Non-Pharmacologic Management in Heart

Failure

Cholid Tri Tjahjono, MD

Department of Cardiology and Vascular Medicine
Faculty of Medicine, Universitas Brawijaya
Saiful Anwar Teaching Hospital
I have no conflict of interest
Definition : Heart Failure
“The situation when the heart is incapable of
maintaining a cardiac output adequate to
accommodate metabolic requirements and the
venous return.“ E. Braunwald
“Pathophysiological state in which an abnormality of
cardiac function is responsible for the failure of the
heart to pump blood at a rate commensurate with the
requirements of the metabolizing tissues.” Euro Heart J; 2001.
22: 1527-1560
 Etiology of Heart Failure
• The most common causes of heart failure are coronary artery
disease, high blood pressure, and diabetes.
• HF is diagnosed on the presence of characteristic signs and
symptoms and not on the basis of any diagnostic tests
– Tests such as echocardiograms and cardiac stress testing establish
the pathophysiologic cause but do not define whether heart failure is
present or not
 Classification of Heart Failure
ACCF/AHA Stages of HF
A At high risk for HF but without structural
heart disease or symptoms of HF.
B Structural heart disease but without signs
or symptoms of HF.
C Structural heart disease with prior or
current symptoms of HF.
D Refractory HF requiring specialized
interventions.
ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)
NYHA Functional Classification
None
I No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
I No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
II Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
III Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
IV Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
 Stages, Phenotypes and Treatment of HF
At Risk for Heart Failure Heart Failure

STAGE A STAGE B STAGE C

At high risk for HF but Structural heart disease Structural heart disease STAGE D
without structural heart but without signs or with prior or current Refractory HF
disease or symptoms of HF symptoms of HF symptoms of HF

e.g., Patients with:

· HTN
· Atherosclerotic disease
e.g., Patients with: e.g., Patients with:
· DM Refractory
· Previous MI e.g., Patients with:
· Obesity Development of symptoms of HF · Marked HF symptoms at
Structural heart · LV remodeling including · Known structural heart disease and
· Metabolic syndrome disease
symptoms of HF at rest, despite rest
LVH and low EF · HF signs and symptoms
or
· Asymptomatic valvular
GDMT · Recurrent hospitalizations
Patients despite GDMT
disease
· Using cardiotoxins
· With family history of
cardiomyopathy

HFpEF HFrEF

THERAPY THERAPY THERAPY THERAPY THERAPY

Goals Goals Goals Goals Goals
· Control symptoms · Control symptoms
· Heart healthy lifestyle · Prevent HF symptoms · Control symptoms · Patient education · Improve HRQOL
· Prevent vascular, · Prevent further cardiac · Improve HRQOL · Prevent hospitalization · Reduce hospital
coronary disease remodeling · Prevent hospitalization · Prevent mortality readmissions
· Prevent LV structural · Prevent mortality · Establish patient’s end-
abnormalities Drugs Drugs for routine use of-life goals
· ACEI or ARB as · Diuretics for fluid retention
Strategies · ACEI or ARB Options
Drugs appropriate · Identification of comorbidities · Beta blockers · Advanced care
· ACEI or ARB in · Beta blockers as
· Aldosterone antagonists measures
appropriate · Heart transplant
appropriate patients for Treatment
vascular disease or DM · Diuresis to relieve symptoms Drugs for use in selected patients · Chronic inotropes
In selected patients · Hydralazine/isosorbide dinitrate · Temporary or permanent
· Statins as appropriate of congestion
· ICD · ACEI and ARB MCS
· Revascularization or · Follow guideline driven · Digoxin · Experimental surgery or
valvular surgery as indications for comorbidities, drugs
appropriate e.g., HTN, AF, CAD, DM In selected patients · Palliative care and
· Revascularization or valvular · CRT hospice
· ICD · ICD deactivation
surgery as appropriate
· Revascularization or valvular
surgery as appropriate

ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)

• Ponikowski P, et.al, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
Effects of deconditioning in heart failure
• Peripheral alterations : Increased peripheral vascular
resistance; impaired oxygen utilisation during exercise
• Abnormalities of autonomic control : Enhanced
sympathetic activation; vagal withdrawal; reduced
baroreflex sensitivity
• Skeletal muscle abnormalities : Reduced mass and
composition, Reduced functional capacity ;Reduced
exercise tolerance; reduced peak oxygen consumption
• Psychological effects : Reduced activity; reduced
overall sense of wellbeing
 Heart failure patients suffer
from recurrent hospitalization

With each hospitalization, there is

likely myocardial and renal damage
which contributes to progressive left
ventricular or renal dysfunction,
leading to an inevitable downward
spiral.1

1. Gheorghiade M et al. Am J Cardiol. 2005;96:11-17.

 Important points regarding HF management
 The number of patients with HF, as well as the cost to treat patients with HF, is
expected to increase in the future.

