discontinue) on for hospital up ended hospitalizatio event rates, (placebo), FUSION II, nesiritide blocker with the most intermittent or cardiovascul admission in 12/06. ns through FUSION II p=0.046. Yancy CW, infusions in 65%, recent within continuous IV ar or renal s. Week 12 was 2008. ACCF/AHA aldosteron the prior 60 vasoactive causes from D alive occurred in underpower 19808265 stage C/D e d. (A medications. randomizati and out of 36.8% of the ed to (351) HF pts. antagonist hospitalizatio >2 output on through the placebo evaluate the 37%, n equivalent infusions of Week 12. hospital. combined effect of nitrates was defined vasoactive Time to group and nesiritide on 18%, ICD as an therapy within cardiovas 36.7% of the the primary 39%, CRT unscheduled 30 d without a cular nesiritide end point. 24%. outpt hospitalization death, all combined The treatment for Biventricular evaluated group. No resulting ADHF with pacemaker through statistically power an within 45 d or Wk 12. significant calculation intravenous a single- or QoL as difference in based on vasoactive dual-chamber assessed secondary the drug or 3 pacemaker, by end-points. observed unscheduled ICD within 15 change in placebo intravenous d. the KCCQ Log-rank event rates diuretic Cardiogenic summary test p=0.79. yielded only treatments shock or score 37% power for ADHF volume from HR: 1.03; to detect a within 60 d.) depletion. baseline 95% CI: conservative LVEF <40% Chronic to Wk 13. 0.82-1.3. relative risk within 24 wk. dialysis. reduction of Investigator 15% documentatio between n of groups. In consistent retrospect, a NYHA III or sample size IV symptoms of 3500 pts during the would have previous 60 d been (estimated needed for creatinine 90% power clearance to detect this <60 mL/min treatment calculated by effect. the However, it
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Cockcroft- should be Gault noted that equation; 24 on the basis h urine of the actual collection results, the was also wide required for confidence NYHA class limits with a III pts). nearly Optimal indistinguish treatment able event with oral rate medications between and device active therapy treatment unless a and placebo documented exclude a contraindicati benefit in on or the primary intolerance end point as was present. small as 15%, making it relatively unlikely that an important positive effect was missed." Acute Study To evaluate RCT ACEI/ARB 7007 60% ICM Age >17 y. Hospitalized 100% NYHA III- Two Self- 30 d Enrollme No Primarily 30 d all-cause of Clinical the effect of 60%, beta Pts >48 h before NYHA III-IV IV; at least coprimary reported mortality: nt 5/07- significant addressed mortality and Effectivenes nesiritide, in blocker 3496 (nesiritide) hospitalized randomization. at time of 1 of end points: overall 4.0% 12/10; effect on 30 safety worsening s of addition to 58%, for ADHF. Probable enrollment. following Composite well-being placebo study d concerns, renal function: Nesiritide in standard Aldosteron 3511 (placebo) Pts discharge in signs: of HF at 6 and vs. 3.6% drug rehospitaliza thus broad 31.4% vs. Decompens care, on e hospitalized <24h. respiratory rehospitaliz 24 h after nesiritide. infusion, tion (6.0% range of pts. 29.5% ated HF, rates of self- antagonist for a reason Hypotension rate >20 ation and study at least nesiritide vs. Rudimentary (Nesiritide vs. ASCEND- reported 28%, other than risk. breaths/mi all-cause drug 24 h and 6.1% , pt Placebo, HF, dyspnea at 6 nitrate ADHF, but Uncontrolled n or mortality initiation. up to 7 d. placebo) or assessment p=0.11). O'Connor and 24 h, 23%, diagnosed hypertension. pulmonary from Composit 30 d of dyspnea. 2. Higher rate CM, 2011. rehospitalizat hydralazine with ADHF Experimental congestion randomizati e of mortality Low clinical of hypotensive 21732835 ion for HF or 7.4%, loop within 48 h of medication or edema on through persistent (3.6% event rate. events (352) death from diuretic admission. (including with rales D 30. or nesiritide vs. amongst any cause at 95%, nesiritide) or >1/3 way Change in worsening 4.0% nesiritide group
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30 d, and inotropic device use. up lung self- HF and placebo). (26.6% vs. renal agent 4%, Pregnant or field; at reported all-cause p=0.31 15.3%, dysfunction. vasodilator suspected least 1 of dyspnea mortality Nesiritide p<0.001). 15%. pregnancy. following symptom at from improved objective 6 and 24 h randomiz dyspnea at 6 measures: after study ation h and 24 h congestion drug through after or edema initiation. hospital treatment on CXR, discharge compared to BNP >400 . placebo but pg/ml or 3. # of did not reach NT-pro- days alive prespecified BNP and level for >1000 outside significance. pg/ml, the p=0.03 (6hr), PCWP >20 hospital p=0.007 mmHg, from (24hr) LVEF randomiz 3) No <40% in ation difference in prior 12 through rate of mo. Day 30. worsening Composit renal e of CV function. death and p=0.11. rehospitali zation due to CV causes from randomiz ation through Day 30. ACCF/AHA indicates American College of Cardiology Foundation/American Heart Association; ACEI, angiotensin-converting enzyme inhibitor; ACS, acute coronary syndrome; ADHF, acute decompensated heart failure; AE, adverse events; ARB, angiotensin-receptor blocker; ASA, aspirin; BPAP, bilevel positive airway pressure; BNP, b-type natriuretic peptide; CAD, coronary artery disease; CCB, calcium channel blocker; CHF, congestive heart failure; CI, confidence interval; CRT, cardiac resynchronization therapy; CV, cardiovascular; CXR, chest X-ray; ED, emergency department; FUSION, Follow-Up Serial Infusions of Nesiritide; GFR, glomerular filtration rate; HCM, hypertrophic cardiomyopathy; HF, heart failure; HR, hazard ratio; Hx, history; ICD, implantable cardioverter-defibrillator; ICM, ischemic cardiomyopathy; ICU, intensive-care unit; IV, intravenous; JVD, jugular venous distention; KCCQ, Kansas City Cardiomyopathy Questionnaire; LOS, length of stay; MI, myocardial infarction; N/A, not applicable; NSGET, Nesiritide Study Group Efficacy Trial; NSVT, non-sustained ventricular tachycardia; NYHA, New York Heart Association; OU, observation unit; PCWP, pulmonary capillary wedge pressure; pHTN, pulmonary hypertension; PND, paroxysmal nocturnal dyspnea; PROACTION, Prospective Randomized Outcomes study of Acutely decompensated CHF Treated Initially as Outpatients with Nesiritide; Pt, patient; RCM, restrictive cardiomyopathy; RCT, randomized controlled trial; RI, renal insuficiency; RR, relative risk; RRMH, relative risk Mantel-Haenszel fixed-effects model; SAE, serious adverse event; SBP, systolic blood pressure; SC; SCr, serum creatinine; SD, standard deviation; UA, unstable angina; and VMAC, Vasodilator in the Management of Acute Heart Failure.
