Heart failure – an update


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An update on heart failure for non cardiologists.

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Heart failure – an update

  2. 2. OBJECTIVE <ul><li>How big is the problem ? </li></ul><ul><li>Current Medical Therapy – the evidence </li></ul><ul><li>Device therapy </li></ul><ul><li>Treatment in the community – its benefits </li></ul>
  3. 3. CASE <ul><li>76 years old male, chronic smoker, HPN </li></ul><ul><li>Presents to ER with acute SOB of one hour duration. </li></ul><ul><li>BP : 170/100 Chest – few wheeze </li></ul><ul><li>ECG- sinus tachycardia </li></ul><ul><li>CXR- Normal heart size, hyper inflated lungs </li></ul><ul><li>Normal initial lab results </li></ul>
  4. 4. Diagnostic Dilemma <ul><li>1. Acute Heart Failure (LVF) </li></ul><ul><li>2.ACS </li></ul><ul><li>3. Acute PE </li></ul><ul><li>4.Acute exacerbation of COPD </li></ul><ul><li>LASIX + ASPIRIN +CLEXANE + NEBULISER </li></ul>
  6. 6. FURTHER CAREFUL EVALUATION <ul><li>Orthopnea </li></ul><ul><li>Cold peripheries </li></ul><ul><li>S3 Gallop </li></ul><ul><li>BNP – markedly elevated </li></ul><ul><li>ECHO- LVH , severe diastolic dysfunction </li></ul>
  7. 7. Epidemiology of Heart Failure <ul><li>Major public health problem </li></ul><ul><li>22 million cases world wide </li></ul><ul><li>550,000 new cases/year in US </li></ul><ul><li>4.7 million symptomatic patients; estimated 10 million in 2037 </li></ul>*Rich M. J Am Geriatric Soc . 1997;45:968–974. American Heart Association. 2001 Heart and Stroke Statistical Update . 2000. 3.5 4.7 10 0 2 4 6 8 10 12 1991 2000 2037* Heart Failure Patients in US (Millions)
  8. 8. Facts on Heart Failure <ul><li>50% readmission rate within 6 months </li></ul><ul><li>One of the leading causes of death. </li></ul><ul><li>35% will die within one year of diagnosis. </li></ul>03/21/11
  9. 9. Heart Failure Admissions British Heart Foundation, 2002 Average duration of hospital admission (days)
  10. 10. Heart Failure Mortality
  11. 11. Causes of Mortality in Heart Failure <ul><li>Pump failure </li></ul><ul><li>Arrhythmia </li></ul><ul><li>Electrolyte imbalance </li></ul><ul><li>Severe Anaemia </li></ul>
  12. 12. Prognostic Value of Haemoglobin Levels at Discharge in Older Patients Admitted With Heart Failure. 2 Syed Raza , 1 Nicolas Wisniacki, 2 Pam Aimson, 2 Chris Manning, 1 Alejandra Abramovsky, 1 Vinod Gowda, 1 Michael Lee, 2 Jason Pyatt. 1 Department of Medicine, University of Liverpool & 2 Department of Cardiology, Royal Liverpool and Broadgreen University Hospitals. United Kingdom.
  13. 13. How Heart Failure Is Diagnosed <ul><li>Medical history </li></ul><ul><li>Physical exam </li></ul><ul><li>Tests </li></ul><ul><ul><li>Blood tests – Hb , KFT, BNP </li></ul></ul><ul><ul><li>Chest X-ray </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Echocardiogram </li></ul></ul><ul><ul><li>Cardiac Catheterization </li></ul></ul>
  14. 14. Symptoms
  15. 15. The Donkey Analogy <ul><li>Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living… </li></ul>
  17. 17. Acute Decompensated Heart Failure /Pulmonary Edema >Medical Emergency !
