Therapy: Patients With Refractory End

Therapy: Patients With Refractory End-Stage HF (Stage D)

Overview of Stage D

Stage D
Refractory HF (heart failure) requiring specialized interventions
e.g., Patients who have marked symptoms at rest despite maximal medical therapy e.g., those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions)
Therapy Goals
- Appropriate measures under Stages A, B, C
- Decision re: appropriate level of care
Options
- Compassionate end-of-life care/hospice
- Extraordinary measures
- heart transplant
- chronic inotropes
- permanent mechanical support
- experimental surgery or drugs

Summary of therapy options - Stage D

Patients With Refractory End-Stage HF (Stage D)

Before a patient is considered to have refractory HF, physicians should confirm the accuracy of the diagnosis, identify any contributing conditions, and ensure that all conventional medical strategies have been optimally employed. Measures listed as Class I recommendations for patients in stages A, B, and C are also appropriate for patients in end-stage HF . When no further therapies are appropriate, careful discussion of the prognosis and options for end-of-life care should be initiated.

Recommendations

Class I

1. Meticulous identification and control of fluid retention is recommended in patients with refractory end-stage HF. (Level of Evidence: B)

2. Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF. (Level of Evidence: B)

3. Referral of patients with refractory end-stage HF to an HF program with expertise in the management of refractory HF is useful. (Level of Evidence: A)

4. Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory end-stage HF persist despite application of all recommended therapies. (Level of Evidence: C)

5. Patients with refractory end-stage HF and implantable defibrillators should receive information about the option to inactivate defibrillation. (Level of Evidence: C)

Class IIa

1. Consideration of an LV assist device as permanent or ?destination? therapy is reasonable in highly selected patients with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy. (Level of Evidence: B)

Class IIb

1. Pulmonary artery catheter placement may be reasonable to guide therapy in patients with refractory end-stage HF and persistently severe symptoms. (Level of Evidence: C)

2. The effectiveness of mitral valve repair or replacement is not established for severe secondary mitral regurgitation in refractory HF. (Level of Evidence: C)

3. Continuous intravenous infusion of a positive inotropic agent may be considered for palliation of symptoms in patients with refractory end-stage HF. (Level of Evidence: C)

Class III

1. Partial left ventriculectomy is not recommended in patients with nonischemic cardiomyopathy and refractory end-stage HF. (Level of Evidence: C)

2. Routine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF. (Level of Evidence: B)

End-of-Life Considerations - Recommendations

Class I

1. Ongoing patient and family education regarding prognosis for functional capacity and survival is recommended for patients with HF at the end of life. (Level of Evidence: C)

2. Patient and family education about options for formulating and implementing advance directives and the role of palliative and hospice care services with re-evaluation for changing clinical status is recommended for patients with HF at the end of life. (Level of Evidence: C)

3. Discussion is recommended regarding the option of inactivating an implanted cardioverterdefibrillator for patients with HF at the end of life. (Level of Evidence: C)

4. It is important to ensure continuity of medical care between inpatient and outpatient settings for patients with HF at the end of life. (Level of Evidence: C)

5. Components of hospice care that are appropriate to the relief of suffering, including opiates, are recommended and do not preclude the options for use of inotropes and intravenous diuretics for symptom palliation for patients with HF at the end of life. (Level of Evidence: C)

6. All professionals working with HF patients should examine current end-of-life processes and work toward improvement in approaches to palliation and end-of-life care. (Level of Evidence: C)

Class III

1. Aggressive procedures performed within the final days of life (including intubation and implantation of a cardioverter-defibrillator in patients with New York Heart Association functional class IV symptoms who are not anticipated to experience clinical improvement from available treatments) are not appropriate. (Level of Evidence: C)

Oral Diuretics Recommended for Use in the Treatment of Chronic Heart Failure
Drug	Initial Daily Dose(s)	Maximum Total Daily Dose	Duration of action
Loop Diuretics
Bumetanide	Oral: 0.5 to 1 mg qd-bid	10 mg	4 to 6 hours
Furosemide	Oral: 20 to 40 mg qd-bid	600 mg	6 to 8 hours
Torsemide	Oral: 10 to 20 mg qd	200 mg	12 to 16 hours
Thiazide Diuretics
Chlorthiazide	250-500 mg qd-bid	1000 mg	6 to 12 hours
Chlorthalidone	12.5 to 25 mg qd	100 mg	24 to 72 hours
Hydrochlorothiazide	25 mg qd - bid	200 mg	6 to 12 hours
Indapamide	2.5 mg qd	5 mg	36 hours
Metolazone	2.5 mg qd	20 mg	12 to 24 hours
Potassium-sparing diuretics
Amiloride	5 mg qd	20 mg	24 hours
Spironolactone	12.5 to 25 mg qd	50 mg (possibly higher doses in select cases)	2 to 3 days
Triamterene	50 to 75 mg bid	200 mg	7 to 9 hours
Sequential Nephron blockade
Metolazone	2.5 to 10 mg qd plus loop diuretic
Hydrochlorothiazide	25 to 100 mg qd-bid plus loop diuretic
Chlorthiazide (IV)	500 to 1000 mg qd plus loop diuretic
Intravenous Diuretic Medications Useful for the Treatment of Severe Heart Failure
Loop Diuretics
Drug	Initial dose	Max single dose
Bumetanide	1 mg	4 to 8 mg
Furosemide	40 mg	160 to 200 mg
Torsemide	10 mg	100 to 200 mg
Thiazide Diuretics
Chlorthiazide	500mg	1000 mg
Intravenous Infusions
Bumetanide	1 mg IV load, then 0.5 to 2 mg per hour
Furosemide	40 mg IV load, then 10 to 40 mg per hour
Torsemide	20 mg IV load, then 5 to 20 mg per hour

Medications Commonly Used for the Treatment of Patients with Heart Failure with Low Ejection Fraction
Drug	Initial Daily Dose(s)	Maximum Dose(s)
ACE-Inhibitors
Captopril	6.25 mg tid	50mg tid
Enalapril	2.5 mg bid	10 to 20 mg bid
Fosinopril	5 to 10mg qd	40mg qd
Lisinopril	2.5 to 5 mg qd	20 to 40 mg qd
Perindopril	2 mg qd	8 to 16 mg qd
Quinapril	5 mg bid	20 mg bid
Ramipril	1.25 to 2.5 mg qd	10mg qd
Trandolapril	1 mg qd	4 mg qd
Angiotensin Receptor Blockers
Candesartan	4 to 8 mg qd	32 mg qd
Losartan	25 to 50 mg qd	50 to 100 mg qd
Valsartan	20 to 40 mg bid	160 mg bid
Aldosterone Antagonists
Spironolactone	12.5 to 25 mg qd	25 mg qd to bid
Eplerenone	25 mg qd	50 mg qd
Beta-Blockers
Bisprolol	1.25 mg qd	10 mg qd
Carvedilol	3.125 mg bid	25 mg bid. 50mg bid for patients > 85 kg.
Metoprolol succinate extended release	12.5 to 25 mg qd	200mg qd

Reference

Direct quotes from this valuable reference:
Hunt SA, Abraham WT, Chin MH, Feldman AM, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20;112(12):e154-235. Epub 2005.
Link: http://circ.ahajournals.org/cgi/content/full/112/12/e154

Overview of Stage D

Summary of therapy options - Stage D

Reference

Reference(s)