2012 CCS Heart Failure Management Guidelines Update Disclaimer

2012 CCS Heart Failure Management Guidelines Update Disclaimer The Canadian Cardiovascular Society (CCS) welcomes reuse of our educational slide deck for medical institution internal education or training (i. e. grand rounds, medical college/classroom education, etc. ). However, if the material is being used in an industry sponsored CME program, permission must be sought through our publisher Elsevier (www. onlinecjc. com). If your reuse request qualifies as medical institution internal education, you may reuse the material under the following conditions: • • You must cite the Canadian Journal of Cardiology and the Canadian Cardiovascular Society as references. You may not use any Canadian Cardiovascular Society logos or trademarks on any slides or anywhere in your presentation or publications. Do not modify the slide content. If repeating recommendations from the published guideline, do not modify the recommendation wording. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 1

2012 CCS Heart Failure Management Guidelines Update Canadian Cardiovascular Society Guidelines 2012 UPDATE Heart Failure Management: Focus on Acute and Chronic Heart Failure Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 2

2012 CCS Heart Failure Management Guidelines Update Learning Objectives At the conclusion of this workshop, participants will be able to: 1. Review changes and updates for optimal management of chronic and acute heart failure; updating 2006 recommendations to 2012 context and environment; 2. Discuss exercise for heart failure patients - where to begin, what to do and where to end; and 3. Identify opportunities and challenges of surgery for patients with an ischemic etiology for heart failure. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 3

2012 CCS Heart Failure Management Guidelines Update Acute Heart Failure Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 4

2012 CCS Heart Failure Management Guidelines Update What is heart failure? • Chronic Heart Failure (CHF): – Heart failure is a complex syndrome in which abnormal heart function results in, or increases the subsequent risk of, clinical symptoms and signs of low cardiac output and/or pulmonary or systemic congestion. • Acute Heart Failure Syndrome (AHF): – “gradual or rapid change in heart failure signs and symptoms resulting in the need for urgent therapy” Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 5

2012 CCS Heart Failure Management Guidelines Update Classification of AHF usually a hx of prog. worsening of known chronic HF on Rx, and evidence of systemic/pulmonary congestion. high BP, +/- preserved LV systolic fxn; increased sympathetic tone with ↑HR, vasoconstriction; may be euvolaemic or only mildly hypervolemic, and frequently with signs of pulmonary or systemic congestion Severe respiratory distress, ↑RR, orthopnea, rales. O 2 sats <90% RA prior to O 2 Clinical and lab evidence of an ACS; ~15% of patients with an ACS have signs and symptoms of HF. Episodes of AHF are frequently assoc w/ or precipitated by arrhythmia (bradycardia, AF, VT). Usually sys BP <90 mm. Hg or drop in MAP >30 mm. Hg and absent/low urine output. Organ hypoperfusion and pulmonary congestion develop rapidly low output in absence of pulmonary congestion with increased JVP, w/ or w/out HSM, and low LV filling pressures Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society ESC 2008 6

2012 CCS Heart Failure Management Guidelines Update Has care evolved? 1950 1974 Morphine 2012 Morphine? Oxygen? Dietary sodium restriction? Sedation Dietary sodium restriction Strict bed rest Early mobilization Digitalis Inotropes Avoid inotropes Mercurial diuretics Diuretics ? Diuretics Venesection Vasodilators ? Vasodilators Harrison’s Principles of Internal Medicine 1 st Edition (1950) Ramirez A et al. N Engl J Med 1974; 290(9): 499 -501 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 7

2012 CCS Heart Failure Management Guidelines Update CASE 1 • 74 year old female • 2 months worsening SOB/orthopnea • Presented to ED after Chinese food • Past Hx unclear, no meds • Physical exam • HR 98, BP 142/82, RR 28, temp 36. 0 C • JVP elevated, crackles, pulses 2+, legs warm and LEE+ Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 8

2012 CCS Heart Failure Management Guidelines Update CASE 1 • 74 year old female • CXR = pending • Labs = pending Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 9

2012 CCS Heart Failure Management Guidelines Update Question … prepare to provide your answer! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 10

2012 CCS Heart Failure Management Guidelines Update How confident are you that it is AHF? 1. 2. 3. 4. 5. <20% 21 -40% 41 -60% 61 -80% >80% Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 11

2012 CCS Heart Failure Management Guidelines Update How confident are you that it is AHF? 1. 2. 3. 4. 5. <20% 21 -40% 41 -60% 61 -80% >80% No right answer Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 12

