Heart Failure: Ten Years of HF Guidelines – Managing A Complex Disease in Canada

Heart Failure: Ten Years of HF Guidelines – Managing A Complex Disease in Canada


hello and thank you for joining us today i’m dr. justin zackham it’s from the university of alberta and co-director of the canadian vigor center I’m joined by dr. Eileen O’Meara from the Montreal heartis Institute who’s my co-chair of the Canadian heart fair guidelines today we’re going to be talking about ten years of guidelines from what we’ve learned and how we’ve done it we want people to understand the guideline process because it’s extremely vigorous it’s voluntary and its really developed over the last ten years as the Canadian cardiovascular society has taken hold of how we do our Canadian guidelines so we can practice better and provide our patients with the best possible care it’s a highly rigorous process and to do this we have to evaluate lots of evidence and sometimes come to an expert opinion as to what’s best for a clinical scenario so sometimes where there is no evidence we have to think about it carefully sometimes where there’s overwhelming evidence we can provide very strong guidance here are our disclosures first of all most of you refer patients or see patients in a very complicated way you sometimes decision initially see patients who are in the outpatient world and electively seeing them or sometimes very acutely so what we’ve come up with is a very simple way of thinking about the initial referral and then how fast do you have to see that patient first of all if you look at the very top you’ll see in the green as in the lowest risk patients that we usually see or outpatient elective referrals and those are often patients who are in YJ class two in their symptomatology or sometimes anyway chi class one and they need further evaluation those patients can often be seen in 12 weeks or ideally in six but we understand that there have a lower urgency as you go down through the yellow and then orange and red you’ll identify that these patients are of increasing urgency and obviously need to be seen in a timely fashion and we have some different time zones in which you have to see them sometimes within four weeks two weeks or within 24 hours at all times you should be making that best clinical judgment but be guided by their overall risk but also there’s symptomatology and how urgently you have to have them seen by a specialist care as well as the primary care when we see patients in clinic we often have to make a decision about the next step of therapy in patients with heart failure echocardiogram has been a go-to in terms of the diagnosis or evaluation of structure and function for heart failure so on this table you’ll see that when patients have new once at heart fair we do want patients to have an early and relatively immediate echocardiogram within the first two weeks of diagnosis or thinking it’s heart failure that’s achievable in most places in Canada but not all and we understand there are some limitations all echocardiograms are the recommended first modality of the of imaging others can be chosen such as mugga cardiac MRI and even others in consideration that you do need to do this relatively urgently on the flip side when patients are done up titrating their medical therapy so triple therapy has been instituted and a person is on those appropriate therapies then three months really is the right time window after that completion of therapy to reevaluate with an echocardiogram and ideally done at the same institution with the same readers or same group of readers so you can really compare what has changed in the same way we definitely want this to be sorted by a numerical quantification with the current technology that is highly possible that should be something like Simpsons method or another appropriate quantification method once people are relatively stable and they’ve gone on to their therapy and they’re doing well repeating the echocardiogram every two to three years is reasonable and especially this can be deferred if the ejection fraction is either recovered or it’s being preserved all along and then choosing a modality that’s appropriate for that patient and also being able to look at the previous echocardiogram Zoar in other imaging is quite important on the flip side if somebody is decompensated you certainly want to think about repeating the imaging because there’s be often a reason they’ve decompensated that you may not be aware of and something quick like an echocardiogram can help give us a window into what has happened so looking at that in in a relatively short timeframe is quite important so in terms of management strategy I’ll ask Ilene to talk about therapy Thank You Justin so there’s what we proposed in the companion to the heart failure guidelines and you can find all the details in that text but with for patients without VF 40% or less and symptoms of heart failure we first recommend to start triple therapy and to titrate that to the maximum tolerated dose or evidence-based dose and this of course includes ACE inhibitors or ARB if a sand tolerant beta blockers and MREs why we put MREs there it’s because there’s enough evidence in that low EF group even in preserved EF although this is not the algorithm for that but there’s evidence after a Meyer there’s evidence in severe heart failure and there’s evidence in less advanced heart failure and why a Class A two and so all the the patients should be on that triple therapy first and then we reassessed symptoms and if the patient has as has an OIG class one you continue triple therapy if an yhe class is two to four in sinus rhythm with a heart rate of 70 beats per minute or more and vibrating should be considered if and when available in Canada also consider switching the ace or ARB to secure virtual valsartan after the results of the paradigm hf trial for eligible patients if nyg is two to four in sinus rhythm but with a heart rate below seventy or an atrial fibrillation or the patient has a pacemaker then you consider switching the ace or ARB to secure virtual visit and again according to the paradigm hf2 our results then you reassess symptoms and that’s the moment to redo we measure lvf and if NYT class is one with our VF above 35 percent you continue the same management and we assess every one to three years or with a change in clinical status as Justin mentioned before if nyg is one two three and IVF of 35 percent Ola are less than you consider ICD and or CRT and refer to the appropriate guidelines from the Canadian cardiovascular society for that and consider LVS IVF reassessment every one to five years if n YT class is for that may be considered hydralazine nitrates and obviously consider referral for advanced heart failure therapy in terms of mechanical circulatory support or transplant and the advanced heart failure team should be contacted if the patient is considered for that kind of procedure then you reassess as needed according to clinical status can I ever stop heart failure therapy is a frequently asked question and we propose here five types of cardiomyopathies or conditions where this would be appropriate if an yg class is one and we’ve also included some other criteria and I won’t name everything on that slide but just to say this would be for tachycardia related cardiomyopathy alcoholic cardiomyopathy chemotherapy related cardiomyopathy pericardium cardiomyopathy or after valve replacement surgery and among the criteria that we’ve included in the comments you can consider lv dimensions namely and I will turn back to Justin for the conclusion thanks Eileen so thanks for joining us today we’re going to have a number of different modules come out over the coming period of time that’ll be based on our upcoming 2016-17 Canadian cardiovascular heart trio guidelines they are really built off 10 years of guidelines and the modules we created within those at 30 years of experience and practice and evidence that is accrued over that time so thanks very much for joining us today and we look forward to seeing you again thank you

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