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Heart Failure . Device Therapy IEY POltIt (uninued) lmplantable Cerdiouerter-Defibrillator Therapy o Cardiac resynchronization therapy is indicated in Arrhythmias are a common cause of death in patients with patients with an ejection fraction of 35'7, or less, New heart failure, and an implantable cardioverter defibrillator York Heart Association functional class II to IV symp (lCD) improves survival when used fbr both primary and toms despite guideline-directed medical therapy. sinus secondary prevention ol sudden cardiac death. Current rh1.thm, and left bundle branch block with a QRS com guidelines recommend ICD placement in patients receiving plex of 150 ms or longer. guideline directed medical therapy with an LVEF of 35'/. or less and NYHA functional class II or III symptoms. Patients with class IV symptoms should only undergo ICD placement Disease Management if they are candidates for heart transplant or LV assist device Patients u,ith chronic heart failure should be serially assessed (LVAD) placement. lmportantly, LVEF and symptoms should for progression of disease in the outpatient setting. Each be reassessed after guideline directed medical therapy follow up visit should include evaluation of current symptoms (+O days after myocardial infarction, 3 months in all others). and functional capacity; assessment of volume status. electro because many patients with new onset heart failure experi lytes. and kidney function; and review of the patient's medi ence substantial improvements in LVEF and may not require cation regimen lor adequacy (both appropriate doses and or benefit from an ICD. appropriate medications as heart failure progresses). Ofequal Results of the VEST trial demonstrated that among patients or greater importance is repeated patient education. nonjudg with LVEF of 35% or less after acute myocardial infarction, a mental assessment of adherence. and evaluation of obstacles wearable cardioverter defibrillator did not reduce the incidence that may prevent patients from taking their medications as ofsudden cardiac death but did reduce the secondary outcome prescribed or following recommendations for diet. activiry of all cause mortality. There are no guideline recommendations and monitoring weight. Patients who appropriately take their on the use of a wearable cardioverter defibrillator in patients medications and avoid excess sodium and fluid intake can with heart failure; however, it is an option for patients at high greatly improve their functional status. risk for arrhythmias as a bridge to ICD therapy. Sleep disordered breathing (obstructive sleep apnea, cen tral sleep apnea) is underdiagnosed in patients with heart Cqrdiac Re sy nchro n izotion T he rap y failure. Recognizing and treating sleep disordered breathing is Cardiac resynchronization therapy (CRT), or biventricular important fbr improving quality of Iife in patients with heart pacing, involves traditional pacing of the right ventricular failure and for potentially improving heart failure related apex and pacing of the LV lateral wall via a lead inserted outcomes. Current guidelines support obtaining a formal sleep through the coronary sinus into a lateral cardiac vein. CRT assessment in patients with symptomatic heart failure (NYHA improves LVEF, reduces heart failure symptoms, and reduces functional class II-IV) and excessive daytime sleepiness or mortality in patients with dyssynchrony (demonstrated in those suspected of having sleep-disordered breathing (see most trials by a prolonged QRS interval or Ieft bundle branch MKSAP 19 Pulmonary and Critical Care Medicine). lnitial block [LBBB]). Patients with LBBB are most likely to benefit therapy for patients with heart failure and sleep disordered from CRT. although patients without LBBB but with a QRS breathing is guideline-directed medical therapy for heart complex of 150 ms or longer may derive a lesser benefit. CRT is failure because it improves both heart failure and sleep indicated in patients with an LVEF of 35'X, or less. NYHA func disordered breathing clinical outcomes. Persistent sleep tional class II to IV symptoms despite guideline-directed medi disordered breathing despite guideline directed heart failure cal therapy, sinus rhythm, and LBBB with a QRS complex of therapy should be treated with continuous positive airway 150 ms or longer (class 1 recommendation). For patients with pressure (CPAP). Treatment of obstructive sleep apnea with LBBB and a QRS duration of 120 to 149 ms or those without CPAP improves sleep quality and reduces the apnea hypopnea