2012 CCS Heart Failure Management Guidelines Update AHF Dx Scoring systems Predictor Elevated NT-pro. BNP Interstitial edema on CXR Orthopnea Absence of fever Current loop diuretic use Age > 75 years Rales on lung examination Absence of cough Interpretation Points 4 Our Case ? 2 2 2 1 - 1 1 4 e. g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93 Baggish AL, et al. Am Heart J 2006; 151: 48 -54]. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 13

2012 CCS Heart Failure Management Guidelines Update CASE 1 • 74 year old female • CXR = increased pulmonary markings c/w edema, no evidence of COPD • Labs = troponin I 0. 20 – BNP 728 pg/ml – Creatinine 130 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 14

2012 CCS Heart Failure Management Guidelines Update AHF Dx Scoring systems Predictor Elevated NT-pro. BNP Interstitial edema on CXR Orthopnea Absence of fever Current loop diuretic use Age > 75 years Rales on lung examination Absence of cough Interpretation Points 4 Our Case 4 2 2 2 1 - 1 1 10 e. g. At a score of 9, PPV 92%, NPV 82%, sens 70, spec 93 Baggish AL, et al. Am Heart J 2006; 151: 48 -54]. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 15

2012 CCS Heart Failure Management Guidelines Update CCS 2012 We recommend the use of a validated diagnostic scoring system for patients in whom the diagnosis of AHF is being considered (Strong Recommendation, Moderate Quality Evidence). e. g. PRIDE score, Boston criteria This recommendation places a relatively high value on evaluating the constellation of clinical findings in a patient with suspected AHF and less value on an individual physical examination finding, presenting symptom or investigation. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 16

2012 CCS Heart Failure Management Guidelines Update CCS 2012 • We recommend that in the clinical scenario when the clinical diagnosis of AHF is of intermediate pre-test probability, NP level be obtained to rule-out (BNP <100 pg/ml; NT-pro. BNP <300 pg/ml) or rule-in (BNP >500 pg/ml; NT-pro. BNP >900 pg/ml if age 50 -75 years, NT-pro. BNP >1800 if age >75 years) AHF as the cause for the presenting symptoms suspicious of AHF (Strong Recommendation, Moderate Quality Evidence) Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 17

2012 CCS Heart Failure Management Guidelines Update CCS 2012: Practical Tips • A precipitating cause for AHF should be sought. • An ECG and a chest x-ray should be performed within 2 hours of initial presentation. • Initial blood tests should include: complete blood count, creatinine, blood urea nitrogen, glucose, sodium, potassium, and troponin. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 18

2012 CCS Heart Failure Management Guidelines Update CCS 2012: Practical Tips • A transthoracic echocardiogram should be performed within 72 hours of presentation. • For patients with a prior echocardiogram, another is not required unless there has been a significant change in clinical status requiring investigation, a lack of clinical response to appropriate therapy and/or it is greater than 12 months since the prior echocardiogram. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 19

2012 CCS Heart Failure Management Guidelines Update CASE 2 • 52 year old male with history of HF – Presented to ED after the Edmonton Oilers won the Stanley Cup • • • SOBOE, orthopnea HR 98, BP 99/52, RR 24, temp 36. 0 c JVP difficult to assess (thick neck) crackles pulses weak, legs cool and LEE Trop 0. 15 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 20

2012 CCS Heart Failure Management Guidelines Update Question … prepare to provide your answer! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 21

2012 CCS Heart Failure Management Guidelines Update Where on this table does this pt fit? 1 Dry and Warm Increasing Perfusion/ Cardiac Output 3 Dry and Cold 2 Wet and Warm 4 Wet and Cold Increasing Congestion / PCWP Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41: 1797 -804 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 22

2012 CCS Heart Failure Management Guidelines Update Where on this table does this pt fit? 1. 2. 3. 4. Dry and Warm Wet and Warm Dry and Cold Wet and Cold Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 23

2012 CCS Heart Failure Management Guidelines Update Where on this table does this pt fit? 1 Dry and Warm Increasing Perfusion/ Cardiac Output 3 Dry and Cold 2 Wet and Warm 4 Wet and Cold Increasing Congestion / PCWP Adapted from Forrester, Am J Med 1978 Nohria et al. JACC 2003; 41: 1797 -804 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 24

2012 CCS Heart Failure Management Guidelines Update Admit or discharge? Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 25

2012 CCS Heart Failure Management Guidelines Update Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 26

2012 CCS Heart Failure Management Guidelines Update Treatment options? Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 27

2012 CCS Heart Failure Management Guidelines Update CCS 2012: Oxygen We recommend supplemental oxygen be considered for patients who are hypoxemic; titrated to an oxygen saturation >90% (Strong Recommendation, Moderate Quality Evidence). • Values and Preferences: This recommendation places relatively higher value on the physiologic studies demonstrating potential harm with the use of excess oxygen in normoxic patients and less value on longterm clinical usage of supplemental oxygen without supportive data. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 28

