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2006 HFSA Comprehensive Heart Failure Practice Guideline Key Recommendations Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Comprehensive Heart Failure Practice Guideline Strength of Recommendation Part of routine care
Exceptions should be
"Should be considered"
Majority of patients should
Some discretion allowed
"May be considered"
Individualization of
therapy is indicated
"Is not recommended"
Therapy should not be
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Comprehensive Heart Failure Practice Guideline Strength of Evidence Randomized controlled trials  May be assigned on results of 1 trial
Cohort and case control studies  Includes sub group analyses, meta-
analyses, observational studies,
Includes observational, epidemiological
findings; in-practice safety reporting
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (3.1) Heart Failure Prevention A careful and thorough clinical
assessment, with appropriate
investigation for known or potential risk
factors, is recommended in an effort to
prevent development of LV remodeling,
cardiac dysfunction, and HF.

Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (3.2) HF Risk Factor Treatment Goals Risk Factor
Generally < 130/80
See ADA guidelines1
See NCEP guidelines2
20-30 min. aerobic 3-5 x wk.
Weight reduction < 30 BMI
Men £ 2 drinks/day, women £ 1
Maximum 2-3 g/day
1. Diabetes Care 2006; 29: S4-S42.
2. JAMA 2001; 285:2486-97.
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Treating Hypertension to Prevent HF Aggressive blood Aggressive BP control pressure control: in patients with prior MI: Lancet 1991;338:1281:1281-5 (STOP-Hypertension).
JAMA 1997;278:212-6 (SHEP).
UKPDS Group. UKPDS 38. BMJ 1998;317:703-713.
HFSA 2006 Practice Guideline (3.3-3.4) Prevention—ACEI and Beta Blockers ACE inhibitors are recommended for prevention of HF in
patients at high risk for this syndrome, including those
Coronary artery disease
Peripheral vascular disease
Stroke
Diabetes and another major risk factor Strength of Evidence = A
ACE inhibitors and beta blockers are recommended for all
patients with prior MI.
Strength of Evidence = A
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Management of Patients with Known Atherosclerotic Disease But No HF Treatment with ACE inhibitors decreases CV Death 6
the risk of CV death, 22% rel. risk red. p < .001
MI, stroke, or cardiac CV Death,
Cardiac Arrest
NEJM 2000;342:145-53 (HOPE).
20% rel. risk red. p = .0003
Lancet 2003;362:782-8 (EUROPA).
Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF £ 40%)  Al -cause mortality ↓19%  CV mortality ↓21%  HF development ↓37% 19% relative risk reduction
p = 0.019