  18. 18. But
  19. 19. CHF- Etiology <ul><ul><li>1. Impaired cardiac function </li></ul></ul><ul><ul><ul><li>Coronary heart disease </li></ul></ul></ul><ul><ul><ul><li>Cardiomyopathies </li></ul></ul></ul><ul><ul><li>2. Increased cardiac workload </li></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Valvular heart disease </li></ul></ul></ul><ul><ul><ul><li>Anemia </li></ul></ul></ul><ul><ul><ul><li>Congenital heart defects </li></ul></ul></ul><ul><ul><li>3.Acute non-cardiac conditions </li></ul></ul><ul><ul><ul><li>Volume overload </li></ul></ul></ul><ul><ul><ul><li>Thyroid disease </li></ul></ul></ul>
  20. 20. Left Ventricular Dysfunction <ul><li>Systolic: Impaired contractility/ejection </li></ul><ul><ul><li>Approximately two-thirds of heart failure patients have systolic dysfunction 1 </li></ul></ul><ul><li>Diastolic: Impaired filling/relaxation </li></ul>30% 70% Diastolic Dysfunction Systolic Dysfunction (EF < 40%) (EF > 40 %) 1 Lilly, L. Pathophysiology of Heart Disease . Second Edition p 200
  21. 21. Systolic vs. Diastolic <ul><li>Diastolic dysfunction </li></ul><ul><ul><li>EF normal or increased </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Due to LVH and chronic replacement by fibrous tissue - decrease in distensibility </li></ul></ul><ul><li>Systolic dysfunction </li></ul><ul><ul><li>EF < 40% </li></ul></ul><ul><ul><li>Usually from coronary disease </li></ul></ul><ul><ul><li>Due to ischemia-induced decrease in contractility </li></ul></ul><ul><li>Most common is a combination of both </li></ul>
  22. 22. <ul><li>Mixed systolic and diastolic failure </li></ul><ul><ul><li>Seen in disease states such as dilated cardiomyopathy (DCM) </li></ul></ul><ul><ul><li>Poor EFs (<35%) </li></ul></ul><ul><ul><li>High pulmonary pressures </li></ul></ul><ul><li>Biventricular failure (both ventricles may be dilated and have poor filling and emptying capacity) </li></ul>
  23. 23. Right Heart Failure <ul><li>Signs and Symptoms </li></ul><ul><ul><li>fatigue, weakness, lethargy </li></ul></ul><ul><ul><li>wt. gain, inc. abd. girth, anorexia, RUQ pain </li></ul></ul><ul><ul><li>elevated neck veins </li></ul></ul><ul><ul><li>Hepatomegaly +HJR </li></ul></ul><ul><ul><li>may not see signs of LVF </li></ul></ul>
  24. 24. What is present in this extremity, common to right sided HF?
  25. 25. EMERGENCY MANAGEMENT (Pneumonic) U Upright Position N Nitrates L Lasix O Oxygen A Amiodorone > ACEI / ARB D Digoxin, Dobutamine M Morphine Sulfate E Extremities Down
  26. 26. Referral and approach to care NICE (UK) GUIDELINES Refer patients to the specialist multidisciplinary heart failure team in the following situations . – Initial diagnosis of heart failure. – Management of severe heart failure (NYHA class IV), heart failure that does not respond to treatment, heart failure due to valve disease, or heart failure that can no longer be managed at home – Advice and care of women who are planning a pregnancy or are pregnant. Care of pregnant women should be shared between the cardiologist and obstetrician. Patients with previous MI Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, to have transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks
  27. 27. Rational for Medications (Why does my doctor have me on so many pills??) <ul><li>Improve Symptoms </li></ul><ul><ul><li>Diuretics (water pills) </li></ul></ul><ul><ul><li>digoxin </li></ul></ul><ul><li>Improve Survival </li></ul><ul><ul><li>Betablockers </li></ul></ul><ul><ul><li>ACE-inhibitors </li></ul></ul><ul><ul><li>Angiotensin receptor blockers (ARB’s) </li></ul></ul><ul><ul><li>Aldosterone antagonists </li></ul></ul>