2012 CCS Heart Failure Management Guidelines Update CCS 2012: CPAP/BIPAP We recommend CPAP or BIPAP not be used routinely (Strong Recommendation, Moderate Quality Evidence). Values and Preferences: This recommendation places high weight on RCT data with a demonstrated lack of efficacy and with safety concerns in routine use. Treatment with BIPAP/CPAP may be appropriate for patients with persistent hypoxia and pulmonary edema. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 29

2012 CCS Heart Failure Management Guidelines Update CASE 2 • 52 year old male with history of HF – Presented to ED after the Edmonton Oilers won the Stanley Cup • • • SOBOE, orthopnea HR 98, BP 99/52, RR 24, temp 36. 0 c JVP difficult to assess (thick neck) crackles pulses weak, legs cool and LEE Trop 0. 15 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 30

2012 CCS Heart Failure Management Guidelines Update Question … prepare to provide your answer! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 31

2012 CCS Heart Failure Management Guidelines Update How much diuretic will you give and how? 1. 2. 3. 4. 5. IV lasix 20 mg bid IV lasix 40 mg bid IV lasix 80 mg bid IV lasix 10 mg/hour infusion Other choice Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 32

2012 CCS Heart Failure Management Guidelines Update DOSE: Study Design Acute Heart Failure (1 symptom AND 1 sign) <24 hours after admission 2 x 2 factorial randomization Low Dose (1 x oral) Low Dose (1 x oral) Continuous Q 12 IV bolus infusion e. g. Home dose = 40 mg BID Bolus = 80 (low) 200 (high) High Dose (2. 5 x oral) Q 12 IV bolus High Dose (2. 5 x oral) Continuous infusion 48 hours 1) Change to oral diuretics 2) continue current strategy 3) 50% increase in dose 72 hours Co-primary endpoints 60 days Clinical endpoints Felker, NEJM 2011 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 33

2012 CCS Heart Failure Management Guidelines Update DOSE: Co-Primary Endpoints • Efficacy: – Patient Global Assessment by visual analog scale over 72 hours using area under the curve • Safety: – Change in creatinine from baseline to 72 hours Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 34

2012 CCS Heart Failure Management Guidelines Update DOSE: patient global assessment Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 35

2012 CCS Heart Failure Management Guidelines Update DOSE: Death, Rehosp, ER visit Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 36

2012 CCS Heart Failure Management Guidelines Update DOSE-AHF Conclusions • There was no statistically significant difference in global symptom relief or change in renal function at 72 hours for either: • bolus vs. infusion or low vs. high • No clinical differences…but – High was associated with favorable trends: – – Symptom relief (global assessment and dyspnea) Weight loss and net volume loss Proportion free from signs of congestion Reduction in NT-pro. BNP Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 37

2012 CCS Heart Failure Management Guidelines Update CCS 2012: Diuretics We recommend intravenous diuretics be given as first line therapy for patients with congestion (Strong Recommendation, Moderate Quality Evidence). We recommend for patients requiring intravenous diuretic therapy, furosemide may be dosed intermittently (e. g. twice daily) or as a continuous infusion (Strong Recommendation, Moderate Quality Evidence). Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 38

2012 CCS Heart Failure Management Guidelines Update Diuretic dosing for ADHF Creatinine clearance* ≥ 60 m. L/min/1. 73 m 2 < 60 m. L/min/1. 73 m 2 Initial IV dose† Patient Maintenance dose New-onset HF or no maintenance diuretic therapy Furosemide 20 -40 mg 2 -3 times daily Lowest diuretic dose that allows for Established HF or chronic oral diuretic therapy Furosemide bolus equivalent to oral dose clinical stability is the ideal dose New-onset HF or no maintenance diuretic therapy Furosemide 20 -80 mg 2 -3 times daily Established HF or chronic oral diuretic therapy Furosemide bolus equivalent to oral dose *Creatinine clearance is calculated from the Cockroft-Gault or Modified Diet in Renal Disease formula. See text for details. † Intravenous continuous furosemide at doses of 5 to 20 mg/h is also an option. Practical Tips When Response to Diuretic is Suboptimal • Reevaluate the need for additional diuresis by assessing volume status • Restrict NA+/H 2 O intake (and exercise caution reducing oral intake below 500 ml per 24 hours). • Review diuretic dosing. Higher bolus doses will be more effective than more frequent lower doses. Diuretic infusions (eg, furosemide 20 -40 mg bolus then 5 -20 mg/h) can be a useful strategy when other options are not available. • Add another type of diuretic with different site of action (thiazides, spironolactone). Thiazide diuretics (eg oral metolazone 2. 5 -5 mg OB/BID or hydrochlorothiazide 25 -50 mg) are often given at least 30 minutes before the loop diuretic to enhance diuresis, although this is not required to have an adequate effect. • Consider hemodynamic assessment and/or positive inotropic agents if clinical evidence of poor perfusion coexists with diuretic resistance. • Refer for hemodialysis, ultrafiltration, or other renal replacement strategies if diuresis is impeded by renal insufficiency. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 39

