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- 1. NEW DATA AND HOW THEY CHANGE WHAT WE KNOW ABOUT HEART FAILURE Presented by DR BEENISH MEMON
- 2. Objectives ā¢ To discuss the definition of heart failure and clinical presentation of heart failure ā¢ To discuss types of heart failure based on ejection fraction ā¢ To discuss the guideline-based management of patients with heart failure
- 3. Burden of Heart Failure ā¢ Lifetime risk > 20% for Americans >40 years of age ā¢ 870,000 new cases diagnosed annually ā¢ Prevalence in US: 5.7 million
- 4. Definition of Heart Failure āHeart failure is a clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject bloodā ACC/AHA Guidelines 2013
- 5. ACC/AHA Guidelines 2013 ā¢ Left Heart Failure: ļ§ Dyspnea on exertion ļ§ Dyspnea at rest ļ§ Orthpnea ļ§ Paroxysmal nocturnal dyspnea (PND) ļ§ Fatigue, inability to exercise ā¢ Right Heart Failure: ļ§ Swelling of feet, hands ļ§ Abdominal distention/fullness ļ§ Right upper quadrant pain ļ§ Early satiety ļ§ Weight loss (cardiac cachexia) Clinical: Symptoms of HF
- 6. ACC/AHA Guidelines 2013 ā¢ Left Heart Failure: ā¢ Rales ā¢ Pleural effusions ā¢ CM: Displaced apical impulse ā¢ Tachycardia, LVS3, murmur of MR ā¢ Narrow pulse pressure ā¢ Right Heart Failure: ā¢ Edema of lower extremities ā¢ Elevated JVP/+ HJR ā¢ RVS3, murmur of TR ā¢ Hepatomegaly, RUQ tenderness ā¢ Ascites ā¢ Pleural effusions Clinical: Signs of HF
- 8. ACC/AHA Guidelines 2013 Asymptomatic Symptomatic A At high risk for HF but without structural heart disease or symptoms of HF (e.g., patients with HTN or CAD) B Structural heart disease but without symptoms of HF C Structural heart disease with prior or current symptoms of HF D Refractory/advanced HF requiring specialized interventions Class I Asymptomatic: No limitation of physical activity. Ordinary activity does not cause sxs. II Symptomatic with moderate exertion. Ordinary physical activity causes SOB, fatigue IV Symptomatic at rest. Unable to carry on any activity without discomfort. III Symptomatic with minimal exertion. Less than usual activity causes sxs NYHA Class Stages of Heart Failure
- 9. ACC/AHA Guidelines 2013 Class I Asymptomatic: No limitation of physical activity. Ordinary activity does not cause sxs. II Symptomatic with moderate exertion. Ordinary physical activity causes SOB, fatigue IV Symptomatic at rest. Unable to carry on any activity without discomfort. III Symptomatic with minimal exertion. Less than usual activity causes sxs NYHA Class 5-10% 5-10% 10-25% 25-60% 1-Yr Mortality NYHA Class and Mortality
- 11. ACC/AHA Guidelines 2013 Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240āe327. HF groups: 2013 ACC/AHA Guidelines The current definition of HF based on left ventricular ejection fraction (EF): ā¢ HF with reduced EF (HFrEF, EF ā¤40%) ā¢ HF failure with preserved EF (HFpEF, EF ā„50%) ā¢ HFpEF, borderline (EF 41-49%) ā¢ HFpEF, improved (EF >40%)
- 13. STAGE A At high risk for HF but without structural heart disease or symptoms of HF STAGE B Structural heart disease but without signs or symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Prevent hospitalization Ā· Prevent mortality Strategies Ā· Identification of comorbidities Treatment Ā· Diuresis to relieve symptoms of congestion Ā· Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Ā· Revascularization or valvular surgery as appropriate STAGE C Structural heart disease with prior or current symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Patient education Ā· Prevent hospitalization Ā· Prevent mortality Drugs for routine use Ā· Diuretics for