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Acute Heart Failure

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Acute Heart Failure

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Acute Heart Failure

  1. 1. Randall C. Starling, M.D., M.P.H., F.A.C.C. Section of Heart Failure and Cardiac Transplant Medicine Department of Cardiovascular Medicine Kaufman Center for Heart Failure Acute Heart Failure
  2. 2. A Public Health Epidemic <ul><li>Over 1 million annual hospital admissions (increased 90% in past 10 years) </li></ul><ul><li>Most common discharge diagnosis for patients older than 65 years </li></ul><ul><li>6.5 million hospital days per year </li></ul><ul><li>Single largest expense for Medicare </li></ul><ul><li>Greatest portion of expense related to hospital care </li></ul>Acute decompensated heart failure 1 AHA. 2006 Heart and Stroke Statistical Update 2 Hunt SA et al. ACC/AHA guidelines. 2005.
  3. 3. Continues to Grow <ul><li>Estimated 10 million in 2037 </li></ul><ul><li>Incidence: about 550,000 new cases each year </li></ul><ul><li>Prevalence is 2% in persons aged 40 to 59 years, progressively increasing to 10% for those aged 70 years and older </li></ul>Patients in US (millions) Year Prevalence of heart failure 1991 2001 2037 3.5 4.8 10.0 0 2 4 6 8 10
  4. 4. Fonarow GC. Rev Cardiovasc Med. 2003; 4 (Suppl. 7): 21 Cleland JG et al. Eur Heart J. 2003; 24: 442 The Major Reason for Heart Failure Hospitalizations Worsening chronic heart failure (75%) De novo heart failure (23%) Advanced/ end-stage heart failure (2%)
  5. 5. Outcomes in Patients Hospitalized With HF Fonarow, GC. Rev Cardiovasc Med. 2002 ;3(suppl 4):S3 Jong P et al. Arch Intern Med. 2002 ;162:1689 0 25 50 75 100 20% 50% 30 Days 6 Months Hospital Readmissions 0 25 50 75 100 12% 50% 30 Days 12 Months Mortality 33% 5 Years Mean LOS: 6.5 days
  6. 6. Most Common IV Medications All Enrolled Discharges (n=105,388) October 2001-January 2004 0 10 20 30 40 50 60 70 80 90 100 Patients (%) IV Diuretic Dobutamine Dopamine Milrinone Nesiritide Nitroglycerin Nitroprusside IV Vasoactive Meds 88% 6% 6% 10% 3% 1% 10%
  7. 7. ADHERE ® CART: Predictors of Mortality Highest to Lowest Risk Cohort OR 12.9 (95% CI 10.4-15.9) Reference: Fonarow GC, et al. Risk stratification for in-hospital mortality in heart failure using classification and regression tree (CART) methodology. JAMA . 2005;293:572-580. YES YES YES SYS >BP 115 n=24,933 SYS >BP 115 n=7,150 6.41% n=5,102 15.28% N=2,048 21.94% n=620 12.42% n=1,425 5.49% n=4,099 2.14% n=20,834 BUN 43 N=33,324 Greater than Less than 2.68% n=25,122 8.98% n=7,202 Cr <2.75 2,045
  8. 8. Baseline BUN Predictive of 60 day Outcomes ACTIV trial Filappatos GJ Cardiac Fail 2007;13:360e364 N=319
  9. 9. Klein L. Circ Heart Fail. 2008;1:25-33. N=949
  10. 10. Mullens W et al. Am J Cardiol 2008;101:1297–1302 N=513
  11. 11. Mullens W et al. Am J Cardiol 2008;101:1297–1302 N=513
  12. 12. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Abraham, W. T. et al. J Am Coll Cardiol 2008;52:347-356 In-Hospital Mortality by SCr and SBP From OPTIMIZE HF Registry
  13. 14. In-Hospital Mortality According to Troponin I or Troponin T Quartile Peacock WF 4th et al. N Engl J Med 2008;358:2117-2126
  14. 15. Mortality According to Type of Treatment and Troponin Status Peacock WF 4th et al. N Engl J Med 2008;358:2117-2126
  15. 16. State of the Art, circa 1974 <ul><li>Diuretics </li></ul><ul><li>Vasodilators </li></ul><ul><li>Oxygen </li></ul><ul><li>Consider inotropic therapy </li></ul>Ramirez and Abelmann, NEJM, 1974 Acute heart failure therapy and 2010?