2012 CCS Heart Failure Management Guidelines Update Question … prepare to provide your answer! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 40

2012 CCS Heart Failure Management Guidelines Update For a persistently symptomatic patient with HF, what is next option? 1. 2. 3. 4. 5. 6. Higher dose lasix Different diuretic Add vasodilator Add inotropic agent Patience…. Other choice Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 41

2012 CCS Heart Failure Management Guidelines Update CCS 2012: Vasodilators • We recommend the following intravenous vasodilators, titrated to systolic blood pressure (SBP) > 100 mm. Hg, for relief of dyspnea in hemodynamically stable patients (SBP > 100 mm. Hg): a) Nitroglycerin (Strong Recommendation, Moderate Quality Evidence); b) Nesiritide (Weak Recommendation, High Quality Evidence); c) Nitroprusside (Weak Recommendation, Low Quality Evidence). AHA 2012: RELAX-AHF, CARRESS Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 42

2012 CCS Heart Failure Management Guidelines Update CCS 2012: Inotropes • We recommend hemodynamically stable patients do not routinely receive inotropes like dobutamine, dopamine or milrinone (Strong Recommendation, High Quality Evidence). • Values and Preferences These recommendations for inotropes place high value on the potential harm demonstrated when systematically studied in clinical trials and less value on potential short term hemodynamic effects of inotropes. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 43

2012 CCS Heart Failure Management Guidelines Update Do I stop the beta-blockers on admission? • Cohorts suggest continuing beta-blockers advantageous • RCT: B-CONVINCED – – Keep vs. Stop strategy in known HF pts on beta-blockers Keep was non-inferior to Stop. Does not delay clinical improvement Predicts staying on BB in the longer term Eur Heart J 2009; 30: 2186 -92 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 44

2012 CCS Heart Failure Management Guidelines Update RESYNCHRONIZATION THERAPY and DEVICES Anique Ducharme, MD MSc FRCPC Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 45

2012 CCS Heart Failure Management Guidelines Update Conflict Disclosures The speaker has received fees/honoraria from the following sources: Abbott vascular, Medtronic, Merck, Otsuka, Pfizer, Sorin & St-Jude Medical None of the drugs, devices, or treatment modalities mentioned in this presentation are non approved indications. Anique Ducharme, Institut de Cardiologie de Montréal, Université de Montréal Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 46

2012 CCS Heart Failure Management Guidelines Update A Case of Mild Heart Failure • 61 years old female, • BP 99/67 mm. Hg, HR 76 previous MI, bpm • stable NYHA II, LVEF 25% • K, 4. 7 m. Eq/L; NT-pro. BNP 4500 pg/m. L • On optimal dose of lisinopril, eplerone and • EKG: old anterior MI, LBBB bisoprolol, occasional QRS 155 ms. diuretics • Has not been assessed for device Rx Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 47

2012 CCS Heart Failure Management Guidelines Update Question … prepare to provide your answer! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 48

2012 CCS Heart Failure Management Guidelines Update You started treating this patient with mild symptoms of HF and low ejection fraction with epleronone as recommended. Dosage was increased up to 50 mg without side effects. What do you do next? 1. 2. 3. 4. Angiotensin receptor blocker ICD CRT + ICD (CRT-D) Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 49

2012 CCS Heart Failure Management Guidelines Update CRT in Patients with Mild HF Symptoms: MADIT-CRT 1820 pts, mostly NYHA II, CRT+ICD vs ICD alone Low risk population, annual mortality ~3% 40% reduction in HF events in CRT-ICD group Moss et al, NEJM 2009 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 50

2012 CCS Heart Failure Management Guidelines Update RAFT: Death or HF hospitalization Outcome ICD (N=904) ICD-CRT (N=894) Hazard ratio (95% CI) P value 363 (40. 3%) 297 (33. 2%) 0. 75 (0. 640. 87) <0. 001 Death from any cause 236 (26. 1%) 186 (20. 8%) 0. 75 (0. 620. 91) 0. 003 Hospitalization for HF 236 (26. 1%) 174 (19. 5%) 0. 68 (0. 560. 83) <0. 001 Primary outcome Death or hospitalization for HF Secondary outcomes 1800 pts, 80% NYHA II CRT-D vs ICD Median follow-up 40 months Tang AS, et al. N Engl J Med 2010 2020 -10 -29 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 Copyright © 2013, Canadian Cardiovascular Society 51