fluid retention Ā· ACEI or ARB Ā· Beta blockers Ā· Aldosterone antagonists Drugs for use in selected patients Ā· Hydralazine/isosorbide dinitrate Ā· ACEI and ARB Ā· Digoxin In selected patients Ā· CRT Ā· ICD Ā· Revascularization or valvular surgery as appropriate STAGE D Refractory HF THERAPY Goals Ā· Prevent HF symptoms Ā· Prevent further cardiac remodeling Drugs Ā· ACEI or ARB as appropriate Ā· Beta blockers as appropriate In selected patients Ā· ICD Ā· Revascularization or valvular surgery as appropriate e.g., Patients with: Ā· Known structural heart disease and Ā· HF signs and symptoms HFpEF HFrEF THERAPY Goals Ā· Heart healthy lifestyle Ā· Prevent vascular, coronary disease Ā· Prevent LV structural abnormalities Drugs Ā· ACEI or ARB in appropriate patients for vascular disease or DM Ā· Statins as appropriate THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Reduce hospital readmissions Ā· Establish patientās end- of-life goals Options Ā· Advanced care measures Ā· Heart transplant Ā· Chronic inotropes Ā· Temporary or permanent MCS Ā· Experimental surgery or drugs Ā· Palliative care and hospice Ā· ICD deactivation Refractory symptoms of HF at rest, despite GDMT At Risk for Heart Failure Heart Failure e.g., Patients with: Ā· Marked HF symptoms at rest Ā· Recurrent hospitalizations despite GDMT e.g., Patients with: Ā· Previous MI Ā· LV remodeling including LVH and low EF Ā· Asymptomatic valvular disease e.g., Patients with: Ā· HTN Ā· Atherosclerotic disease Ā· DM Ā· Obesity Ā· Metabolic syndrome or Patients Ā· Using cardiotoxins Ā· With family history of cardiomyopathy Development of symptoms of HF Structural heart disease STAGE A At high risk for HF but without structural heart disease or symptoms of HF STAGE B Structural heart disease but without signs or symptoms of HF THERAPY Goals Ā· Prevent HF symptoms Ā· Prevent further cardiac remodeling Drugs Ā· ACEI or ARB as appropriate Ā· Beta blockers as appropriate In selected patients Ā· ICD Ā· Revascularization or valvular surgery as THERAPY Goals Ā· Heart healthy lifestyle Ā· Prevent vascular, coronary disease Ā· Prevent LV structural abnormalities Drugs Ā· ACEI or ARB in appropriate patients for vascular disease or DM Ā· Statins as appropriate At Risk for Heart Failure e.g., Patients with: Ā· Previous MI Ā· LV remodeling including LVH and low EF Ā· Asymptomatic valvular disease e.g., Patients with: Ā· HTN Ā· Atherosclerotic disease Ā· DM Ā· Obesity Ā· Metabolic syndrome or Patients Ā· Using cardiotoxins Ā· With family history of cardiomyopathy Structural heart disease 2013 ACCF/AHA Guideline for the Management of Heart Failure
- 14. STAGE A At high risk for HF but without structural heart disease or symptoms of HF STAGE B Structural heart disease but without signs or symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Prevent hospitalization Ā· Prevent mortality Strategies Ā· Identification of comorbidities Treatment Ā· Diuresis to relieve symptoms of congestion Ā· Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Ā· Revascularization or valvular surgery as appropriate STAGE C Structural heart disease with prior or current symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Patient education Ā· Prevent hospitalization Ā· Prevent mortality Drugs for routine use Ā· Diuretics for fluid retention Ā· ACEI or ARB Ā· Beta blockers Ā· Aldosterone antagonists Drugs for use in selected patients Ā· Hydralazine/isosorbide dinitrate Ā· ACEI and ARB Ā· Digoxin In selected patients Ā· CRT Ā· ICD Ā· Revascularization or valvular surgery as appropriate STAGE D Refractory HF THERAPY Goals