  16. 17. What Should be the Goals of Therapy of ADHF? <ul><li>Make the patient feel better: reduce dyspnea and improve QOL </li></ul><ul><li>Reduce Mortality </li></ul><ul><li>Reduce Rehospitalization </li></ul><ul><li>Do it safely </li></ul>
  17. 18. VMAC: Primary End Point VMAC Investigators. JAMA. 2002;187:1531–1540. Dyspnea at 3 Hours – 10 0 10 20 30 40 50 60 70 80 90 100 Nesiritide Placebo Nitroglycerin Improved (%) Worsened (%) P = 0.034 P = 0.191 P values are based on van Elteren test with 7-point ordinal scale
  18. 20. Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure Adrian F. Hernandez, MD On behalf of the ASCEND-HF Committees, Investigators and Study Coordinators
  19. 21. International Steering Committee Study organization >800 Investigators and Study Coordinators at 398 Sites Clinical Event Committee Chair: John McMurray Executive Committee Chair: Rob Califf Chris O’Connor (Co-PI), Randy Starling (Co-PI) Paul Armstrong, Kenneth Dickstein, Michel Komajda, Barry Massie, John McMurray, Markku Nieminen, Jean Rouleau, Karl Swedberg, Vic Hasselblad Sponsor Scios Inc. Independent DSMB Chair: Sidney Goldstein Salim Yusuf, David DeMets, Milton Packer, John Kjekshus North America Academic Consortium: (DCRI, C5, Jefferson, Henry Ford, Canadian VIGOUR Centre) ROW: Johnson & Johnson Global Clinical Operations Coordinating center: DCRI Adrian Hernandez, Craig Reist, Gretchen Heizer
  20. 22. Background <ul><li>Acute decompensated heart failure is a major health problem responsible for several million hospitalizations worldwide each year. </li></ul><ul><li>Standard therapy has not changed since 1970s and includes diuretics and variable use of vasodilators or inotropes. </li></ul><ul><li>In 2001, nesiritide (recombinant human B-type natriuretic peptide) was approved by the FDA to reduce PCWP and improve dyspnea, based on efficacy at 3 hrs in ADHF. </li></ul><ul><li>However, in 2005 two meta-analyses raised concerns regarding the risks of mortality and renal injury. </li></ul><ul><li>Subsequently, an independent panel* was convened by Scios Inc and recommended that a clinical trial be conducted to definitively answer the question of nesiritide’ s safety and efficacy. </li></ul><ul><li>* chaired by Eugene Braunwald </li></ul>
  21. 23. <ul><li>Investigator independence framed by a joint academic executive and steering committee </li></ul><ul><li>Large, pragmatic international trial model </li></ul><ul><ul><li>Focused </li></ul></ul><ul><ul><li>Efficient study design </li></ul></ul><ul><ul><li>Streamlined procedures </li></ul></ul><ul><ul><li>Simple follow-up </li></ul></ul><ul><li>Permissive enrollment criteria for broad population clinical ADHF </li></ul><ul><li>Meaningful outcomes </li></ul><ul><li>“ Real world” treatment (local standards of care guided by manual constructed by international committee of ADHF experts) </li></ul>Design of ASCEND-HF: Guiding principles
  22. 24. <ul><li>To assess whether nesiritide vs placebo, in addition to standard care provides: </li></ul><ul><ul><ul><li>Reduction in rate of HF rehospitalization or all-cause mortality through Day 30 </li></ul></ul></ul><ul><ul><ul><li>Significant improvement in self-assessed dyspnea at 6 or 24 hrs using 7-point Likert scale </li></ul></ul></ul>Co-Primary objectives