2012 CCS Heart Failure Management Guidelines Update CRT: Mortality reduction Al-Majed et al, Annals of Internal Medicine 2011 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 52

2012 CCS Heart Failure Management Guidelines Update CRT: HF Hosp reduction Al-Majed et al, Annals of Internal Medicine 2011 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 53

2012 CCS Heart Failure Management Guidelines Update Medical Therapy in Perspective RAFT 1800 pts, 80% NYHA II CRT-D vs ICD; median f/u 40 months 25% reduction in mortality Tang et al, N Engl J Med 2010 2020 -10 -29 EMPHASIS HF 2700+ patients, NYHA II Eplerenone vs Placebo; median f/u 21 mo 25% reduction in mortality Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 Copyright © 2013, Canadian Cardiovascular Society Zannad et al, N Engl J Med, 2010 54

2012 CCS Heart Failure Management Guidelines Update Recommendation 2011 (Update) • We recommend the use of CRT in combination with an ICD for HF patients on optimal medical therapy with NYHA II HF symptoms, LVEF < 30%, and QRS duration > 150 ms. (Strong Recommendation, High Quality Evidence) Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 55

2012 CCS Heart Failure Management Guidelines Update Practical tips • QRS> 150 ms based on a subgroup analysis of MADIT-CRT and RAFT studies – Most LBBB are >150 msec • The selection of patients should be individualized and based on risk features Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 56

2012 CCS Heart Failure Management Guidelines Update CRT for Everyone? …Maybe not • Not everyone will benefit “Non-response” is ~30% depending on the definition of: • • • Death Hospitalization Failure to improve 1 NYHA functional class Failure to improve peak VO 2 or 6 min walk distance Absence of reverse remodelling (LVESV or EF) Absence of improvement in dyssynchrony Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 57

2012 CCS Heart Failure Management Guidelines Update Consider Risks vs Benefits: Real World N = 1081 ICD replacements N = 713 Upgrade Procedures Krahn et al, Ont ICD Database Circulation 2011 Poole et al, REPLACE Registry Circulation 2010 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 58

2012 CCS Heart Failure Management Guidelines Update Importance of Patient Selection • Much uncertainty persists: n o i t a l u – Narrow QRS with mechanical dyssynchrony p o t P – LV dysfunction and chronic RV pacing n e i – Atrial fibrillation and LBBB t a P d l r – Right bundle branch block o W l a – Asymptomatic patients e R – Class IV/Stage D patients Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 59

2012 CCS Heart Failure Management Guidelines Update Recommendation • Routine CRT implantation is not currently recommended for patients with heart failure and narrow QRS (<120 ms) Practical tips • Patients enrolled in CRT studies who show benefit have a QRS duration >150 ms, on average. The benefit in patients with QRS 120 ms to 150 ms is less clear • Echocardiography derived parameters of dyssynchrony cannot be recommended on a routine basis since clinical utility has not been established Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 60

2012 CCS Heart Failure Management Guidelines Update Practical tip • The use of CRT may prevent worsening in patients with LV systolic dysfunction who require permanent pacing and who are expected to have a high burden of ventricular pacing Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 61

2012 CCS Heart Failure Management Guidelines Update The ACEI-ARB-MRA Dilemma Jonathan Howlett MD Disclosures at www. hfcc. ca Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 62

2012 CCS Heart Failure Management Guidelines Update Questions … prepare to provide your answers! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 63

2012 CCS Heart Failure Management Guidelines Update Case 1. 34 year old female with NYHA FC II HF with LVEF 29% BP 130/70, HR 63, Na 139, Creat 100, K+ 4. 0 On BB, ACE, diuretic target doses. Which drug should you start next? A. B. C. D. ARB Aldo Inhibitor Neither Does not matter, going for device anyway Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 64

2012 CCS Heart Failure Management Guidelines Update Case 2. 64 year old female with NYHA FC I HF with LVEF 29% BP 160/70, HR 63, Na 139, Creat 100, K+ 4. 2 On BB, ACE, CCB, diuretic target doses. Which drug should you start next? A. B. C. D. ARB Aldo Inhibitor Neither Both Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 65

