CONTINUING EDUCATION • LVEF < 35 percent; • Needing ventricular pacing when a device is to be replaced or implanted. CTR may be considered in those who are receiving GDMT with: • LVEF < 35 percent; • Sinus rhythm; • Non-left bundle branch block • With a QRS duration 120-149 ms and NYHA class III or ambulatory class IV; or • With a QRS duration >150 ms and NYHA class II.6 or • LVEF < 30 percent; • Ischemic HF; • Sinus rhythm; and • LBBB with QRS duration >150 ms and NYHA class I.6
CRT is not for patients with: • NYHA class I or II and non-left bundle branch block with QRS duration <150 ms and • NYHA class I or II or patients that do not have at least one-year survival expectation.6
ACC/AHA Stage D/NYHA Functional Classification IV - Refractory HF requiring specialized interventions/ unable to carry out any physical activity without HF symptoms or HF symptoms at rest must be assessed and stabilized using GDMT. Clinicians should rule out all other causes that may contribute to the refectory HF before proceeding. Things to consider are pulmonary disorders, weight loss etiology, thyroid function, and medication/diet adherence.6 Treatment is initiated to control symptoms while improving quality of life, reducing hospital admissions, and establishing end-of-life goals.6 Intravenous inotropic support with adrenergic agonists (dopamine or dobutamine) or PDE inhibitors (milrinone) to maintain organ perfusion and prevent end-organ damage until eventual treatment is defined is recommended (see Appendix C).6 For some with GDMT, cardiac transplant, device use, and surgical management may be warranted.6 Also recommended is: • Fluid restriction to reduce congestion; and • Intravenous inotropic support to maintain organ perfusion and prevent end-organ damage as bridge therapy in those that may receive mechanical circulatory support (MCS) or cardiac transplant.6 Mechanical Circulatory Support (MCS) may be helpful in some with HFrEF awaiting transplant or whose recovery is anticipated. Nondurable MCS many be helpful as bridge therapy in those with HFrEF with acute, profound hemodynamic compromise to prolong survival.6 24 |
Insight
Intravenous inotropic support may be used short-term to support and maintain organ perfusion and prevent end-organ damage in hospitalized patients with severe systolic dysfunction, low blood pressure, and low cardiac output. They are used as long-term support to maintain organ perfusion and prevent end-organ damage in palliative care patients receiving GDMT not eligible to receive mechanical circulatory support (MCS) or cardiac transplant.6 Intravenous inotropic use long-term (other than in palliative care) without defined indications as seen with severe systolic dysfunction, low blood pressure or diminished perfusion and evidence of significantly depressed cardiac output is not recommended and may cause harm.6
Summary Heart failure is a complex syndrome that can be challenging to diagnosis and treat. Patients often have multiple comorbidities, which demand: • The use of GDMT; • A team-based approach to manage care; • The creation of care plan goals and objectives; • The removal of clinical and other barriers to success; and • Appropriate education for patients and caregivers.