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Data Supplement 40. Hospitalized Patients – Oral Medications (Section 8.8) P Values & OR: HR: Study Study Name, Author, Year Aim of Study Study Type Study Size Patient Population Results 95% CI: RR: Limitations Inclusion Criteria Exclusion Criteria Beta Blockers During and at Discharge of HF Hospitalization Fonarow GC, Abraham WT, To determine Registry 5791 pts admitted Hospitalization for episode of N/A Among 2373 pts eligible for beta 95% CI: 0.37- HR: 0.60 Registry Albert NM et al. Influence of whether beta-blocker (OPTIMIZE-HF) with HF at 91 worsening HF as primary blockers at discharge: 1350 (56.9%) 0.99; p=0.04 Beta blocker Continuation or therapy should be academic and cause of admission. receiving beta blockers before Withdrawal on Outcomes in Pts continued or community hospitals admission and continued on therapy, Hospitalized with HF: Findings withdrawn during throughout the U.S. 632 (26.6%) newly started, 79 (3.3%) in From the OPTIMIZE-HF hospitalization for which therapy was withdrawn, and 303 Program. J Am Coll Cardiol decompensated HF. (12.8%) eligible but not treated. 2008 July 15;52(3):190-9. Continuation of beta blockers with lower 18617067 (353) risk for death (HR: 0.60; p=0.04) and death/rehospitalization (HR: 0.69; p=0.01). Withdrawal of beta blocker associated with higher risk for mortality (HR: 2.3; p=0.01), but with similar risk as HF pts eligible but not treated with beta blockers. Fonarow GC, Abraham WT, The doses of beta Registry 5791 pts admitted Hospitalization for episode of None The mean total daily dose for beta N/A N/A Registry Albert NM et al. Dosing of Beta blockers used in pts (OPTIMIZE-HF). with HF at 91 worsening HF as primary blockers before hospital admission <1/2 blocker Therapy Before, with HF in routine academic and cause of admission. the recommended target dose During, and After clinical practice community hospitals (carvedilol 21.5 +/- 17.8 mg and Hospitalization for HF before, during, and throughout the U.S. metoprolol succinate 69.2 +/- 51.9 mg), (OPTIMIZE-HF). Am J Cardiol after hospitalization with infrequent up- or down-titration 2008 December for HF. during the HF hospitalization. 2/3 of pts 1;102(11):1524-9. had no change in their beta blocker 19026308 (354) doses in the first 60-90 d after hospital discharge. At 60-90 d postdischarge follow-up, only 17.5% and 7.9% of pts treated with recommended target doses of carvedilol and metoprolol succinate
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Gattis WA, O'Connor CM, To evaluate if RCT (IMPACT-HF) 363 Pts hospitalized for HF. N/A At 60 d 165 pts (91.2%) randomized to p<0.0001 N/A N/A Gallup DS, Hasselblad V, predischarge predischarge carvedilol initiation treated Gheorghiade M. Predischarge carvedilol initiation in with a beta blocker, compared with 130 Initiation of Carvedilol in Pts stabilized pts pts (73.4%) randomized to initiation Hospitalized for hospitalized for HF postdischarge (p < 0.0001). Decompensated HF: Results of increased the Predischarge initiation was not the Initiation Management number of pts treated associated with increased risk of SAEs. Predischarge: Process for with beta-blockade at The median length of stay was 5 d in Assessment of Carvedilol 60 d after both groups. Therapy in HF (IMPACT-HF) randomization trial. J Am Coll Cardiol 2004 without increasing May 5;43(9):1534-41. side effects or length 15120808 (355) of hospital stay. Metra M, Torp-Pedersen C, To study the Retrospective 3029 Pts with LVEF <35, NYHA Intolerance to beta 752/3029 pts (25%) with HF 95%CI: 1.28- HR:1.59 Post-hoc Cleland JG et al. Should Beta- relationship between subgroup analysis class II-IV HF hospitalized for blockers hospitalization. 61 (8%) had beta- 1.98; p<0.001 analysis blocker Therapy be Reduced or changes in beta of RCT. HF were subdivided on the blocker treatment withdrawn, 162 (22%) Withdrawn After an Episode of blocker dose and basis of the beta blocker dose had a dose reduction and 529 (70%) Decompensated HF? Results outcome in pts administered at the visit maintained on the same dose. From COMET. Eur J Heart Fail surviving a HF following hospitalization, 1 and 2 y cumulative mortality rates 2007 September;9(9):901-9. hospitalization in compared to that administered 28.7% and 44.6% for pts withdrawn 17581778 (356) COMET. before. from study medication, 37.4% and 51.4% for those with a reduced dosage, 19.1% and 32.5% for those maintained on the same dose (HR: 1.59; 95% CI: 1.28 to 1.98; p<0.001). No interaction with the beneficial effects of carvedilol, compared to metoprolol. Fonarow GC, Abraham WT, To prospectively Registry 20118 Data from the OPTIMIZE-HF N/A At discharge, 90.6% of pts eligible to 95% CI: 0.32- HR: 0.48 Registry Albert NM et al. Prospective evaluate beta blocker registry for pts hospitalized receive beta blockers, 83.7% ACEI or 0.74; p<0.001 Evaluation of Beta-blocker use use at hospital with HF from 259 hospitals ARB. at the Time of Hospital discharge as an were prospectively collected Eligible pts discharged with beta Discharge as a HF indicator of quality of and analyzed. 20118 pts with blockers significantly more likely to be Performance Measure: Results care and outcomes in systolic dysfunction were treated at follow-up than those not From OPTIMIZE-HF.J Card Fail pts with HF. included. discharged with beta blockers (93.1% 2007;13:722-31. vs. 30.5%; P<0.0001). 17996820 (357) Discharge use of beta blockers in eligible pts lowers risk of death (HR: 0.48; 95% CI: 0.32-0.74; p<0.001) and death/rehospitalization (OR: 0.74; 95% CI: 0.55-0.99; p=0.04).
