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 ...
Evaluation /Investigation

   How do I assess CAD in HF ?
   When should I do endomyocardial biopsy ?
   When should I ...
Assessment of CAD in HF

     Is the patient a potential
      revascularization candidate?
     Recommendations linked ...
Get Angiogram First

      Angina (I)
      Atypical Chest Pain (IIa)
      Known CAD + No 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 ...
   Spotty Disease
   Sensitivity 50%
   False negative 40%
   No specific Rx even immunosuppressive Rx
    does not improved outcomes
   Giant Cell Myocarditis
       Trial Immuno...
Biopsy is useful for

      Confirm diagnosis (Strongly
       suspected)
      Altered management
       – Anthracyclin...
Evaluation /Investigation

   How do I assess CAD in HF ?
   When should I do endomyocardial biopsy ?
   When should I ...
B-Natriuretic Peptide in HF


    Physiology
    Caveats of Natriuretic Peptide
    Clinical Utility of Natriuretic Peptid...
B-Natriuretic Peptide in HF


    Physiology
    Caveats of Natriuretic Peptide
    Clinical Utility of Natriuretic Peptid...
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
      ...
B-Natriuretic Peptide in HF

      Physiology
      CaveatS of Natriuretic Peptide
      Clinical Utility of Natriuretic P...
High BNP                        Low BNP

Elderly                          Tamponade
Female                           Const...
B-Natriuretic Peptide in HF

  Physiology
  Caveat of Natriuretic Peptide
  Clinical Utility of Natriuretic
    Peptide
  ...
Clinical Utility of Natriuretic Peptide
in Heart Failure


    1. Diagnosis  Ruling out
    2. Risk Stratification
    3....
Clinical Utility of Natriuretic Peptide
in Heart Failure


    1. Diagnosis  Ruling out
    2. Risk Stratification
    3....
Clinical Utility of Natriuretic Peptide
in Heart Failure



    Confirm or Rule out HF
      Diagnosis
    Ambiguous signs...
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    ...
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


                                    ...
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 ...
Clinical Utility of Natriuretic Peptide
in Heart Failure


    Confirm or Rule out HF
      Diagnosis
    Ambiguous signs ...
Clinical Utility of Natriuretic Peptide in
Diagnosis of Heart Failure in Non-Acute Setting

   1. Class II a, Level of evi...
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, ES...
• N=558, Chronic stable systolic HF


• Asymptomatic (n=60)  BNP 5-572 pg/ml, median
147



• Symptomatic (n=498)  21% h...
r=0.32                          r=0.69




•   Weak correlation of BNP and PCWP in ICU pts with LV
    dysfx -Circulation....
Clinical Utility of Natriuretic Peptide
in Heart Failure


    1. Diagnosis  Ruling out
    2. Risk Stratification
    3....
Risk Stratification
• Provide robust prognostic information
      - Normal Population
      - ACS
      - CAD
      - CRT
...
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 = stro...
Clinical Utility of Natriuretic Peptide
in Heart Failure


    1. Diagnosis  Ruling out
    2. Risk Stratification
    3....
Screening for Cardiac Dysfunction
AHA/ACC Stage

    A              CV Risk Factors

                                     ...
Screening for Cardiac Dysfunction

    Approach 1 – Post MI w/o overt HF
• Inconclusive data    (vary ranges, cost
effecti...
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....
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 s...
•   BNP is not a perfect surrogate for intravascular volume
•   Driving down BNP at all costs may be potentially harmful
•...
B-Natriuretic Peptide in HF


      Physiology
      Caveats of Natriuretic Peptide
      Clinical Utility of Natriuretic ...
When Should we order
     BNP/NT- proBNP ?

1.   To exclude or diagnose HF patients presented with acute dyspnea and
     ...
Not Recommend ordering
  BNP/NT-PBNP :

1. Routine BNP/NT-pro BNP testing for screening of asymptomatic LV
   dysfunction
...
Have to ask before
interpretation
 1. NT pro BNP vs. BNP?
 2. What kind of essay?
     Research [Shionogi®] vs. Commercial...
Evaluation /Investigation

   How do I assess CAD in HF ?
   When should I do endomyocardial biopsy ?
   When should I ...
When should I screen for rare diseases
and comorbidities?

              Anthracycline
              Herceptin
         ...
HF and systemic disease

     Recognize Clinical Clue
     Routine screening not recommended if
      nothing suggested ...
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 ...
When should I get metabolic
stress testing ?