Ā· Prevent HF symptoms Ā· Prevent further cardiac remodeling Drugs Ā· ACEI or ARB as appropriate Ā· Beta blockers as appropriate In selected patients Ā· ICD Ā· Revascularization or valvular surgery as appropriate e.g., Patients with: Ā· Known structural heart disease and Ā· HF signs and symptoms HFpEF HFrEF THERAPY Goals Ā· Heart healthy lifestyle Ā· Prevent vascular, coronary disease Ā· Prevent LV structural abnormalities Drugs Ā· ACEI or ARB in appropriate patients for vascular disease or DM Ā· Statins as appropriate THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Reduce hospital readmissions Ā· Establish patientās end- of-life goals Options Ā· Advanced care measures Ā· Heart transplant Ā· Chronic inotropes Ā· Temporary or permanent MCS Ā· Experimental surgery or drugs Ā· Palliative care and hospice Ā· ICD deactivation Refractory symptoms of HF at rest, despite GDMT At Risk for Heart Failure Heart Failure e.g., Patients with: Ā· Marked HF symptoms at rest Ā· Recurrent hospitalizations despite GDMT e.g., Patients with: Ā· Previous MI Ā· LV remodeling including LVH and low EF Ā· Asymptomatic valvular disease e.g., Patients with: Ā· HTN Ā· Atherosclerotic disease Ā· DM Ā· Obesity Ā· Metabolic syndrome or Patients Ā· Using cardiotoxins Ā· With family history of cardiomyopathy Development of symptoms of HF Structural heart disease STAGE A At high risk for HF but without structural heart isease or symptoms of HF STAGE B Structural heart disease but without signs or symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Prevent hospitalization Ā· Prevent mortality Strategies Ā· Identification of comorbidities Treatment Ā· Diuresis to relieve symptoms of congestion Ā· Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Ā· Revascularization or valvular surgery as appropriate STAGE Structural hear with prior or symptoms G Ā· Ā· Ā· Ā· D Ā· Ā· Ā· Ā· D Ā· Ā· Ā· I Ā· Ā· THERAPY Goals Ā· Prevent HF symptoms Ā· Prevent further cardiac remodeling Drugs Ā· ACEI or ARB as appropriate Ā· Beta blockers as appropriate In selected patients Ā· ICD Ā· Revascularization or valvular surgery as appropriate e.g., Patients with: Ā· Known structural he Ā· HF signs and sympt HFpEF THERAPY Goals Heart healthy lifestyle Prevent vascular, coronary disease Prevent LV structural abnormalities rugs ACEI or ARB in appropriate patients for vascular disease or DM Statins as appropriate e.g., Patients with: Ā· Previous MI Ā· LV remodeling including LVH and low EF Ā· Asymptomatic valvular disease .g., Patients with: HTN Atherosclerotic disease DM Obesity Metabolic syndrome or atients Using cardiotoxins With family history of cardiomyopathy Development of symptoms of HF Structural heart disease
- 15. STAGE A At high risk for HF but without structural heart disease or symptoms of HF STAGE B Structural heart disease but without signs or symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Prevent hospitalization Ā· Prevent mortality Strategies Ā· Identification of comorbidities Treatment Ā· Diuresis to relieve symptoms of congestion Ā· Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Ā· Revascularization or valvular surgery as appropriate STAGE C Structural heart disease with prior or current symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Patient education Ā· Prevent hospitalization Ā· Prevent mortality Drugs for routine use Ā· Diuretics for fluid retention Ā· ACEI or ARB Ā· Beta blockers Ā· Aldosterone antagonists Drugs for use in selected patients Ā· Hydralazine/isosorbide dinitrate Ā· ACEI and ARB Ā· Digoxin In selected patients Ā· CRT Ā· ICD