2012 CCS Heart Failure Management Guidelines Update Case 3. 84 year old female with NYHA FC IIIb HF with LVEF 29% BP 100/70, HR 70, Na 139, Creat 160, K+ 4. 7 On BB, ACE, Digoxin, diuretic optimal doses. Which drug should you start next? A. B. C. D. ARB Aldo Inhibitor Neither- I will use nitrates preferentially Both Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 66

2012 CCS Heart Failure Management Guidelines Update When to Use ARBs as Add-on Therapy? • In patients with persistent HF symptoms, and who are at increased risk of HF hospitalization, despite optimal treatment with ACE inhibitors and betablockers (Class I, Level A) CHARM – Proportion of patients with CV death or hospital admission for CHF Val-He. FT – Probability of freedom from combined endpoint (All-cause mortality, cardiac arrest with resuscitation, hospitalization for worsening HF, or therapy with intravenous inotropes or vasodilators) Pfeffer MA et al. Lancet 2003; 363: 759 -66. Cohn JN et al. N Engl J Med 2001; 345: 1667 -75. Arnold JMO et al. Can J Cardiol 2006; 22(1): 23 -45. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 67

2012 CCS Heart Failure Management Guidelines Update CHARM-Added Permanent study drug discontinuations Placebo Percent of patients 20 Candesartan 24. 2 25 What are the effects of Spiro? 18. 3 15 10 7. 8 5 3. 1 4. 5 4. 1 3. 4 0. 7 0 AE/ lab. abnorm. Hypotension Increased creatinine Increased potassium p=0. 0003 p=0. 079 p=0. 0001 p<0. 0001 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 68

2012 CCS Heart Failure Management Guidelines Update 2006 Recommendation • Patients with LVEF 30% and severe symptoms despite optimized otherapies (Class I, Level B) • Or with AHF with an LVEF less than 30% following acute myocardial infarction (Class IIa, level B) Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 69 69

2012 CCS Heart Failure Management Guidelines Update EMPHASIS: Baseline Characteristics Characteristic Eplerenone (N=1364) Placebo (N=1373) 68. 7 (7. 7) 68. 6 (7. 6) 22. 7% 21. 9% 70 68 124 ± 17/75 ± 10 124± 17/75± 10 Atrial fibrillation or flutter – % 30 32 Diabetes mellitus— no. (%) 34 29 Serum Creatinine – mg/dl 1. 14 (0. 30) 1. 16 (0. 31) Estimated GFR ml/min/1. 73 m 2 71. 2 (21. 9) 70. 4 (21. 7) < 60 ml/min/1. 73 m 2 – no. (%) 32 35 Serum Potassium – mmol/liter 4. 3 (0. 4) Mean age — yr Female sex — % Ischemic heart disease – % Blood pressure – mm Hg Zannad, NEJM 2011; 364: 11 -21 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 70

2012 CCS Heart Failure Management Guidelines Update EMPHASIS: Primary Endpoint 356 (25. 9) 253 (18. 4) 249 (18. 3) 164 (12. 0) 213 (15. 5) 171 (12. 5) *Unadjusted HR, 0. 78; 0. 64, 0. 95; p=0. 01 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 71 71

2012 CCS Heart Failure Management Guidelines Update Patient Follow-up and Dosing Eplerenone Placebo 16. 3% 16. 6% Discontinuations for AE – n (%) 188 (13. 8%) 222 (16. 2%)* Mean dose at month 5 (mg/day) 39. 1 ± 13. 8 40. 8 ± 12. 9 Discontinuations in surviving patients (%) * p = 0. 09 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 72

2012 CCS Heart Failure Management Guidelines Update Recommendation 2011 • We recommend that an aldosterone receptor blocking agent such as eplerenone be considered for patients with mild to moderate (NYHA II) HF, aged > 55 years with LV systolic dysfunction (LVEF < 30%, or if LVEF is 30% and 35% with QRS duration >130 ms), and recent hospitalization for CVD or elevated BNP/NT-pro. BNP levels, who are on standard HF therapy • (Strong Recommendation, High-Quality Evidence) Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 73

2012 CCS Heart Failure Management Guidelines Update • • • Combination RAAS Blockade- Options Add an ARB Mean BP reduction 5 -7 / 3 -5 mm. Hg Mean Δ in creatinine < 30 umol/L Mean Δ in potasssium 0. 3 Mmol/L Reduction in CHF/CV Death in Mild/mod HF Evidence with triple therapy · · · Combination RAAS Blockade Add Spironolactone Mean BP reduction -1 to +5/ _1+3 mm. Hg Mean Δ in creatinine < 50 umol/L Mean Δ in potasssium 0. 5 - 0. 9 Mmol/L Trials stopped early in ‘enhanced moderate HF’ No evidence in triple therapy 2020 -10 -29 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 Copyright © 2013, Canadian Cardiovascular Society 74

