This document summarizes a presentation on cardiology topics including acute and advanced heart failure. It discusses trends in heart failure hospitalizations and mortality. It describes different hemodynamic profiles in acute heart failure patients and their corresponding treatments. It also discusses topics like iron deficiency in heart failure, sleep disordered breathing, and a study showing sleep disordered breathing is common in acute heart failure and predicts mortality.

1. The European Heart Journal’s / European Journal
of Heart Failure’s year in cardiology
Piotr Ponikowski, MD, PhD, FESC
Medical University, Centre for Heart Disease
Clinical Military Hospital
Wroclaw, Poland
Acute and Advanced Heart Failure

2. Disclosure
Consultancy fees and speaker’s honoraria from:
Vifor Pharma Ltd, Amgen, Servier, Novartis, Bayer, Pfizer,
Johnson&Johnson, Abbott Vascular, Coridea, Respicardia
Research grant: Vifor Pharma Ltd, Respicardia

3. Heart Failure: treatable and preventable disease (?)
Landscape at the end of 20th century: HF more malignant than cancer
Framingham study
Median survival:
Men – 1.7 yrs, women – 3.2 yrs
Ho KKL et al., Circulation 1993;88:107-15

4. Hospitalizations due to HF worsening often complicate
patient’s journey
Severity of
symptoms
Death
Time
Sudden death
Hospitalization
Hospitalization
Hospitalization
Mild HF
Moderate-severe HF
End-stage HF
Repeated
Hospitalizations

5. 161.131 pts; mean age: 78 yrs (M:77 vs F:82); 20% ≥ 2 HHF; LOS: 10 days
In-hospital mortality: 7.8%
Average annual change in mortality for HF (2000-12)Trends in age-standardized rates of HHF pts and
proportion of readmissions (2002-12)
Year 2012

6. Patient characteristics by geographic region

7. Conclusion for designing future HHF clinical trials:
region of enrolment for clinical trial as independent and strong
predictor of death
Relative risk of clinical outcomes by geographic region relative to North America
Greene SJ et al. Eur J Heart Fail 2015 (in press)

8. CardShock Study: 219 pts, ACS – 81%, in-hospital mortality – 37%
CardShock risk Score for risk prediction
of in-hospital mortality in cardiogenic shock
Distribution of the population (red) and in-hospital
mortality (blue) according to cumulative points
low risk
intermediate
risk
high risk

9. Simple index of diuretic response: ∆weight (kg) / 40 mg furosemide
Day 4 response: differentiation in responsiveness and diuretics adjustment to clinical response
Predictors of poor diuretic response: low SBP, high BUN, diabetes, atherosclerotic disease

10. “This is the first guidance to insist that acute heart failure (AHF) is like acute coronary syndrome
(ACS) in that it needs urgent diagnosis and appropriate treatment.
In ACS when the coronary is occluded we say ‘time is muscle’ which means that the quicker the
vessel is dilated, the more heart muscle is saved. The same principle is true for AHF.
By introducing the time to therapy concept together with new medications for AHF we hope to
achieve the reductions in mortality and morbidity seen with ACS.”
ESC WEBPAGE
„Time is muscle in acute heart failure”
Urgent treatment emphasised for the first time
in recommendations from across specialties
and continents
Alexandre Mebazaa

11. Mebazaa A et al. Eur J Heart Fail 2015 (in press)

12. Bedside assessment to identify hemodynamic profiles
Patient with acute heart failure
signs/symptoms:
•orthopnea, PND, breathlessness, bi-basal rales, an abnormal BP response to the Valsalva maneuver (left-sided);
•symptoms of gut congestion, elevated jugular venous distention, hepato-jugular reflux, hepatomegaly, ascites, and
peripheral edema (right-sided);
Presence of congestion
YES (95% of all AHF
patients)
„Wet” patient
NO
(5% of all AHF patients
„Dry” patient
Adequate peripheral perfusion
YES
„Wet and Warm” patient
(typically elevated/normal
systolic blood pressure)
NO
„Wet and Cold” patient
(typically low systolic blood pressure)
•inotropes: dobutamine, levosimendan,
milrinone
•vasodilators (if peripheral vasoconstriction):
nitroprusside, nitrates
•diuretics
Vascular type
(fluid redistribution):
•Vasodilators
•diuretics (small dose)
Cardiac type
(fluid accumulation):
•diuretics
•ultrafiltration
(if diuretic resistance)
Ponikowski P et al. submitted

13. Treatment of iron deficiency:
Attractive therapeutic target in heart failure ?
• Iron deficiency (ID) – frequent co-morbidity in stable CHF
• CHF complicated with ID – associated with impaired
functional capacity, poor quality of life and increased
mortality
• Deleterious consequences of ID in CHF are irrespective of
anaemia
• Correction of ID itself as an attractive therapeutic target
in CHF – hypothesis recently being tested in clinical studies
• What about iron status in Acute Heart Failure ?

14. Iron deficiency (new definition):
•depleted body iron stores (low serum hepcidin)
•insufficient iron amount in metabolizing cells (high serum sTfR)
20%
40%
60%
80%
% of AHF pts
Preserved
iron status
Isolated
high sTfR
Isolated
low hepcidin
Iron deficiency
(↓hepcidin & ↑sTfR)
75% of AHF - impaired iron status

15. Iron deficiency is common and predicts poor outcome
in patients hospitalized for AHF
Cumulative survival
Follow-up (months)
χ2=29.45, p<0.001
100%
93% (81-100%)
85% (75-95%)
59% (47-71%)
Iron deficiency (both low hepcidin and high sTfR) (1)
Isolated high sTfR (2)
Isolated low hepcidin (3)
Preserved iron status (4)
Jankowska EA et al. Eur Heart J 2014

16. Sleep disordered breathing in heart failure
Problems with nomenclature and perception
Sleep Physician
• obstructive sleep apnoea
• central sleep apnoea
Nomenclature accepted
Prevalent and relevant for
M&M and QoL
Target for intervention
Prevalent in obese & HTN pts
Snoring problem
Affecting QoL
Cardiologist

17. Sleep disordered breathing in heart failure
Problems with nomenclature and perception
Sleep Physician
• obstructive sleep apnoea
• central sleep apnoea
Nomenclature accepted
Prevalent and relevant for
M&M and QoL
Target for intervention
Heart Failure Specialist
Breathing abnormality
•Cheyne-Stokes respiration
•During sleep (also at rest)
Nomenclature accepted ?
Prevalent and relevant for
M&M and QoL
Target for intervention ?
Prevalent in obese & HTN pts
Snoring problem
Affecting QoL
Cardiologist

18. Prevalence of sleep apnoea
in patients with chronic HFrEF
Krawczyk M et al. Cardiol J 2013
Ominous pathophysiological and clinical consequences
(progression of the disease, increased M&M)

19. Largest prospective evaluation of SDB in AHF: 1117 pts with HFrEF
Excluded: unstable, hypoxic, unable to sleep flat; 97 % with chronic decompensated HF
Prevalence: 31% central sleep apnoea, 47% obstructive sleep apnoea, 22% with nmSDB
CSA and OSA – independent risk factors for post-discharge mortality

20. Modification of the mortality effect with SDB treatment
Khayat R et al. Eur Heart J 2015 (in press)

21. The great thing in this world is not so much where we
stand, as in what direction we are moving
Oliver Wendell Holmes 1841-1935