Ā· Revascularization or valvular surgery as appropriate STAGE D Refractory HF THERAPY Goals Ā· Prevent HF symptoms Ā· Prevent further cardiac remodeling Drugs Ā· ACEI or ARB as appropriate Ā· Beta blockers as appropriate In selected patients Ā· ICD Ā· Revascularization or valvular surgery as appropriate e.g., Patients with: Ā· Known structural heart disease and Ā· HF signs and symptoms HFpEF HFrEF THERAPY Goals Ā· Heart healthy lifestyle Ā· Prevent vascular, coronary disease Ā· Prevent LV structural abnormalities Drugs Ā· ACEI or ARB in appropriate patients for vascular disease or DM Ā· Statins as appropriate THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Reduce hospital readmissions Ā· Establish patientās end- of-life goals Options Ā· Advanced care measures Ā· Heart transplant Ā· Chronic inotropes Ā· Temporary or permanent MCS Ā· Experimental surgery or drugs Ā· Palliative care and hospice Ā· ICD deactivation Refractory symptoms of HF at rest, despite GDMT At Risk for Heart Failure Heart Failure e.g., Patients with: Ā· Marked HF symptoms at rest Ā· Recurrent hospitalizations despite GDMT e.g., Patients with: Ā· Previous MI Ā· LV remodeling including LVH and low EF Ā· Asymptomatic valvular disease e.g., Patients with: Ā· HTN Ā· Atherosclerotic disease Ā· DM Ā· Obesity Ā· Metabolic syndrome or Patients Ā· Using cardiotoxins Ā· With family history of cardiomyopathy Development of symptoms of HF Structural heart disease A HF but heart ms of HF STAGE B Structural heart disease but without signs or symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Prevent hospitalization Ā· Prevent mortality Strategies Ā· Identification of comorbidities Treatment Ā· Diuresis to relieve symptoms of congestion Ā· Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Ā· Revascularization or valvular surgery as appropriate STAGE C Structural heart disease with prior or current symptoms of HF THERAPY Goals Ā· Control symptoms Ā· Patient education Ā· Prevent hospitalization Ā· Prevent mortality Drugs for routine use Ā· Diuretics for fluid retention Ā· ACEI or ARB Ā· Beta blockers Ā· Aldosterone antagonists Drugs for use in selected patients Ā· Hydralazine/isosorbide dinitrate Ā· ACEI and ARB Ā· Digoxin In selected patients Ā· CRT Ā· ICD Ā· Revascularization or valvular surgery as appropriate STAGE D Refractory HF THERAPY Goals Ā· Prevent HF symptoms Ā· Prevent further cardiac remodeling Drugs Ā· ACEI or ARB as appropriate Ā· Beta blockers as appropriate In selected patients Ā· ICD Ā· Revascularization or valvular surgery as appropriate e.g., Patients with: Ā· Known structural heart disease and Ā· HF signs and symptoms HFpEF HFrEF style ural nts for or DM priate THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Reduce hospital readmissions Ā· Establish patientās end- of-life goals Options Ā· Advanced care measures Ā· Heart transplant Ā· Chronic inotropes Ā· Temporary or permanent MCS Ā· Experimental surgery or drugs Ā· Palliative care and hospice Ā· ICD deactivation Refractory symptoms of HF at rest, despite GDMT At Risk for Heart Failure Heart Failure e.g., Patients with: Ā· Marked HF symptoms at rest Ā· Recurrent hospitalizations despite GDMT e.g., Patients with: Ā· Previous MI Ā· LV remodeling including LVH and low EF Ā· Asymptomatic valvular disease sease me s y of Development of symptoms of HF Structural heart disease THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Prevent hospitalization Ā· Prevent mortality Strategies Ā· Identification of comorbidities Treatment Ā· Diuresis to relieve symptoms of congestion