The 2013 Canadian Cardiovascular Society Heart Failure Management

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The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Rehabilitation and

The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Rehabilitation and Exercise and Surgical Coronary Revascularization

Disclaimer The Canadian Cardiovascular Society (CCS) welcomes reuse of our educational slide deck for

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. Heart Failure Guidelines

CCS Heart Failure Guidelines 2013 Update Primary Panel Gordon W. Moe, (Chair) Justin A.

CCS Heart Failure Guidelines 2013 Update Primary Panel Gordon W. Moe, (Chair) Justin A. Ezekowitz, (Co-Chair) Eileen O’Meara Jonathan G. Howlett Steve Fremes Abdul Al-Hesayen George A. Heckman Anique Ducharme Adam Grzeslo Karen Harkness Serge Lepage Michael Mc. Donald Robert Mc. Kelvie Anil Nigam Miroslaw Rajda Vivek Rao Elizabeth Swiggum Sean Virani Estrellita Estrella-Holder Vy Van Le Shelley Zieroth Heart Failure Guidelines

CCS Heart Failure Guidelines 2013 Update Secondary Panel Simon Kouz J. Malcolm O. Arnold

CCS Heart Failure Guidelines 2013 Update Secondary Panel Simon Kouz J. Malcolm O. Arnold Tom Ashton Michel D’Astous Paul Dorian Nadia Giannetti Haissam Haddad Debra L. Isaac Marie-Hélène Leblanc Peter Liu Heather J. Ross Bruce Sussex Michel White Heart Failure Guidelines

Surgical Coronary Revascularization

Surgical Coronary Revascularization

Recommendations - Surgical Coronary Revascularization in Heart Failure We recommend that non-invasive imaging for

Recommendations - Surgical Coronary Revascularization in Heart Failure We recommend that non-invasive imaging for patients with heart failure be considered in order to determine the presence or absence of coronary artery disease. Strong Recommendation Moderate Quality Evidence Values and Preferences: This recommendation places value upon identification of coronary artery disease, which may identify the cause of heart failure, have prognostic implications and require treatments aimed toward secondary vascular prevention. Heart Failure Guidelines

Recommendations - Revascularization Procedures Assessment for Coronary Disease We recommend that coronary angiography be:

Recommendations - Revascularization Procedures Assessment for Coronary Disease We recommend that coronary angiography be: a)Performed in patients with heart failure with ischemic symptoms and who are likely to be good candidates for revascularization. b)Considered in patients with systolic heart failure (LVEF < 35%), at risk of coronary artery disease, irrespective of angina, who may be good candidates for revascularization. Strong Recommendation Moderate Quality Evidence Strong Recommendation Low Quality Evidence Heart Failure Guidelines

Recommendations - Revascularization Procedures Assessment for Coronary Disease We recommend that coronary angiography be:

Recommendations - Revascularization Procedures Assessment for Coronary Disease We recommend that coronary angiography be: c) Considered in patients with systolic heart Strong Recommendation failure and in whom non-invasive coronary Moderate Quality Evidence perfusion testing yields features consistent with high risk. Values and Preferences: These recommendations place value on the need of coronary angiography to identify coronary artery disease amenable to revascularization. Available evidence suggests that coronary revascularization may provide quality of life and prognostic benefits to patients with heart failure and non-invasive imaging delineating high risk. In particular, patients with systolic heart failure due to ischemic heart disease may derive clinical benefit from coronary revascularization even in the absence of angina or reversible ischemia. Heart Failure Guidelines

Practical Tips Revascularization Procedures Imaging 1. Several non-invasive methods for detection of coronary artery

Practical Tips Revascularization Procedures Imaging 1. Several non-invasive methods for detection of coronary artery disease are in widespread use, including: • Dobutamine stress echocardiography (DSE) • perfusion cardiac magnetic resonance (CMR) • cardiac positron emission testing (PET) • nuclear stress imaging Local factors (availability, price, expertise, practice patterns) will determine the optimal strategy for imaging. 2. Non- invasive imaging modalities may provide critical information such as the amount and degree of ischemic or hibernating myocardium, and may be used to determine the likelihood of regional and global improvement in left ventricular systolic function following revascularization. Heart Failure Guidelines

Practical Tips (cont’d) Revascularization Procedures Imaging 3. Patients with heart failure and reduced LVEF

