Heart Failure

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by Seema Nour, MD, FACC;
Interventional Cardiologist, Abudhabi, UAE

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  • Today I will mostly focus on systolic heart failure
  • Initiation of a beta blocker prior to hospital discharge is safe and well tolerated in the majority of patients and dramatically improves utilization of this evidence-based therapy following discharge.
  • Heart Failure

    1. 1. Seema Nour MDInterventional Cardiologist USA
    2. 2. OutlineIntroductionIncidenceEtiologyDiagnosisTherapies
    3. 3. IntroductionHeart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject bloodNo longer use the term “congestive” because all heart failure does not result in clinically apparent volume overload
    4. 4. How to define heart failure?Systolic Versus Diastolic Heart FailureA. Systolic cardiac (heart) dysfunction (or systolic heart failure) occurs when the heart muscle doesnt contract with enough force, so there is not enough oxygen-rich blood to be pumped throughout the body.B. Diastolic cardiac dysfunction (or diastolic heart failure) occurs when the heart contracts normally, but the ventricle doesnt relax properly so less blood can enter the heart.
    5. 5. What is the incidence of heart failure?Estimated 500,000 new cases per yearWithin 5 years, half of those diagnosed will be deadOver 1 million hospitalizations per year with HF as primary diagnosisMost common reason for hospitalization in those >65 years oldHeart failure is 4th in a list of quality of care initiatives in vulnerable older adults
    6. 6. Case-Mr Abdallah45 yr old man with poorly controlled hypertension, DM presents with 3 weeks of progressive shortness of breath, LE edemaExam remarkable for HR 150, BP 80/40, RR 26Appears lethargic, Elevated JVP, PMI displaced, irregular, S1, S2, S3 on exam, no murmurs, lungs with crackles, Extremities cold with edema
    7. 7. EKG
    8. 8. What do you think caused MrAbdallah’s heart failure?
    9. 9. Causes of heart failureCoronary artery disease (up to 70%)HypertensionArrhythmiasValvular heart diseaseViral myocarditis, etcCongenital heart diseaseToxic substances (EtOH, cocaine)Diabetes, thyroid problems, HIVRestrictive causes-amyloid, radiation
    10. 10. Back to our patientSo Mr Abdallah has risk factors for CADAlso has elevated BP-so hypertensive heartNo murmur on exam so valvular heart disease unlikelyArrythmias……..afib, tachycardia induced cardiomyopathyWhat about amyloidosis ALWAYS LOOK FOR REVERSIBLE CAUSES
    11. 11. So how will we work up Mr Abdallah?
    12. 12. Initial WorkupBasic labs, check for anemia-high output failure, chem8, TSH, ferritinEKG-look for acute MI or prior infarctsCXR- pulmonary edema, heart sizeEchocardiogram to assess LV function, assess for diastolic dysfunction
    13. 13. Future workupCoronary AngiogramIf flash pulmonary edema and severe HTN, consider renal angiogramIf no clear cause in young patient consider cardiac biopsy
    14. 14. Mr Abdallah tests showedNormal CBCElevated BUN/Creatinine 45/1.8Elevated LFTS ( AST/ALT)CXR showed pulmonary edemaEcho showed an EF of 30% with diffuse global hypokinesis
    15. 15. Now how are we going to treat Mr Abdallah??
    16. 16. Management of Heart FailureAcuteChronic
    17. 17. Acute Treatment Congestion? Orthopnea, rales, JVD, edema, ascites Warm and Dry Warm and WetAdequateperfusionLethargy,cool, pulsepressure Cold and Dry Cold and Wet (Mr Abdallah) Nohria, A. et al. JAMA 2002;287:628-640
    18. 18. Cardiogenic Shock(Cold and Wet)1. Systemic Hypotension systolic arterial pressure < 80 mmHg2. Persistent Hypotension at least 30 minutes3. Reduced Systolic Cardiac Function Cardiac index < 1.8 x m²/min4. Tissue Hypoperfusion Oliguria, cold extremities, confusion5. Increased Left Ventricular Filling Pulmonary capillary wedge pressure > 18mmHg mmHg
    19. 19. Choice of Ionotropes Dopamine <2 renal vascular dilation <2-10 +chronotropic/inotropic (beta effects) >10 vasoconstriction (alpha effects)Dobutamine – positive inotrope, vasodilates, arrhythmogenic at higher dosesNorepinephrine (Levophed): vasoconstriction, inotropic stimulant. Should only be used for refractory hypotension with dec SVR.Vasopression – vasoconstrictionVASO and LEVO should only be used as a last resort
    20. 20. If patient tachycardic, dopamine and dobutamine are not great choicesSo in Mr Abdallah would attempt to cardiovert him as he will not sustain pressor supportTEE to r/o left atrial appendage thrombusFollowed by Cardioversion
    21. 21. So Mr Abdallah underwent TEEWas cardiovertedBP improvedHR stabilizedStill congested but now hemodynamically stable NOW WHAT??
    22. 22. Diurese, diurese, diurese!!!Do you start an ACEI?Do you start a beta blocker?
    23. 23. Furosemide DosingIf patient is lasix naive start slow and titrate up per urine outputLasix dose usually 0.5-1mg/kg twice a dayUsually expect response in first 5-10mins with IVUsual start dose 40mg or 80mg IV q8hrsAlways give potassium supplements when diuresing patient
    24. 24. Regular monitoring of electrolytes with IV diuresisSwitch to PO when more euvolemic, BUN/creatinine start risingRemember 80mg PO =40mg IVIf patient already on PO lasix e.g 80mg PO would start treating with higher IV dose (ie 80mg IV)If poor response to lasix add thiazide diuretic
    25. 25. ACEI and Beta BlockersStart ACEI in patients as soon hemodynamically stableHelp reduce preload and afterloadTitrate up per patient, don’t look at BP!!Beta Blockers-start low dose prior to dischargeTitrate dose as outpatient
