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.
IntroductionHeart 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 bloodNo longer use the term “congestive” because all heart failure does not result in clinically apparent volume overload
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.
What is the incidence of heart failure?Estimated 500,000 new cases per yearWithin 5 years, half of those diagnosed will be deadOver 1 million hospitalizations per year with HF as primary diagnosisMost common reason for hospitalization in those >65 years oldHeart failure is 4th in a list of quality of care initiatives in vulnerable older adults
Case-Mr Abdallah45 yr old man with poorly controlled hypertension, DM presents with 3 weeks of progressive shortness of breath, LE edemaExam remarkable for HR 150, BP 80/40, RR 26Appears lethargic, Elevated JVP, PMI displaced, irregular, S1, S2, S3 on exam, no murmurs, lungs with crackles, Extremities cold with edema
Back to our patientSo Mr Abdallah has risk factors for CADAlso has elevated BP-so hypertensive heartNo murmur on exam so valvular heart disease unlikelyArrythmias……..afib, tachycardia induced cardiomyopathyWhat about amyloidosis ALWAYS LOOK FOR REVERSIBLE CAUSES
Initial WorkupBasic labs, check for anemia-high output failure, chem8, TSH, ferritinEKG-look for acute MI or prior infarctsCXR- pulmonary edema, heart sizeEchocardiogram to assess LV function, assess for diastolic dysfunction
Future workupCoronary AngiogramIf flash pulmonary edema and severe HTN, consider renal angiogramIf no clear cause in young patient consider cardiac biopsy
Mr Abdallah tests showedNormal CBCElevated BUN/Creatinine 45/1.8Elevated LFTS ( AST/ALT)CXR showed pulmonary edemaEcho showed an EF of 30% with diffuse global hypokinesis
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
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
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 dosesNorepinephrine (Levophed): vasoconstriction, inotropic stimulant. Should only be used for refractory hypotension with dec SVR.Vasopression – vasoconstrictionVASO and LEVO should only be used as a last resort
If patient tachycardic, dopamine and dobutamine are not great choicesSo in Mr Abdallah would attempt to cardiovert him as he will not sustain pressor supportTEE to r/o left atrial appendage thrombusFollowed by Cardioversion
So Mr Abdallah underwent TEEWas cardiovertedBP improvedHR stabilizedStill congested but now hemodynamically stable NOW WHAT??
Diurese, diurese, diurese!!!Do you start an ACEI?Do you start a beta blocker?
Furosemide DosingIf patient is lasix naive start slow and titrate up per urine outputLasix dose usually 0.5-1mg/kg twice a dayUsually expect response in first 5-10mins with IVUsual start dose 40mg or 80mg IV q8hrsAlways give potassium supplements when diuresing patient
Regular monitoring of electrolytes with IV diuresisSwitch to PO when more euvolemic, BUN/creatinine start risingRemember 80mg PO =40mg IVIf 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
ACEI and Beta BlockersStart ACEI in patients as soon hemodynamically stableHelp reduce preload and afterloadTitrate up per patient, don’t look at BP!!Beta Blockers-start low dose prior to dischargeTitrate dose as outpatient
Back to Mr AbdallahSo Mr Abdallah is doing well, he maintained sinus rhythm and is being dischargedWhat medications should he be on long term for a mortality benefit??
Beta Blockers34% reduction in all mortality with use of beta-blockersDecrease Cardiac Sympathetic ActivityTitrate slowlyContraindications-bradycardia, heart block or hemodynamic instabilityMild asthma is not a contraindicationWork irrespective of the etiology of the heart failure
Three beta-blockersBisoprolol (Zebeta) -Trial CIBIS-IIMetoprolol (Toprol XL) –Trial MERIT-HF (sustained release) Carvedilol (Coreg) Trial-COPERNICUS6 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
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)
Beta Blockers and concomitantdiseaseBeta 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.
HFSA 2010 Practice Guideline ACEInhibitorsACE 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).
ACEICONSENSUS-Enalapril 2.5-40mg (188 days) vs placeboPts were already taking digoxin and diuretics253 Patient with NYHA Class IVDec 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-IIIAll cause mortality dec by 16%Morality rate from HF dec by 16%
HFSA 2010 Practice GuidelineAngiotensin Receptor BlockersARBs 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.
ACEI+ARBCHARM-Added (Lancet 2003) 2548 NYHA II-IV; LVEF < 40% CV death, hospital admission NNT=25 Second study found no benefitBut 23% discontinued due to side effects (increased cr, hypotension, hyperkalemia)Currently Ace + Arb is not recommended
Nitrates/hydralazineA 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
Pharmacologic Therapy:Aldosterone AntagonistsAn 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.
Aldosterone receptor antagonsistsSpironolactone (Aldactone; RALES 1999) Pts 1,663 Class III/IV, ACE, Loop,Dig, EF < 35% Decreased all cause mortality of 30%, NNT=10 Hyperkalemia, gynecomastiaEplerenone (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
Aldosterone Antagonists and RenalFunctionAldosterone 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 diureticsIt is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 monthsSupplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength
DigoxinDigoxin, 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 mortalityConsider digoxin if the person continues to be symptomatic despite adequate doses of diuretic and ACE inhibitorGive digoxin to all people with heart failure and atrial fibrillation who need control of the ventricular rate.
So Mr Abdallah is going homeWhich of the following medications has not been shown to improve mortality in patients with systolic heart failure?1. Beta Blocker2. ACEI3. Aldosterone antagonist4. Digoxin5. ARB
What discharge instructions do wegive MR AbdallahLow salt diet <2gm/dayNo Faseekh or maloo7aTake medicationsWeigh yourself everydayIf weight increases over 3-5lb take extra lasix dose and contact doctor
Mr Abdallah wishes to know ifthere are any drugs he needs toavoidNSAIDsMost antiarrhythmicsMost calcium channel blockersThiazolidinediones e.g Actos, Avandia
Further testing??Remember presumed LV systolic dysfunction from tachycardia and HTNBut has risk factors for CADSo will need a coronary angiogram
Mr Abdallah underwent coronary angiogram and showed no significant CAD,Now what…………..A. Continue with medical therapy onlyB. Repeat echo in 1 yearC. Repeat echo in 3 monthsD. Refer for Biv/ICD immediately
Device Therapy:Prophylactic ICD PlacementProphylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms: Ischemic etiology Non-ischemic etiology