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Fonarow GC, Abraham WT, Examine effects on Registry 5791 OPTIMIZE-HF program N/A 2373 (87.2%) eligible to receive a beta p=0.0006 HR: 0.46 N/A Albert NM et al. Carvedilol use mortality and enrolled 5791 pts admitted blocker at discharge. at Discharge in Pts Hospitalized rehospitalization of with HF, web-based registry at Carvedilol prescribed in 1162 (49.0%). for HF is Associated With carvedilol use at 91 hospitals participating with Discharge carvedilol associated with a Improved Survival: an Analysis discharge in pts prespecified 60-90 d follow-up significant reduction in mortality (HR: From OPTIMIZE-HF. Am Heart hospitalized for HF from March 2003 to 0.46; p=0.0006) and mortality and J 2007 January;153(1):82-11. and LVSD compared December 2004. rehospitalization (OR: 0.71, p=0.0175) 17174643 (358) with outcomes in pts compared to no predischarge beta who are eligible for, blocker. but do not receive, beta blockers before discharge. Ace-Inhibitors During and at Discharge of HF Hospitalization Willenheimer R, van To determine RCT 101 Mild to moderate HF N/A Bisoprolol-first treatment noninferior to p=ns HR: 0.94 N/A Veldhuisen DJ, Silke B et al. whether the and LVEF ≤35%, enalapril-first treatment (HR: 1.17). Effect on Survival and sequence of initiation who were not Primary end point in 178 pts allocated to Hospitalization of Initiating of beta blockers or receiving ACEI, beta bisoprolol-first treatment vs 186 Treatment for Chronic HF With ACEI during blocker, or ARB allocated to enalapril-first treatment Bisoprolol Followed by hospitalization make therapy randomized (HR: 0.94; 95% CI: 0.77-1.16). Enalapril, as Compared With a difference in to open-label Bisoprolol-first treatment: 65 pts died, vs the Opposite Sequence: outcomes. bisoprolol (target 73 with enalapril-first treatment (HR: Results of the Randomized dose 10 mg QD; 0.88; 95% CI: 0.63 to 1.22), and 151 vs CIBIS III. Circulation n=505) or enalapril 157 pts hospitalized (HR: 0.95; 95% CI: 2005;112:2426-35. (target dose 10 mg 0.76-1.19). 16143696 (186) BID; n=505) for 6 mo, followed by their combination for 6 to 24 mo. Thilly N, Briançon S, Juillière Y, To evaluate the effect RCT 20 cardiology units HF pts <75 y old Age >75 y Compliance with the CPG relating to N/A N/A N/A Dufay E, Zannad F. Improving of developing and in France ACEI dose on discharge higher in the ACE inhibitor use in patients implementing CPGs (Experimental group experimental group (p=0.003). hospitalized with systolic heart on the quality of care (n=10) in each failure: a cluster randomized given to pts receiving experimental unit, controlled trial of clinical ACEI for systolic HF. doctors were practice guideline development involved in drafting and use. J Eval Clin Pract. and implementing 2003 Aug; 9(3):373-82. CPGs; those at 12895159 (359) control units were not.) Spironolactone During and at Discharge of HF Hospitalization
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Hamaguchi S, Kinugawa S, Whether the Prospective cohort 946 Hospitalized HF pts N/A Spironolactone prescribed at discharge p=0.02 HR: 0.612 N/A Tsuchihashi-Makaya M et al. discharge use with reduced LVEF in 435 pts (46%). Spironolactone use at of spironolactone is <40%. Discharge use of spironolactone Discharge was Associated With associated with associated with reduction in death (HR: Improved Survival in better mortality and 0.612; p=0.020) and cardiac death (HR: Hospitalized Pts With Systolic rehospitalization 0.524; p=0.013). HF. Am Heart J among hospitalized s 2010;160:1156-62. ystolic HF pts. 21146672 (360) Ko DT, Juurlink DN, Mamdani Appropriateness of Population based 9165 Hospitalized HF pts N/A 1502 pts prescribed spironolactone at N/A N/A N/A MM et al. Appropriateness of spironolactone Cohort in Ontario, Canada, discharge. Spironolactone Prescribing in prescription at 1999-2001. 18% had hyperkalemia during HF Pts: a Population-Based discharge. hospitalization and 23% were Study. J Card Fail 2006;12:205- discharged on concurrent potassium 10. supplements. 16624686 (361) Although only 8% of pts with SCr >2.5 mg/dL, many with stage III (53.1%), stage IV (12.8%), or stage V (3.9%) chronic renal insufficiency. Digoxin During and at Discharge of HF Hospitalization Dhaliwal AS, Bredikis A, Habib To determine Cohort 347 Hospitalized pts with Competing non-HF diagnoses HF hospitalizations (HR: 1.08; 95% CI: p=0.66 HR: 1.08 Retrospective G, Carabello BA, Ramasubbu the effect HF. 0.77-1.50; p=0.66), total mortality (HR: cohort K, Bozkurt B. Digoxin and of digoxin at 1.03; 95% CI: 0.78-1.35, p=0.85), or the Clinical Outcomes in Systolic discharge in pts combined end point of HF HF Pts on Contemporary hospitalized with hospitalization and total mortality (HR: Background HF Therapy. Am J HF. 1.11, 95% CI: 0.81-1.53, p=0.52) not Cardiol 2008;102:1356-60. different in pts treated with digoxin 18993155 (362) compared with those not treated with digoxin. Ahmed A, Allman RM, DeLong To determine Cohort 603 Older hospitalized N/A Digoxin use considered inappropriate if N/A N/A N/A JF. Inappropriate use of the correlates of HF pts with pts had preserved LVEF (≥40%) or if Digoxin in Older Hospitalized inappropriate dig documented LVEF they had no AF. HF Pts. J Gerontol A Biol Sci oxin use in and EKG. 376 pts (62%) discharged on digoxin, Med Sci 2002;57:M138-M143. older HF pts. and 223 (37%) without indication for 11818435 (363) use. Of 132 pts without an indication and not already on digoxin, 38 (29%) initiated on it. Adherence to Performance Measurements or Guidelines for Evidence Based Medication Use During Hospitalization Krantz MJ, Ambardekar AV, To assess Registry (GTWG- 9474 N/A N/A Of those treated before hospitalization, N/A N/A N/A Kaltenbach L, Hernandez AF, noncontraindicated HF) continuation rates: 88.5% for ACEI/ARBs, Heidenreich PA, Fonarow GC. use patterns for 91.6% for beta blockers, and 71.9% for Patterns and Predictors of ACEI/ARBs, beta aldosterone-antagonists.
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Evidence-Based Medication blockers, and Of pts untreated before admission, Continuation Among aldosterone 87.4% started on ACEI/ARBs, 90.1% Hospitalized HF Pts (from Get antagonists using the beta blocker and 25.2% on an With the Guidelines-HF). Am J GWTG-HF registry. aldosterone antagonist during Cardiol 2011 June hospitalization or at discharge. 15;107(12):1818-23. Admission therapy most strongly 21482418 (364) associated with discharge use (OR: 7.4, 6.0, and 20.9 for ACEI/ARBs, beta blockers, and aldosterone antagonists, respectively) Fonarow GC, Gheorghiade M, Review of AHF Review N/A N/A N/A Message: Adopting in-hospital initiation N/A N/A Review paper Abraham WT. Importance of In- therapies. of HF therapies as the standard of care hospital Initiation of Evidence- could improve treatment rates, decrease based Medical Therapies for the risk of future hospitalizations, and HF-a Review. Am J Cardiol prolong life. 2004 November 1;94(9):1155- 60. 15518610 (365)
Fonarow GC, Yancy CW, To determine the Registry (ADHERE) 81142 admissions 81142 admissions N/A Median rates of conformity with HF-1, N/A N/A Registry Heywood JT. Adherence to HF current rates of occurring between HF-2, HF-3, and HF-4 24.0%, 86.2%, Quality-of-care Indicators in US conformity with July 1, 2002, and 72.0%, and 43.2%, respectively. Hospitals: Analysis of the quality of care December 31, 2003, ADHERE Registry. Arch Intern indicators or their at 223 academic Med 2005 July variability across and non-academic 11;165(13):1469-77. hospitals. hospitals in the US 16009861 (366) participating in the ADHERE. Fonarow GC, Abraham WT, To examine the Registry 5791 pts at 91 US OPTIMIZE-HF, a Incomplete data Mortality during follow-up 8.6% and p=0.004 for Registry Albert NM et al. Association relationship between (OPTIMIZE-HF) hospitals registry and mortality/rehospitalization 36.2%. beta- blocker, Between Performance current (ACCF/AHA) performance None of the 5 ACCF/AHA HF p<0.05 for Measures and Clinical performance improvement performance measures was significantly ACEI. Outcomes for Pts Hospitalized measures for pts program. associated with reduced early mortality With HF. JAMA 2007 January hospitalized with HF risk. 3;297(1):61-70. and relevant clinical Only ACEI or ARB use at discharge was 17200476 (367) outcomes. associated with 60 to 90 d postdischarge mortality or rehospitalization. Beta-blockade at the time of hospital discharge, (not a HF performance measure then) strongly associated with reduced mortality (HR: 0.48; 95% CI: 0.30-0.79; p=0.004).
