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Cardiac Investigation In Heart Failure
 

Cardiac Investigation In Heart Failure

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    Cardiac Investigation In Heart Failure Cardiac Investigation In Heart Failure Presentation Transcript

    • Cardiac Investigation in Heart Failure What Internist Needs to know Sarinya Puwanant, MD, FASE
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare disease and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare disease and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?
    • Assessment of CAD in HF  Is the patient a potential revascularization candidate?  Recommendations linked to proof that revasc alters outcomes. EST Perfusion Stress Echo
    • Get Angiogram First  Angina (I)  Atypical Chest Pain (IIa)  Known CAD + No chest pain (IIa)  Suspected CAD with Chest pain (IIa)
    • Stress Test, Viability, Perfusion Study  Known CAD (extent) (IIa)  Diagnostic CAD (IIb)
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare disease and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?
    •  Spotty Disease  Sensitivity 50%  False negative 40%
    •  No specific Rx even immunosuppressive Rx does not improved outcomes  Giant Cell Myocarditis Trial Immunosuppressive LVAD OHTx  GCM- Young, Female, rapid deterioration (VT, CHB, rapid drop of EF)
    • Biopsy is useful for  Confirm diagnosis (Strongly suspected)  Altered management – Anthracycline toxicity – Affect Suitability for OHTX ( Amyloid) – GCM
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare disease and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?
    • B-Natriuretic Peptide in HF Physiology Caveats of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
    • B-Natriuretic Peptide in HF Physiology Caveats of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
    • BNP Release Atrial stretch Not always = pressure i.e., tamponade Increased LV wall stress
    • Pre-ProBNP ProBNP NT-ProBNP -In-active -Half Life 90 min BNP -Active -Half Life 20 min
    • B-Natriuretic Peptide in HF Physiology CaveatS of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
    • High BNP Low BNP Elderly Tamponade Female Constriction Pulmonary Emboli Obesity –NPR-C Renal Failure H/o HF w/ undiagnosed dyspnea Anemia NT 1200 pg/ml-se 89, sp 72 Hyperthyroid (NT) 400 pg/ml pg/ml-se 87, sp 76
    • B-Natriuretic Peptide in HF Physiology Caveat of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
    • Clinical Utility of Natriuretic Peptide in Heart Failure 1. Diagnosis  Ruling out 2. Risk Stratification 3. Screening Cardiac Dysfunction 4. Guiding Management of Heart Failure
    • Clinical Utility of Natriuretic Peptide in Heart Failure 1. Diagnosis  Ruling out 2. Risk Stratification 3. Screening Cardiac Dysfunction 4. Guiding Management of Heart Failure
    • Clinical Utility of Natriuretic Peptide in Heart Failure Confirm or Rule out HF Diagnosis Ambiguous signs and symptoms Acute Setting
    • BNP Cut – Off BNP Study N=1586 Maisel. N Engl J Med 2002;347:161
    • References Ranges BNP (pg/ml) 767 Subjects w/o CV diseases or LV dysfunction (5th-95th percentile) Age 45-54 55-64 65-75 74- 83 Female 8-73 10-93 13-120 16- 155 Male 4-40 5-52 7-67 JACC 2002 Redfield
    • NT-Pro BNP Cut - Off PRIDE STUDY N=600 Am J Cardiol 2005;95:948
    • Pro-NT BNP Cut - Off The International Collaborative of NT-proBNP Study N=1256 Januzzi EHJ 2006:27:330
    • Preserved EF HF - BNP Sub-study JACC 2003; 41:2010 –7
    • BASEL STUDY • N=452, ER w/ acute dyspnea, Biosite Essay • 2 Diagnostic strategies- BNP and no BNP • BNP group - Less need for hospitalization (75% vs. 85%, p< 0.05) - Less need for intensive care (15 vs. 24%, p<0.05) - Rapid time to discharge (8 vs. 11 days, p<0.05) - Less total cost of treatment (5410 $ vs. 7264$, p<0.05) - Similar 30- day mortality
    • Clinical Utility of Natriuretic Peptide in Heart Failure Confirm or Rule out HF Diagnosis Ambiguous signs and symptoms Non- Acute Setting
    • Clinical Utility of Natriuretic Peptide in Diagnosis of Heart Failure in Non-Acute Setting 1. Class II a, Level of evidence C 2. Skeptical, various cut-off values (80-300 pg/ml) 3. Lack of good prospective randomized control trials 4. Presently, NT pro-BNP improved HF diagnostic accuracy (21 vs. 8%, p<0.002). Number needed to Dx =7 5. Great impact on ruling out HF 6. Lower cut-off compared to those in acute setting
    • N=306 ESC HF criteria Zaphirio European Journal of Heart Failure 7 (2005) 537– 541
    • NT-pro BNP <11 pg/ml NT-pro BNP <17 pg/ml Age >=50 Age >=50 N= 345, ESC HF Dx Sens 95% Spect 68% PPV 54% NPV 97% Nielsen et al. The European Journal of Heart Failure 6 (2004) 63–70
    • • N=558, Chronic stable systolic HF • Asymptomatic (n=60)  BNP 5-572 pg/ml, median 147 • Symptomatic (n=498)  21% had BNP <100 pg/ml
    • r=0.32 r=0.69 • Weak correlation of BNP and PCWP in ICU pts with LV dysfx -Circulation. 2004;109:2432-2439 • Poor correlation of BNP, pro BNP and LVEDP (r=0.05- 0.08) -Am Heart J 2006; 152:107126
    • Clinical Utility of Natriuretic Peptide in Heart Failure 1. Diagnosis  Ruling out 2. Risk Stratification 3. Screening Cardiac Dysfunction 4. Guiding Management of Heart Failure
    • Risk Stratification • Provide robust prognostic information - Normal Population - ACS - CAD - CRT - HF - PE for both BNP and proBNP for both absolute values and delta values on F/U • Provide incremental prognostic information • Lack of clear clinical utility of guiding of clinical management
    • N=4300 HF patients Valheft Study (Circulation. 2003;107:1278-1283.)