Ā· Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Ā· Revascularization or valvular surgery as appropriate THERAPY Goals Ā· Control symptoms Ā· Patient education Ā· Prevent hospitalization Ā· Prevent mortality Drugs for routine use Ā· Diuretics for fluid retention Ā· ACEI or ARB Ā· Beta blockers Ā· Aldosterone antagonists Drugs for use in selected patients Ā· Hydralazine/isosorbide dinitrate Ā· ACEI and ARB Ā· Digoxin In selected patients Ā· CRT Ā· ICD Ā· Revascularization or valvular surgery as appropriate THERAPY Goals Ā· Prevent HF symptoms Ā· Prevent further cardiac remodeling Drugs Ā· ACEI or ARB as appropriate Ā· Beta blockers as appropriate In selected patients Ā· ICD Ā· Revascularization or valvular surgery as appropriate e.g., Patients with: Ā· Known structural heart disease and Ā· HF signs and symptoms HFpEF HFrEF THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Reduce hospital readmissions Ā· Establish patientās end- of-life goals Options Ā· Advanced care measures Ā· Heart transplant Ā· Chronic inotropes Ā· Temporary or permanen MCS Ā· Experimental surgery or drugs Ā· Palliative care and hospice Ā· ICD deactivation Refractory symptoms of HF at rest, despite GDMT e.g., Patients with: Ā·Marked HF symptoms a rest Ā·Recurrent hospitalization despite GDMT e.g., Patients with: Ā· Previous MI Ā· LV remodeling including LVH and low EF Ā· Asymptomatic valvular disease Development of symptoms of HF heart
- 16. THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Prevent hospitalization Ā· Prevent mortality Strategies Ā· Identification of comorbidities Treatment Ā· Diuresis to relieve symptoms of congestion Ā· Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Ā· Revascularization or valvular surgery as appropriate THERAPY Goals Ā· Control symptoms Ā· Patient education Ā· Prevent hospitalization Ā· Prevent mortality Drugs for routine use Ā· Diuretics for fluid retention Ā· ACEI or ARB Ā· Beta blockers Ā· Aldosterone antagonists Drugs for use in selected patients Ā· Hydralazine/isosorbide dinitrate Ā· ACEI and ARB Ā· Digoxin In selected patients Ā· CRT Ā· ICD Ā· Revascularization or valvular surgery as appropriate HFpEF HFrEF Goals Ā· Con Ā· Imp Ā· Red rea Ā· Est of-li Optio Ā· Adv mea Ā· Hea Ā· Chr Ā· Tem MC Ā· Exp dru Ā· Pal hos Ā· ICD ā¢ Trials have not shown significant mortality or morbidity benefit with use of ACEI/ARB specifically in HFpEF ā¢ No trials showing definite benefit of Beta blockers, sildenafil ā¢ TOPCAT trial: Randomized- double blind trial of spironolactone (15-45 mg) vs. placebo in HFpEF patients (LVEF >45%) with ā¢ Prior HF hospitalization or ā¢ BNP > 100 pg/ml HFpEF
- 17. THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Prevent hospitalization Ā· Prevent mortality Strategies Ā· Identification of comorbidities Treatment Ā· Diuresis to relieve symptoms of congestion Ā· Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM Ā· Revascularization or valvular surgery as appropriate THERAPY Goals Ā· Control symptoms Ā· Patient education Ā· Prevent hospitalization Ā· Prevent mortality Drugs for routine use Ā· Diuretics for fluid retention Ā· ACEI or ARB Ā· Beta blockers Ā· Aldosterone antagonists Drugs for use in selected patients Ā· Hydralazine/isosorbide dinitrate Ā· ACEI and ARB Ā· Digoxin In selected patients Ā· CRT Ā· ICD Ā· Revascularization or valvular surgery as appropriate HFpEF HFrEF G Ā· Ā· Ā· Ā· O Ā· Ā· Ā· Ā· Ā· Ā· Ā· ? Spironolactone in select pts