 All causes of HF must be evaluated, with consideration of multigenerational

family histories and genetic testing.

 Risk factors need to be continually addressed when managing a patient with HF:
hypertension, lipid disorders, obesity, diabetes mellitus, tobacco use, and known
cardiotoxic agents.

 There is a clear mortality benefit from using guideline-directed medical therapy.

Tami Ward MS, 2013, Exercise and Heart Failure

 Important points regarding HF management
 Anticoagulation should not be used in patients with chronic HFrEF with no risk factors (atrial
fibrillation, thromboembolic event, or cardioembolic source).

 Aim for control of systolic and diastolic blood pressures, as well as volume status, to treat
HFpEF.

 Re-evaluate patients with left ventricular EF ≤35%, New York Heart Association class II-IV, left
bundle branch block, and a QRS ≥150 ms for cardiac resynchronization therapy.

 HF education, dietary restrictions, and exercise training should be provided for all patients
to enhance self-care.

 A HF multidisciplinary team, including a palliative care team, should be involved when

treating patients with advanced HF.

Tami Ward MS, 2013, Exercise and Heart Failure

 Non-Pharmacologic Treatment for Heart Failure

• Advise heart failure patients to do moderate exercise, starting

in a supervised setting.
• Advise heart failure patients to limit their fluid and salt intake
and monitor their weight daily.
• Immunize heart failure patients against influenza and
pneumococcal pneumonia.
Nonpharmacological Interventions
I IIa IIb III
Patients with HF should receive specific education to
facilitate HF self-care.

I IIa IIb III

Exercise training (or regular physical activity) is
recommended as safe and effective for patients with HF who
are able to participate to improve functional status.

I IIa IIb III

Sodium restriction is reasonable for patients with
symptomatic HF to reduce congestive symptoms.

Yancy, CW et al.
2013 ACCF/AHA Heart Failure Guideline
Nonpharmacological Interventions (cont.)
I IIa IIb III
Continuous positive airway pressure (CPAP) can be beneficial
to increase LVEF and improve functional status in patients
with HF and sleep apnea.

I IIa IIb III

Cardiac rehabilitation can be useful in clinically stable
patients with HF to improve functional capacity, exercise
duration, HRQOL, and mortality.

Yancy, CW et al.
2013 ACCF/AHA Heart Failure Guideline, Circulation. 2013;128:000–000
ESC Guideline, 2012
Exercise training resulted in nonsignificant reductions in
the primary end point of all-cause mortality or
hospitalization and in secondary clinical end points
 Role of Exercise Training in HF
 Current Guidelines 2013:
◦ Class I
 Exercise training (or regular physical activity) is recommended as safe and
effective for patients with HF who are able to participate to improve functional
status
(Level of Evidence: A)

◦ Class IIa
 Cardiac rehabilitation can be useful in clinically stable patients with HF to
improve functional capacity, exercise duration, HRQOL, and mortality.
(Level of Evidence: B)
 Benefits with exercise and cardiac rehabilitation
• Improvement in exercise capacity after exercise training due to
peripheral adaptations (increased oxygen extraction)
• Improvement in quality of life
• Reduced hospitalizations and mortality
• Improved endothelial function
• Reduction in catecholamine levels

Tami Ward MS, 2013, Exercise and Heart Failure

 Risks to exercise
• Three major risk factors: age, presence of heart disease and
intensity of exercise
– Lowest incidence: walking, cycling and treadmill walking
– Least active patients are higher risk
– In HF patients, most common events include: post-exercise
hypotension, atrial and ventricular arrhythmias and worsening HF
symptoms

Tami Ward MS, 2013, Exercise and Heart Failure

 Relative Contraindications to Exercise in Stable HF
Patients
• Weight gain > 3 lb in 1-3 days
• Drop in systolic BP with exercise (marked/symptomatic)
• NYHA IV (can exercise selective patients)
• Complex ventricular arrhythmias
• Resting heart rate ≥ 100 bpm
• Pre-existing unstable co-morbidities