  23. 25. <ul><li>Secondary endpoints: </li></ul><ul><ul><li>Overall well-being by self‑assessed Likert scale at 6 and 24 hours </li></ul></ul><ul><ul><li>Persistent or worsening HF and all-cause mortality from randomization through discharge </li></ul></ul><ul><ul><li>Number of days alive and outside of the hospital from randomization through Day 30 </li></ul></ul><ul><ul><li>Cardiovascular rehospitalization and cardiovascular mortality from randomization through Day 30 </li></ul></ul><ul><li>Safety endpoints: </li></ul><ul><ul><li>All cause mortality </li></ul></ul><ul><ul><li>Renal function: 25% decrease in eGFR at any time from study drug initiation through Day 30 </li></ul></ul><ul><ul><li>Hypotension: As reported by investigator as symptomatic or asymptomatic </li></ul></ul>Secondary and safety objectives
  24. 26. <ul><li>Double – blind placebo controlled </li></ul><ul><li>IV bolus (loading dose) of 2 µg/kg nesiritide or placebo </li></ul><ul><ul><li>Investigator ’s discretion for bolus </li></ul></ul><ul><ul><li>Followed by continuous IV infusion of nesiritide 0.01 µg/kg/min or placebo for up to 7 days </li></ul></ul><ul><li>Usual care per investigators including diuretics and/or other therapies as needed </li></ul><ul><li>Duration of treatment per investigator based on clinical improvement </li></ul>Study design and drug procedures Nesiritide Placebo 24–168 hrs Rx Acute HF < 24 hrs from IV RX Co-primary endpoint: Dyspnea relief at 6 and 24 hrs Co-primary endpoint: 30-day death or HF rehosp All-cause mortality at 180 days
  25. 27. <ul><li>Hospitalized for ADHF <24 hrs from IV treatment </li></ul><ul><li>Dyspnea at rest or with minimal activity </li></ul><ul><li>1 clinical sign: </li></ul><ul><ul><li>Respiratory rate ≥ 20 breaths /min </li></ul></ul><ul><ul><li>Rales >1/3 bases </li></ul></ul><ul><li>1 objective measure: </li></ul><ul><ul><li>CXR with pulmonary edema </li></ul></ul><ul><ul><li>BNP ≥400 pg/mL or NT-proBNP≥1000 pg/mL </li></ul></ul><ul><ul><li>Prior EF <40% within 12 months </li></ul></ul><ul><ul><li>PCWP > 20 mmHg </li></ul></ul><ul><li>Hypotension at baseline (SBP <100 mm Hg or SBP<110 mm Hg with IV vasodilator) </li></ul><ul><li>Significant lung disease that could interfere with interpretation of dypsnea </li></ul><ul><li>Acute coronary syndrome </li></ul><ul><li>Severe anemia or active bleeding </li></ul><ul><li>Treatment with levosimendan or milrinone </li></ul><ul><li>Unstable doses of IV vasoactive medication within 3 hours </li></ul>Key inclusion criteria Key exclusion criteria Inclusion and exclusion criteria
  26. 28. Enrollment North America = 45% 214 sites Latin America = 9% 39 sites Asia-Pacific = 25% 62 sites Central Europe = 14% 48 sites Western Europe = 7% 35 sites 7141 patients 30 Countries & 398 Sites >800 Investigators and Study Coordinators
  27. 29. Randomized (n=7141) Study population Placebo MITT=3511 <ul><li>Placebo (n=3577) </li></ul><ul><li>  Did not receive study drug (n=66) </li></ul><ul><li>Hypotension (n=28) </li></ul><ul><li>Exclusion criteria (n=8) </li></ul><ul><li>Physician decision (n=6) </li></ul><ul><li>Participant withdrew consent (n=14) </li></ul><ul><li>Other reason (n=10) </li></ul>Nesiritide MITT=3496 <ul><li>Nesiritide (n=3564) </li></ul><ul><li>Did not receive study drug (n=68) </li></ul><ul><li>Hypotension (n=26) </li></ul><ul><li>Exclusion criteria identified (n=9) </li></ul><ul><li>Physician decision (n=6) </li></ul><ul><li>Participant withdrew consent (n=16) </li></ul><ul><li>Other reason (n=11) </li></ul>