    26. 26. Back to Mr AbdallahSo Mr Abdallah is doing well, he maintained sinus rhythm and is being dischargedWhat medications should he be on long term for a mortality benefit??
    27. 27. Long Term Therapy
    28. 28. Beta Blockers34% reduction in all mortality with use of beta-blockersDecrease Cardiac Sympathetic ActivityTitrate slowlyContraindications-bradycardia, heart block or hemodynamic instabilityMild asthma is not a contraindicationWork irrespective of the etiology of the heart failure
    29. 29. Three beta-blockersBisoprolol (Zebeta) -Trial CIBIS-IIMetoprolol (Toprol XL) –Trial MERIT-HF (sustained release) Carvedilol (Coreg) Trial-COPERNICUS6 RCT’s with > 9,000 pts already taking ACE-I showed a significant reduction in total mortality and sudden death (NNT 24, and 35 over 1-2 years) regardless of severity
    30. 30. Carvedilol vs. Metoprolol (COMET2003) 3029 pts; carvedilol 25mg bid vs. metoprolol 50 mg bid Patient with NYHA Classes II-IV Carvedilol –greater reduction in mortality (NNT, 18 over 5 years) and cardiovascular mortality (NNT, 16 over 5 years) than metoprolol but hypotension was greater in carvedilol (14 vs 11 percent)
    31. 31. Beta Blockers and concomitantdiseaseBeta blocker therapy is recommended in the great majority of patients with HF and reduced LVEF—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 bronchospasm.
    32. 32. HFSA 2010 Practice Guideline ACEInhibitorsACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers).
    33. 33. ACEICONSENSUS-Enalapril 2.5-40mg (188 days) vs placeboPts were already taking digoxin and diuretics253 Patient with NYHA Class IVDec mortality at: 6 months -40% 1 Year – 27%SOLVD-Enalapril 20mg/day (41 mo)2569 Patients with and EF <35% Earlier stages of HF even asymptomatic NYHA Class II-IIIAll cause mortality dec by 16%Morality rate from HF dec by 16%
    34. 34. HFSA 2010 Practice GuidelineAngiotensin 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.
    35. 35. ACEI+ARBCHARM-Added (Lancet 2003) 2548 NYHA II-IV; LVEF < 40% CV death, hospital admission NNT=25 Second study found no benefitBut 23% discontinued due to side effects (increased cr, hypotension, hyperkalemia)Currently Ace + Arb is not recommended
    36. 36. Nitrates/hydralazine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 HF and reduced LVEF: NYHA III or IV HF NYHA II HF
    37. 37. 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) HF from reduced 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 ARB) and a beta blocker.
    38. 38. Aldosterone receptor antagonsistsSpironolactone (Aldactone; RALES 1999) Pts 1,663 Class III/IV, ACE, Loop,Dig, EF < 35% Decreased all cause mortality of 30%, NNT=10 Hyperkalemia, gynecomastiaEplerenone (Inspra; EPHESUS 2003) Pts 6,642 asym LV dysfunction, DM, or after MI Dec CV mortality of 13%, NNT=43 Newer more selective inhibitor; fewer side effects More pts on beta-blockers
    39. 39. Aldosterone Antagonists and RenalFunction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It is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 monthsSupplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength
    40. 40. DigoxinDigoxin, given in combination with a diuretic and an ACE inhibitor to people with heart failure (NYHA grades II-IV) in normal sinus rhythm, has been found to reduce hospitalization and clinical deterioration, but not mortalityConsider digoxin if the person continues to be symptomatic despite adequate doses of diuretic and ACE inhibitorGive digoxin to all people with heart failure and atrial fibrillation who need control of the ventricular rate.
    41. 41. So Mr Abdallah is going homeWhich of the following medications has not been shown to improve mortality in patients with systolic heart failure?1. Beta Blocker2. ACEI3. Aldosterone antagonist4. Digoxin5. ARB
    42. 42. What discharge instructions do wegive MR AbdallahLow salt diet <2gm/dayNo Faseekh or maloo7aTake medicationsWeigh yourself everydayIf weight increases over 3-5lb take extra lasix dose and contact doctor
    43. 43. Mr Abdallah wishes to know ifthere are any drugs he needs toavoidNSAIDsMost antiarrhythmicsMost calcium channel blockersThiazolidinediones e.g Actos, Avandia
    44. 44. Further testing??Remember presumed LV systolic dysfunction from tachycardia and HTNBut has risk factors for CADSo will need a coronary angiogram
    45. 45. Mr Abdallah underwent coronary angiogram and showed no significant CAD,Now what…………..A. Continue with medical therapy onlyB. Repeat echo in 1 yearC. Repeat echo in 3 monthsD. Refer for Biv/ICD immediately
    46. 46. Device Therapy:Prophylactic ICD PlacementProphylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms: Ischemic etiology Non-ischemic etiology
    47. 47. MADIT II: Prophylactic ICD inIschemic LVD (LVEF ≤30%)
    48. 48. Device Therapy:Biventricular PacingBiventricular pacing therapy is recommended for patients with all of the following: Sinus rhythm A widened QRS interval (≥120 ms) Severe LV systolic dysfunction (LVEF < 35%) Persistent, moderate-to-severe HF (NYHA III) despite optimal medical therapy.
    49. 49. CRT Improves Quality of Life andNYHA Functional Class
    50. 50. Effect of CRT Without an ICD onAll-Cause Mortality: CARE-HF
    51. 51. Back to Mr AbdallahRepeat echo in 3 months showed improvement in EF to 50%So no indication for ICD or Biv-ICD
    52. 52. Thank you!!

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