 Recurrent MI ↓25% 0 0.5 1 1.5 2 2.5 3 3.5 4
Pfeffer et al. NEJM 1992;327:669-77.
The Additional Value of Beta Blockers Post-MI: CAPRICORN Studied impact of beta blocker (carvedilol) on post-MI patients with LVEF £ 40% already receiving contemporary treatments, including revascularization, anticoagulants, ASA, and ACEI:  Al -cause mortality reduced (HR = 0.077; p = 0.03)  Cardiovascular mortality reduced (HR = 0.75; p = .024)  Recurrent non-fatal MIs reduced (HR =.59; p = .014) Dargie HJ. Lancet 2001;357:1385-90.
HFSA 2006 Practice Guideline (4.8, 4.10) Heart Failure Patient Evaluation Recommended evaluation for patients with a diagnosis of HF:
Assess clinical severity and functional limitation by history, physical
examination, and determination of functional class*
Assess cardiac structure and function
Determine the etiology of HF
Evaluate for coronary disease and myocardial ischemia
Evaluate the risk of life threatening arrhythmia
Identify any exacerbating factors for HF
Identify co-morbidities which influence therapy
Identify barriers to adherence and compliance Strength of Evidence = C
* Metrics to consider include the 6-minute walk test and NYHA functional class
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (4.18) Evaluation—Fol ow Up Assessments Recommended Components of Follow-Up Visits
Signs and symptoms evaluated during initial visit
Functional capacity and activity level
Changes in body weight
Patient understanding of and compliance with dietary sodium
Patient understanding of and compliance with medical regimen
History of arrhythmia, syncope, pre-syncope or palpitation
Compliance and response to therapeutic interventions
Exacerbating factors for HF, including worsening ischemic
heart disease, hypertension, and new or worsening valvular
Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.1, 7.4) Pharmacologic Therapy: ACE Inhibitors ACE inhibitors are recommended for symptomatic and
asymptomatic patients with an LVEF £ 40%.
Strength of Evidence = A
ACE inhibitors should be titrated to doses used in clinical
trials (as tolerated during uptitration of other medications,
such as beta blockers).
Strength of Evidence = C
ACE inhibitors are recommended as routine therapy for
asymptomatic patients with an LVEF £ 40%.
Post MI
Strength of Evidence = B
Non Post-MI
Strength of Evidence = C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF SOLVD Prevention (Asymptomatic LVD) (Severe Heart Failure) 20% death or HF hosp.
40% mortality at 6 mos.
29% death or new HF 31% mortality at 1 year 27% mortality at end of (Chronic Heart Failure)  No difference in incidence of sudden cardiac death SOLVD Investigators. N Engl J Med 1992;327:685-91.
SOLVD Investigators. N Engl J Med 1991;325:293-302.
CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35.
HFSA 2006 Practice Guideline (7.2) Pharmacologic Therapy: Substitutes for ACEI It is recommended that other therapy be substituted for
ACE inhibitors in the following circumstances:
In patients who cannot tolerate ACE inhibitors due to cough,
ARBs are recommended.
Strength of Evidence = A
The combination of hydralazine and an oral nitrate
may be considered in such patients not tolerating ARBs.
Strength of Evidence = C
Patients intolerant to ACE inhibitors due to hyperkalemia or
renal insufficiency are likely to experience the same side
effects with ARBs. In these cases, the combination of
hydralazine and an oral nitrate should be considered.
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.3, 7.4) Pharmacologic Therapy: Beta Blockers Beta blockers shown to be effective in clinical trials
are recommended for symptomatic and
asymptomatic patients with an LVEF £ 40%.
Strength of Evidence = A
Beta blockers are recommended as routine therapy
for asymptomatic patients with an LVEF £ 40%.
Post MI
Strength of Evidence = B
Non Post-MI
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Effect of Beta Blockade on Outcome in Patients With HF and Post-MI LVD Dose (mg) Outcome
↓48% disease progression ↓34% mortality (p <.0001) ↓34% mortality (p = .0062) ↓35% mortality (p = .0014) ↓23% mortality (p =.031) 1. Colucci WS et al. Circulation 1196;94:2800-6. 4. Packer M et al. N Engl J Med 2001;3441651-8. 2. CIBIS II Investigators. Lancet 1999;353:9-13.
5. The CAPRICORN Investigators. Lancet 2001;357:1385-90.
3. MERIT-HF Study Group. Lancet 1999;353:2001-7. HFSA 2006 Practice Guideline (7.5, 7.8) Pharmacologic Therapy: Beta Blockers RECENT DECOMPENSATION OR EXACERBATION
Beta blocker therapy is recommended for patients with a recent
decompensation of HF after optimization of volume status and
successful discontinuation of IV diuretics and vasoactive agents.
Whenever possible, beta blocker therapy should be initiated in
the hospital at a low dose prior to discharge of stable patients.
Strength of Evidence = B
Continuation of beta blocker therapy is recommended in most
patients experiencing a symptomatic exacerbation of HF during
chronic maintenance treatment.
Strength of Evidence = C
If necessary, consider temporary dose reduction
Avoid abrupt discontinuation
Reinstate or gradually increase before discharge
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
COPERNICUS: Death, Hospitalization, or Study Drug Withdrawal in High Risk Patients HR = 0.67 (CI = 0.47-0.96)
Weeks After Randomization
Krum H et al. JAMA 2003;289:754-6.
IMPACT-HF Primary End Point: Patients Receiving Beta Blocker at 60 Days P < .0001
Gattis WA et al. JACC 2004;43:1534-41.
HFSA 2006 Practice Guideline (7.6) Pharmacologic Therapy: Beta Blockers Beta blocker therapy is recommended in the great majority of
patients with LV systolic dysfunction—even if there is
concomitant diabetes, chronic obstructive lung disease or
peripheral vascular disease.
Use with caution in patients with:
Diabetes with recurrent hypoglycemia
Asthma or resting limb ischemia.
Use with considerable caution in patients with marked
bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).
Not recommended in patients with asthma with active
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Diabetes and the Use of Beta Blockers for HF: Relative Risk for Mortality and Hospitalization for Heart Failure MERIT-HF (ER metoprolol succinate)2
1. Mohacsi. Circulation. 2001;104(17):abstr 3551.
2. Hjalmarson. JAMA. 2000;283(10):1295.
HFSA 2006 Practice Guideline (11.8, 15.2) Pharmacologic Therapy: Beta Blockers Beta blocker treatment is recommended in patients with HF and
preserved LVEF who have:
Prior MI
Strength of Evidence = A
Strength of Evidence = B
Atrial fib. requiring control of ventricular rate
Strength of Evidence = B
THE ELDERLY
Beta-blocker and ACE inhibitor therapy is recommended as standard
therapy in all elderly patients with HF due to LV systolic dysfunction.
Strength of Evidence = B
In the absence of contraindications, these therapies are also
recommended in the very elderly (age > 80 years). Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline Pharmacologic Therapy: Beta Blocker Overview* Initiate at low doses
Up-titrate gradually, generally no sooner than at 2 week
intervals