Practical Tips (cont’d) Revascularization Procedures Imaging 3. Patients with heart failure and reduced LVEF are more likely to experience significant improvement in LVEF following successful coronary revascularization if they demonstrate: a) Reversible ischemia or a large segment of viable myocardium (> 30% of the left ventricle) by nuclear stress testing/ viability study; b) Reversible ischemia or >7% hibernating myocardium on PET scanning; c) Reversible ischemia or > 20% of the left ventricle shown as viable by DSE; Heart Failure Guidelines d) <50% wall thickness scarring as shown by late gadolinium

Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care We recommend that the

Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care We recommend that the decision to refer patients with heart failure and ischemic heart disease for coronary revascularization should be made on a individual basis and in consideration of all cardiac and non- cardiac factors which affect procedural candidacy. Strong Recommendation Low Quality Evidence We recommend that efforts be made to optimize medical status prior to coronary revascularization, including optimizing intravascular volume medical therapy. Strong Recommendation Low Quality Evidence Heart Failure Guidelines

Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care We recommend that performance

Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care We recommend that performance of coronary Strong Recommendation revascularization procedures in patients with Low Quality Evidence chronic heart failure and reduced left ventricular ejection fraction be undertaken with a medicalsurgical team approach with experience and expertise in high risk interventions. Values and Preferences: This recommendation reflects the preference that high risk revascularization is best performed in higher volume centers with significant experience, and known, published outcomes. Heart Failure Guidelines

Practical Tip Revascularization Procedures Disease Management, Referral and Peri-operative Care 1. Assessment for advanced

Practical Tip Revascularization Procedures Disease Management, Referral and Peri-operative Care 1. Assessment for advanced heart failure therapies, by an appropriate team, should be performed prior to revascularization procedure in any patient with advanced heart failure Heart Failure Guidelines

Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF We recommend

Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF We recommend consideration of coronary artery bypass surgery for patients with chronic ischemic cardiomyopathy, left venticular ejection fraction < 35%, graftable coronary arteries and who are otherwise suitable candidates for surgery, irrespective of the presence of angina and heart failure symptoms in order to improve quality of life, cardiovascular death and hospitalization. Strong Recommendation Moderate Quality Evidence Heart Failure Guidelines

Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF We suggest

Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF We suggest consideration of percutaneous coronary intervention for patients with heart failure and limiting symptoms of cardiac ischemia, and for whom CABG is not considered appropriate. Conditional Recommendation Low Quality Evidence Heart Failure Guidelines

Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF We recommend

Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF We recommend against routine performance of surgical ventricular restoration for patients with heart failure undergoing CABG who have akinetic or dyskinetic segments. Strong Recommendation Moderate Quality Evidence Values and Preferences: These recommendations are based on data from RCTs on CABG and surgical ventricular restoration on patients with reduced systolic function and CAD. The recommendation on percutaneous coronary intervention is based on clinical need rather than RCT trial data. Heart Failure Guidelines

Practical Tips Revascularization Procedures Surgical Revascularization for Patients with IHD and HF 1. In

Practical Tips Revascularization Procedures Surgical Revascularization for Patients with IHD and HF 1. In the setting of heart failure, angina and single territory coronary artery disease, PCI may be the treatment of first choice. However, PCI has not been shown to improve outcomes for patients with chronic stable heart failure, irrespective of underlying anatomy. 2. In contrast to the chronic stable patient with heart failure, urgent directed culprit vessel angioplasty continues to be the revascularization modality of choice for patients with acute coronary syndrome complicated by heart failure. 3. In highly selected cases, patients with advanced heart failure symptoms in association with large areas of dyskinetic and non-viable myocardium may experience clinical improvement with SVR or similar type procedures, when performed by experienced surgeons. 4. Mitral valve repair, when used concomitantly during CABG, may lead to clinical improvement in symptoms of heart failure in highly selected cases. Heart Failure Guidelines

Recommendations - Revascularization Procedures Device Considerations in HF Patients Following Cardiac Surgery We recommend

Recommendations - Revascularization Procedures Device Considerations in HF Patients Following Cardiac Surgery We recommend that following successful cardiac surgery, patients with heart failure undergo assessment for implantable cardiac devices within 3 -6 months of optimal treatment. Strong Recommendation High Quality Evidence We recommend that patients with implantable cardiac devices in situ should be evaluated for programming changes prior to surgery and again following surgery, in accordance with existing CCS recommendations. Strong Recommendation Low Quality Evidence We recommend that following successful cardiac surgery, all patients be referred to a local cardiac rehabilitation program. Strong Recommendation High Quality Evidence Values and Preferences: These recommendations reflect our support of and conformity with pre-existing cardiac device and rehabilitation guidelines statements. Heart Failure Guidelines