Device Therapy IEY POltIt (uninued) lmplantable Cerdiouerter-Defibrillator Therapy o Cardiac resynchronization therapy is indicated in Arrhythmias are a common cause of death in patients with patients with an ejection fraction of 35'7, or less, New heart failure, and an implantable cardioverter defibrillator York Heart Association functional class II to IV symp (lCD) improves survival when used fbr both primary and toms despite guideline-directed medical therapy. sinus secondary prevention ol sudden cardiac death. Current rh1.thm, and left bundle branch block with a QRS com guidelines recommend ICD placement in patients receiving plex of 150 ms or longer. guideline directed medical therapy with an LVEF of 35'/. or less and NYHA functional class II or III symptoms. Patients with class IV symptoms should only undergo ICD placement Disease Management if they are candidates for heart transplant or LV assist device Patients u,ith chronic heart failure should be serially assessed (LVAD) placement. lmportantly, LVEF and symptoms should for progression of disease in the outpatient setting. Each be reassessed after guideline directed medical therapy follow up visit should include evaluation of current symptoms (+O days after myocardial infarction, 3 months in all others). and functional capacity; assessment of volume status. electro because many patients with new onset heart failure experi lytes. and kidney function; and review of the patient's medi ence substantial improvements in LVEF and may not require cation regimen lor adequacy (both appropriate doses and or benefit from an ICD. appropriate medications as heart failure progresses). Ofequal Results of the VEST trial demonstrated that among patients or greater importance is repeated patient education. nonjudg with LVEF of 35% or less after acute myocardial infarction, a mental assessment of adherence. and evaluation of obstacles wearable cardioverter defibrillator did not reduce the incidence that may prevent patients from taking their medications as ofsudden cardiac death but did reduce the secondary outcome prescribed or following recommendations for diet. activiry of all cause mortality. There are no guideline recommendations and monitoring weight. Patients who appropriately take their on the use of a wearable cardioverter defibrillator in patients medications and avoid excess sodium and fluid intake can with heart failure; however, it is an option for patients at high greatly improve their functional status. risk for arrhythmias as a bridge to ICD therapy. Sleep disordered breathing (obstructive sleep apnea, cen tral sleep apnea) is underdiagnosed in patients with heart Cqrdiac Re sy nchro n izotion T he rap y failure. Recognizing and treating sleep disordered breathing is Cardiac resynchronization therapy (CRT), or biventricular important fbr improving quality of Iife in patients with heart pacing, involves traditional pacing of the right ventricular failure and for potentially improving heart failure related apex and pacing of the LV lateral wall via a lead inserted outcomes. Current guidelines support obtaining a formal sleep through the coronary sinus into a lateral cardiac vein. CRT assessment in patients with symptomatic heart failure (NYHA improves LVEF, reduces heart failure symptoms, and reduces functional class II-IV) and excessive daytime sleepiness or mortality in patients with dyssynchrony (demonstrated in those suspected of having sleep-disordered breathing (see most trials by a prolonged QRS interval or Ieft bundle branch MKSAP 19 Pulmonary and Critical Care Medicine). lnitial block [LBBB]). Patients with LBBB are most likely to benefit therapy for patients with heart failure and sleep disordered from CRT. although patients without LBBB but with a QRS breathing is guideline-directed medical therapy for heart complex of 150 ms or longer may derive a lesser benefit. CRT is failure because it improves both heart failure and sleep indicated in patients with an LVEF of 35'X, or less. NYHA func disordered breathing clinical outcomes. Persistent sleep tional class II to IV symptoms despite guideline-directed medi disordered breathing despite guideline directed heart failure cal therapy, sinus rhythm, and LBBB with a QRS complex of therapy should be treated with continuous positive airway 150 ms or longer (class 1 recommendation). For patients with pressure (CPAP). Treatment of obstructive sleep apnea with LBBB and a QRS duration of 120 to 149 ms or those without CPAP improves sleep quality and reduces the apnea hypopnea LBBB but with a QRS duration greater than 150 ms, CRT can be index. In contrast, treatment of central sleep apnea adap "l'ith useful and should be considered (class 2a recommendation). tive servoventilation in patients with an LVEF less than 45',4, is Patients meeting the criteria for CRT typically have an indica associated with an increased risk for death. tion for a concomitant ICD. and in these cases. a CRT defibrillator device is indicated. Echocardiography in Chronic Heart Failure Echocardiography is the most common method of assessing f,TY PO I l{I5 LV function. ln patients with new onset heart failure, guide- . Implantable cardioverter-defibrillator placement is rec- lines suggest repeating assessment of LV function after optimi- ommended in patients with heart failure who have an zation of medical therapy. Patients with an LVEF of 35'X, or less ejection fraction of 35u1, or less and New York Heart may be candidates for ICD placement or CRT. Current guide Association functional class II or III symptoms while lines recommend against routine surveillance echocardiogra- taking guideline directed medical therapy. ' (Continued) phy in the absence of a change in clinical status or planned intervention.