Use target doses shown to be effective in clinical trials
Aim to achieve target dose in 8-12 weeks
Maintain at maximum tolerated dose
If symptoms worsen
Adjust dose of diuretic or concomitant vasoactive med.
or other side effects
Continue titration to target after symptoms return to
If up-titration
Prolong titration interval
continues to be
Reduce target dose
Consider referral to a HF specialist
* Consult language of specific recommendations
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.10) Pharmacologic Therapy: Angiotensin Receptor Blockers ARBs are recommended for routine
administration to symptomatic and
asymptomatic patients with an
LVEF
£ 40% who are intolerant to
ACE inhibitors for reasons other than
hyperkalemia or renal insufficiency.

Strength of Evidence = A
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative HR 0.77, p = 0.0004
9 12 15 18 21 24 27
Maggioni AP et al. JACC 2002;40:1422-4.
Granger CB et al. Lancet 2003;362:772-6.
HFSA 2006 Practice Guideline (7.14-7.15) Pharmacologic Therapy: Aldosterone Antagonists An aldosterone antagonist is recommended for
patients on standard therapy, including diuretics,
who have:

NYHA class IV HF (or class III, previously class IV)
due to LV systolic dysfunction (LVEF
£ 35%)
One should be considered in patients post-MI
with clinical HF or diabetes and an LVEF < 40%
who are on standard therapy, including an ACE
inhibitor or an ARB.

Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Aldosterone Antagonists in HF RALES (Advanced HF)
P < 0.001
P < 0.008
0 3 6 9 12 15 18 21 24 27 30 33 36
0 3 6 9 12 15 18 21 24 27 30 33 36
Pitt B. N Engl J Med 1999;341:709-17.
Pitt B. N Engl J Med 2003;348:1309-21.
HFSA 2006 Practice Guideline (7.16-7.18) Aldosterone Antagonists and Renal Function Aldosterone antagonists are not recommended when:
Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
Serum potassium> 5.0 mmol/L
Therapy includes other potassium-sparing diuretics
Strength of Evidence = A
It is recommended that potassium be measured at
baseline, then 1 week, 1 month, and every 3 months
Strength of Evidence = A
Supplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.19) Pharmacologic Therapy: Hydralazine and Oral Nitrates A combination of hydralazine and
isosorbide dinitrate is recommended as
part of standard therapy, in addition to
beta-blockers and ACE-inhibitors, for
African Americans with LV systolic
NYHA III or IV HF
Strength of Evidence = A
NYHA II HF
Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
End point
ISDN-HDZN P
Primary end point
All-cause mortality (%)
1st HF hospitalization (%)
Change in quality-of-life
score at 6 months**
Taylor AL et al. N Engl J Med 2004; 351;2049-2057.
A-HeFT All-Cause Mortality 43% Decrease in Mortality Fixed Dose ISDN/HDZN
rvival %
u
S 90