       Vo2 max < 14 ml/k/min or
       <50% age and sex matched
       ...
Evaluation /Investigation

   How do I assess CAD in HF ?
   When should I do endomyocardial biopsy ?
   When should I ...
Systolic dysfunction           Structural Abnormalities




                         Heart
                         Failur...
Diastolic LV filling pressure ?

Mitral E = 110 cm/s




                            110/5
                            E/e...
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 i...
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%
...
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
                                  ...
RV


     RA


mRAP =5 mmHg




               RVSP-RASP = Peak gradient TR= 85 mmHg
                    RVSP = 85 + RASP
...
Evaluation /Investigation

   How do I assess CAD in HF ?
   When should I do endomyocardial biopsy ?
   When should I ...
Right Atrial
   Lead




                       Left Ventricular
                             Lead




               Righ...
(Death and hospitalization)                            (Death from any cause)




•NYHA class III         •PR 150         ...
•NYHA class III   •QRS 120-149 plus echo criteria     •QRS > 149
•LVEF < 35%       •LVEDD 30 mm




                      ...
Cardiac Resynchronization Therapy* in
     Patients With Severe Systolic Heart
                   Failure

I IIa IIb III
 ...
Cardiac Resynchronization Therapy*
         in Patients With Severe Systolic Heart
                         Failure
I IIa ...
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 ...
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 (Apne...
Sleep and HF


     Polysomnogram
Sleep and HF

   General pop
         SDB 24% men, 9% women

         OSAH syndrome 4% male, 2 % female.
   HF with lo...
Sleep and HF


   CSA caused by HF
   OSA caused HF
Sleep and HF Rx

   OSAHS
       Weight Loss
       CPAP

   CSR-CSA
      Nocturnal O2
      CPAP needed?
      Theop...
Cardiac Investigation In Heart Failure
Cardiac Investigation In Heart Failure
Cardiac Investigation In Heart Failure
Cardiac Investigation In Heart Failure
Cardiac Investigation In Heart Failure
Upcoming SlideShare
Loading in …5
×

Cardiac Investigation In Heart Failure

1,516 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,516
On SlideShare
0
From Embeds
0
Number of Embeds
18
Actions
Shares
0
Downloads
58
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Cardiac Investigation In Heart Failure