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Lappe JM, Muhlestein JB, To develop and Prospective cohort 57465 enrolled from A nonrandomized / Rate of prescription of each medication 95% CI: 0.75- HR: 0.79 Observational Lappe DL et al. Improvements implement a program 10 largest hospitals before-after study increased significantly to >90% 0.84; p<0.001 and in 1 y Cardiovascular Clinical ensuring appropriate in the Utah-based comparing pts (p<0.001). nonrandomized Outcomes Associated With a prescription of Intermountain hospitalized before RR for death and readmission at 30 d , authors could Hospital-based Discharge aspirin, statins, beta Health Care system. (1996-1998) and decreased after DMP implementation; not control for Medication Program. Ann Intern blockers, ACEI, and after (1999-2002) HRs for death and readmission: 0.81 potential Med 2004 September warfarin at hospital implementation of a (95% CI: 0.73-0.89) and 0.92 (95% CI: confounders or 21;141(6):446-53. discharge. DMP. 0.87-0.99) (p<0.001 and p=0.017, determine the 15381518 (368) respectively). extent to which At 1 y, risk for death still low (HR: 0.79; secular trends 95% CI: 0.75-0.84; p<0.001) while risk for accounted for readmission stabilized (HR: 0.94; 95% the observed CI: 0.90-0.98; p=0.002). improvements. AHA Scientific Statement for Treatment of Acute HF Syndromes Weintraub NL, Collins SP, To characterize acute AHA scientific N/A N/A N/A N/A N/A N/A N/A Pang PS et al. Acute HF HF syndromes: from statement Syndromes: ED Presentation, presentation, Treatment, and Disposition: treatment, and Current Approaches and Future disposition. Aims: a Scientific Statement From the AHA. Circulation 2010 November 9;122(19):1975-96. 20937981 (369) Recent Studies with Other Oral Medications for Treatment of Acute HF Gheorghiade M, Konstam MA, To evaluate short- RCT (EVEREST) 2048 trial A, 2085 Age ≥18 y; current Women who will not adhere to Tolvaptan had no effect on long-term 95% CI: 0.87- HR: 0.98 N/A Burnett JC, Jr. et al. Short-term term effects of (trial B) 4133 hospitalization for the reproductive precautions mortality or HF-related morbidity. 1.11; p=0.68 Clinical Effects of Tolvaptan, an tolvaptan when tolvaptan (30 mg/d), CHF with admission as outlined in the ICF. Mortality for tolvaptan vs placebo not Oral Vasopressin Antagonist, in added to standard or matching up to 48 h prior to Positive urine pregnancy test. different (HR: 0.98; 95% CI: 0.87-1.11; Pts Hospitalized for HF: the therapy in pts placebo, within 48 h randomization; Inability to provide written p=0.68). EVEREST Clinical Status hospitalized with HF. of admission. chronic HF is informed consent. Cardiac Composite of CV death or hospitalization Trials. JAMA 2007 March defined as requiring surgery within 60 d of for HF not different (HR: 1.04; 95% CI: 28;297(12):1332-43. treatment for a potential study enrollment, 0.95-1.14; p=0.55). 17384438 (153) minimum of 30 d excluding PCI. Planned Secondary end points CV mortality, CV prior to revascularization procedures, death or hospitalization, and worsening hospitalization. EP device implantation, HF not different between tolvaptan and Subject must have cardiac mechanical support placebo. signs of extracellular implantation, cardiac Tolvaptan significantly improved volume expansion, transplantation, or other secondary end points of Day 1 pt- defined as ≥2 of the cardiac surgery within 30 d assessed dyspnea, Day 1 body weight, following: a) JVD; b) following study enrollment. and Day 7 edema. pitting edema (>1+); Subjects who are on cardiac In pts with hyponatremia, serum sodium or c) dyspnea. mechanical support. Hx of levels significantly increased. NYHA Class III or IV biventricular pacer placement © American College of Cardiology Foundation and American Heart Association, Inc. 182
at the time of within the last 60 d. Co- hospitalization. morbid condition with an LVEF ≤40% within 1 expected survival less than 6 y. mo. Subjects with acute STEMI at the time of hospitalization. Hx of sustained ventricular tachycardia or ventricular fibrillation within 30 d, unless in the presence of an automatic ICD. Hx of a cerebrovascular accident within the last 30 d. Hemodynamically significant uncorrected primary cardiac valvular disease. Hypertrophic cardiomyopathy (obstructive or non-obstructive). CHF due to uncorrected thyroid disease, active myocarditis or known amyloid cardiomyopathy. Subjects with progressive or episodic neurological disease such as multiple sclerosis or Hx of multiple strokes. Hx of primary significant liver disease or acute hepatic failure, as defined by the investigator. Hx of poorly controlled DM. Morbid obesity, defined as >159 kg (or 350 lbs) or BMI >40. Supine systolic arterial blood pressure <90 mmHg. SCr >3.5 mg/dL or >309.4 mmol/L. Serum potassium >5.5 mEq/L or >5.5 mmol/L. Hgb <9 g/dL or <90 g/L. Hx of hypersensitivity and/or idiosyncratic reaction to benzazepine derivatives (such
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as benazapril). Hx of drug or medication abuse within the past year, or current alcohol abuse. Inability to take oral medications. Participation in another clinical drug or device trial within the past 30 d. Previous participation in this or any other tolvaptan clinical trial.. Konstam MA, Gheorghiade M, To investigate the RCT (EVEREST- 4133 (tolvaptan, 30 Age ≥18 y. Current Women who will not adhere to Tolvaptan had no effect on long-term 95% CI: 0.87- HR: 0.98 N/A Burnett JC, Jr. et al. Effects of effects of tolvaptan Outcome) mg once per day hospitalization for the reproductive precautions mortality or HF-related morbidity. 1.11; p=0.68 Oral Tolvaptan in Pts initiated in pts (n=2072) or placebo chronic CHF with as outlined in the ICF. Mortality for tolvaptan versus placebo not Hospitalized for Worsening HF: hospitalized with HF. (2062) within 48 h of admission up to 48 Positive urine pregnancy test. different (HR: 0.98; 95% CI: 0.87-1.11; the EVEREST Outcome Trial. admission. h prior to Inability to provide written p=0.68). JAMA 2007 March randomization. informed consent. Cardiac Composite of CV death or hospitalization 28;297(12):1319-31. Chronic HF is surgery within 60 d of for HF not different (HR: 1.04; 95% CI: 17384437 (154) defined as requiring potential study enrollment, 0.95-1.14; p=0.55). treatment for a excluding PCI. Planned Secondary end points CV mortality, CV minimum of 30 d revascularization procedures, death or hospitalization, and worsening prior to EP device implantation, HF not different between tolvaptan and hospitalization. cardiac mechanical support placebo. The subject must implantation, cardiac Tolvaptan significantly improved have signs of transplantation, or other secondary end points of Day 1 pt- extracellular volume cardiac surgery within 30 d assessed dyspnea, Day 1 body weight, expansion, defined following study enrollment. and Day 7 edema. as ≥2 of the Subjects who are on cardiac In pts with hyponatremia, serum sodium following: a) JVD; b) mechanical support. Hx of levels significantly increased. pitting edema (>1+); biventricular pacer placement or c) dyspnea. within the last 60 d. Comorbid NYHA Class III or IV condition with an expected at the time of survival less than 6 mo. hospitalization. Subjects with acute STEMI at LVEF ≤40% within 1 the time of hospitalization. Hx y. of sustained ventricular tachycardia or ventricular fibrillation within 30 d, unless in the presence of an automatic ICD. Hx of a cerebrovascular accident within the last 30 d. Hemodynamically significant uncorrected primary cardiac