LBBB but with a QRS duration greater than 150 ms, CRT can be index. In contrast, treatment of central sleep apnea adap "l'ith useful and should be considered (class 2a recommendation). tive servoventilation in patients with an LVEF less than 45',4, is Patients meeting the criteria for CRT typically have an indica associated with an increased risk for death. tion for a concomitant ICD. and in these cases. a CRT defibrillator device is indicated. Echocardiography in Chronic Heart Failure Echocardiography is the most common method of assessing f,TY PO I l{I5 LV function. ln patients with new onset heart failure, guide- . Implantable cardioverter-defibrillator placement is rec- lines suggest repeating assessment of LV function after optimi- ommended in patients with heart failure who have an zation of medical therapy. Patients with an LVEF of 35'X, or less ejection fraction of 35u1, or less and New York Heart may be candidates for ICD placement or CRT. Current guide Association functional class II or III symptoms while lines recommend against routine surveillance echocardiogra- taking guideline directed medical therapy. ' (Continued) phy in the absence of a change in clinical status or planned intervention. 36

Heart Failure Serial B 'I'ype Natriuretic Peptide Assessment duration, and quality of lif'e, and exercise training is recom BNP measurement may support the diagnosis of volume over- mended fbr all patients. Most trials of exercise training have load in patients with acute or chronic heart failure and, in been small. although the large HF ACTION trial of 2331 patients with stable heart failure. can provide infbrmation patients showed a trend toward benefit in survival or hospitali about prognosis and disease severity. Serial measurements and zation. ln patients with risk lactors fbr worse prognosis BNP guided treatment, however, have not been shown to (including atrial fibrillation or flufter, poor exercise tolerance, reduce hospitalizations or mortality in patients with heart depression, and Iower LVEt"), exercise improved survival. failure. Assessing Prognosis Mult id isc pl i no r A Te am Ma nage me nt i Many prognostic models have been developed to assist in pre Heart failure is a complex disease. and as many as 50'1, of dicting morbidity and mortality in patients with heart failure. elderly patients with heart failure have four or more comorbid These models are usually derived from retrospective analyses of conditions, such as hypertension, diabetes, chronic kidney clinical trials or large admission databases. To some extent, the disease, COPD, dementia, malignancy. and depression. The models reflect the unique patient populations enrolled in clini number of con.rorbidities correlates with an increased risk tbr cal trials. which tend to have f'ewer comorbid conditions. It has mortality. Optimal treatment ol heart failure and con.rorbid been suggested that these tools be used in addition to, not in conditions involves a collaborative. team based approach to place of, clinical judgment for heart failure management. care. The multidisciplinary teanl should comprise l primary Clinical indicators associated with worse outcomes in the care physician, cardiologist, and other specialists. Ideally, care 1 b 2 years after diagnosis include heart failure hospitaliza decisions should involve all interested groups rather than each tion, poor exercise tolerance, ICD firings, hyponatremia, wors team member treating the patient individually. ening kidney lunction, cardiac cachexia, required loop diuretic Hospital discharge is an especially important time fbr doses of more than I mgikg, and symptomatic hypotension multidisciplinary team management. Discussions of therapy necessitating reduced dosage of heart lailure medications. selection, strategizing medication uptitration, identifying Heart failure hospitalization is associated with a mortality rate early- and long term caregivers, and establishing early fbllow- ol l0',1, to 20'2, over the next 6 months. Patients with poor prog up can help prevent reudmission. nosis should be engaged in a trank discussion of advanced therapies, such as LVAD placement or heart transplantation. Primary Care Preuention Strclfegies End ofllife goals should be discussed with patients who are Hypertension and diabetes are the two greatest modiliable risk ineligible lor or uninterested in such therapies, and palliative factors for heart failure and should be the focus of prevention care or hospice should be considered. elforts in the primary care setting. Evidence has shown that t(tY P0lilrs heart failure incidence can be reduced by significantly lower ing blood pressure to a goal of less than 130/80 mm Hg, and o Current guidelines recommend against routine surveil HVC

