Heart failure – an update [autosaved]


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  • Dr. (Name) says: Heart failure is a disease that reduces the heart’s ability to pump blood. To give you a better idea of what happens during heart failure, I’m first going to show you a normal heart. Click on the animation: In a normal heart, the blood is pumped in a smooth and synchronized way. (Explain the flow patterns to and from the right and left heart if you wish.) In a normal heart, the heart pumps enough blood to match the body’s need for oxygen. Discuss “plumbing” functions and “electrical” functions.
  • Some of the information we gathered was very interesting…..
  • The figure shows the average length of hospital admission by main diagnosis in NHS hospitals in England for 2000/01. Petersen S, Rayner M, Wolstenholme J. Coronary heart disease statistics: heart failure supplement. London: British Heart Foundation, 2002.
  • Dr. (Name) says: Short explanation of the diagnostic process – what might take place during each test. Discuss commonly done tests including the role of the echocardiogram .
  • Let’s compare our heart to this donkey, and our body to the wagon that this donkey has to pull every day. A healthy heart is like an energetic donkey, which without fatigue, pulls the wagon full of weights. Conversely, a diseased heart will have difficulty meeting metabolic demands (or pulling the wagon).
  • As previously seen, there are many causes of heart failure. Some diseases, however, tend to more adversely affect the heart’s systolic function (ventricular contraction/ejection), while others tend to more adversely affect diastolic function (ventricular filling/relaxation). This provides a useful way of classifying heart failure from a hemodynamic standpoint. Most patients who have systolic dysfunction also have a component of diastolic dysfunction.
  • Systolic and Diastolic Dysfunction Diastolic dysfunction caused by compromise myocardial relaxation in the presence of myocardial contractility and ejection fraction. One third to one half of patients with heart failure have normal ventricular contractile function, and are said to have diastolic heart failure. Abnormal diastolic function may be due to impaired early relaxation, increased stiffness of the ventricle, or both. Diastolic dysfunction results in impairment in ventricular filling. LV end-diastolic pressures are elevated, leading to pulmonary venous congestion. Diastolic dysfunction is most commonly associated with left ventricular hypertrophy (LVH) due to hypertension, and occurs frequently in elderly women. Increased resistance to filling results from the increased LV mass itself, and also from interstitial fibrosis and subendocardial ischemia. Diastolic dysfunction can occur in the absence of LVH due to ischemia, myocardial infiltration (e.g., amyloidosis), or pericardial constriction. Systolic Heart Failure Most commonly, heart failure reflects an abnormality of ventricular contractile function. End-systolic volume, end-diastolic volume, and end-diastolic pressure are increased, and stroke volume falls. Symptoms of reduced cardiac output (e.g., fatigue) develop. In addition, increased LV end-diastolic pressure is transmitted back to the pulmonary veins, resulting in transudation of fluid into the pulmonary interstitium and symptoms of pulmonary congestion. The most common cause of contractile dysfunction is loss of myocytes due to myocardial infarction. Other causes of systolic heart failure include dilated cardiomyopathy, myocarditis, and chronic alcohol use. The most common form of heart failure , that due to coronary artery disease, often reflects a combination of systolic and diastolic dysfunction. Systolic dysfunction is due to prior infarction and ischemia-induced decrease in contractility. Diastolic dysfunction is due to chronic replacement fibrosis and ischemia-induced decrease in distensibility.
  • Mixed systolic and diastolic failure Disease states as dilated cardiomyopathy (DCM), poor EFs (<35%), high pulmonary pressures Biventricula r failure (both ventricles may be dilated, poor filling and emptying capacity)
  • The other mechanism in the neurohumoral response to heart failure is the renin-angiotensin-aldosterone system (RAAS). In the RAAS, Renin ( secreted by the kidney ) acts on Angiotensinogen (secreted by the liver) to make Angiotensin I. The Angiotensin converting enzyme (secreted by the lungs) acts on Angiotensin I to make Angiotensin II. Angiotensin II in turn causes vasoconstriction, an increase in aldosterone, facilitates the release of norepinephrine from the SNS, causes sodium reabsorption, stimulates vasopressin secretion from the brain (discussed later), and increases contractility. Subsequently, remodeling of the heart occurs. In a heart failure patient, the effects of Angiotensin II are not beneficial. Why not think about using a medication to block the conversion of Angiotensin I to II? Or, an agent that blocks the Angiotensin I receptor? These blocking agents will be discussed later when we talk about the treatment of heart failure.
  • Consensus- COOPERATIVE NORTH SCANDINAVIAN ENALAPRIL SURVIVAL STUDY pt were already taking digoxin and diuretics. Subsequent SOLVD- STUDIES OF LEFT VENTRICULAR DYSFUNCTION- Proved consensus at a earlier stage of heart failure even asymptomatic
  • ARBs are comparable to ACE-I in reduction all-cause mortality and heart failure-related hospitalizations in patients with NYHA classes II and III heart failure.