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valvular disease. Hypertrophic cardiomyopathy (obstructive or non-obstructive). CHF due to uncorrected thyroid disease, active myocarditis or known amyloid cardiomyopathy. Subjects with progressive or episodic neurological disease such as multiple sclerosis or Hx of multiple strokes. Hx of primary significant liver disease or acute hepatic failure, as defined by the investigator. Hx of poorly controlled DM. Morbid obesity, defined as >159 kg (or 350 lbs) or BMI >40. Supine systolic arterial blood pressure <90 mmHg. SCr >3.5 mg/dL or >309.4 mmol/L. Serum potassium >5.5 mEq/L or >5.5 mmol/L. Hgb <9 g/dL or <90 g/L. Hx of hypersensitivity and/or idiosyncratic reaction to benzazepine derivatives (such as benazapril). Hx of drug or medication abuse within the past y, or current alcohol abuse. Inability to take oral medications. Participation in another clinical drug or device trial within the past 30 d. Previous participation in this or any other tolvaptan clinical trial. ACCF/AHA indicates American College of Cardiology Foundation/American Heart Association; ACEI, angiotensin-converting enzyme inhibitor; ADHERE, Acute Decompensated HF National Registry; AF, atrial fibrillation; AHF, acute heart failure; ARB, angiotensin-receptor blocker; BMI, body mass index; CHF, congestive heart failure; CI, confidence interval; CIBIS, Cardiac Insufficiency Bisoprolol Study; COMET, Carvedilol or Metoprolol European Trial; CPG, clinical practice guidelines; CV, cardiovascular; DM, diabetes mellitus; DMP, discharge medication program; ED, emergency department; EKG, electrocardiogram; EP, electrophysiology; GWTG-HF, Get With the Guidelines-HF; HF, heart failure; Hx, history; ICD, implantable cardioverter-defibrillator; JVD, jugular venous distention; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; NS, not significant; NYHA, New York Heart Association; OPTIMIZE-HF, Organized Program to Initiate Lifesaving Treatment in Hospitalized Pts with HF; PCI, percutaneous coronary intervention; Pts, patients; RCT, randomized controlled trial; SAE, serious adverse event; SCr, serum creatinine, STEMI, ST segment elevation myocardial infarction; and US, United States.
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Data Supplement 41. Atrial Fibrillation (Section 9.1) Study Aim of Study Study Study Patient Population Endpoints Statistical Analysis (Results) Study Limitations Findings/ Comments Name, Type Size Author, Year Inclusion Criteria Exclusion Primary Endpoint Secondary Criteria Endpoint
AF CHF Rhythm control Multi- 1,376 LVEF ≤35%, N/A Death from CV Death from any Death from all CV causes: 27% in Results cannot be The use of rhythm-control did not Roy, 2008 reduces mortality center history of CHF, causes cause, worsening of rhytm-control group vs. 25% in rate- generalized to pts with HF reduce the rate of death from CV 19102036 as compared to RCT and history of AF CHF, or stroke. control group and preserved LV function causes compared with rate- (370) rate control HR: 1.0 6; p=0.59; 95% CI: 0.86-1.30 (in whom AF is common). control. No significant differences in secondary outcomes either. AFFIRM, Rhythm control Multi- 4,060 ≥65 y with history N/A Overall mortality Composite death, Difference in mortality not statistically Findings cannot be Rhythm-control strategy did not 2002 reduces mortality center of AF and other dsabling stroke, significant. HR: 1.15 95%CI: 0.99- generalized to pts with improve morality when 12466506 as compared to RCT risk factors for diabling anoxic 1.34; ; p=0.08 more severe AF or to compared to rate-control. (371) rate control stroke or death encephalopathy, younger pts without risk major bleeding or factors for stroke cardiac arrest RE-LY, Compare 2 doses Multi- 18,113 Pts with AF and at N/A Major bleeding N/A Dabigatran 110 mg twice d compared N/A Both doses of Dabigatran were Eikelboom, (110 mg and 150 center least 1 additional with warfain: 2.87% vs. 3.57 % associated with lower risks of 2011 mg) of dabigatran RCT risk factor for (p=0.0002) major bleeding than warfarin. 21576658 2 x d vs. warfarin stroke Dabigatran 150 mg twice d vs Found an interaction between (372) for stroke warfarin: 3.31% vs. 3.57% (p=0.32) treatment and age for major prevention in pts Dabigatran 150 mg twice d vs. bleeding. Both doses of with AF Dabigatran 110 mg: 3.31% vs. Dabigatran associated with lower 2.87%( p=0.04) risk of extracranial bleeding in pts <75 y, though associated with similar or higher risks in pts ≥75 y. Risk of intracranial bleeding was lower with either dose of Dabigatran, regardless of age. RE-LY, Compare 2 doses Mutli- 18,113 Pts with previous N/A Stroke or systemic N/A The 150 mg dose of Dabigatran was N/A Both doses of Dabigatran were Connolly, SJ, (110 mg and 150 center stroke or TIA, embolism superior to warfarin in reducing stroke noninferior to warafin with 2009 mg) of dabigatran RCT LVEF <40%, and systemic embolism (RR:0.66; respect to the primary outcome 19717844 2x d vs. warfarin NYHA class II or 95% CI: 0.53-0.82; p<0.0001) but the (193) in pts with AF at higher 110 mg dose was not when increased risk of compared to warafin (RR: 0.91; 95% stroke CI: 0.74-1.11; p=0.34) © American College of Cardiology Foundation and American Heart Association, Inc. 186
ROCKET AF, Compare Double 14,264; Pts with non- N/A Stroke or systemic N/A Primary outcome occurred in 2.32 per Analysis was not powered While not able to show a Fox KAA, rivaroxaban with blind RCT 2,950 pts valvular AF and embolism 100 pt-y in rivaroxaban vs. 2.77 per to detect differences difference between drugs, 2011 warfarin in with moderate renal 100 pt-y in warafin group. between drugs in pts with rivaroxaban was associated with 21873708 prevention of moderate impairment (CrCl Fatal bleeding was 0.28% in renal insuficiency reduction in fatal bleeding in pts (373) stroke or renal 30-49 mL/min) rivaroxaban vs. 0.74% per 100 pt-y in with renal insufieniency. systemic impairment warafin (ITT analysis HR: 0.86; 95% embolism in pts CI: 0.63-1.17; p=0.0047) with AF ROCKET AF, Compare Double 14,264 Non-valvular AF N/A Stroke or systemic N/A Primary outcome occurred in less No between group Showed noninferiority of Patel MR, rivaroxaban with blind RCT embolism often in rivaroxaban group than differences in the ITT rivaroxaban. 2011 warfarin in warfarin group (2.1 % vs. 2.4% per y) analysis. 21830957 prevention of ITT analysis noninferiority: HR: 0.88; (196) stroke or 95% CI: 0.74-1.03; p<0.0001 systemic embolism in pts with AF AF indicates atrial fibrillation; AFFIRM, Atrial Fibrillation Follow-up Investigation of Rhythm Management; CHF, congestive heart failure; CrCl , creatinine clearance; CV, cardiovascular; HR, hazard ratio; ITT, intent-to-treat; LV, left ventricular; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; Pts, patients; RCT, randomized control trial; RE-LY, randomized evaluation of long-term anticoagulant therapy trial; ROCKET-AF, Rivaroxaban Once Daily Oral Direct Factor Xa Inhibitor Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation; RR, relative risk; and TIA, transient ischemic attack;
Data Supplement 42. HF Disease Management (Section 11.2) Study Name, Aim of study Study Type Study Size Patient Population Endpoints Statistical Analysis (Results) Study Limitations Findings/ Comments Author, Year Inclusion Criteria Exclusion Criteria Primary Secondary Endpoint Endpoint What Works In The effect of Meta analysis 2,028 Not Reported Not Reported All-cause hospital N/A Pts enrolled in chronic care Possible study selection A team-based approach in Chronic Care delivery of RCTs readmissions and management programs using a bias; were not able to chronic care management Management: methods in the readmission d multidisciplinary team in addition to evaluate cost savings; programs for HF pts The Case Of management in-person communication had a retrospective analysis. meets AHA’s principles for HF of HF care on 2.9% reduction in readmissions/ mo high-quality disease 19124869 hospital and a 6.4% reduction in management programs (374) readmissions readmission d/mo compared to and the Disease routine care (p < 0.001). Management Association of America’s key components of disease management programs.
