The 2013 Canadian Cardiovascular

Society Heart Failure Management

Guidelines Update: Focus on
Rehabilitation and Exercise and
Surgical Coronary Revascularization
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Heart Failure Guidelines

 CCS Heart Failure Guidelines
2013 Update
Primary Panel

Gordon W. Moe, (Chair)

Justin A. Ezekowitz, (Co-Chair)

Eileen O’Meara Michael McDonald

Jonathan G. Howlett Robert McKelvie
Steve Fremes Anil Nigam
Abdul Al-Hesayen Miroslaw Rajda
George A. Heckman Vivek Rao
Anique Ducharme Elizabeth Swiggum
Adam Grzeslo Sean Virani
Karen Harkness Estrellita Estrella-Holder
Serge Lepage Vy Van Le
Shelley Zieroth

Heart Failure Guidelines

CCS Heart Failure Guidelines
2013 Update
Secondary Panel

Simon Kouz
J.Malcolm O. Arnold
Tom Ashton
Michel D’Astous
Paul Dorian
Nadia Giannetti
Haissam Haddad
Debra L. Isaac
Marie-Hélène Leblanc
Peter Liu
Heather J. Ross
Bruce Sussex
Michel White

Heart Failure Guidelines

Surgical Coronary Revascularization
 Recommendations - Surgical Coronary
Revascularization in Heart Failure

We recommend that non-invasive imaging for Strong Recommendation

patients with heart failure be considered in Moderate Quality
order to determine the presence or absence of Evidence
coronary artery disease.

Values and Preferences:

This recommendation places value upon identification of coronary artery disease,
which may identify the cause of heart failure, have prognostic implications and
require treatments aimed toward secondary vascular prevention.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be:

a)Performed in patients with heart failure with Strong Recommendation

ischemic symptoms and who are likely to be Moderate Quality
good candidates for revascularization. Evidence

b)Considered in patients with systolic heart Strong Recommendation

failure (LVEF < 35%), at risk of coronary artery Low Quality Evidence
disease, irrespective of angina, who may be
good candidates for revascularization.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be:

c) Considered in patients with systolic heart Strong Recommendation

failure and in whom non-invasive coronary Moderate Quality
perfusion testing yields features consistent with Evidence
high risk.

Values and Preferences:

These recommendations place value on the need of coronary angiography to
identify coronary artery disease amenable to revascularization. Available
evidence suggests that coronary revascularization may provide quality of life and
prognostic benefits to patients with heart failure and non-invasive imaging
delineating high risk. In particular, patients with systolic heart failure due to
ischemic heart disease may derive clinical benefit from coronary
revascularization even in the absence of angina or reversible ischemia.

Heart Failure Guidelines

 Practical Tips
Revascularization Procedures
Imaging

1. Several non-invasive methods for detection of coronary artery disease are in

widespread use, including:
• Dobutamine stress echocardiography (DSE)
• perfusion cardiac magnetic resonance (CMR)
• cardiac positron emission testing (PET)
• nuclear stress imaging

Local factors (availability, price, expertise, practice patterns) will determine the
optimal strategy for imaging.

2. Non- invasive imaging modalities may provide critical information such as the
amount and degree of ischemic or hibernating myocardium, and may be used
to determine the likelihood of regional and global improvement in left
ventricular systolic function following revascularization.

Heart Failure Guidelines

 Practical Tips (cont’d)
Revascularization Procedures
Imaging

3. Patients with heart failure and reduced LVEF are more likely to experience
significant improvement in LVEF following successful coronary revascularization if
they demonstrate:

a) Reversible ischemia or a large segment of viable myocardium (> 30% of

the left ventricle) by nuclear stress testing/ viability study;

b) Reversible ischemia or >7% hibernating myocardium on PET scanning;

c) Reversible ischemia or > 20% of the left ventricle shown as viable by

DSE;

d) <50% wall thicknessHeart Failure

scarring Guidelines
as shown by late gadolinium
 Recommendations - Revascularization
Procedures
Disease Management, Referral and Peri-operative Care