    • • N= 72, NYHA class 3-4 • Last BNP strongly associate combine endpoints (death, re-HF hospitalization) • BNP @ DC = strong predictor of re-admission J Am Coll Cardiol 2001;37:386 –91
    • Clinical Utility of Natriuretic Peptide in Heart Failure 1. Diagnosis  Ruling out 2. Risk Stratification 3. Screening Cardiac Dysfunction 4. Guiding Management of Heart Failure
    • Screening for Cardiac Dysfunction AHA/ACC Stage A CV Risk Factors ? B Asymptomatic LV dysfx C Overt Heart Failure D Advanced/Terminal Heart Failure
    • Screening for Cardiac Dysfunction Approach 1 – Post MI w/o overt HF • Inconclusive data (vary ranges, cost effectiveness) • Pro and Con Approach 2- Other Population • Class II b Higher BNP, higher LV abn. Olmsted • Still not warranted/recommended
    • LV diastolic dysfunction N=294 Circulation. 2002;105:595-601
    • Clinical Utility of Natriuretic Peptide in Heart Failure 1. Diagnosis  Ruling out 2. Risk Stratification 3. Screening Cardiac Dysfunction 4. Guiding Management of Heart Failure
    • N=220 NYHA 2-3 LVEF <45% BNP <100 = target Median 15 months FU JACC 2007;49:1733–9
    • Clinical Utility of Natriuretic Peptide in Heart Failure ? Track changes in Clinical Status
    • Track changes in Risk and Clinical Status • BNP falls rapidly after diuretics - Independent of hemodynamic status - vary widely - Lag period? • BNP correlates w/ functional status in OPD pts. - High intra-individual variability
    • • BNP is not a perfect surrogate for intravascular volume • Driving down BNP at all costs may be potentially harmful • NT pro-BNP comes down slower than BNP • What is optimal level? • Therefore … at best this is an unproven concept •Pre DC BNP is superior to Admission BNP in predicting of death, HF hospitalization in pts with acute LVF
    • B-Natriuretic Peptide in HF Physiology Caveats of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
    • When Should we order BNP/NT- proBNP ? 1. To exclude or diagnose HF patients presented with acute dyspnea and ambiguous signs and symptoms of HF (Ruling out > Diagnose) 2. To exclude HF in patient presented with non-acute dyspnea and ambiguous signs and symptoms of HF in some patients (not routine !) 3. To assess risk stratification if needed in selected patients (not routine !) Adapted from Tang Circulation July 31, 2007
    • Not Recommend ordering BNP/NT-PBNP : 1. Routine BNP/NT-pro BNP testing for screening of asymptomatic LV dysfunction 2. Routine blood biomarker testing for the sole purpose of risk stratification in patients with HF 3. Routine blood BNP or NT-proBNP testing for making specific therapeutic decisions for patients with acute or chronic heart failure (Reasons: still emerging but incomplete data as well as intra- and inter-individual variations) Adapted from Tang Circulation July 31, 2007
    • Have to ask before interpretation 1. NT pro BNP vs. BNP? 2. What kind of essay? Research [Shionogi®] vs. Commercial [Abbots®, Biosite®] 3. Any factors affecting BNP/ pro BNP level? 4. Is ordering physician clever ? Why did he/she order?
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare diseases and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?
    • When should I screen for rare diseases and comorbidities?  Anthracycline  Herceptin  Cyclophosphamide  Chloroquine  ETOH, Cocain  NSAIDS-Cox2  XRT  Premature CAD  Valvular disease  CP
    • HF and systemic disease  Recognize Clinical Clue  Routine screening not recommended if nothing suggested in clinical history Hemochromatosis HIV CNTD Amyloid Pheochromocytoma Familial CM
    • ROUTINE LAB: CBC, UA, BUN, Cr, Elyte BG, Lipid, LFT, TSH 12 lead EG CXR PA, lat
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare diseases and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?  Hot Topic-Sleep and HF
    • When should I get metabolic stress testing ?  Vo2 max < 14 ml/k/min or  <50% age and sex matched  RER >=1.15  Don’t do until medical Rx optimized.