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CM in a Test the effect RCT 287 Primary or Discharge to a long- 90-d readmission Adherence to There was no difference between Study was not blinded, The intervention did not heterogeneous of CHF case secondary diagnosis term care facility, rate treatment plan the 2 groups in 90-d re-admission adherence was assessed increase costs and study CHF management of CHF, LVD <40%, planned cardiac and pt rates (both were 37%, p>0.99). via pt self-report; and no showed that strong population: a with the or radiologic surgery, cognitive satisfaction The intervention group showed consistent method for working relationships RCT following 4 evidence of impairment, greater adherence to most aspects NYHA classification. between the CM and 12695272 components: 1. pulmonary edema anticipated survival of the treatment plan (p<0.01) and cardiologists decreased (375) early discharge for which they of <3 mo, and long- pts in this group reported greater pt CHF hospital readmission planning, 2. pt underwent diuresis; term hemodialysis satisfaction (p<0.01). rates. and family CHF had to be at risk for Subgroup of pts who live in area education, 3. early readmission and received care from local 12 wk of cardiologists decreased CHF telephone f/u, readmission rate (2%vs. 14%; and, 4. p=0.03). promotion of optimal CHF medications CM for pts with To compare RCT 197 Adults with LVEF Not reported HRQoL, HF self- Nonsignificant between group Small, unblended sample of The intervention failed to chronic systolic CM vs. usual ≤45% care, and pt- differences for the KCCQ overall patients from a non- improve overall QoL, HF in primary care on pt reported quality of summary scores favored CM: 1.7 representative sample of though showed significant care: the outcomes. care. (95%CI: -3.0-6.4; p=0.477). physicians. improvements in pt- HICMan Heart failure self-care behavior reported quality of care exploratory scores were significant group and chronic HF self-care. RCT. differences favoring CM: -3.6 20478035 (95%CI: -5.7- -1.6; Cohen's d 0.55; (376) p=0.001) Significant between group differences quality of chronic illness care (0.5; 95% CI : 0.3-0.7; p=0.000) and behavior counseling (0.5; 95%CI : 0.3-0.8; p=0.000), with moderate effect sizes (Cohen's d 0.7 for each summary score). Impact of a To evaluate the Retrospective 147 Not reported Not reported Frequency and Significant improvement in NYHA Small retrospective study No significant differences specialized impact of a duration of class during the mean follow-up were found in the outpatient HF specialized hospitalization for period: 55% of the pts were in class proportion of pts follow-up outpatient HF HF and functional III, 37% in class II, 5% in class I and on therapeutic drugs or in program on follow-up status 3% in class IV (p<0.0001). mean duration of hospitalization program Hospitalizations for acute hospitalization frequency and decompensation of HF decreased: functional 87 at baseline vs. 25 (p<0.0001) status of pts with AHF. 17695729
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(377) Outpatient To evaluate an Prospective 115 Adults with chronic Hospitalization MLWHF, NYHA EF improved from 31 +/- 10 to 36 Small trial, not Showed a decrease in the medical and outpatient trial HF in the Piedmont and ED functional class, +/- 12%. ED admissions and generalizable to number of hospitalizations nurse management region of Italy. admissions in the pharmacological hospitalizations decreased (p < populations outside of Italy. and improvement in NYHA management program for pts 12 mo before the therapies at the 0.001). NYHA classes I-II improved functional class and program in pts with chronic HF 1st evaluation and referral time and from 65.5 to 87.7% and NYHA adherence to medical with chronic HF every y after at the end of classes III-IV were reduced from therapy. These results in a large referral follow-up. 34.5 to 12.3%. MLWHF score kept constant over time in territorial area decreased from 25 to 21.9. Pts the subsequent 4 y. in Piedmont. 4 treated with ACEI + ARB increased y of follow-up. from 91 to 96%, beta blockers from 16444925 35.2 to 69%, potassium sparing (378) drugs increased from 54 to 64%. ACEI indicates angiotensin-converting-enzyme inhibitor; AHF, acute heart failure; ARB, angiotensin receptor blockers; CHF, congestive heart failure; CM, case management; ED, emergency department; EF, ejection fraction; HF, heart failure; HRQoL, health related quality of life; KCCQ, LVD, left ventricular dysfunction; MLHF, Minnesota Living with Heart Failure; NYHA, pts, patients; and QoL, quality of life.
Data Supplement 43. Telemonitoring (Section 11.2) Study Name, Aim of study Study Study Patient Population Endpoints Statistical Analysis (Results) Study Limitations Findings/ Comments Author, Year Type Size Inclusion Exclusion Criteria Primary Secondary Criteria Endpoint Endpoint Telemonitoring To determine Meta 4,264 Published RCTs All-cause mortality, 20% reduction in all-cause mortality Relatively small Remote monitoring or structured whether remote analysis comparing all-cause rate of (95% CI: 8- 31%) with telemonitoring. number of studies programs for pts with telephone monitoring remote admission to No change in all-cause hospital and pts; few trials chronic HF reduced support (structured monitoring hospital, and rate admission rate. had follow-up beyond admissions to hospital and programs for pts telephone programs with of admission to Hospital admissions due to chronic 6 mo. all-cause mortality by nearly with chronic HF: support or usual care in hospital as a result HF saw a reduction of 21% (95% CI: 1/5. systematic telemonitoring) patients with of chronic HF 11 -31%) with remote monitoring review and without regular chronic HF programmes meta-analysis. clinic or home managed within 17426062 (379) visits improves the community. outcomes for pts with chronic HF.