  28. 30. Baseline characteristics Continuous variables as median (IQR 25 th , 75 th ); MITT population Placebo (n=3511) Nesiritide (n=3496) Age (yrs) 67 (56, 76) 67 (56, 76) Female (%) 34.9 33.4 Black or African American 15.0 14.7 Systolic Blood Pressure (mmHg) 124 (110, 140) 123 (110, 140) Heart rate (beats/min) 82 (72, 95) 82 (72, 95) Respiratory rate (breaths/min) 24 (21,26) 23 (21, 26) Medical History (%) Ischemic heart disease 60.8 59.5 Hypertension 72.6 71.8 Atrial fibrillation 37.7 37.4 Chronic respiratory disease 16.6 16.3 Diabetes 42.9 42.3 LVEF <40% 79.5 80.8
  29. 31. Baseline characteristics Continuous variables as median (IQR 25 th , 75 th ); MITT population Placebo (n=3511) Nesiritide (n=3496) Labs/Studies BNP (pg/mL) 989 (544, 1782) 994 (549, 1925) NT pro-BNP (pg/mL) 4461 (2123, 9217) 4508 (2076, 9174) Creatinine (mg/dL) 1.2 (1.0, 1.6) 1.2 (1.0, 1.5) Pre-randomization treatment (%) Loop diuretics 95.3 94.9 Inotropes 4.4 4.3 Vasodilators 14.1 15.7
  30. 32. Co-Primary outcome: 30-day all-cause mortality or HF rehospitalization Placebo Nesiritide HF Rehospitalization 30-day Death/HF Rehospitalization 30-day Death 0 2 4 6 8 10 12 Risk Diff (95 % CI) -0.7 (-2.1; 0.7) -0.4 (-1.3; 0.5) -0.1 (-1.2; 1.0) % 10.1 4.0 6.1 P=0.31 9.4 3.6 6.0
  31. 33. Regional variation in outcomes
  32. 34. Regional variation in outcomes
  33. 35. 30 day death/HF readmission subgroups Difference (%) and 95% Confidence Interval Risk Difference <0: Favors Nesiritide; Risk Difference >0: Favors Placebo All-Cause Death/HF Rehosp Day 30 N=6836 Sex Female Male N=1192 N=2221 Age ≤ 64 65-74 ≥ 75 N=1514 N=871 N=1028 Race White Black or African American Asian Other N=1913 N=512 N=834 N=154 Region North America Latin America Asia-Pacific Central Europe Western Europe N=1547 N=324 N=837 N=474 N=231
  34. 36. 30 day death/HF readmission subgroups Difference (%) and 95% Confidence Interval Risk Difference <0: Favors Nesiritide; Risk Difference >0: Favors Placebo All-Cause Death/HF Rehosp Day 30 N=6836 Baseline SBP (mmHg) < 123 ≥ 123 N=1646 N=1767 Baseline Ejection Fraction (%) <40 ≥ 40 N=2179 N=604 Renal function- MDRD GFR (mL/min/m 2 ) <60 ≥ 60 N=1704 N=1534 History of CAD No Yes N=1525 N=1887 History of Diabetes Mellitus No Yes N=1949 N=1464
  35. 37. 30 day death/HF readmission subgroups Difference (%) and 95% Confidence Interval Risk Difference <0: Favors Nesiritide; Risk Difference >0: Favors Placebo All-Cause Death/HF Rehosp Day 30 N=6836 Inotrope Use at Randomization No Yes N=3272 N=141 Vasodilators None Any IV Vasodilators No IV Nitroglycerin IV Nitroglycerin N=2962 N=448 N=2987 N=425 Diuretic Use from Hosp through Rand No Yes N=329 N=3084 Study Drug Bolus No Yes N=1310 N=2103
  36. 38. Co-Primary Endpoint: 6 and 24 hour dyspnea 70 60 50 40 30 20 10 0 10 20 30 40 % Subjects 24 Hours Markedly Better Minimally Worse Moderately Better Moderately Worse Minimally Better Markedly Worse No Change 70 60 50 40 30 20 10 0 10 20 30 40 % Subjects 50 60 6 Hours 42.1% 44.5% 66.1% 68.2% 3444 Placebo 13.4 28.7 34.1 21.7 P=0.030 3416 Nesiritide 15.0 29.5 32.8 20.3 3398 Placebo 27.5 38.6 22.1 9.5 3371 Nesiritide 30.4 37.8 21.2 P=0.007 8.6