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare diseases and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?  Hot Topic-Sleep and HF
    • Systolic dysfunction Structural Abnormalities Heart Failure Diastolic dysfunction •RV - LV filling pressure - Exercise/rest •Pericardial disease
    • Diastolic LV filling pressure ? Mitral E = 110 cm/s 110/5 E/e’ = 22 Critical LM CAD Mitral e’ = 5 cm/s LVEDP 28 mmHg
    • Estimation of LV Filling Pressure mLAP PCWP LVEDP
    • E / E’ ratio
    • M-LVDP vs. Groups Defied by Values of Septal E/E’ M -LVDP (m m Hg) 40 Patients with EF < 50% w ith 35 Patients w ith EF > 50% with 30 25 20 15 10 5 0 E/E’ < 8 E/E’ 8-15 E/E’ > 15 Ommen et al. Circulation 2000 110-103
    • Omens SR Circ 102: 10/10/2000
    • Septal vs. Lateral Omens SR Circ 102: 10/10/2000
    • Diastolic Dysfunction  Lateral E/E’ >10 predicts LVEDP >12 mmHg  Sensitivity 91%  Specificity 81% Nagueh et al. JACC 1997; 30:1527-33
    • Correlations between PCWP and BNP vs. Mitral E/e’
    • Echocardiography is now able to estimated LV filling pressure under various conditions
    • RA pressure RA IVC ∆ with resp pressure <1.5 cm collapse 0-5 mmhg nl (1.5-2.5) >50% 5-10 nl <50% 11-15 >2.5 <50% 16-20 >2.5 no change >20 Note in intubated patients, IVC size is not reliable for RA pressure assessment (unless it is small).
    • RV RA mRAP =5 mmHg RVSP-RASP = Peak gradient TR= 85 mmHg RVSP = 85 + RASP = 85+5= 90
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare diseases and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?  Hot Topic-Sleep and HF
    • Right Atrial Lead Left Ventricular Lead Right Ventricular Lead
    • (Death and hospitalization) (Death from any cause) •NYHA class III •PR 150 •NSR •QRS 120 •LVEF < 35% •VDD pacing COMPANION study N Engl J Med 2004;350:2140-50.
    • •NYHA class III •QRS 120-149 plus echo criteria •QRS > 149 •LVEF < 35% •LVEDD 30 mm CARE-HF N Engl J Med 2005;352:1539-49.
    • Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure I IIa IIb III IIb III 1. LVEF <=35% 2. QRS >=120 ms 3. Sinus rhythm 4. NYHA III or ambulatory IV 5. Optimal medical Rx I IIa IIb III IIb III 1. LVEF <=35% 2. QRS >=120 ms 3. AFib 4. NYHA III or ambulatory IV 5. Optimal medical Rx I IIa IIb III 1. LVEF <=35% 2. QRS >=120 ms 3. V pacing dependent 4. NYHA III or ambulatory IV 5. Optimal medical Rx
    • Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure I IIa IIb III For patients with LVEF less than or equal to 35% with NYHA functional Class I or II symptoms who are receiving optimal recommended medical therapy and who are undergoing implantation of a permanent pacemaker and/or ICD with anticipated frequent ventricular pacing, I IIa IIb III CRT may be considered. CRT is not indicated for asymptomatic patients with reduced LVEF in the absence of other indications for I IIa IIb III pacing. CRT is not indicated for patients whose functional status and life expectancy are limited predominantly by chronic noncardiac conditions.
    • N=2521 LVEF 35% NYHA class II N Engl J Med 2005;352:225-37
    • Evaluation /Investigation  How do I assess CAD in HF ?  When should I do endomyocardial biopsy ?  When should I order BNP?  When should I screen for rare diseases and comorbidities?  When should I get metabolic stress testing ?  When should I use echo for guiding management?  When should I place CRT/ICD?  Hot Topic-Sleep and HF
    • Sleep and HF  OSA  Central Apnea- Chyne stroke Resp
    • Sleep and HF  Sleep Disordered Breathing (SDB) [Apnea-Hypopnea syndrome]  SDB – apnea or hypopnea  AH index (Apnea/hypopnea index)  5-15 Mild  >15 Moderate or severe  AH syndrome (SDB)  Daytime somnolence
    • Sleep and HF  Polysomnogram
    • Sleep and HF  General pop  SDB 24% men, 9% women  OSAH syndrome 4% male, 2 % female.  HF with low LVEF  Prevalence is higher  SDB = 51% (78% CSA, 22% OSAH)
    • Sleep and HF  CSA caused by HF  OSA caused HF
    • Sleep and HF Rx  OSAHS  Weight Loss  CPAP  CSR-CSA Nocturnal O2 CPAP needed? Theophylline ASV-Alternating servo ventilation