Tami Ward MS, 2013, Exercise and Heart Failure

 Absolute Contraindications to Exercise with Stable
HF Patients
• Progressive worsening of exercise intolerance (dyspnea at rest)
• Ischemia is suspected
• Severe AS or severe regurgitant valvular disease
• Acute systemic illness
• New onset afib
• Acute pericarditis/myocarditis/embolism
 Exercise Recommendations
Aerobic activity such as walking or cycling
Frequency – 3-5 days a week or most days
Intensity – 55-80% heart rate reserve with perceived exertion
Duration of each session – start at 5 minutes if needed and
progress to 30-60 minutes

Tami Ward MS, 2013, Exercise and Heart Failure

 Exercise Recommendations
 Cycling
◦ Allows low level workloads
◦ Easily reproducible
◦ May be safer with orthopedic or balance problems

 Walking
 Swimming
 yoga
 Interval training
 Flexibility and resistance training
Tami Ward MS, 2013, Exercise and Heart Failure
 Monitor and reduce fluid retention

• Advise all patients with symptomatic heart failure to limit their salt intake in
to 2-3 g daily (“no added salt”). [Level of Evidence: Class I, Level C]

• Advise those with more advanced heart failure and fluid retention to limit
their salt intake to 1-2 g daily (“low-salt”). [Level of Evidence: Class I, Level C]

• Ask patients with renal dysfunction or ongoing fluid retention to monitor

their daily morning weights and restrict fluid intake to 1.5-2 L daily. Patients
with hyponatremia should restrict their fluid intake similarly. [Level of
Evidence: Class I, Level C]
 Other interventions for heart failure patients

• Immunize eligible heart failure patients against pneumococcal

pneumonia and influenza as respiratory infections may worsen
heart failure. [Level of Evidence: Class I, Level C]

• Avoid use of the following therapies in heart failure patients:

– Vitamin and herbal remedies, coenzyme Q10 or chelation therapy. [Level
of Evidence: Class III, Level C]
– Continuous positive airway pressure for central sleep apnea. [Level of
Evidence: Class III, Level B]
– Enhanced external counterpulsation. [Level of Evidence: Class III, Level C]
 System considerations can have an impact on heart failure
outcomes

• Consider referring heart failure patients to a specialist if they have:

– recently been diagnosed or hospitalized,
– complications of heart failure or comorbidities (e.g. ischemia, hypertension,
valvular disease, syncope, renal failure), or
– poor response to drug therapy. [Level of Evidence: Class I, Level C]

• Consider using specialized hospital-based clinics or disease management

programs staffed by physicians, nurses, pharmacists and other health care
professionals with expertise in heart failure management for assessment
and management of higher risk patients with heart failure. [Level of
Evidence: Class I, Level A]
System considerations can have an impact on heart
failure outcomes

• Refer patients with recurrent heart failure hospitalizations to these

clinics for follow-up within four weeks of hospital discharge, or
sooner when feasible. [Level of Evidence: Class I, Level A]

• Multidisciplinary care should include close clinical follow-up,

patient and caregiver education, telemanagement or
telemonitoring, and home visits by specialized heart failure health
care professionals where resources are available. [Level of
Evidence: Class I, Level A]
• Referral to specialist care has been shown to: improve outcomes, reduce
hospitalisation and improve symptoms in people with CHF.
• GPs are ideally placed to coordinate ongoing care for people with CHF.
• • Referral to a specialist may be warranted when:
– the diagnosis is uncertain
– complex management (including comorbidities) is needed
– acute decompensation occurs
– help is needed to clarify the prognosis
– revascularisation, implantation of devices or heart and/or lung transplantation
are being considered
- the person is young (e.g. < 65 years of age).
Comprehensive Management of Heart Failure
Non-compliance with non-pharmacological recommendations in
HF patients is associated with adverse outcome
 Non Pharmacologic intervention (Surgical
intervention)
• Revascularizaton (Coronary artery bypass grafting)
• Per cutaneous coronary intervention (PCI)
• Valve replacement
• Biventricular pacemaker
• Heart transplantation
• Left ventricular assist device (LVAD)
 Summary
• Heart failure (HF) still has a poor outcome,
• Prognosis has improved considerably in the last decades by the
achievements in pharmacological and non-pharmacological
treatment.
• Patients should follow a low sodium diet, restrict the amount
of fluid, weigh themselves daily, follow recommendations on
exercise, and contact a healthcare provider in case of
worsening symptoms.