CHF_status
CHFCare.org stage, class, profile integration

 

Until recently heart failure was only described in terms based on the degree of symptoms a patient presented with. This approach misses patients with heart failure without symptoms and those at risk for developing heart failure, two groups who represent the vast majority of the heart failure population. The AHA staging system sought to correct this nomenclature deficit and follows the convention of oncology nomenclature for cancer. The use of stages of heart failure captures the notion that this is a progressive condition and it is not enough to treat symptoms but also efforts should be made to stop progression.

What is confusing to clinicians-especially those new to heart failure management-is how the AHA stages fit in with the old New York Heart Association (NYHA) classes and the profiles used by Interagency Registry of Mechanically Assisted Circulatory Support (INTERMACS) to stratify advanced patients. The best way to remember the relationships is to again go back to the CHF continuum above. Stage A and B patients do not have heart failure symptoms. When a patient develops symptoms they become stage C (even if those symptoms are treated and later go away).

The NYHA classes are used to describe the degree of symptoms experienced by patients in stage C and range from no symptoms (Class I), mild symptoms (class II), moderate symptoms (class III) or severe symptoms at rest (class IV). Patients with persistent severe symptoms (class IV) despite treatment are no longer considered stage C and are grouped into stage D. These patients with advanced heart failure symptoms sometimes need consideration of mechanical circulatory support and INTERMACS profiles were developed to further stratify patients. Unfortunately, unlike AHA stages and NYHA classes, INTERMACS profiles are numbered in reverse progression where profile 1 are the sickest patients and profile 7 are relatively stable patients.

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American Heart Association HF Stages

Stage A: High risk for developing heart failure due to presence of one or more risk factors (CAD, hypertension, diabetes, obesity, etc)

Stage B: Asymptomatic heart failure despite presence of damaged myocardium and LV dysfunction

Stage C: Symptomatic heart failure (from very little symptoms all the way to severe limitation with minimal exertion and at rest)

Stage D: Refractory end-stage heart failure (persistent symptoms at rest despite medical treatment)
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[tab title=”NYHA Classes”]

New York Heart Association Symptom Classes

The New York Heart Association class system identifies patients in AHA stage C (symptomatic heart failure) according to their physical limitations.

Class I: No limitations of physical activity, no symptoms with ordinary activities

Class II: Slight limitation, symptoms with ordinary activities

Class III: Marked limitation, symptoms with less than ordinary activities

Class IV: Severe limitation, symptoms of heart failure at rest
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[tab title=”INTERMACS Profiles”]

Interagency Registry of Mechanically Assisted Circulatory Support Profiles

Interagency Registry of Mechanically Assisted Circulatory Support or INTERMACS created a system of profiles that assesses the comprehensive status of patients with advanced heart failure takes into consideration therapeutic interventions and extenuating circumstances (modifiers). The profiles allow more uniform decision making with regard to which patients are in need of mechanical circulatory support and the immediacy of such need. The profiles range from 1 to 7 and are in reverse numerical progression with increasing numbers representing more stability.

(Definitions from INTERMACS worksheet)

INTERMACS 1: Critical cardiogenic shock

Describes a patient who is “crashing and burning”, in which a patient has life-threatening hypotension and rapidly escalating inotropic pressor support, with critical organ hypoperfusion often confirmed by worsening acidosis and lactate levels.

INTERMACS 2: Progressive decline

Describes a patient who has been demonstrated “dependent” on inotropic support but nonetheless shows signs of continuing deterioration in nutrition, renal function, fluid retention, or other major status indicator. Patient profile 2 can also describe a patient with refractory volume overload, perhaps with evidence of impaired perfusion, in whom inotropic infusions cannot be maintained due to tachyarrhythmias, clinical ischemia, or other intolerance.

INTERMACS 3: Stable but inotrope dependent

Describes a patient who is clinically stable on mild-moderate doses of intravenous inotropes (or has a temporary circulatory support device) after repeated documentation of failure to wean without symptomatic hypotension, worsening symptoms, or progressive organ dysfunction (usually renal).

INTERMACS 4: Resting symptoms

Describes a patient who is at home on oral therapy but frequently has symptoms of congestion at rest or with activities of daily living (ADL). He or she may have orthopnea, shortness of breath during ADL such as dressing or bathing, gastrointestinal symptoms (abdominal discomfort, nausea, poor appetite), disabling ascites or severe lower extremity edema. This patient should be carefully considered for more intensive management and surveillance programs, which may in some cases, reveal poor compliance that would compromise outcomes with any therapy.

INTERMACS 5: Exertion Intolerant

Describes a patient who is comfortable at rest but unable to engage in any activity, living predominantly within the house or housebound. This patient has no congestive symptoms, but may have chronically elevated volume status, frequently with renal dysfunction, and may be characterized as exercise intolerant.

INTERMACS 6: Exertion Limited

Describes a patient who is comfortable at rest without evidence of fluid overload, but who is able to do some mild activity. Activities of daily living are comfortable and minor activities outside the home such as visiting friends or going to a restaurant can be performed, but fatigue results within a few minutes of any meaningful physical exertion. This patient has occasional episodes of worsening symptoms and is likely to have had a hospitalization for heart failure within the past year.

