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HEART FAILURE SYMPOSIUM 23rd of January 2013 GULF HOTELSponsor : SERVIER Laboratories
Programme5-5.30 pm Registration5.30 – 5.45 pm Welcome and Introduction SESSION I Chaired by Dr Fuad Saeed, BDF Hospital Dr Taysir Garadah, AGU/Dr Sulaiman Al Habib5.45 – 6.15 pm Heart Failure in the 21st century – An Overview Speaker -Dr Syed Raza, Awali Hospital6.15 – 6.45 pm Management of Acute Heart Failure Dr Haitham Amin, BDF Hospital6.45 – 7.15 pm Evidence based management of Chronic Heart Failure Speaker: Dr Hussam Noor, BDF Hospital7.15 – 7.25 pm Panel discussion7.25- 7.40 pm Coffee break
SESSION II Chaired by Dr Rashed Al Bannay, Salmaniya Hospital Dr Sadananda Shivappa, BDF Hospital7.40 – 8.10 pm Diastolic Heart Failure Speaker : Dr Said Al Said, Salmaniya Hospital8.10 – 8.40 pm Device Therapy in Heart Failure Speaker: Dr Adel Khalifa, BDF Hospital8.40 – 9.10 pm Cardio-renal Syndrome – Definition and Management. Speaker: Dr Jafar Al- Said, Consultant Nephrology &Internal Med. Bahrain Specialist Hospital9.10 – 9.40 pm Integrated and End of Life Care in Heart Failure Speaker: Dr Syed Raza, Awali Hospital9.40 -9.50 pm Panel Discussion9.50 pm Vote of thanks followed by dinner
Heart Failure in the 21 st Century-An Overview SYED RAZA
OBJECTIVES• Size of the problem• Assessment and making the diagnosis• Therapy – Drug and Device• Novel Therapy in heart failure
Case• 76 years old male, chronic smoker, HPN, Previous MI• Presents to ER with acute SOB and chest tightness of one hour duration.• BP : 170/100 Chest -few wheeze CVS- no murmur• ECG- sinus tachycardia, Q waves in anterior leads.• CXR- ?Cardiomegaly, hyper inflated lungs, increased broncho- vascular markings.• Normal initial lab results
Further Careful Evaluation• Orthopnoea, PND• Cold peripheries, leg swelling, fine inspiratory crackles at lung bases , JVP rise• S3 Gallop• BNP – markedly elevated• ECHO- Dilated LV , severe LV systolic dysfunction- EF 20%
• “The very essence of cardiovascular practice is the early detection of heart failure” Sir Thomas Lewis, 1933
Epidemiology of Heart Failure 12 10 Heart Failure Patients in US 10 • Major public health problem • 22 million cases world wide 8 (Millions) • 550,000 new cases/year in US 6 4.7 • 4.7 million symptomatic 4 3.5 patients; estimated 10 million in 2037 2 0 1991 2000 2037**Rich M. J Am Geriatric Soc. 1997;45:968–974.American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.
Facts on Heart Failure One of the leading causes of death.• 35% will die within one year of diagnosis. 50% of HF patients will die 5 years after the diagnosis.01/29/13
• Less than 50% of patients with HF have typical physical signs• Less than 50% of patients being correctly identified during the initial consultation.• 50% readmission rate within 6 months• It is estimated that in Europe total cost of HF exceeds 50 billion Euro every year.
Heart Failure Admissions Injuries and poisoningComplications of pregnancy and childbirth All GU system All digestive system All respiratory system All nervous system All cancer Diabetes Stroke Heart failure Acute MI Angina Coronary Heart Disease All circulatory All diagnoses 0 5 10 15 20 25 30 Average duration of hospital admission (days) British Heart Foundation, 2002
Left Ventricular Dysfunction • Systolic: Impaired contractility/ejection – Approximately two-thirds of heart failure patients have systolic dysfunction1 • Diastolic: Impaired filling/relaxation 30% (EF > 40 %) (EF < 40%) 70% Diastolic Dysfunction Systolic Dysfunction1 Lilly, L. Pathophysiology of Heart Disease. Second Edition p 200
Advanced Imaging in Heart Failure• Real Time and contrast enhanced 3- Dimenstional Echocardiography Nuclear Imaging : SESTAMIBI SPECT – Myocardial Perfusion scan.• Cardiac Magnetic Resonance (CMR) Imaging
Cardiac MRI in Heart Failure Ability to assess in a single setting• Cardiac morphology,• Function, flow, perfusion,• Acute tissue injury, and fibrosis in a single setting.• Risk stratification
Referral and approach to careNICE (UK) GUIDELINESRefer patients to the specialist multidisciplinaryheart failure team in the following situation:1.Initial diagnosis of heart failure. 2. Management of severe heart failure (NYHAclass IV), heart failure that does not respond totreatment, 3. Patients with previous MI 4.heart failure due to valve disease. 5.Patient who is pregnant or planning apregnancy
Heart Failure Diagnosis – Not A Death Sentence !