Serial B 'I'ype Natriuretic Peptide Assessment duration, and quality of lif'e, and exercise training is recom BNP measurement may support the diagnosis of volume over- mended fbr all patients. Most trials of exercise training have load in patients with acute or chronic heart failure and, in been small. although the large HF ACTION trial of 2331 patients with stable heart failure. can provide infbrmation patients showed a trend toward benefit in survival or hospitali about prognosis and disease severity. Serial measurements and zation. ln patients with risk lactors fbr worse prognosis BNP guided treatment, however, have not been shown to (including atrial fibrillation or flufter, poor exercise tolerance, reduce hospitalizations or mortality in patients with heart depression, and Iower LVEt"), exercise improved survival. failure. Assessing Prognosis Mult id isc pl i no r A Te am Ma nage me nt i Many prognostic models have been developed to assist in pre Heart failure is a complex disease. and as many as 50'1, of dicting morbidity and mortality in patients with heart failure. elderly patients with heart failure have four or more comorbid These models are usually derived from retrospective analyses of conditions, such as hypertension, diabetes, chronic kidney clinical trials or large admission databases. To some extent, the disease, COPD, dementia, malignancy. and depression. The models reflect the unique patient populations enrolled in clini number of con.rorbidities correlates with an increased risk tbr cal trials. which tend to have f'ewer comorbid conditions. It has mortality. Optimal treatment ol heart failure and con.rorbid been suggested that these tools be used in addition to, not in conditions involves a collaborative. team based approach to place of, clinical judgment for heart failure management. care. The multidisciplinary teanl should comprise l primary Clinical indicators associated with worse outcomes in the care physician, cardiologist, and other specialists. Ideally, care 1 b 2 years after diagnosis include heart failure hospitaliza decisions should involve all interested groups rather than each tion, poor exercise tolerance, ICD firings, hyponatremia, wors team member treating the patient individually. ening kidney lunction, cardiac cachexia, required loop diuretic Hospital discharge is an especially important time fbr doses of more than I mgikg, and symptomatic hypotension multidisciplinary team management. Discussions of therapy necessitating reduced dosage of heart lailure medications. selection, strategizing medication uptitration, identifying Heart failure hospitalization is associated with a mortality rate early- and long term caregivers, and establishing early fbllow- ol l0',1, to 20'2, over the next 6 months. Patients with poor prog up can help prevent reudmission. nosis should be engaged in a trank discussion of advanced therapies, such as LVAD placement or heart transplantation. Primary Care Preuention Strclfegies End ofllife goals should be discussed with patients who are Hypertension and diabetes are the two greatest modiliable risk ineligible lor or uninterested in such therapies, and palliative factors for heart failure and should be the focus of prevention care or hospice should be considered. elforts in the primary care setting. Evidence has shown that t(tY P0lilrs heart failure incidence can be reduced by significantly lower ing blood pressure to a goal of less than 130/80 mm Hg, and o Current guidelines recommend against routine surveil HVC ACCTAHA guidelines recommend treating to this target in lance echocardiography in