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Structured To examine the Meta 25 studies, RCTs, adults ≥18 Trials of general cardiac All-cause mortality All-cause All-cause mortality: Unable to stratify by Telemonitoring and telephone effect of analysis 16 y, diagnosed with disorders rather than readmissions Telemonitoring RR: 0.66; 95% CI: age, sex, or NYHA structured telephone support or telemonitoring structured chronic HF. chronic HF were to hospital and 0.54-0.81, p< 0.0001 class. Unable to support interventions telemonitoring and structured telephone excluded. chronic HF- Structured telephone support RR: adjust for the differing for assisting with programs for pts telephone support (n = related 0.88; 95% CI: 0.76-1.01; p=0.08 lengths of follow-up. management of pts with with chronic HF support on HF 5613 admission to All-cause hospitalization: chronic HF 20687083 (380) outcomes. ) and 11 of hospital Telemonitoring RR:0.91; 95% CI: are beneficial and may play telemonitori 0.84-0.99; p=0.02 a significant role in the care ng Structured telephone support RR: of ’standard’ (n = 2710) 0.92; 95% CI: 0.85-0.99; p=0.02 management of chronic HF. Chronic HF-related hospitalizations: Telemonitoring RR: 0.79; 95% CI: 0.67-0.94; p=0.008. Structured telephone support RR: 0.77; 95% CI: 0.68-0.87; p<0.0001 Effect of a To assess the RCT 358; 130 N/A N/A HF hospitalization All-cause HF hospitalization rate was 45.7% Selection bias due to Telephonic case standardized effectiveness of a (interventio rates hospitalization lower in the intervention group at 3 randomization of management can reduce nurse case- standardized n); 228 rates; HF mo (p=0.03) and 47.8% lower at 6 mo physicians, rather HF hospitalization resulting management telephonic case- (usual care) readmission (p=0.01). than pts. Impossible in significant cost savings. telephone management rate; HF HF hospital d (p=0.03) and multiple to completely blind intervention on intervention in pts hospital d readmissions (p=0.03) were physicians to resource use in with chronic HF. significantly lower in the intervention treatment. patients with group at 6 mo – though not significant chronic HF. after adjustment for other covariates. 11911726 (381) RCT of Tested the RCT 134; 69 Hospitalized N/A HF re- All-cause No significant group differences were Small sample size. None telephone case effectiveness of (interventio Hispanics with hospitalization hospitalization, found in HF hospitalizations, Possible confounders management in telephone n); 65 chronic HF d in the HF readmission rate, d in the included very ill Hispanics of case (usual care) hospital hospital, population, poorly Mexican origin management in (HF and all- HF cost of care, all-cause acute care educated, with HF. decreasing cause), use or cost, mortality, economically poor, 16624687 (382) hospitalizations multiple HRQL, or depression. and unacculturated and improving readmissions, into US society. HRQL and acute care depression costs, all-cause mortality, HRQL, depression Telemonitoring Test the RCT 1653; 826 Pts were enrolled Residence in a long-term All-cause HF All-cause readmission or mortality: Automated system Telemonitoring did not in pts with HF. effectiveness of (interventio from 2006-2009 nursing home; inability to readmission or all- hospitalization, telemonitoring vs. usual care HR: with low adherence improve outcomes among 21080835 (383) telemonitoring vs. n); 827 at participate in the protocol cause mortality d in the 1.04; 95% CI: 0.91-1.19. rate. pts recently hospitalized for usual care. (usual care) 33 cardiology for any reason, including (within 180 d post hospital, No significant differences were seen HF. practices across a low expected enrollment) and number of between the 2 groups with respect to © American College of Cardiology Foundation and American Heart Association, Inc. 190
the US. Pts probability of survival for hospitalizations the secondary endpoints hospitalized the next 6 mo; inability to for HF in the stand on a scale; severe previous 30 d cognitive impairment; and a planned hospitalization for a procedure HF indicates heart failure; HR, hazard ratio; HRQL, health related quality of life; NYHA, New York Heart Association; pts, patients; RCT, randomized control trial; RR, relative risk; and US, United States.
Data Supplement 44. Quality Metrics and Performance Measures (Section 12) Study Name, Aim of study Study Study Patient Population Endpoints Statistical Analysis (Results) Study Limitations Findings/ Author, Year Type Size Comments Inclusion Exclusion Criteria Primary Endpoint Secondary Criteria Endpoint Temporal trends in To assess temporal Prospective 159,168 N/A N/A N/A N/A Inhospital treatment changed significantly over time N/A N/A clinical trends in clinical with inotrope use decreasing from 14.7% to 7.9% characteristics, characteristics, (p<0 .0001). Discharge instructions increased treatments, and treatments, quality 133%; smoking counseling, 132%; LV function outcomes for HF indicators, and outcomes measurement, 8%; and beta blocker use, 29% (all hospitalizations, for HF hospitalizations. p<0.0001). 2002-2004: findings Clinical outcomes improved over time, including from ADHERE. need for mechanical ventilation, RR: 0.64, p < 17540205 (384) .0001); length of stay (mean), 6.3 to 5.5 d; and mortality, RR: 0.71, p<0.0001). Improving evidence- To evaluate the Prospective 34,810 HF or prior Those with 7 quality measures: N/A Significant improvement was demonstrated in 5 of Data collected by Study based care for HF in effectiveness of a MI with noncardiovascula use of 1) ACEI or the 7 quality measures at the practice level at 24 chart review, which demonstrates the outpatient cardiology practice-specific LVEF r medical ARB, 2) Beta blocker, mo after implementation of the performance may be incomplete; positive impact of practices: primary performance ≤35% condition 3) aldosterone improvement intervention, use of aldosterone selection bias as applying results of the improvement intervention associated with antagonist, 4) antagonists, CRT, ICD, beta blocker, and HF eligible pts not performance Registry to Improve on the use of guideline- an anticoagulant therapy education (p<0.001); included in analysis improvement the Use of Evidence- recommended therapies estimated survival for AF or flutter, 5) Use of anticoagulation in eligible patients with AF may differ by techniques Based HF Therapies for pts of <1 y and those CRT with a did not improve over time. Use of ACEI/ARB contraindication from of guideline- in the Outpatient with diagnosed HF and who had defibrillator/CRT with increased (+6.8%), but this was not statistically those who were; driven care and Setting (IMPROVE reduced LVEF or prior MI undergone a pacemaker, 6) significant (p=0.063) analysis not adjusted improvement HF). and reduced cardiac ICD (ICD or CRT with for differing lengths of tools, in real- 20660805 (385) LVEF in outpatient transplantation a defibrillator), and 7) follow up. world cardiology cardiology practices HF education for practices. eligible pts. ACEI indicates angiotensin-converting-enzyme inhibitor; ADHERE, Acute Decompensated Heart Failure National Registry; AF, atrial fibrillation; ARB, angiotensin receptor blockers; CRT, cardiac resynchronization therapy; HF, heart failure; ICD, implantable cardioverter-defibrillator; LV, left ventricular; MI, myocardial infarction; pt, patient; and RR, relative risk.
