Heart Failure and Pulmonary Hypertension: How it can be treated

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Heart failure means that your heart isn’t pumping enough blood to keep up with the needs of the other organs. So what are the warning signs of heart failure? What can be done to treat it? Springfield Clinic Cardiologist, Dr. Singla answers those questions and more. Please join us for an in-depth discussion about a topic that is becoming all too familiar as heart disease continues to be the leading cause of death for men and women.

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Heart Failure and Pulmonary Hypertension: How it can be treated

  1. 1. Heart Failure & Pulmonary Hypertension: What you need to know Ish Kumar Singla , MD
  2. 2. National Heart Failure Awareness Week February 9-15, 2014
  3. 3. What you need to know • Heart Failure • Pulmonary Hypertension
  4. 4. A Word of Anatomy • Right side of heart gets blood from body. • Right Ventricle sends blood to Lungs via pulmonary arteries for oxygenation. • Left side of heart gets oxygenated blood from lungs. • Left Ventricle pumps oxygen rich blood to body.
  5. 5. What is Heart Failure • Not able to pump enough blood to body “ Heart failure is NOT heart attack” • Muscle weakness or stiffness
  6. 6. Heart Failure is Very common • Affects nearly 5 million • 1% of Adults 50-60 • 10% of Adults over 80 • 8 million by 2030( 46% increase) • 400,000 -700,000 new cases each year • 5%-10% of all hospital admissions
  7. 7. Types of Heart Failure • Systolic HF ( Muscle weakness ) - Not able to pump enough blood • Diastolic HF(Muscle thickening and stiffness) - Not able to pump blood in normal way • Right Sided Heart failure
  8. 8. Risk factors for Heart Failure • • • • • • • Coronary Artery Disease (Heart attack ) Heart valve damage(Leaky or narrow valves) Cardiomyopathy Congenital heart disease Hypertension Obesity Aging
  9. 9. Symptoms of Heart Failure • • • • • • Shortness of Breath Fatigue Leg edema Weight gain Cough Not able to lie flat due to difficulty breathing
  10. 10. NYHA Classification of symptoms • Class I: No Symptoms. No limitation in physical activity. Ordinary physical activity does not cause dyspnea or fatigue. • Class II: Mild symptoms and Slight limitation in physical activity. Ordinary physical activity causes undue dyspnea or fatigue. • Class III: Marked limitation in physical activity due to symptoms. Less than ordinary physical activity causes undue dyspnea or fatigue. • Class IV: Severe limitations. dyspnea and/or fatigue may be present at rest.
  11. 11. Systolic Heart Failure • Etiology - Coronary artery Disease ( CAD) Myocardial Infarction (MI) Cardiomyopathy ( Viral, Familial etc) Valvular heart disease
  12. 12. Diagnosis of Heart Failure • • • • • • Echocardiogram ( Heart Ultrasound) EKG Chest X ray Labs Heart catheterization Stress test
  13. 13. Diagnosis of Heart Failure • Echocardiogram - Heart Ultrasound Outpatient office procedure To measure EF(Ejection Fraction) Normal EF is 55%-60% Evaluate Heart valves Evaluate Pressures in heart
  14. 14. Diagnosis of Heart Failure • Left heart catheterization - Outpatient procedure ,done at hospital - Radial (wrist) or Femoral (groin) approach - Dye test to look at the heart arteries
  15. 15. Treatment of Systolic Heart Failure • • • • • • Diet Restriction Exercise regimen Lifestyle changes Medications Treatment of specific etiology Surgical Rx
  16. 16. Dietary Modifications • Salt Restriction - 2000 mg sodium/ day - 1 teaspoon of salt=2000 milligrams (mg) • Fluid restriction - 2000 ml/day
  17. 17. How to Restrict Salt intake
  18. 18. How to Restrict Salt intake • • • • • • Stop using salt shaker Salt substitutes Eliminate salty foods Read the labels Eliminate canned foods Fresh fruits and vegetables “ Don’t eat anything that tastes good”
  19. 19. Fluid restriction • 2000 ml /day ~ 64 oz of fluid a day • 1 cup ~ 250 ml of water
  20. 20. Fluid Retention • Weigh daily • Call your doctor for weight gain more than 3 lbs
  21. 21. Lifestyle changes • • • • Quit smoking Limit alcohol intake Exercise regimen Weight loss
  22. 22. Exercise • Start aerobic exercise • Avoid lifting weights more than 15-20lbs.