Days Since Baseline Visit
Taylor AL et al. N Engl J Med 2004;351:2049-57.
HFSA 2006 Practice Guideline (7.23) Pharmacologic Therapy: Diuretics Diuretic therapy is recommended to restore and
maintain normal volume status in patients with
clinical evidence of fluid overload, generally
manifested by:
Congestive symptoms
Signs of elevated filling pressures
Strength of Evidence = A
Loop diuretics rather than thiazide-type diuretics
are typically necessary to restore normal volume
status in patients with HF.
Strength of Evidence = B
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.23) Initial Daily
Max Total
Elimination: Duration of
Daily Dose
Renal – Met. Action
20-40mg qd
65%R-35%M 4-6 hrs
Bumetanide 0.5-1.0 mg
62%R/38%M 6-8 hrs
10-20 mg qd
20%R-80%M 12-16 hrs
25-50 mg qd
67%R-33%M 6 hrs
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.23) Initial Daily Max Total
Duration
Daily Dose
of Action
12.5-25 mg
48-72 hrs
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (7.24) Pharmacologic Therapy: Diuretics  Restoration of normal volume status may require multiple
Once a diuretic effect is achieved with short-acting loop
diuretics, increase frequency to 2-3 times a day if necessary,
rather than increasing a single dose.
Strength of Evidence = B
Oral torsemide may be considered in patients exhibiting poor
absorption of oral medication or erratic diuretic effect.
Strength of Evidence = C
IV administration of diuretics may be necessary.
Strength of Evidence = A
Diuretic refractoriness may represent patient noncompliance,
a direct effect of diuretic use on the kidney, or progression of
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (9.1, 9.4) Prophylactic ICD Placement In patients on optimal medical therapy (ideally 3-6 months)
with or without concomitant coronary artery disease
(including a prior MI > 1 month ago):
Prophylactic ICD placement should be considered in
those with NYHA II-III HF (LVEF £ 30%)
Prophylactic ICD placement may be considered in those
with NYHA II-III HF (LVEF 31-35%)
Strength of Evidence = A
Concomitant placement should be considered in NYHA III-
IV patients undergoing implantation of a biventricular
Strength of Evidence = B
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
MADIT II: Prophylactic ICD in Ischemic LVD (LVEF £30%) rviv
u
f S .8

Number at Risk
Defibrillator

503 (.91)
274 (.84)
110 (.78)
329 (.90)
170 (.78)
Moss AJ et al. N Engl J Med 2002;346:877-83.
ICD Therapy in the SCD-HeFT Trial: Mortality by Intention-to-Treat Amiodarone vs Placebo
ICD vs Placebo
rtality .2
Months of Follow-Up
Bardy GH et al. N Engl J Med 2005;352:225-37.
HFSA 2006 Practice Guideline (9.7) Biventricular Pacing Biventricular pacing therapy should be considered
for patients with all of the following:
Sinus rhythm
A widened QRS interval (³120 ms)
Severe LV systolic dysfunction (LVEF £ 35% with LV
dilation > 5.5 cm)
Persistent, moderate-to-severe HF (NYHA III) despite
optimal medical therapy.
Strength of Evidence = A
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
CRT Improves Quality of Life and NYHA Functional Class Average Change in Score
NYHA: Proportion Improving
by 1 or More Class
MIRACLE CONTAK MIRACLE
* P < .05 Abraham WT et al. Circulation 2003;108:2596-2603.
CRT in Patients with Advanced HF and a Prolonged QRS Interval: COMPANION Primary End Point: All-Cause Mortality
Death or Hospitalization Due to HF
Risk of all-cause mortality reduced by 19%
in group with CRT and ICD (p =.014)
Risk of death or hospitalization from HF
reduced by 34% in ICD group and by 40% in
ICD-CRT group (p < .001)

Bristow MR et al. N Engl J Med 2004;350:2140-50.
Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF HR = 0.64 (95% CI = .48-.85)
p = .0019

