Heart failure as mentioned is a growing public health problem and so Objectives of my talk would be to give you some facts and figures of heart failure. I would talk about how the patients of suspected HF are assessed in reaching an accurate diagnosis. I would touch upon very briefly on the drug, device and some novel therapy in HF.
In order to draw audience’s interest and attention, I usually prefer to break the subject with a case. This would be a typical case which we all see in our daily clinical practice.
As a physician it is our responsibility to differentiate a normal from a failing heart.
LV S3 (3 rd heart sound) gallop is most important and pathognomic sign for HF (specificity 99%). Low pitched sound best heard with a bell at cardiac apex . The ones in italics are major Framingham criteria for diagnosis of HF.
Some of the information we gathered was very interesting…..
Patients do not present with typical signs and symptoms of heart failure and so diagnosis is often missed. It incurs high cost on total health care budget.
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.
There is a huge range of heart failure biomarkers but in practice only the following are more commonly used..
These markers are cardiac specific and some are non cardiac specific
Galectin 3 is a new bio marker. It is a marker for inflammation , fibrosis and ventricular remodelling
Bnp and NT –pro BNP are more commonly used biomarkers for HF.If levels are above.. Diagnosis of HF in conjuction with clinical diagnosis confirms the diagnosis. If the levels are between ….. , further evaluation is required i.e use of echocardiogram.
Echo is the most important diagnostic tool used in HF,It tells about the structure and funtion of the heart. Risk startify and provides guidance for use CRT ICD.
Commonest cause for HF is CAD (> 60%) , followed by HPN and Valvular heart ds.
Atleast 1/3 rd of patients have normal EF and they are classified as HF with preserved systolic function or diastolic heart failure.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.
All is not lost when one is diagnosed with HF and certainly HF is not a death sentence, however prognosis is poor in patients who are old…
Commonest cause for HF moratality is pump failure (70%). Commonest cause for sudden death is due to arrhthmia usually due to electrolyte imbalance.(hypokalemia more gdangerous than hyperlkalemia. HENCE renal function and electroltyes should be very closely monitored.
This is from one of our research where we looked at the prognostic markers of heart failure in the elderly population. We found anaemia as an independent predictor of mortality and hospital re-admission
For centuries blood letting and leeches were used to remove body fluid in patients of heart failure until 19 th and eraly 20 th century when southey’s tubes were introduced …
In early 20 th century injectable organomercurials were used for treating syphyllis. Medical student in Vienna noted that these patients passed a large amount of urine. For next 20 years used as a potent diuretic but replaced by carbonic anhydrase (metb acidosis) and later thiazide diuretics due to toxic side effects.
Acute heart failure is a medical emergency
Emergency management of acute HF has not changed for many years.Easy pneumonic to remember the management of acute heart failure.
Atleast 20 randomised con. Trials suggest that they improve survival. Increase intra thoracic pressurre/decrease pre and after load-improve LV systolic function as well as improve oxygenation. Decrease mortality. Pressure start 5cm H2O – max 10 cm H2O
Some of medications improve symptoms while others like... Improve survival
There is good evidence from some landmark trials in heart failure as … that the treatment reduces annual mortality significantly.
Newer drugs like eplerenone which is another aldosterone antagonsit reduces mortality. Nesiritide..
Ivabradine is a fairly new drug being used in the West for atleast few years and recently introduced in the middlke east market is a specific SA node blocker. It has recently been included in the ESC guideline for CHF treatnment in patients whose functional class is 2-4 and have a heart rate of more than 70. SHIFT trial used > 6000 patients and has shown mortality benefit in addition to reducing hospitalization and improving exercise tolerance.
Direct renin inhibitor (Aliskern) also used in HPN. Better tolerated compared to ACEI and ARB. Also used for HPN. The rest N R and S help in cardiac contractlity in some way or the other thereby improving LV systolic function.
Dicarbonyl breaking compounds help in reducing the stiffness and improving the compliance of LV myocardium.
Developed initially for Used for refractory angina but later started being used for HF Late 1990s. Hooked to ECG monitor and large pneumatic cuff are applied to legs/thighs and pelvis. Cuff inflation is synchronised to diastolic phase which compresses the veins to push blood upwards to allow cardiac and coronary filling in diastole. It also leads to formation of collaterals.
Patients often are admitted with fluid overload . Low urine output and renal failure adds to the problem further. It is with the use of devices like this that large amount of isotonic fluid using extracorporeal membrane can be removed.
There is a need for using device thearpy for selected patients since despite medical thearpy, morbidity and mortality due to HF remains unacceptably high.
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.
Although the no of heart transplants have gone up worldwide, the figures are still low as about 2000 transplants per year in the USA. And the figures are even less in other countries including Europe. This is mainly due to limited donors.
Most modern and recent treatment is stem cell therapy where autologous or allogenic stem cells from bone marrow are harvested and injected intravenously or intracoronary/ encodcardia via catheter based treatment/
Must think beyond …. And this can be achieved using multidiciplinary team and adopting integrated care pathway.
Keeping that recommendation in mind, the HVHC HF Task force was created. It’s purpose was to…..
Heart failure symposium
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.