  23. 23. Medications • Diuretics ( Fluid pills) - Furosemide, Torsemide, Bumetanide • Beta blockers - Carvedilol, Metoprolol succinate • Ace- Inhibtors - Lisinopril, Captopril, Enalapril
  24. 24. Medications • • • • Angiotensin Receptor Blockers Aldosterone Inhibtors Hydralazine and Nitrates Digitalis
  25. 25. Cardiac Arrest • - EF < 35%-40% ICD( Implantable cardiac defibrillator) BiV- pacemaker Combined BiV- ICD
  26. 26. Diastolic Heart Failure • Etiology - Hypertension Obesity Diabetes Lack of exercise Sleep Apnea
  27. 27. Diastolic Heart Failure • Tests - Echocardiogram Heart Catheterization EKG Sleep study Labs
  28. 28. Treatment • • • • • • • Diet Restriction Exercise regimen Loose weight Quit smoking Treatment of sleep apnea Treatment of primary disease ?? Medications
  29. 29. Medications • Diuretics ( Fluid pills) - Furosemide, Torsemide, Bumetanide • ?? Beta blockers - Carvedilol • ?? Aldosterone antagonist - Spironolcatone
  30. 30. Surgical Treatment of Heart Failure • Heart Transplant - Needed for more than 4000 patients - 2500 heart donors yearly - Scarcity of donors - “It is not a cure, it is an exchange of one set of problems for the other” (Dr Bourge) • Left Ventricle Assist Device ( Mechanical Heart Pump)
  31. 31. Right Sided Heart Failure • • • • Pulmonary Hypertension Cardiomyopathy Congenital heart disease Heart attack
  32. 32. Pulmonary Artery Hypertension
  33. 33. Pulmonary Hypertension • • • • • • Definition Epidemiology Classification Symptoms Etiology Treatment
  34. 34. Pulmonary Hypertension • Normal Mean PA pressures are 12-16. • Definition: Mean Pulmonary Artery (PA) pressure > 25 mm Hg at rest • Chronic condition with no cure. • Without treatment only 34% survival at 5 years.
  35. 35. Severity • Degree of disease ( Mean PAP mmHg) • Mild : 25 – 40 • Moderate: 41 – 55 • Severe: >55
  36. 36. Pulmonary Hypertension
  37. 37. Pulmonary Hypertension Lesion 2.Pulmonary Venous HTN 1.Arterial VC RA RV PA Mitral Valve Disease PV PC LA LV Ao Aortic Valve Disease Left sided heart failure 4. Embolic 3. Hypoxic Lung Diseases HTN
  38. 38. Epidemiology • • • • • Pulmonary Venous HTN - very common PAH - rare disease Hypoxic - 1-2% Embolic - 5% Miscellaneous
  39. 39. PH Classification • Based on similarities in their pathophysiology and responses to treatment. • Classify patients accurately to ensure appropriate treatment.
  40. 40. PH Classification • Group I (Arterial ) Idiopathic, Familial, HIV, Scleroderma, drugs, toxins, Congenital heart disease, Sickle cell disease • Group II (Venous ) Pulmonary venous hypertension due to left sided heart disease. • Group III (Hypoxia) COPD, Interstitial lung disease, Sleep apnea • Group IV (Embolic) Chronic thromboembolic disease • Group V (Misc) Sarcoidosis, Compression of pulmonary artery by tumor
  41. 41. Pulmonary Artery Hypertension • Idiopathic - Incidence 2-3 /million per year Female: Male 3:1 • Common with Rheumatological diseases - Scleroderma 50% Rheumatoid Arthritis 20% Lupus 10% • Congenital heart disease : 30% - 50%
  42. 42. Pulmonary Artery Hypertension • • • • Sickle cell disease 25% Liver disease 5% HIV 0.5% Dexfenfluramine (fen-phen) Risk 20 times if taken for more than 3 months • Cocaine or amphetamine use risk by 3 fold
  43. 43. Symptoms • Gradual onset of Shortness of breath - Often results in delayed diagnosis ~ 18 months • Fatigue • Chest pain • Syncope/presyncope • Peripheral edema or ascites • Raynaud’s in about 10%
  44. 44. Diagnosis • Echocardiography is excellent screening tool • No treatment based on echocardiography alone • Right heart catheterization for accurate diagnosis and appropriate treatment • Labs • CT scan
  45. 45. Pathogenesis of Pulmonary Arterial Hypertension NORMAL REVERSIBLE DISEASE IRREVERSIBLE DISEASE
  46. 46. WHO functional classification PAH • Class I: No limitation in physical activity. Ordinary physical activity does not cause undue dyspnea or fatigue, chest pain or near syncope. • Class II: Slight limitation in physical activity. Ordinary physical activity causes undue dyspnea or fatigue, chest pain or near syncope. • Class III: Marked limitation in physical activity. Less than ordinary physical activity causes undue dyspnea or fatigue, chest pain or near syncope. • Class IV: Inability to perform any physical activity without symptoms. Signs of right heart failure. Dyspnea and/or fatigue may be present at rest. H/o Syncope.
  47. 47. Clinical Sequeale • Increased pressure load on Right Ventricle. • Right Ventricle failure. • Once RV failure is present prognosis poor.