We recommend that the decision to refer Strong Recommendation

patients with heart failure and ischemic heart Low Quality Evidence
disease for coronary revascularization should
be made on a individual basis and in
consideration of all cardiac and non- cardiac
factors which affect procedural candidacy.
We recommend that efforts be made to optimize Strong Recommendation
medical status prior to coronary Low Quality Evidence
revascularization, including optimizing
intravascular volume medical therapy.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Disease Management, Referral and Peri-operative Care

We recommend that performance of coronary Strong Recommendation

revascularization procedures in patients with Low Quality Evidence
chronic heart failure and reduced left ventricular
ejection fraction be undertaken with a medical-
surgical team approach with experience and
expertise in high risk interventions.

Values and Preferences:

This recommendation reflects the preference that high risk revascularization is best
performed in higher volume centers with significant experience, and known,
published outcomes.

Heart Failure Guidelines

 Practical Tip
Revascularization Procedures
Disease Management, Referral and Peri-operative Care

1. Assessment for advanced heart failure therapies, by an appropriate team,

should be performed prior to revascularization procedure in any patient with
advanced heart failure

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF

We recommend consideration of coronary Strong Recommendation

artery bypass surgery for patients with chronic Moderate Quality
ischemic cardiomyopathy, left venticular Evidence
ejection fraction < 35%, graftable coronary
arteries and who are otherwise suitable
candidates for surgery, irrespective of the
presence of angina and heart failure symptoms
in order to improve quality of life,
cardiovascular death and hospitalization.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF

We suggest consideration of percutaneous Conditional

coronary intervention for patients with heart Recommendation
failure and limiting symptoms of cardiac Low Quality Evidence
ischemia, and for whom CABG is not
considered appropriate.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF

We recommend against routine performance of Strong Recommendation

surgical ventricular restoration for patients with Moderate Quality
heart failure undergoing CABG who have Evidence
akinetic or dyskinetic segments.

Values and Preferences:

These recommendations are based on data from RCTs on CABG and surgical
ventricular restoration on patients with reduced systolic function and CAD. The
recommendation on percutaneous coronary intervention is based on clinical need
rather than RCT trial data.

Heart Failure Guidelines

 Practical Tips
Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF

1.In the setting of heart failure, angina and single territory coronary artery disease,
PCI may be the treatment of first choice. However, PCI has not been shown to
improve outcomes for patients with chronic stable heart failure, irrespective of
underlying anatomy.

2.In contrast to the chronic stable patient with heart failure, urgent directed culprit
vessel angioplasty continues to be the revascularization modality of choice for
patients with acute coronary syndrome complicated by heart failure.

3.In highly selected cases, patients with advanced heart failure symptoms in
association with large areas of dyskinetic and non-viable myocardium may
experience clinical improvement with SVR or similar type procedures, when
performed by experienced surgeons.

4.Mitral valve repair, when used concomitantly during CABG, may lead to clinical
improvement in symptoms of heart failure in highly selected cases.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Device Considerations in HF Patients Following Cardiac Surgery
We recommend that following successful Strong Recommendation
cardiac surgery, patients with heart failure High Quality Evidence
undergo assessment for implantable cardiac
devices within 3-6 months of optimal treatment.

We recommend that patients with implantable Strong Recommendation

cardiac devices in situ should be evaluated for Low Quality Evidence
programming changes prior to surgery and
again following surgery, in accordance with
existing CCS recommendations.
We recommend that following successful Strong Recommendation
cardiac surgery, all patients be referred to a High Quality Evidence
local cardiac rehabilitation program.

Values and Preferences:

These recommendations reflect our support of and conformity with pre-existing
cardiac device and rehabilitation guidelines statements.