Number at risk
CRT

Cleland JG et al. N Engl J Med 2005;352:1539-49.
HFSA 2006 Practice Guideline (11.1-11.2) HF with Preserved LVEF—Diagnosis Careful attention to differential diagnosis is recommended
in patients with HF and preserved LVEF.
Treatments may differ based on cardiac disorder.
Evaluation for ischemic disease and inducible myocardial
ischemia should be included.
Recommended diagnostic tools:
Stress imaging (via exercise or pharmacologic means, using
myocardial perfusion or echocardiographic imaging)
Strength of Evidence = C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Figure 11.1. Diagnostic Categories of Heart Failure with Preserved LVEF Heart Failure with Preserved LVEF
Dilated LV
r disease
Increased th
Normal th
t Ventricular Dysfunction*
r Increased
Low QRS voltage
No mitral
QRS voltage
A rtic valve
Aortic valve disease
a disease
No pericardial
Hypertensive Hx or PE
l ischemi
i ; collagen-vascular; Reconsider diagnosis of LVEF=left ventricular ejection fraction; HF=heart failure; QRS=electrocardiographic ventricular depolarization; AR= aortic * Some patients with right ventricular regurgitation; MR=mitral regurgitation; MS=mitral stenosis; RVMI=right dysfunction have LV dysfunction due to ventricular myocardial infarction; Hx=history; PE= physical examination. Figure courtesy of Marvin Konstam MD and Marvin Kronenberg MD.
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (12.3, Table 12.3) Acute Decompensated Heart Failure (ADHF)— Treatment Goals for Hospitalized Patients • Improve symptoms, especially congestion and low-output symptoms • Optimize volume status • Identify etiology • Identify precipitating factors • Optimize chronic oral therapy; minimize side effects • Identify who might benefit from revascularization • Educate patients concerning medication and HF self-assessment • Consider enrol ment in a disease management program Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HFSA 2006 Practice Guideline (12.5-12.18) Overview of Treatment Options for Patients with Acute Decompensated HF  Fluid and sodium restriction  Diuretics, especially loop diuretics  Ultrafiltration/renal replacement therapy (in selected patients only)  Parenteral vasodilators * (nitroglycerin, nitroprusside, nesiritide)  Inotropes * (milrinone or dobutamine) *See recommendations for stipulations and restrictions.
HFSA 2006 Practice Guideline (12.23, Table 12.7) Discharge Criteria for Hospitalized ADHF Patients Recommended prior to discharge for all patients with HF:
Exacerbating factors addressed
Near optimum fluid status achieved
Transition from IV to oral diuretic completed
Near optimum pharmacologic therapy achieved
Follow-up clinic visit scheduled, usually 7-10 days
Should be considered prior to discharge for patients with
advanced HF or a history of recurrent admissions:
Oral regimen stable for 24 hours
No IV inotrope or vasodilator for 24 hours
Ambulation before discharge to assess functional capacity
Plans for post-discharge management
Referral to a disease management program
Strength of Evidence =C
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Predictors of Mortality Based on Analysis of ADHERE Database Classification and Regression Tree (CART) analysis of ADHERE data shows: Three variables are the strongest predictors of mortality in hospitalized ADHF patients: Fonarow GC et al. JAMA 2005;293:572-80.
HFSA 2006 Practice Guideline (8.1) Heart Failure Patient Education  It is recommended that patients with HF and
their family members or caregivers receive
individualized education and counseling that
emphasizes self-care.
This education and counseling should be
delivered by providers using a team approach.
Teaching should include skill building and
Strength of Evidence = B
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
The Potential Impact of Effective Education on Patient Compliance Noncompliance rate when patients . . Don't recall advice Kravitz et al. Arch Int Med 1993;153:1869-78.
Sample Target Behavior: Be Able to Read and Understand Food Labels Labels from cups of soup HFSA 2006 Practice Guideline (8.7) Heart Failure Disease Management Patients recently hospitalized for HF
and other patients at high risk
should be considered for referral
to a comprehensive HF disease
management program that delivers
individualized care.

Strength of Evidence = A
Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
HF Disease Management and the Risk of Readmission Summary RR = 0.76 (95% CI .68-.87)
Summary RR for randomized only = 0.75 (CI = .60-.95)

HFSA 2006 Practice Guideline (8.13) End-of-Life Care in Heart Failure End-of-life care should be considered in patients who have
advanced, persistent HF with symptoms at rest despite
repeated attempts to optimize pharmacologic and
nonpharmacologic therapy, as evidenced by
one or more of the following:
Frequent hospitalizations (3 or more per year)
Chronic poor quality of life with inability to accomplish
activities of daily living
Need for intermittent or continuous intravenous support
Consideration of assist devices as destination therapy
Strength of Evidence = C
Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.
Evidence-Based Treatment Across the Continuum of Systolic LVD and HF Improve Clinical Outcomes
b-Blocker Antagonist
*In selected patients
Treat Residual Symptoms

Source: http://www.k5.dion.ne.jp/~yama.ahp/fhsa06.pdf

femax.md

MS Schippers has now grown into one of the largest suppliers to the professional livestock farming industry in Europe. We supply agricultural equipment and services to our customers and partners all over the world, from The Netherlands to South Africa and from Belgium to New Zealand. The head office of MS Schippers is located in Bladel, The Netherlands. In addition to the head office, we have a centrally located distribution centre in Lommel, Belgium. This warehouse, with an area of 20.000 m², supplies all our branches and foreign partners. More than 250 people are employed within the MS Schippers Group. Commercial activities are taken care of by our representatives, office sales staff and product specialists. We are active in all areas of livestock farming, especially pig, poultry, mink and dairy farming.

Caring for gulf war i veterans

Caring for Gulf War I Veterans Revised October 2010 Released July 2011 Sponsored by: Department of Veterans Affairs Employee Education System This is a Veterans Health Administration system-wide training program, sponsored by the Employee Education System in cooperation with the Office of Public Health, Department of Veterans Affairs. It is produced by the Employee Education System.