INTERMACS 7: Advanced NYHA Class 3

Describes a patient who is clinically stable with a reasonable level of comfortable activity, despite history of previous decompensation that is not recent. This patient is usually able to walk more than a block. Any decompensation requiring intravenous diuretics or hospitalization within the previous month should make this person a Patient Profile 6 or lower.
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Choosing anticoagulation for HF and AFIB

As the population ages we are seeing more and more people with both atrial fibrillation (AF) and heart failure (HF). In fact some investigators have argued that there is a close relationship between the two. For example, we know from clinical experience that scarring of atrial tissue and increased filling pressures associated with HF can set up conditions that promote AF development. Similarly, AF with rapid ventricular response can precipitate an episode of decompensation and even persistent indolent AF is a suspected cause of tachycardia associated LV dysfunction and heart failure. But no matter how the two conditions came to be together it is clear that the risk of stroke in such patients is higher. Despite this increased risk many healthcare providers still regularly wrestle with the question of whether to anticoagulate elderly patients at all. Most of the hesitation comes from an exaggerated fear of the risk of bleeding. A popular boogeyman is “fall risk”. The possibility of a fall leading to bleeding, particularly in the head, is responsible for a sizable number of elderly patients being denied prophylaxis against stroke.

Non-Coumadin Oral Anticoagulants (NOACs)

The newer oral anticoagulants are advantageous in that the randomized clinical trials used by the FDA to approve them also showed each agent has a better intracranial bleeding profile than warfarin. Even the argument that these agents are not reversible in the event of a a serious bleed is now countered by the recent approval of a specific antidote for Pradaxa called Praxbind (marketed and sold by the same company). And it is believed that the other new oral anticoagulants also have antidotes in development. Importantly, these new agents, some of which have demonstrated significant superiority over warfarin (see Table 1), are also much more convenient and can be taken like any other medication without the need for regular blood testing.

The availability of these new agents should make consideration of anticoagulation for at-risk patients somewhat easier. And while the risk of falls is an important consideration in elderly patients, the very real and well documented risk of a potentially fatal or devastating stroke from AF in patients with advanced heart failure should equally give clinicians pause when making a decision to withhold anticoagulation.

Table 1. Summary of Comparison of NOACs with Coumadin (Warfarin)

Medication Superior stroke prevention  Less intracranial hemorrhage  Less overall bleeding  Antidote available
Pradaxa Yes Yes Yes
Xarelto same Yes No
Eliquis Yes Yes Yes No
Savaysa Yes Yes Yes No

Table 2. Dosing of NOACs for Atrial Fibrillation

Medication Brand Name   Afib Dose   Renal Adjustment
(GFR 15-30) 
Comments 
Dabigatran Pradaxa 150 mg BID 75 mg bid Praxbind: 2.5g/50ml  (max 5g)
Rivaroxaban Xarelto 20 mg QD 15 mg QD Take with meal
Apixaban Eliquis 5 mg BID 2.5 mg BID Used in renal failure
Edoxaban Savaysa  60 mg PO QD 30 mg PO QD 30 mg PO QD

 

 

Digoxin is one of the oldest medications utilized in contemporary medicine with its documentation dating back 200 years. HFSA guidelines state that digoxin may be considered to improve symptoms in patients with reduced LVEF (<40%) who have signs or symptoms of HF despite use of standard therapy (ACE inhibitors and beta blockers). The most recent ACC/AHA guidelines recommend digoxin for symptomatic chronic heart failure for patients with reduced systolic function (Class IIa recommendation).

The Digitalis Investigation Group (DIG) trial assessed all-cause mortality in patients in sinus rhythm with HF and reduced systolic function while receiving diuretics and ACE-inhibitors and found that although digoxin had neutral effects on mortality, digoxin use was associated with a 34% reduction in 30 day all-cause hospital admission. Studies have also shown that treatment with digoxin does not increase all-cause mortality in the first 30 days post-hospitalization. In fact, in the PROVED trial, patients in whom digoxin was discontinued had a two fold increase in worsening heart failure and a decrease in both exercise capacity and LVEF compared with patients who continued on digoxin therapy.

Low dose digoxin (0.125mg daily) resulting in a serum concentration level less than 1 ng/mL, has beneficial hemodynamic, neurohormonal, and clinical effects. The key to obtaining the most mortality benefit lies in maintaining the appropriate level of 0.5-0.9 ng/ml. A digoxin level above 1.0 actually is associated with an increase in mortality despite a level of >2.0 being considered as toxic. Women tend to be at increased risk of mortality on digoxin so it is practical to administer low doses of digoxin only in women with HF with EF below 40%. It typically takes 5 daily doses to achieve steady state and it is prudent to check a digoxin level at that point especially in the elderly, women and those with impaired renal function.

Caution should be observed when digoxin is administered with other medications that may potentiate its effects or increase the serum concentration level. Common cardiac offenders include amiodarone and verapamil. Hypokalemia is a common electrolyte imbalance in HF patients on diuretics and can result in dig toxicity.

Digoxin doses should be personalized for the patient. No loading dose is required. A dose of 0.125mg daily in a patient with normal renal function will generally result in a serum concentration level of ~0.8ng/ml. Alternative regimens for those at risk of toxicity include every other day dosing or low dose 0.0625mg daily.

 

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Dosage: 0.125mg PO QD ( Alternative regimens for those at risk of toxicity include every other day dosing or low dose 0.0625mg daily.)
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[pane title=”Guideline message”]
Digoxin is indicated in patients with moderate to severe HF who continue to have symptoms while on optimal doses of standard therapy.
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Beta blockers proven effective through clinical trials (bisoprolol, carvedilol, or sustained-release metoprolol succinate) are recommended for all hemodynamically stable patients without documented contraindications (Class I, Level A). Continue reading “All beta blockers are not equal: Selecting the right one for the right patient”