Heart Failure Guidelines

 Practical Tips
Revascularization Procedures
Device Considerations in HF Patients Following Cardiac Surgery

1.During surgical revascularization, consideration can be given to implantation of

epicardial left ventricular leads to facilitate biventricular pacing in eligible patients
who may be candidates for cardiac resynchronization therapy, especially if the
coronary sinus anatomy is known to be unfavourable for lead placement.

2.Patients with heart failure and who have successful surgical coronary
revascularization can be referred to a cardiac rehabilitation program.

Heart Failure Guidelines

Approach to Assessment for Coronary Artery
Disease in Patients with Heart Failure

Angina or angina
equivalent symptoms?

Is the patient a suitable Is the patient a suitable

risk for surgical risk for surgical
revascularization? revascularization?

Either a) non-invasive
Non-invasive rest and rest and stress imaging
stress imaging according to local Is patient potential
Coronary angiography*
according to local preferences or b) candidate for PCI?
preferences# directly to coronary
angiography

Non-invasive rest and

stress imaging
Medical therapy^
according to local
preferences#

Heart Failure Guidelines

Decision Regarding Coronary Revascularization in
Heart Failure

Angina or
ischemic
equivalent?

Acceptable risk for Acceptable risk

surgical for surgical
revascularization? revascularization?

Evidence of
extensive
Surgical ischemia on non-
Anatomy
revascularization most invasive imaging
acceptable for
appropriate given Is LVEF < 35%?? AND/OR another
PCI? cardiac surgery
coronary anatomy?*
i.e. AVR
indicated?

PCI focus on Anatomy appropriate for Is surgical

PCI, +/- directed surgical
culprit artery using revascularization
Surgical by non-invasive revascularization OR
non-invasive Medical therapy Medical therapy# most appropriate Medical therapy
Revascularization imaging or I.C. another cardiac surgery
approach or I.C. given coronary
Flowire indicated i.e. AVR?
Flowire anatomy?*

Surgical
Revascularization Surgical
Medical therapy# Medical therapy#
+/- other indicated revascularization
procedure

Heart Failure Guidelines

Exercise Training and Heart Failure
 Recommendations - Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure

We recommend that all patients with stable New Strong Recommendation

York Heart Association class I-III symptoms be Moderate Quality
considered for enrolment in a supervised Evidence
tailored exercise training program, in order to
improve exercise tolerance and quality of life .

Values and Preferences:

This recommendation places a high value on improvements in non-morbid
outcomes and recognizes that not all patients will be able to participate in a
structured exercise training program due to patient preferences or availability of
resources.

Heart Failure Guidelines

 Recommendations - Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure

We recommend that an assessment of clinical Strong Recommendation

status by a clinician experienced in the Low Quality Evidence
management of heart failure patients be
completed prior to considering an exercise
training program.

Values and Preferences:

This recommendation places a high value on clinician’s assessment of both the clinical
stability of a patient and their appropriateness to start exercise, recognizing that most
patients will be eligible to participate.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure

Adherence to an Exercise Program

1.Frequent reinforcement, including letters, phone calls and home visits, may
enhance adherence to exercise.

2.Identifying and addressing patient-specific barriers may aid in the uptake of

exercise for patients.

3.Once a home-based program is initiated, more frequent follow-up visits and

occasional supervised “refresher” sessions to answer questions, review concerns
or modify the training program may give patients the guidance needed to ensure
that home-based cardiac rehabilitation is successful.

Heart Failure Guidelines

 Recommendations -
Rehabilitation and Exercise in HF
Cardiac Rehabilitation Programs for Patients with Recently Decompensated or
Advanced Heart Failure

We recommend that gradual mobilization and/or Strong Recommendation

small muscle group strength/flexibility Low Quality Evidence
exercises be considered as soon as possible
either alone or in combination for patients with
New York Heart Association class IV symptoms
or recently decompensated heart failure. This
should be considered only in consultation with
an experienced heart failure team.