  • Adding an ARB to ACE-inhibitor therapy provides further mortality benfit in slected patients. In this trial of patients with NYHA classes II to IV heart failure, candesartan added to existing ACE-I therapy reduced cardiovasular death (NNT, 28 over 3.5 years) and reduced heart-failure related hospital admission. A second study found no benefit
  • POTENTIAL CONCERNS REGARDING INITIATION OF β BLOCKERS BEFORE DISCHARGE The 1999 guidelines of the Heart Failure Society of America suggested that, to maximize safety, there should be a period of clinical stability while on standard therapy before instituting β blockers and that initiation in patients who have HF requires a careful baseline evaluation of clinical status. 26 Because it is based on early, large-scale trials in which patients who had chronic HF were treated with standard therapy consisting of ACE inhibitors, digoxin, and a diuretic for ≥2 months before starting β-blocker therapy, this recommendation led to many HF clinicians postponing β-blocker therapy for ≥2 to 4 weeks until stability had been achieved. This plays into the concern many practitioners have that beginning β blockade in patients who have HF will necessarily worsen HF during the titration period. In the Randomized Evaluation of Strategies for Left Ventricular Dysfunction, there was a significantly larger number of hospitalizations for worsening HF with controlled-release metoprolol than with placebo (p = 0.026). However, there was also a 54% lower risk of death with controlled-release metoprolol (p = 0.057) and a significant increase in LV ejection fraction (p = 0.001). 2 , 27 In the COPERNICUS study, there were significantly fewer patients who used carvedilol and then developed serious adverse events than those who used placebo (p <0.002). 10 This trial showed that the adverse event of utmost concern to clinicians regarding the initiation of β blockers, i.e., worsening HF, occurred less frequently with carvedilol than with placebo. 10 , 28 The COPERNICUS, in effect, indicated that the early initiation of life-saving therapies should be approached with a sense of urgency and provides a mandate for expediting the administration of β-blocker therapy in patients who have HF. After comparing initiation before and after discharge with respect to tolerability and safety in the IMPACT-HF study, it was found that there were no significant differences between groups in the occurrence of serious adverse events (bradycardia, hypotension, and worsening HF) or the occurrence of these events leading to the permanent withdrawal of the β blocker. Fewer patients developed worsening of HF before than after discharge (0.5% vs 1.7%), and there was a lower composite rate of death and rehospitalization. 25 These major trials clearly refute the common practices and perceptions regarding β-blocker therapy for HF that lead to unnecessary delays in treatment and deny patients established benefits of this therapy. Specifically, the results of these studies challenge the beliefs commonly held by many clinicians that initiation of β blockade is characterized by an unfavorable benefit/risk ratio, that survival curves do not diverge in favor of β blockers for many months, and that early initiation necessarily carries the risk of worsening HF or intolerance that leads to withdrawal of treatment. Rather, these studies clearly demonstrate the high degree of tolerability for β blockers and that there is a lower relative rate of discontinuation with β blockers than with placebo. Several β blockers, e.g., atenolol, timolol, and propranolol, have proven efficacy as secondary prevention after myocardial infarction but not as therapy for HF. Among those agents that have established efficacy in HF, e.g., carvedilol, bisoprolol, and metoprolol, there are pharmacologic differences that may alter the clinical responses to these agents in HF 24 and may have an affect on in-hospital initiation of therapy. The β-1–specific blockers may decrease cardiac output, increase vascular resistance, or decrease renal blood flow, all of which can contribute to worsening HF. 30 The β blockers with an α blockade, such as carvedilol, increase cardiac output and decrease vascular resistance. The vasodilatory activity due to α-1 blockade offsets myocardial depression due to β blockade, and the broad-based sympathetic antagonism may protect the patient against worsening HF in the early stages of initiation. 30 In the MERIT-HF trial of patients who had HF of New York Heart Association classes III and IV, a decrease in the mortality rate was observed with the use of metoprolol, a β-1–specific blocker; however, the metoprolol-treated group had a higher rate (8.1%) of withdrawal in the first 90 days than did the placebo-treated group (5.9%). 31 Data from COPERNICUS trial showed that the carvedilol-treated group had a lower rate of worsening HF (5.1%) than did the placebo group (6.4%) during the initiation phase. 25 In the IMPACT-HF study, only 0.5% of patients withdrew due to worsening HF if they had been initiated with carvedilol before discharge versus 1.7% of patients who had been initiated with a β blocker of the physician's choice after discharge. 25 Therefore, these considerations may make carvedilol a better agent for initiating β-blocker therapy in the hospital setting.