2012 CCS Heart Failure Management Guidelines Update But we vote with our feet! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 75

2012 CCS Heart Failure Management Guidelines Update Fonarow, Circulation 2011. ; p 1601 -10 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 76

2012 CCS Heart Failure Management Guidelines Update CHF Clinics Increased use of EBM versus Community- the First 1933 Patients First visit from Community (n= 1155) Previously seen in clinic (n= 778) P value Age (SD) 62 (16) 63 (14) ns LVEF (SD) 30 (14) 31 (14) ns ACE inhibitor (%) 79 81 ns ACE inhibitor (% at target) 25 60 0. 01 Diuretic (%) 49 66 0. 01 Beta Blocker (%) 49 58 0. 01 Aldo Antagonist (%) 15 30 0. 01 EB Therapy J Card Fail, Volume 7, Issue 3 Suppl 2, p. 90 (2001) Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 77

2012 CCS Heart Failure Management Guidelines Update Impact of HF Clinic Care on LVEF in Canadians with HF • • • 21 Clinics with data from 1999 -2010 599 patients with LVEF data at 0, 1, 2 years 74% male, 63% ischemic etiology Measurement Baseline Assessment (SD) Year 1 follow Year 2 follow P value baseline up (SD) to 2 years (SD) LVEF 32 (14) 38 (15) 38 (14) p< 0. 001 Improve by > 20% baseline 30 (14) 31 (14) p< 0. 001 Improve by >10% ACE inhibitor (%) 79 81 p< 0. 001 ACE use 54% 69% p< 0. 001 ACE or ARB 70% 93% 95% p< 0. 001 Beta blocker use 63% 85% p< 0. 001 Aldo Antagonist 21% 35% 45% P< 0. 001 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Eur Heart J 2011; 32 (suppl 1) Copyright © 2013, Canadian Cardiovascular Society 78

2012 CCS Heart Failure Management Guidelines Update Management of Patients with HF and Acute Intercurrent Medical Illness • HF patients with an acute dehydrating illness of any kind should undergo prompt evaluation (electrolytes, BUN, Crcl). • If diarrhea or vomiting occurs, the aldosterone blocker should be stopped until resolution. • Caution is also necessary when there are other potential causes of dehydration, including increase in diuretic dose. Canadian Cardiovascular Society Consensus Conference recommendations update 2007 American College of Cardiology Foundation/American Heart Association practice guidelines 2009 Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 79 79

2012 CCS Heart Failure Management Guidelines Update Suggested addition……. • Most of the time, the Aldosterone Antagonist is the way to go • Monitoring is the most important aspect of Rx • Triple therapy is discouraged outside special circumstances • Role for ARBs if: – Very high BP – Difficulty with K+ high – Cannot tolerate AA due to side effects – Osteoarthritis? Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 80

2012 CCS Heart Failure Management Guidelines Update Should all patients with HF exercise and how? Eileen O’Meara, M. D. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 81

2012 CCS Heart Failure Management Guidelines Update Question … prepare to provide your answer! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 82

2012 CCS Heart Failure Management Guidelines Update EXERCISE TRAINING IN CHRONIC HEART FAILURE QUESTION 1. TRUE OR FALSE? All patients with stable New York Heart Association (NYHA) class I-III should be considered for enrolment in a tailored exercise training program, in order to improve exercise tolerance and quality of life. A. True B. False Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 83

2012 CCS Heart Failure Management Guidelines Update The benefits of rehabilitation in HF It is now well recognized that exercise-based cardiac rehabilitation programs for patients with HF improve exercise capacity, skeletal and respiratory muscle function, quality of life, autonomic function, biomarkers, and reduce depressive symptoms as well as cardiovascular risk factors. Piepoli MF et al. Eur J Heart Fail 2011; 13(4): 347– 357. Vanhees L et al. Eur J Cardiovasc Prev Rehabil 2011. Based on the results of prior studies of exercise training, the Canadian Cardiovascular Society has adopted recommendations that physical activity be considered for stable patients with systolic dysfunction. Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 2006; 22(1): 23– 45. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 84

2012 CCS Heart Failure Management Guidelines Update The HF-ACTION trial Ø The HF-ACTION trial demonstrated no significant reduction in the combined endpoint of all-cause mortality or hospitalization (hazard ratio, 0. 93; 95% confidence interval, 0. 84– 1. 02; P=0. 13). Ø After adjusting for 4 covariables associated with an increase in the primary endpoint and for HF etiology, exercise training was found to reduce the incidence of all-cause mortality or all-cause hospitalization by 11% (HR, 0. 89; 95% CI, 0. 81– 0. 99; P = 0. 03). Ø exercise training conferred modest but statistically significant improvements in self-reported health status. O’Connor CM et al. JAMA 2009; 301: 1439– 1450. Flynn KE et al. JAMA 2009; 301: 1451– 1459. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 85