Values and Preferences:

This recommendation places high value on initiating mobilization and therapy early (even
if only limited exercises are prescribed) in order to prevent further decline of muscle
function, improve function during day to day activities and provide a baseline from which
to add further exercise modalities.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation Programs for Patients with Recently Decompensated or
Advanced Heart Failure

1. Selected patients may benefit from limited exercise therapy, such as lower-
extremity or inspiratory muscle strengthening, directed towards alleviating
symptom of muscle fatigue.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation in Heart Failure with Preserved Ejection Fraction

1. Until data specific for patients with heart failure and preserved ejection fraction
are available, exercise programs using a similar approach to patients with
impaired systolic function may be considered in patients with heart failure and
preserved ejection fraction.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation in Patients with Cardiac Resynchronization Therapy and
Implantable Cardioverter Defibrillators

1. Exercise training is safe and not associated with an increased risk of ICD
therapy. The maximal target HR should be at least 20 beats below the ICD
intervention heart rate to avoid inappropriate ICD shocks.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Exercise in Frail Senior with Heart Failure

1. Frail seniors with heart failure should be offered multi-component (endurance

and resistance, balance) tailored exercise programs appropriate for their
comorbidities.

Heart Failure Guidelines

 Recommendations - Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in Heart Failure

We recommend moderate-intensity continuous Strong Recommendation

aerobic exercise training (e.g. brisk walking, Moderate Quality
jogging, and cycling) at rate of Modified Borg Evidence
Rating Perceived Exertion (RPE) scale 3-5, 65-
85% maximum heart rate, or 50-75% of peak VO2
in patients with heart failure.

Values and Preferences:

This recommendation places a high value on using commonly available measurements to
assist in developing the exercise prescription. The priority is safety, hence, if a patient has a
history of ICD discharges, exercise should be avoided if a short loss of consciousness is
dangerous, i.e. swimming and activities associated with an increased risk of falling.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF

Strength Training
1. For strength training, the use of light (5-10 lbs) free weights for 10-20 repetitions 2 to
3 times per week may improve muscle tone and strength.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF

Interval Training
1. Interval training sessions should use 15-30s exercise intervals (RPE 3-5) with rest
intervals of equal duration and may last 15-30 seconds.

Heart Failure Guidelines

 Practical Tips
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF

Aerobic Exercise Training Intensity

1. The Modified Borg RPE scale and % HRmax are easier to use in practice than
equations based on heart rate reserve (HRR) or measurement of peak VO2.

Heart Failure Guidelines

 Rate of Perceived Exertion (RPE)*
Sing – Talk –Gasp Test
Maximal

10 very, very hard

9
Gasp: breathing heavily 8
7 very hard
6

5 hard
Talk: enough breath to carry a conversation 4 somewhat hard
3 moderate

2 easy
1 very easy
Sing: Enough breath to sing
0.5 very, very easy
0 nothing at all

*Modified Scale adapted by Borg

Heart Failure Guidelines

 Table: Exercise Modalities According to Clinical Scenario

Discharged with
Heart Failure NYHA I-III NYHA IV
Flexibility Exercises Recommended Recommended Recommended
Aerobic Exercises
• Suggested modality •Selected population only • Walk •Selected population only
•Supervision by an expert • Treadmill •Supervision by an expert
team needed (see text) • Ergocycle team needed (see text)
• Swimming

• Intensity Continuous training:

Moderate intensity:
• RPE scale 3-5,or
• 65-855 HRmax, or
• 50-75% peak VO2
Moderate intensity aerobic interval may be incorporated in
selected patients
• Intervals of 15-30 seconds with a RPE scale of 3-5
• Rest intervals of 15-30 seconds

• Frequency • Starting with 2-3 days/week

• Goal: 5 days/week
• Selected population only • Starting with 10-15 minutes •Selected population only
• Supervision by an expert • Goal: 30 minutes •Supervision by an expert
team needed (see text) team needed (see text)

Isometric/Resistance
Exercises

• Intensity • 10-20 repetitions of 5-10 pounds free weights

• Frequency • 2-3 days/week