  • 6 RCT’s that included more than 9,000 patients already taking ACE-I showed a significant reduction in total mortality and sudden dearth (NNT 24, and #% over 1-2 years) Carvedilol or Metoprolol European Trial 2003 In a recent trial , patient with NYHA classes II to IV heart failure who were treated with carvedilol had greater reductions in mortality (NNT, 18 over 5 years) and cardiovascular mortality (NNT, 16 over five years) than those treated with metoprolol but, hypotension was more common among the carvedilol group (14 versus 11 percent) Bisoprolol and metoprolol are b1-selective with no vasodilating properties Coreg- is alpha 1 beta 1 and beta 2 with vasoldilating properties
  • Add aldactone in moderate to severe heart failure, favorable effects on LV remodeling Randomized Aldactone RALES-survival benefit of spironolactone in patient with severe heart failure and favorable effexts on LV remodeling Most common risk is hyperkalemia and 10 % of men will experinece breast pain an gynecomastia Eplerenone-newer more selective aldosterone inhibitor has been shown to reduce all-cause mortality following myocardial infraction with Left ventricular dysfunction (NNT, 43 for 16 months) Has not yet been studied in patient with CHF who have not yet had a MI
  • Patients taking digoxin are less lekely to be hospitalized for worseing heart failrue (NNT, 27 to 115 over three years) and their heart failure symptoms may worsen if digoxin is withdrawn Positive inotrope with autonomic effects: increased parasympathetic tone DIG Trial (Garg R et al. N Engl J Med 1997;336:525-33.) : 6,800 pts w/ EF < 45% randomized to digoxin vs. placebo (Background tx: ACEI, diuretic) No difference in mortality between two groups 25% reduction in CV death or hospitalization for HF (p<0.001) 28% reduction in hospitalization for HF (p<0.001) Toxicity: renal dysfunction, elderly
  • $530/dy Decreased 30 days survival Side effect of hypotension No benefit as an outpatient basis
  • Many patients with advanced systolic heart failure exhibit significant inter- or intraventricular conduction delays that disturb the synchronous beating of the left and right ventricles so that they pump less efficiently. This delayed ventricular activation and contraction is referred to as ventricular dysynchrony and is easily recognized by a wide QRS complex on an ECG. This IVCD (inter- or intraventricular conduction delay) typically has left bundle branch morphology.
  • Dr. (Name) says: Sudden Cardiac Arrest is as scary as it sounds. It means that your heart suddenly starts beating very fast and quivers instead of beating in a regular and organized way. No blood gets pumped, and you will die unless you get treatment within minutes. We’ll talk more about treatments in a moment. Unlike a heart attack, SCA is caused by an electrical problem in your heart. SCA can strike without warning, and there are no symptoms.
  • Click on animation. Dr. (Name) says: Some people with Class III and IV heart failure can benefit from a heart failure pacemaker that can help your heart beat more efficiently by coordinating or synchronizing the way the heart beats, so your heart pumps more efficiently. It works by automatically checking your heart function 24 hours a day. This type of heart device is also called cardiac resynchronization therapy or CRT. You may also hear the term biventricular pacing. All refer to the same kind of treatment. Treatment with a heart device may make you feel better. Although many people experience dramatic improvements in their quality of life and in their heart failure symptoms, results may vary. Not everyone responds to the treatment in the same way. It is also important to note that heart failure pacemakers do not cure heart failure--a heart failure pacemaker is part of an overall treatment plan. Describe heart failure pacemaker device: A heart failure pacemaker is about the size of a small pocket watch that contains a battery and computer circuitry to correct your heart rhythm and help your heart beat more efficiently. Small insulated wires called leads connect the device to the heart. We’re going to pass around a plastic replica of a Medtronic combination heart failure pacemaker and defibrillator pacemaker . Facilitators circulate and pass around replicas and collect them. Before I move on, I’d like to say a few words about Medtronic, the company helping us put on the seminar today. Medtronic was the first company to introduce a pacemaker in the United States. Physicians worldwide have prescribed heart failure pacemakers for more than 120,000 patients. Other people with heart failure are in danger of having heartbeats that are irregular and/or too fast. These irregular heart beats can cause you to feel short of breath and light headed. Such episodes may also be life threatening if not treated quickly. Some heart devices also contain a defibrillator in addition to the special kind of pacemaker. This combination device also sends out small electrical signals to restore your normal heart rhythm. If the small signals do not work, the device sends out a shock to reset your heart rhythm. This kind of device is also used to treat SCA.
  • Looking at demographics nation-wide… Currently 12% of our pop is over the age of 65, by 2030 it is expected to be at about 20%
  • Keeping that recommendation in mind, the HVHC HF Task force was created. It’s purpose was to…..
  • Patients are screened for the Telehealth program…..some may refuse
  • Heart failure – an update [autosaved]

    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>
    16. 16. I GIVE UP . I CAN’T TAKE IT ANY MORE !!
    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>