  1. 1. Cardiac Investigation in Heart Failure What Internist Needs to know Sarinya Puwanant, MD, FASE
  2. 2. 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?
  3. 3. 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?
  4. 4. Assessment of CAD in HF  Is the patient a potential revascularization candidate?  Recommendations linked to proof that revasc alters outcomes. EST Perfusion Stress Echo
  5. 5. Get Angiogram First  Angina (I)  Atypical Chest Pain (IIa)  Known CAD + No chest pain (IIa)  Suspected CAD with Chest pain (IIa)
  6. 6. Stress Test, Viability, Perfusion Study  Known CAD (extent) (IIa)  Diagnostic CAD (IIb)
  7. 7. 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?
  8. 8.  Spotty Disease  Sensitivity 50%  False negative 40%
  9. 9.  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)
  10. 10. Biopsy is useful for  Confirm diagnosis (Strongly suspected)  Altered management – Anthracycline toxicity – Affect Suitability for OHTX ( Amyloid) – GCM
  11. 11. 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?
  12. 12. B-Natriuretic Peptide in HF Physiology Caveats of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
  13. 13. B-Natriuretic Peptide in HF Physiology Caveats of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
  14. 14. BNP Release Atrial stretch Not always = pressure i.e., tamponade Increased LV wall stress
  15. 15. Pre-ProBNP ProBNP NT-ProBNP -In-active -Half Life 90 min BNP -Active -Half Life 20 min
  16. 16. B-Natriuretic Peptide in HF Physiology CaveatS of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
  17. 17. 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
  18. 18. B-Natriuretic Peptide in HF Physiology Caveat of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
  19. 19. 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
  20. 20. 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
  21. 21. Clinical Utility of Natriuretic Peptide in Heart Failure Confirm or Rule out HF Diagnosis Ambiguous signs and symptoms Acute Setting
  22. 22. BNP Cut – Off BNP Study N=1586 Maisel. N Engl J Med 2002;347:161
  23. 23. 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
  24. 24. NT-Pro BNP Cut - Off PRIDE STUDY N=600 Am J Cardiol 2005;95:948
  25. 25. Pro-NT BNP Cut - Off The International Collaborative of NT-proBNP Study N=1256 Januzzi EHJ 2006:27:330
  26. 26. Preserved EF HF - BNP Sub-study JACC 2003; 41:2010 –7
  27. 27. 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
  28. 28. Clinical Utility of Natriuretic Peptide in Heart Failure Confirm or Rule out HF Diagnosis Ambiguous signs and symptoms Non- Acute Setting
  29. 29. 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
  30. 30. N=306 ESC HF criteria Zaphirio European Journal of Heart Failure 7 (2005) 537– 541
  31. 31. 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
  32. 32. • 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. N=4300 HF patients Valheft Study (Circulation. 2003;107:1278-1283.)
  37. 37. • 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
  38. 38. 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
  39. 39. Screening for Cardiac Dysfunction AHA/ACC Stage A CV Risk Factors ? B Asymptomatic LV dysfx C Overt Heart Failure D Advanced/Terminal Heart Failure
  40. 40. 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
  41. 41. LV diastolic dysfunction N=294 Circulation. 2002;105:595-601
  42. 42. 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
  43. 43. N=220 NYHA 2-3 LVEF <45% BNP <100 = target Median 15 months FU JACC 2007;49:1733–9
  44. 44. Clinical Utility of Natriuretic Peptide in Heart Failure ? Track changes in Clinical Status
  45. 45. 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
  46. 46. • 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
  47. 47. B-Natriuretic Peptide in HF Physiology Caveats of Natriuretic Peptide Clinical Utility of Natriuretic Peptide and Landmark Trials When should we order Natriuretic Peptide?
  48. 48. 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
  49. 49. 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
  50. 50. 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?
  51. 51. 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?
  52. 52. When should I screen for rare diseases and comorbidities?  Anthracycline  Herceptin  Cyclophosphamide  Chloroquine  ETOH, Cocain  NSAIDS-Cox2  XRT  Premature CAD  Valvular disease  CP
  53. 53. HF and systemic disease  Recognize Clinical Clue  Routine screening not recommended if nothing suggested in clinical history Hemochromatosis HIV CNTD Amyloid Pheochromocytoma Familial CM
  54. 54. ROUTINE LAB: CBC, UA, BUN, Cr, Elyte BG, Lipid, LFT, TSH 12 lead EG CXR PA, lat
  55. 55. 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
  56. 56. 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.
  57. 57. 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
  58. 58. Systolic dysfunction Structural Abnormalities Heart Failure Diastolic dysfunction •RV - LV filling pressure - Exercise/rest •Pericardial disease
  59. 59. 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
  60. 60. Estimation of LV Filling Pressure mLAP PCWP LVEDP
  61. 61. E / E’ ratio
  62. 62. 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
  63. 63. Omens SR Circ 102: 10/10/2000
  64. 64. Septal vs. Lateral Omens SR Circ 102: 10/10/2000
  65. 65. Diastolic Dysfunction  Lateral E/E’ >10 predicts LVEDP >12 mmHg  Sensitivity 91%  Specificity 81% Nagueh et al. JACC 1997; 30:1527-33
  66. 66. Correlations between PCWP and BNP vs. Mitral E/e’
  67. 67. Echocardiography is now able to estimated LV filling pressure under various conditions
  68. 68. 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).
  69. 69. RV RA mRAP =5 mmHg RVSP-RASP = Peak gradient TR= 85 mmHg RVSP = 85 + RASP = 85+5= 90
  70. 70. 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
  71. 71. Right Atrial Lead Left Ventricular Lead Right Ventricular Lead
  72. 72. (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.
  73. 73. •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.
  74. 74. 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
  75. 75. 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.
  76. 76. N=2521 LVEF 35% NYHA class II N Engl J Med 2005;352:225-37
  77. 77. 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
  78. 78. Sleep and HF  OSA  Central Apnea- Chyne stroke Resp
  79. 79. 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
  80. 80. Sleep and HF  Polysomnogram
  81. 81. 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)
  82. 82. Sleep and HF  CSA caused by HF  OSA caused HF
  83. 83. Sleep and HF Rx  OSAHS  Weight Loss  CPAP  CSR-CSA Nocturnal O2 CPAP needed? Theophylline ASV-Alternating servo ventilation

×