  28. 28. Compensatory Mechanisms: Renin-Angiotensin-Aldosterone (RAAS) Vasoconstriction Oxidative Stress Cell Growth Proteinuria LV remodeling Angiotensinogen Angiotensin I Angiotensin II 3 .AT II receptor 1 .Renin 2 .Angiotensin Converting Enzyme 1.Direct Renin Inhibitor (Aliskiren) 2.ACEI 3.A2RB
  29. 29. ACE-I <ul><li>SOLVD-Enalapril 20mg/day (41 mo) </li></ul><ul><li>2569 Patients with and EF <35% </li></ul><ul><ul><li>Earlier stages of HF even asymptomatic </li></ul></ul><ul><ul><li>NYHA Class II-III </li></ul></ul><ul><li>All cause mortality dec by 16% </li></ul><ul><li>Morality rate from HF dec by 16% </li></ul><ul><li>CONSENSUS-Enalapril 2.5-40mg (188 days) vs placebo </li></ul><ul><li>Pts were already taking digoxin and diuretics </li></ul><ul><li>253 Patient with NYHA Class IV </li></ul><ul><li>Dec mortality at: </li></ul><ul><ul><li>6 months -40% </li></ul></ul><ul><ul><li>1 Year – 27% </li></ul></ul>
  30. 31. Angiotensin-Receptor Blockers <ul><ul><li>Comparable to ACE inhibitors </li></ul></ul><ul><ul><li>Reduce all-cause mortality </li></ul></ul><ul><ul><li>Suitable alternative for patient with adverse events (angioedema and cough) occur with ACEI </li></ul></ul>
  31. 32. ACE + ARB <ul><li>CHARM-Added (Lancet 2003) </li></ul><ul><ul><li>2548 NYHA II-IV; LVEF < 40% </li></ul></ul><ul><ul><li>Reduced CV death, hospital admission </li></ul></ul><ul><ul><li>Second study found no benefit </li></ul></ul><ul><li>But 23% discontinued due to side effects (increased cr, hypotension, hyperkalemia) </li></ul><ul><li>Currently ACEI + ARB is not recommended </li></ul>
  32. 33. Beta-Blockers <ul><li>34% reduction in all mortality with use of beta-blockers </li></ul><ul><li>Decrease Cardiac Sympathetic Activity </li></ul><ul><li>Use in stable patients (start as early as discharge-IMPACT-HF) </li></ul><ul><li>Titrate slowly </li></ul><ul><li>Work irrespective of the etiology of the heart failure </li></ul>
  33. 34. Beta- Blocker therapy-which to pick? <ul><li>Three beta-blockers : </li></ul><ul><li>Bisoprolol (Zebeta ) -Trial CIBIS-II </li></ul><ul><li>Metoprolol (Toprol XL ) –Trial MERIT-HF (sustained release) </li></ul><ul><li> Carvedilol (Coreg) Trial-COPERNICUS and CAPRICORN </li></ul><ul><li>Carvedilol vs. Metoprolol (COMET 2003) </li></ul><ul><ul><li>3029 pts; carvedilol 25mg bid vs. metoprolol 50 mg bid </li></ul></ul><ul><ul><li>Patient with NYHA Classes II-IV </li></ul></ul><ul><ul><li>Carvedilol –greater reduction in mortality </li></ul></ul>
  34. 35. Initial and Target Doses of beta-blockers for HF Medication Starting Dose Target Dosage Bisoprolol 1.25mg daily 10mg daily Carvedilol 3.125mg bid 25mg bid Metoprolol CR/XL 12.5-25mg daily 200mg daily
  35. 36. Aldosterone Antagonists <ul><li>Spironolactone (Aldactone; RALES 1999 ) </li></ul><ul><ul><li>Pts 1,663 Class III/IV, EF < 35% </li></ul></ul><ul><ul><li>Decreased all cause mortality of 30% </li></ul></ul><ul><ul><li>Hyperkalemia, gynecomastia </li></ul></ul><ul><li>Eplerenone (Inspra; EPHESUS 2003 ) </li></ul><ul><ul><li>Pts 6,642 asym LV dysfunction, DM, or after MI </li></ul></ul><ul><ul><li>Dec CV mortality of 13%, </li></ul></ul><ul><ul><li>Newer more selective inhibitor; fewer side effects </li></ul></ul>
  36. 37. Digoxin <ul><li>May relieve symptoms, does not reduce mortality . Beneficial in AF </li></ul><ul><li>Reduced hospital admission due to heart failure </li></ul><ul><li>More admissions for suspected digoxin toxicity </li></ul><ul><li>Should not be used in ischaemic cardiomyopathy </li></ul>
  37. 38. Treatment of Special Populations <ul><li>Class I Level A </li></ul><ul><li>African Americans: NYHA functional class III or IV HF </li></ul><ul><ul><li>Combination of a fixed dose of isosorbide dinitrate and hydralazine . </li></ul></ul><ul><ul><li>29% Reduction in mortality. </li></ul></ul><ul><ul><li>Headache, flushing </li></ul></ul>Jessup M et al. J Am Coll Cardiol . 2009;53;1343-82.