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2013 ACCF/AHA Guideline for the Management of Heart Failure—ONLINE AUTHOR LISTING OF COMPREHENSIVE RELATIONSHIPS WITH INDUSTRY AND OTHERS (May 2013 ) Committee Employment Consultant Speaker’s Ownership/ Personal Research Institutional, Expert Member Bureau Partnership/ Organizational or Witness Principal Other Financial Benefit Clyde W. Yancy, Northwestern None None None None • AHA† None Chair University—Chief, Division of Cardiology and Magerstadt Professor of Medicine Mariell Jessup, University of None None None • Amgen† • AHA† None Vice Chair Pennsylvania—Professor • Celladon† • HFSA† of Medicine • HeartWare† Biykem Bozkurt Michael E. DeBakey VA None None None • NIH* • Amgen† None Medical Center—The • Corthera Mary and Gordon Cain • NIH† Chair and Professor of • Novartis† Medicine Javed Butler Emory Healthcare— None None None None • Amgen None Director of Heart Failure • Biotronic Research; Emory • Cardiomems University School of • Corthera Medicine—Professor of • FoldRx Medicine • iCoapsys • NIH* • Johnson & Johnson — ASCEND-HF • Medtronic • Rule 90 • Thoratec • World Heart Inc. Donald E. Casey, Clinically Integrated None None None None None None Jr. Physician Network, NYU Langone Medical Center—Vice President and Medical Director
© American College of Cardiology Foundation and American Heart Association, Inc. Mark H. Drazner University of Texas • Optum Health None None • HeartWare† • American Heart None Southwestern Medical • NIH/NHLBI* Journal Center—Professor, • Journal of Cardiac Internal Medicine Failure • Medtronic • Thoratec* Gregg C. Director Ahmanson— • Medtronic None None • NHLBI* (Co-I) • ACCF/AHA Data None Fonarow UCLA Cardiomyopathy • Novartis* • Novartis* Standards Center; Co-Chief— Committee UCLA Division of • ACTION Registry Cardiology GWTG—Steering Chair • GWTG—Steering Committee • Medtronic— IMPROVE HF† Stephen A. Quillen College of None None None None None None Geraci Medicine/East Tennessee State University— Chairman of Internal Medicine Tamara Horwich Ahmanson—UCLA None None • EP Dynamics* • NHLBI* None None Cardiomyopathy • Iris Cantor-UCLA Center—Assistant Women’s Health Professor of Medicine, Center Cardiology • UCLA Clinical and Transitional Science Institute* James L. Januzzi Harvard Medical • Critical None None • Critical None None School—Associate Diagnostics* Diagnostics* Professor of Medicine; • Roche • Dade-Boehring/ Massachusetts General Diagnostics* Siemens* Hospital—Director, • Roche Cardiac Intensive Care Diagnostics* Unit Maryl R. University of • CareMark None None None • American Society None Johnson Wisconsin −Madison— • Transmedics of Transplantation- Professor of Medicine, (Clinical Trials Current President Director, Heart Failure Committee) • NIH—Heart Failure
© American College of Cardiology Foundation and American Heart Association, Inc. and Transplantation Clinical Trials Network (DSMB) • UNOS Thoracic Organ Committee Edward K. Johns Hopkins Hospital— None None None None None None Kasper E. Cowles Andrus Professor in Cardiology Director, Clinical Cardiology Wayne C. Levy University of • Boehringer • GlaxoSmithKli • Amgen—RED-HF • Amgen—RED- None None Washington—Professor Ingelheim ne • HeartWare* HF* of Medicine, Division of • Cardiac • NIH-DCRI • CardioMems— Cardiology Dimensions* CHAMPION • Thomson Reuters • Epocrates • General Electric • Johnson & Johnson/Scios— ASCEND HF Frederick A. University of Colorado, • Axio Research* None None • ACC* None Masoudi Denver—Associate • AHA Professor of Medicine, • AHRQ Division of Cardiology • Massachusetts Medical Society • NHLBI* • Oklahoma Foundation for Medical Quality* Patrick E. University of Wisconsin None None None None • NIH-NIDDK— None McBride School of Medicine and LOOK AHEAD Public Health—Professor (DSMB) of Medicine and Family Medicine, Associate Dean for Students, Associate Director, Preventive Cardiology John J. V. University of Glasgow, None None None • GlaxoSmithKline* • Novartis— None McMurray Scotland, BHF Glasgow • Novartis ALTITUDE/ Cardiovascular Research • Oxford/Duke PARADIGM-HF Center—Professor of University—
© American College of Cardiology Foundation and American Heart Association, Inc. Medical Cardiology EXSCEL (DSMB) • Oxford/Duke University— TECOS (DSMB) • Roche— ALECARDIO (DSMB) Judith E. SUNY Downstate None None None • NHLBI—PRIDE None None Mitchell Medical Center— Director, Heart Failure Center; Associate Professor of Medicine Pamela N. University of Colorado, None None None None None None Peterson Denver Health Medical Center—Associate Professor of Medicine, Division of Cardiology Barbara Riegel University of None None None • AHA† None None Pennsylvania School of • NIH (PI)* Nursing—Professor Flora Sam Boston University School None None None None None None of Medicine, Whitaker Cardiovascular Institute— Associate Professor of Medicine, Division of Cardiology/ Cardiomyopathy Program Lynne W. Brigham and Women’s None None None • NHLBI† • Circulation Heart None Stevenson Hospital Cardiovascular • NHLBI— Failure (Senior Division—Director, INTERMACS† Associate Editor)† Cardiomyopathy and Heart Failure Program W.H. Wilson Cleveland Clinic • Medtronic None • NIH* • Abbott • HFSA None Tang Foundation—Associate • St. Jude Medical* Laboratories Professor of Medicine, • Asahi Kasei Research Director for • FoldRx Heart Failure/Transplant • Medtronic • St. Jude Medical Emily J. Tsai Temple University School None None None • AHA Scientist None None
© American College of Cardiology Foundation and American Heart Association, Inc. of Medicine—Assistant Development Professor of Medicine, Grant* Cardiology • NIH* • NHLBI Bruce L. Wilkoff Cleveland Clinic— None None None • Biotronic None None Director, Cardiac Pacing • Boston Scientific and Tachyarrhythmia • Medtronic Devices; Director, • St. Jude Medical Clinical EP Research This table represents all healthcare relationships of committee members with industry and other entities that were reported by authors, including those not deemed to be relevant to this document, at the time this document was under development. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$10 000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Please refer to http://www.cardiosource.org/Science-And- Quality/Practice-Guidelines-and-Quality-Standards/Relationships-With-Industry-Policy.aspx for definitions of disclosure categories or additional information about the ACCF/AHA Disclosure Policy for Writing Committees.
*Indicates significant relationship. †No financial benefit.
ACC indicates American College of Cardiology; AHA, American Heart Association; AHEAD, Action For Health in Diabetes; AHRQ, Agency for Healthcare Research & Quality; ALECARDIO, Cardiovascular Outcomes Study to Evaluate the Potential of Aleglitazar to Reduce Cardiovascular Risk in Patients With a Recent Acute Coronary Syndrome Event and Type 2 Diabetes Mellitus; ALTITUDE, Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints; ASCEND-HF, Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure; CHAMPION, CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Patients; DCRI, Department of Clinical Research Informatics; DSMB, Data Safety Monitoring Board; EP, electrophysiology; EXSCEL, Exenatide Study of Cardiovascular Event Lowering; GWTG, Get With The Guidelines; HF, heart failure; HFSA, Heart Failure Society of America; IMPROVE HF, Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; NHLBI, National Heart, Lung, and Blood Institute; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; NIH, National Institute of Health; NYU, New York University; PARADIGM-HF, Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Patients With Heart Failure; PRIDE, Prolonging Remission in Depressed Elderly; SUNY, State University of New York; TECOS, Trial Evaluating Cardiovascular Outcomes with Sitagliptin in Patients with Type 2 Diabetes; UCLA, University of California, Los Angeles; UNOS, United Network for Organ Sharing; and VA, veterans affairs.
© American College of Cardiology Foundation and American Heart Association, Inc.