  48. 48. Goals of Therapy • Alleviate symptoms, improve exercise capacity and quality of life • Delay time to clinical worsening • Reduce morbidity and mortality
  49. 49. Treatment of Pulmonary Hypertension • • • • • Lifestyle modifications Oxygen Treatment of specific etiology Medications Transplantation
  50. 50. Dietary Modifications • Salt Restriction - 2000 mg sodium/ day - 1 teaspoon of salt=2000 milligrams (mg) • Fluid restriction - 2000 ml/day
  51. 51. Lifestyle Modifications • Sodium restriction • Abstinence from smoking • Avoid high altitude • <4,000 feet above sea level • Avoid physical exertion in setting of presyncope sx • Avoid pregnancy
  52. 52. PAH: Therapy • Supplemental O2 • Anticoagulation • Diuretics • Vasodilators Therapy
  53. 53. Targets for Therapy in PAH Endothelin cells
  54. 54. PAH: Therapy • Calcium-channel blockers -pills • Endothelial receptor antagonists (ERAs) - pills • Phosphodiesterase-5 Inhibitors (PDE5-I) -pills • Prostanoids -Inhalers, intravenous, subcutaneous
  55. 55. Epoprostenol (Flolan) • Intravenous Prostacyclin • First drug, became available in 1990s. • Delivered via continuous infusion • PPH study • Improvement in survival
  56. 56. SQ or IV Treprostinil (Remodulin) • Stable Prostacyclin, t ½ 4 hours. • Continuous subcutaneous infusion • Approved 2002 • Significant pain at infusion site limits use • NYHA class II,III,IV • Group I PAH • Stable at room temperature.
  57. 57. Bosentan (Tracleer) • Endothelin Receptor Antagonist • First oral Drug,Approved 2002 • Dose 125mg BID • Risk of Liver Toxicity • Group I PAH (Idiopathic, CTD and congenital)
  58. 58. Ambrisentan (Letairis) • • • • • • Selective Type A ERA. Oral dose 10 mg once daily Much less risk of liver toxicity Monthly monitoring not required Approved 2005 Group I PAH (Idiopathic and CTD ) Badesch et al. J Am Coll Cardiol. 2005;46(3):529.
  59. 59. Macitentan (Opsumit) • • • • • • Non-selective ERA Dose 3mg or 10mg po daily Approved 2013 CBC and LFTs monitoring Group I PAH (Idiopathic,congenital,CTD) Improvement in mortality and morbidity. Pulido et al. N Engl J Med Aug 2013; 369:809-818
  60. 60. Sildenafil (Revatio) • • • • • • • PDE-5 inhibtor FDA approved dose 20 mg po tid Approved 2005 Hypotension, Sudden hearing loss First dose in monitored setting Contraindicated with nitrates Group I PAH(Idiopathic,CTD,Congenital)
  61. 61. Tadalafil ( Adcirca ) • • • • • • PDE-5 inhibtor FDA approved dose 40 mg po daily Approved 2009 Hypotension, Headaches, Myalgias Contraindicated with nitrates Group I PAH(Idiopathic and CTD)
  62. 62. Riociguat (Adempas ) • • • • • • Oral sGC stimulant. First in Class Dose 1.5mg to 2.5 po TID Approved 2013 Group IV PAH Group I PAH
  63. 63. Inhaled Iloprost ( Ventavis ) • Synthetic PGI 2 • Selective pulmonary vasodilator • Inhaled form 6-9 times while patient awake • Approved 2002 • Exerts preferential vasodilatation in well- ventilated regions. • No known contraindications.
  64. 64. Inhaled Treprostinil (Tyvaso) • • • • • • • Synthetic Prostacyclin Inhaler,4 doses used 4 hrs apart while awake. Approved 2011 Group I PAH (Idiopathic, CTD, HIV,Fen-phen) NYHA III pt Background therapy with oral drugs SE: dizziness,cough,headache,flushing
  65. 65. Simplicity Efficacy & Cost Treatment Summary
  66. 66. Conclusion Progressive disease Significant morbidity and mortality Right heart failure marks disease progression Therapies with proven benefit in improving hemodynamics, functional class and exercise tolerance Continuous IV Flolan is reserved for advanced (class IV) disease where there is a proven survival benefit
  67. 67. Acknowledgements • Dr Robert C. Bourge (Vice Chair ,Dept of Medicine ,UAB, Birmingham) • UAB Heart Failure and Transplant Division • Springfield Clinic
  68. 68. References • • • • • • • • • • • • www.heart.org www.phaassociation.org www.abouthf.org www.escardio.org http://www.nutrition411.com www.hfsa.org http://lungs.wikispaces.com http://www.acponline.org http://www.cardiachealth.org https://encrypted-tbn0.gstatic.com/images http://www.lsuagcenter.com/ https://www.unitypoint.org
  69. 69. Thank You

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