2012 CCS Heart Failure Management Guidelines Update The case of Madame T… • 2007: 42 y. o. patient presents with EF 38% and sustained VT. No significant CAD on angio. • Diagnosis: Familial cardiomyopathy • 2007 - A defibrillator is implanted i. e. secondary prevention and medical therapy is optimized • 2008: EF increased to 45% • 2010: EF is 50% on echocardiogram • 2010 – Amiodarone is stopped since patient fears the side effects and EF is now « normalized » • She undergoes a treadmill test prior to exercise training in November 2010… Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 86

2012 CCS Heart Failure Management Guidelines Update Sinus tachycardia then multiple PVCs then VT Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 87

2012 CCS Heart Failure Management Guidelines Update Question … prepare to provide your answer! Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 88

2012 CCS Heart Failure Management Guidelines Update Question 2. Select the best answer? A. She had ischemia and this should have been investigated by another test B. The adrenaline surge during the test lead to ventricular tachycardia and the defibrillator shocks were appropriate C. The treadmill test should have been stopped before her heart rate reached the programmed VT zone so she would not receive shocks D. She should not be allowed to reach this level of exercise even if she did not have a defibrillator anyway E. She should have been on amiodarone or a higher dose of beta-blockers Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 89

2012 CCS Heart Failure Management Guidelines Update PATIENT EVALUATION PRIOR TO AN EXERCISE PROGRAM The following should be obtained prior to a tailored exercise training program: Ø An assessment of clinical status by a clinician experienced in the management of heart failure patients should be completed Ø Establish if the patient has an ICD and if yes, verify if previous shocks have been delivered and note the programmed VT zone Ø Exercise test (evaluate ischemia, arrhythmias, rate responses of patients with pacemakers, and determine training heart rate ranges) Ø Non-cardiac causes of dyspnea or musculoskeletal disorders may limit exercise tolerance and should be evaluated Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 90

2012 CCS Heart Failure Management Guidelines Update Madame T: Actions and Reactions She complained to the hospital authorities and had to receive the help of a psychologist to cope with the fear of defibrillator shocks. The technician was unaware of how to prepare a patient with a defibrillator for a treadmill test and the attending physician should have supervised more closely in preparation for the test. A written protocol was made to ensure that this would not happen again. The patient was satisfied with the procedure. She began training again about 1 year later and still sees her cardiologist in that same hospital. Current EF is 45% (July 2012 echocardiogram) Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 91

2012 CCS Heart Failure Management Guidelines Update Treadmill test protocol for patients with defibrillators Ø The indication for the treadmill test should be clearly described and the patient must be flagged as having a defibrillator Ø Defibrillator programmation will be verified immediately prior to the treadmill test Ø Maximal HR will be the programmed HR for VT therapy minus 20 beats per minute. The test should be stopped immediately as that HR is reached. Ø All pharmacological treatments should be continued (especially beta-blockers and antiarrhythmics) Ø No adjustment to the defibrillator programmation should be made in view of the treadmill test Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 92

2012 CCS Heart Failure Management Guidelines Update Exercise Training in Stable HF is SAFE A stepwise approach to exercise training in stable HF is suggested, including: Ø Cardiopulmonary/exercise testing is used for safety assessment and exercise prescription. Ø Initial supervision ensures safety of the prescribed program and may help patients understand their limits. For patients who prefer home-based exercise, after a minimum of 6 -8 supervised sessions, exercise training may continue with a home-based program. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 93

2012 CCS Heart Failure Management Guidelines Update Aerobic Exercise Training Prescription Moderate-intensity continuous aerobic exercise training at rate of perceived exertion (RPE) 3 -5 (Figure), 65 -85% maximum heart rate, and 50 -75% peak V 02 is recommended in HF patients Exercise program schedule in stable patients should begin with aerobic exercise training, 10 -15 minutes in duration, 2 -3 days per week frequency, before gradually increasing training to a target of 30 minutes, 5 days per week. Walking, treadmill, and stationary cycling can be chosen as primary training modes. Moderate-intensity aerobic interval training may be incorporated into the ET program in selected, stable HF patients. Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 94

2012 CCS Heart Failure Management Guidelines Update Thank you and questions Mc. Kelvie RS, Moe GW et al. , Can J Cardiol 2013 Feb; 29(2): 168 -181 2020 -10 -29 Copyright © 2013, Canadian Cardiovascular Society 95