patients with chronic heart patients w,ith HFTEF. A meta analysis showed that each failure in the absence ofa change in clinical status or 10 mm Hg reduction in systolic blood pressure was associated planned intervention. with a 2B'2, reduction in heart failure incidence. Control of r Serial B type natriuretic peptide measurements should HVC diabetes with metformin and/or SGLI2 inhibitors also may not be used to guide care of patients with chronic heart L reduce heart failure. Additional prevention strategies include failure. weight loss and smoking cessation. which decrease the inci o Heart failure incidence can be reduced by treating to a dence of CAD. the most common cause of heart failure. target blood pressure of less than 130/80 mm Hg. Routine prin.rary care interventions. including vaccination lbr pneumonia and influenza, should be performed. Heart Failure With Preserved Ejection Fraction Lifestyle Modification The incidence of HFpEF increases with age, although younger Lifestyle modification, including weight loss and smoking patients may be affected. Patients hospitalized with HFpEF are cessation, should be encouraged. Atcohol may be consumed more likely to be older women with obesity and hypertension in moderation. Patients should be instructed to weigh them and less likely to have overt CAD than those hospitalized selves daily because rapid changes in weight may be a pre with HFTEF. dictor of heart failure decompensation. Although sodium The primary therapies tbr HFpEF are diuretics to control restriction (<1.5 g/day) and t'luid restriction (t.s z Llday) symptoms of volume overload and antihypertensive agents to t are routinely advised, few data are available on these target a systolic blood pressure of less than 130 mm Hg. [n interventions. patients with worsened symptoms of heart failure and con Cardiac rehabilitation fbr heart failure patients has been comitant atrial fibrillation, restoration of sinus rhythm or rate associated lr,'ith improvements in functional capacity, exercise control may reduce symptoms.

ACCTAHA guidelines recommend treating to this target in lance echocardiography in patients with chronic heart patients w,ith HFTEF. A meta analysis showed that each failure in the absence ofa change in clinical status or 10 mm Hg reduction in systolic blood pressure was associated planned intervention. with a 2B'2, reduction in heart failure incidence. Control of r Serial B type natriuretic peptide measurements should HVC diabetes with metformin and/or SGLI2 inhibitors also may not be used to guide care of patients with chronic heart L reduce heart failure. Additional prevention strategies include failure. weight loss and smoking cessation. which decrease the inci o Heart failure incidence can be reduced by treating to a dence of CAD. the most common cause of heart failure. target blood pressure of less than 130/80 mm Hg. Routine prin.rary care interventions. including vaccination lbr pneumonia and influenza, should be performed. Heart Failure With Preserved Ejection Fraction Lifestyle Modification The incidence of HFpEF increases with age, although younger Lifestyle modification, including weight loss and smoking patients may be affected. Patients hospitalized with HFpEF are cessation, should be encouraged. Atcohol may be consumed more likely to be older women with obesity and hypertension in moderation. Patients should be instructed to weigh them and less likely to have overt CAD than those hospitalized selves daily because rapid changes in weight may be a pre with HFTEF. dictor of heart failure decompensation. Although sodium The primary therapies tbr HFpEF are diuretics to control restriction (<1.5 g/day) and t'luid restriction (t.s z Llday) symptoms of volume overload and antihypertensive agents to t are routinely advised, few data are available on these target a systolic blood pressure of less than 130 mm Hg. [n interventions. patients with worsened symptoms of heart failure and con Cardiac rehabilitation fbr heart failure patients has been comitant atrial fibrillation, restoration of sinus rhythm or rate associated lr,'ith improvements in functional capacity, exercise control may reduce symptoms. 37