  38. 39. Nesiritide (Natrecor) <ul><li>Recombinant form of human BNP </li></ul><ul><li>Causes venous and arterial vasodilation </li></ul><ul><ul><li>has been shown to improve dyspnea </li></ul></ul><ul><ul><li>Shown to reduce 30 day mortality </li></ul></ul>
  39. 40. Some Practical Tips <ul><li>Diuretics : Intravenous for 48-72 hours in </li></ul><ul><li>acute decompensation, then change to oral </li></ul><ul><li>Beta blocker to be initiated when lungs are ‘Dry’ </li></ul><ul><li>( “Start low and go slow” ) </li></ul><ul><li>First dose of ACEI /ARB (small dose) usually at night </li></ul><ul><li>Calcium channel blocker esp. Diltiazem useful for Diastolic heart failure </li></ul><ul><li>Do not forget prophylactic clexane to prevent VTE </li></ul>
  41. 42. Ultrafiltration
  42. 43. DEVICE THERAPY <ul><li>Unacceptably high morbidity and mortality despite medical therapy. </li></ul><ul><li>Device therapy in heart failure has shown to improve symptoms as well as reduce mortality and sudden death. </li></ul><ul><li>Must be used in patients with good indications </li></ul><ul><li>Needs skills and resources </li></ul>
  43. 44. Biventricular Pacing (CARDIAC RESYNCHRONISATION THEARPY) <ul><li>Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction </li></ul>Overview of Device Therapy
  44. 46. Cardiac Resynchronization Therapy Key Points <ul><li>Indications </li></ul><ul><ul><li>Moderate to severe CHF who have failed optimal medical therapy </li></ul></ul><ul><ul><li>EF<30% </li></ul></ul><ul><ul><li>Evidence of electrical conduction delay ( QRS > 120 ms) or Dysynchrony demonstrated on ECHO. </li></ul></ul>
  45. 47. Heart Failure and Sudden Cardiac Death <ul><li>Sudden Cardiac Death (SCD) </li></ul><ul><ul><li>Usually caused by serious ventricular arrhythmia i.e. VT and VF </li></ul></ul><ul><ul><li>SCD is one of the leading causes of death in the U.S. – approximately 450,000 deaths a year </li></ul></ul><ul><ul><li>Patients with heart failure are 6-9 times as likely to develop sudden cardiac death as the general population </li></ul></ul>
  46. 48. IMPLANTABLE CARDIAC DEFIBRILLATOR Device Shown: Combination Pacemaker & Defibrillator
  47. 49. Who should receive an ICD? <ul><li>New York Heart Association (NYHA) Class II and III heart failure </li></ul><ul><li>Left ventricular ejection fraction (LVEF) < 35% </li></ul><ul><li>Usually combined with BiVentricular pacemaker </li></ul><ul><li>(CRT-D) </li></ul>
  48. 50. Implantable Cardiac Defribrillators EBM Therapies Relative Risk Reduction Mortality 2 year ACE-I 23% 27% Β -Blockers 35% 12% Aldosterone Antagonists 30% 19% ICD 31% 8.5%
  49. 51. Other Therapies? <ul><li>Left Ventricular Assist Device </li></ul><ul><li>Artificial hearts </li></ul><ul><li>Heart Transplant </li></ul>
  50. 52. Left ventricular assist device
  51. 54. Newer Generation Artificial Hearts
  53. 58. Heart Transplantation <ul><li>A good solution to the failing heart– get a new heart </li></ul><ul><li>Demand is high , limited donor hearts </li></ul><ul><li>Approximately 2200 transplants are performed yearly in the US </li></ul>
  54. 59. Worldwide Heart Transplants
  55. 60. Trends in Hospitalization for Heart Failure by Age Group 1979-2004 (CDC, 2006) 03/21/11
  56. 61. MULTI DISCIPLINARY APPROACH (INTEGRATED CARE) <ul><li>Purpose: To improve the care delivered to heart failure patients across the continuum </li></ul>03/21/11
  57. 62. Outcomes of the Heart Failure Team <ul><li>Interdisciplinary approach </li></ul><ul><li>Physician Support </li></ul><ul><li>Patient Education </li></ul><ul><li>Comprehensive discharge instructions </li></ul><ul><li>Regular follow up in the community </li></ul><ul><li>Telehealth program </li></ul><ul><li>Increase in patient self-management skills </li></ul><ul><li>Increase in patient satisfaction </li></ul><ul><li>Decrease variation in care delivered </li></ul><ul><li>Decrease LOS </li></ul><ul><li>Decrease readmissions </li></ul><ul><li>Decrease mortality </li></ul>03/21/11
  58. 63. Telehealth Program <ul><li>Remote home monitoring will include vital signs, oxygen level assessment and body weight </li></ul><ul><li>Screening for eligibility is performed while the patient is hospitalized </li></ul><ul><li>Patient education provided by nurses </li></ul>03/21/11
  59. 66. One of the Best Devices for Monitoring Heart Failure <ul><li>OptiVol (Medtronic) </li></ul><ul><li>Measures body fluid </li></ul><ul><li>status by measuring </li></ul><ul><li>intra thoracic </li></ul><ul><li>impedance. </li></ul>
  60. 68.                                                                                                                                                                                                                                                     Recent Developments and Future Challenges of Integrated Care in Heart Failure in Europe and Northern America   The International Network of Integrated Care, The Julius Center of the University Medical Center Utrecht and the University of Southern Denmark 11th International Conference on Integrated Care: 4.7. Paper session: IC for heart failure patients Pilot Study of Integrated home Care for Patients of Congestive Cardiac Failure: British District Hospital Experience – Dr Syed S.M. Raza et al., Dept. of Cardiology & Acute Medicine, Huddersfield and Calderdale Royal Hospitals NHS Trust, UK   March 30 - April 1, 2011 in Odense, Denmark  
  62. 70. In Summary…. <ul><li>Heart failure is common and has high mortality </li></ul><ul><li>Drug therapy improves survival </li></ul><ul><li>Newer device therapies are showing promise for symptom relief and improved survival </li></ul><ul><li>Transplants remain rare, but technology for mechanical assist devices continues to improve- stay tuned! </li></ul>