ADVERSE PROGNOSTIC MARKERS IN CHRONIC HEART FAILURE• Old Age,• Severity of heart failure (NYHA class)• Left ventricular dysfunction,• Diabetes Mellitus,• Raised creatinine,• Hyponatremia , Hypoalbuminaemia,Anaemia• Presence of arrhythmia : AF / VT
Causes of Mortality in Heart Failure• Pump failure• Arrhythmia• Severe Anaemia• Associated serious co-morbidities i.e. Renal failure
Prognostic Value of Haemoglobin Levels atDischarge in Older Patients Admitted With HeartFailure. 2Syed Raza, 1Nicolas Wisniacki, 2Pam Aimson, 2ChrisManning, 1Alejandra Abramovsky, 1Vinod Gowda, 1MichaelLee, 2Jason Pyatt.1Department of Medicine,University of Liverpool & 2Department of Cardiology,Royal Liverpool and Broadgreen University Hospitals.United Kingdom.
Southey’s TubesIn the 19th and early 20th centuries, heart failure associated with fluidretention was treated with Southeys tubes, which were inserted intoedematous peripheries, allowing some drainage of fluid.
Heart Failure Management: The Time Line• 1920 Organo-mercurial diuretics• 1970s and before- Bed rest and fluid restriction• 1980s- Diuretics and Digoxin• 1990s- Nitrate, ACEI and ARB• 2000s (early)- Aldosterone antagonist• 2000s (late) – Device therapy ,Artificial heart• 2010s- Gene and Stem Cell therapy.
Use of CPAP /BiPAP• Ample evidence• CHF and Sleep Apnea/COPD often co-exist• Bi PAP useful at later stage of acute heart failure when patient starts to fatigue.
Acute Heart Failure• In the setting of acute heart failure, new inotropes such as cardiac myosin activators and new vasodilators such as relaxin have been developed
Rational for Medications (Why does my doctor have me on so many pills??)• Improve Symptoms • Improve Survival – Diuretics (water pills) – Betablockers – digoxin – ACE-inhibitors – Angiotensin receptor blockers (ARB’s) – Aldosterone antagonists
Newer Drugs• Eplerenone (Inspra; EPHESUS 2003) – Pts 6,642 asym LV dysfunction, DM, or after MI – Dec CV mortality of 13%,• Newer more selective inhibitor; fewer side effects• Nesiritide (Natrecor) Recombinant form of human BNP• Causes venous and arterial vasodilation – has been shown to improve dyspnea – Shown to reduce 30 day mortality
Newer Drugs- contd.• Ivabradine - Ifc current inhibitor in SA node• SH IFc T study (6505 pts, 37 countries)• Reduce hospitalization, mortality and improve exercise tolerance.• Add on therapy- chronic symptomatic systolic heart failure (NYHA functional class II–IV) and a heart rate ≥70 bpm.-ESC guideline May 2012
Drugs for systolic heart failure• Direct Renin Inhibitors• Neprilysin inhibitor• Ryanodine receptor stabilizers, SERCA activators
Diastolic Heart Failure• no therapy has been demonstrated to improve symptoms or outcomes• Dicarbonyl-breaking compounds reverse advanced glycation-induced cross-linking of collagen reduce stiffness and improve the compliance of aged and/or diabetic myocardium
Some Practical Tips • Diuretics : Intravenous for 48-72 hours in acute decompensation, then change to oralBeta blocker to be initiated when lungs are ‘Dry’ (“Start low and go slow” ) First dose of ACEI /ARB (small dose) usually at night. Combination not recommended.Calcium channel blocker - Limited evidence for Amlodipine (PRAISE ) Do not forget prophylactic clexane to prevent VTE
ULTRAFILTRATION• Removal of isotonic fluid through an extra- corporeal filter.• Controlled and predictable even if urine output is low i.e. Renal Failure
DEVICE THERAPY• Unacceptably high morbidity and mortality despite medical therapy.• Device therapy in heart failure has shown to improve symptoms as well as reduce mortality and sudden death.• Must be used in patients with good indications• Needs skills and resources
Biventricular Pacing (CARDIAC RESYNCHRONISATION THEARPY)• Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction Overview of Device Therapy 50
Heart Failure and Sudden Cardiac Death– Usually caused by serious ventricular arrhythmia i.e. VT and VF– SCD is one of the leading causes of death in the U.S. – approximately 450,000 deaths a year– Patients with heart failure are 6-9 times as likely to develop sudden cardiac death as the general population
Heart Transplantation• A good solution to the failing heart– get a new heart• Demand is high , limited donor hearts• Approximately 2200 transplants are performed yearly in the US
Beyond Drug and Device Therapy!• Cardiac rehabilitation programme• Discharge planning• Patient monitoring and follow up.• Patient and family education
MULTI DISCIPLINARY APPROACH (INTEGRATED CARE)Purpose: To improve the care delivered to heart failure patients across the continuum01/29/13
In Summary….• Heart failure is common and has high mortality• Timely and accurate assessment is the key to management• Drug therapy improves survival• Newer device therapies are showing promise for symptom relief and improve survival• Transplants remain rare.• Think beyond drug and device therapy.