  37. 39. Secondary endpoints *Combined response for moderately/markedly better Placebo (n= 3511 ) Nesiritide (n=3496) Difference (95% CI) P-value Persistent or worsening HF or all-cause mortality through discharge 4.8% (165) 4.2% (147) -0.5 (-1.5 to 0.5) 0.30 Days alive and outside of hospital through Day 30 20.7 20.9 0.2 (-0.13 to 0.53) 0.16 CV death or CV rehosp through Day 30 11.8% (402) 10.9% (372) -0.9 (-2.4 to 0.6) 0.24 Placebo (n=3511) Nesiritide (n=3496) P-value Well Being at 6 hours* 40.3% 41.4% 0.32 Well Being at 24 hours* 63.7% 65.7% 0.02
  38. 40. 30-day mortality meta-analysis 1 10 0.1 Odds ratio (95% CI) Mills (311) Colluci/Efficacy (325) Comparative (326) PRECEDENT (329) VMAC (339) PROACTION (341) ASCEND-HF COMBINED 30 day w/out ASCEND COMBINED with ASCEND Odds Ratio (95% CI) 0.38 (0.05, 2.74) 1.24 (0.23, 6.59) 1.43 (0.50, 4.09) 0.59 (0.18, 2.01) 1.63 (0.77, 3.44) 6.93 (0.89, 53.91) 0.89 (0.69, 1.14) 1.28 (0.73, 2.25) 1.00 (0.76, 1.30)
  39. 41. <ul><li>Nesiritide did not reduce the rate of recurrent heart failure hospitalization or death at 30 days. </li></ul><ul><li>Nesiritide reduced dyspnea to a modest degree, consistent with previous findings but did not meet pre-specified protocol criteria for statistical significance at 6 and 24 hours. </li></ul><ul><li>Nesiritide did not affect 30-day all cause mortality nor did it worsen renal function as had been suggested by prior meta-analyses of smaller studies. </li></ul>Conclusions
  40. 42. Implications <ul><li>Nesiritide can now be considered a safe therapy in patients with ADHF. </li></ul><ul><li>Further analysis of ASCEND-HF may allow a better understanding of patients with ADHF and patient profiles that may potentially benefit from nesiritide. </li></ul><ul><li>Our results from this large randomized trial emphasize the challenges of making therapeutic decisions on inadequate evidence and highlight the urgent need for large, well-conducted trials capable of informing clinical practice. </li></ul>
  41. 43. Steering Committee <ul><li>North America: Kirkwood F. Adams Jr MD; Javed Butler, MD;Maria Rosa Costanzo, MD; Mark E. Dunlap, MD; Justin A. Ezekowitz, MBBCh, MSc; David Feldman, MD, PhD; Gregg C. Fonarow, MD; Stephen S. Gottlieb, MD, MHS; James A. Hill, MD, MS; Judd E. Hollander, MD; Jonathan G. Howlett, MD; Michael Hudson, MD; Mariell L. Jessup, MD; Serge Lepage, MD; Wayne C. Levy, MD; Naveen Pereira, MD; W.H. Wilson Tan, MD; John R. Teerlink, MD </li></ul><ul><li>Europe: Stefan D. Anker, MD, PhD; Dan Atar, MD; Alexander Battler, MD; Ulf Dahlstrom, MD, PhD; Aleksandras Laucevicius, MD; Marco Metra, MD; Alexander Parkhomenko, MD; Piotr Ponikowski, MD, PhD; Jindrich Spinar, MD; Svetla Torbova, MD; Filippos Triposkiadis, MD;Vyacheslav Mareev, MD; Adriaan A. Voors, MD, PhD;David J. Whellan, MD, MHS; Clyde W. Yancy, MD; Faiez Zannad, MD, PhD </li></ul><ul><li>Latin America: Rodrigo Botero, MD; Nadine Clausell, MD; Ramón Corbalán, MD; Rafael Diaz, MD; Gustavo Méndez Machedo </li></ul><ul><li>Asia Pacific: Ping Chai, MD; Wen-Jone Chen, MD; Henry Krum, MBBS, PhD; Sanjay Mittal, MD; Byung Hee Oh, MD; Supachai Tanomsup, MD; Richard W. Troughton, MD, PhD; YueJin Yang, MD; </li></ul>

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