Practical Tips Revascularization Procedures Device Considerations in HF Patients Following Cardiac Surgery 1. During

Practical Tips Revascularization Procedures Device Considerations in HF Patients Following Cardiac Surgery 1. During surgical revascularization, consideration can be given to implantation of epicardial left ventricular leads to facilitate biventricular pacing in eligible patients who may be candidates for cardiac resynchronization therapy, especially if the coronary sinus anatomy is known to be unfavourable for lead placement. 2. Patients with heart failure and who have successful surgical coronary revascularization can be referred to a cardiac rehabilitation program. Heart Failure Guidelines

Approach to Assessment for Coronary Artery Disease in Patients with Heart Failure Angina or

Approach to Assessment for Coronary Artery Disease in Patients with Heart Failure Angina or angina equivalent symptoms? Is the patient a suitable risk for surgical revascularization? Coronary angiography* Is the patient a suitable risk for surgical revascularization? Non-invasive rest and stress imaging according to local preferences# Either a) non-invasive rest and stress imaging according to local preferences or b) directly to coronary angiography Is patient potential candidate for PCI? Non-invasive rest and stress imaging according to local preferences# Heart Failure Guidelines Medical therapy^

Decision Regarding Coronary Revascularization in Heart Failure Angina or ischemic equivalent? Acceptable risk for

Decision Regarding Coronary Revascularization in Heart Failure Angina or ischemic equivalent? Acceptable risk for surgical revascularization? Surgical revascularization most appropriate given coronary anatomy? * Surgical Revascularization PCI focus on culprit artery using non-invasive approach or I. C. Flowire Anatomy acceptable for PCI? PCI, +/- directed by non-invasive imaging or I. C. Flowire Evidence of extensive ischemia on noninvasive imaging AND/OR another cardiac surgery i. e. AVR indicated? Is LVEF < 35%? ? Medical therapy Anatomy appropriate for surgical revascularization OR another cardiac surgery indicated i. e. AVR? Surgical Revascularization +/- other indicated procedure Is surgical revascularization most appropriate given coronary anatomy? * Medical therapy# Heart Failure Guidelines Surgical revascularization Medical therapy#

Exercise Training and Heart Failure

Exercise Training and Heart Failure

Recommendations - Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure

Recommendations - Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure We recommend that all patients with stable New York Heart Association class I-III symptoms be considered for enrolment in a supervised tailored exercise training program, in order to improve exercise tolerance and quality of life. Strong Recommendation Moderate Quality Evidence Values and Preferences: This recommendation places a high value on improvements in non-morbid outcomes and recognizes that not all patients will be able to participate in a structured exercise training program due to patient preferences or availability of resources. Heart Failure Guidelines

Recommendations - Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure

Recommendations - Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure We recommend that an assessment of clinical status by a clinician experienced in the management of heart failure patients be completed prior to considering an exercise training program. Strong Recommendation Low Quality Evidence Values and Preferences: This recommendation places a high value on clinician’s assessment of both the clinical stability of a patient and their appropriateness to start exercise, recognizing that most patients will be eligible to participate. Heart Failure Guidelines

Practical Tip Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure

Practical Tip Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure Adherence to an Exercise Program 1. Frequent reinforcement, including letters, phone calls and home visits, may enhance adherence to exercise. 2. Identifying and addressing patient-specific barriers may aid in the uptake of exercise for patients. 3. Once a home-based program is initiated, more frequent follow-up visits and occasional supervised “refresher” sessions to answer questions, review concerns or modify the training program may give patients the guidance needed to ensure that home-based cardiac rehabilitation is successful. Heart Failure Guidelines

Recommendations Rehabilitation and Exercise in HF Cardiac Rehabilitation Programs for Patients with Recently Decompensated

Recommendations Rehabilitation and Exercise in HF Cardiac Rehabilitation Programs for Patients with Recently Decompensated or Advanced Heart Failure We recommend that gradual mobilization and/or Strong Recommendation small muscle group strength/flexibility Low Quality Evidence exercises be considered as soon as possible either alone or in combination for patients with New York Heart Association class IV symptoms or recently decompensated heart failure. This should be considered only in consultation with an experienced heart failure team. Values and Preferences: This recommendation places high value on initiating mobilization and therapy early (even if only limited exercises are prescribed) in order to prevent further decline of muscle function, improve function during day to day activities and provide a baseline from which to add further exercise modalities. Heart Failure Guidelines

Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation Programs for Patients with Recently

Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation Programs for Patients with Recently Decompensated or Advanced Heart Failure 1. Selected patients may benefit from limited exercise therapy, such as lowerextremity or inspiratory muscle strengthening, directed towards alleviating symptom of muscle fatigue. Heart Failure Guidelines

Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation in Heart Failure with Preserved

Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation in Heart Failure with Preserved Ejection Fraction 1. Until data specific for patients with heart failure and preserved ejection fraction are available, exercise programs using a similar approach to patients with impaired systolic function may be considered in patients with heart failure and preserved ejection fraction. Heart Failure Guidelines

Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation in Patients with Cardiac Resynchronization

Practical Tip Rehabilitation and Exercise in HF Cardiac Rehabilitation in Patients with Cardiac Resynchronization Therapy and Implantable Cardioverter Defibrillators 1. Exercise training is safe and not associated with an increased risk of ICD therapy. The maximal target HR should be at least 20 beats below the ICD intervention heart rate to avoid inappropriate ICD shocks. Heart Failure Guidelines

Practical Tip Rehabilitation and Exercise in HF Exercise in Frail Senior with Heart Failure

Practical Tip Rehabilitation and Exercise in HF Exercise in Frail Senior with Heart Failure 1. Frail seniors with heart failure should be offered multi-component (endurance and resistance, balance) tailored exercise programs appropriate for their comorbidities. Heart Failure Guidelines

Recommendations - Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in Heart

Recommendations - Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in Heart Failure We recommend moderate-intensity continuous Strong Recommendation aerobic exercise training (e. g. brisk walking, Moderate Quality Evidence jogging, and cycling) at rate of Modified Borg Rating Perceived Exertion (RPE) scale 3 -5, 6585% maximum heart rate, or 50 -75% of peak VO 2 in patients with heart failure. Values and Preferences: This recommendation places a high value on using commonly available measurements to assist in developing the exercise prescription. The priority is safety, hence, if a patient has a history of ICD discharges, exercise should be avoided if a short loss of consciousness is dangerous, i. e. swimming and activities associated with an increased risk of falling. Heart Failure Guidelines

Practical Tip Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF

Practical Tip Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF Strength Training 1. For strength training, the use of light (5 -10 lbs) free weights for 10 -20 repetitions 2 to 3 times per week may improve muscle tone and strength. Heart Failure Guidelines

Practical Tip Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF

Practical Tip Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF Interval Training 1. Interval training sessions should use 15 -30 s exercise intervals (RPE 3 -5) with rest intervals of equal duration and may last 15 -30 seconds. Heart Failure Guidelines

Practical Tips Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF

Practical Tips Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF Aerobic Exercise Training Intensity 1. The Modified Borg RPE scale and % HRmax are easier to use in practice than equations based on heart rate reserve (HRR) or measurement of peak VO 2. Heart Failure Guidelines

Rate of Perceived Exertion (RPE)* Sing – Talk –Gasp Test Maximal Gasp: breathing heavily

Rate of Perceived Exertion (RPE)* Sing – Talk –Gasp Test Maximal Gasp: breathing heavily Talk: enough breath to carry a conversation Sing: Enough breath to sing 10 9 8 7 6 very, very hard 5 4 3 hard somewhat hard moderate 2 1 0. 5 0 very hard easy very, very easy nothing at all *Modified Scale adapted by Borg Heart Failure Guidelines

Table: Exercise Modalities According to Clinical Scenario Discharged with Heart Failure Flexibility Exercises Aerobic

Table: Exercise Modalities According to Clinical Scenario Discharged with Heart Failure Flexibility Exercises Aerobic Exercises • Suggested modality Recommended • Selected population only • Supervision by an expert team needed (see text) • • Walk Treadmill Ergocycle Swimming Recommended • Selected population only • Supervision by an expert team needed (see text) • Starting with 2 -3 days/week • Goal: 5 days/week • Frequency • Intensity • Frequency Recommended NYHA IV Continuous training: Moderate intensity: • RPE scale 3 -5, or • 65 -855 HRmax, or • 50 -75% peak VO 2 Moderate intensity aerobic interval may be incorporated in selected patients • Intervals of 15 -30 seconds with a RPE scale of 3 -5 • Rest intervals of 15 -30 seconds • Intensity Isometric/Resistanc e Exercises NYHA I-III • Selected population only • Supervision by an expert team needed (see text) • Starting with 10 -15 minutes • Goal: 30 minutes • 10 -20 repetitions of 5 -10 pounds free • weights 2 -3 days/week • Selected population only • Supervision by an expert team needed (see text)