- 18. Stage D Refractory HF Marked HF symptoms at rest Recurrent hospitalizations despite GDMT THERAPY Goals Ā· Control symptoms Ā· Patient education Ā· Prevent hospitalization Ā· Prevent mortality Drugs for routine use Ā· Diuretics for fluid retention Ā· ACEI or ARB Ā· Beta blockers Ā· Aldosterone antagonists Drugs for use in selected patients Ā· Hydralazine/isosorbide dinitrate Ā· ACEI and ARB Ā· Digoxin In selected patients Ā· CRT Ā· ICD Ā· Revascularization or valvular surgery as appropriate HFrEF THERAPY Goals Ā· Control symptoms Ā· Improve HRQOL Ā· Reduce hospital readmissions Ā· Establish patientās end- of-life goals Options Ā· Advanced care measures Ā· Heart transplant Ā· Chronic inotropes Ā· Temporary or permanent MCS Ā· Experimental surgery or drugs Ā· Palliative care and hospice Ā· ICD deactivation
- 19. ā¢ After detailed history; Initial laboratory evaluation: ā¢ CBC, urinalysis, CMP (including calcium and magnesium), fasting lipid profile, TSH, iron panel ā¢ Serial monitoring, when indicated, should include serum electrolytes and renal function. ā¢ A 12-lead ECG should be performed initially on all patients presenting with HF. ā¢ Chest X-ray is all patients with new onset HF. ā¢ Echocardiogram in all patients with new dx of HF (MUGA in some) ā¢ Repeat echo usually for a significant change in clinical status or for consideration of changes after therapy or to evaluate for device therapy. ā¢ Noninvasive stress imaging or cardiac cath is reasonable in HF and suspected CAD Initial Workup of Stage C HF
- 20. BNP (NT-proBNP) in HF ā¢ BNP or B-type natriuretic peptide is produced mostly by cardiac ventricles in response to stress/strain/stretch on the myocardium ā¢ BNP has beneficial effects in heart failure: promotes vasodilation, diuresis and natriuresis ā¢ Levels increased in patients with HF; levels correlate with wedge pressures and prognosis ā¢ BNP < 100 pg/ml usually will r/o significant HF in acute dyspnea
- 21. BNP (NT-proBNP) in HF (2) ā¢ Patients discharged with BNP > 400-500 pg/ml at discharge are at a higher risk for HF readmissions and mortality ā¢ However, patients with low LVEF can have normal levels if diuresed well (20-25% chronic HF) ā¢ Levels ā with age, especially in older women, and with renal dysfunction ā¢ā in HFrEF & HFpEF (overall higher in HFrEF) ā¢ā ā in obesity ā¢ Elevated BNP also seen with RV dysfunction, PE ā¢ Although prognostic- no definitive data to recommend titrating diuretics or meds to BNP levels- outside of structured HF programs.
- 22. Management of Patients with Heart Failure
- 25. Pathophysiology of HFrEF & Therapeutic Targets Adapted from Langenickel TH, Dole WP. Drug Discovery Today 2012;9:131ā9. LV remodeling SNS SNS= sympathetic nervous system RAAS= Renin angiotensin aldosterone system
- 27. Stage C (HFrEF & HFpEF) ā¢ Non-pharmacologic interventions ā¢ Education to facilitate self care ā¢ Regular physical activity; cardiac rehabilitation ā¢ Sodium restriction ā¢ Treat comorbidities: Hypertension, diabetes, CAD, sleep apnea, anemia ā¢ Influenza and pneumococcal immunization ā¢ Decrease/stop alcohol, smoking, other drug abuse ā¢ Close outpatient follow-up ā¢ Avoid certain drug classes: ā¢ NSAIDs ā¢ Ca channel blockers except amlodipine (in HFrEF) ā¢ Antiarrhythmics except amiodarone, dofetalide ā¢ Thiazolidinediones (TZDs)
- 28. HFrEF: Medications & Devices ā Symptoms ā Hospitalizations ā Mortality Diuretics ā ā (?) ? ACE I /ARBs ā ā ā Beta-Blockers ā ā ā Aldosterone Antagonists ā ā ā Digitalis ā ā X Nitrates/Hydralazine ā ā ā ARNI ā ā ā Ivabradine ā ā X AICD (Defibrillators) X X ā CRT (BiV pacemakers) ā ā ā
- 30. Medical Therapy for Stage C HFrEF: Magnitude of Benefit in RCTs RR ā Mortality NNT to ā mortality (standardized 36 months) RR ā HF Hospital. ACE I / ARB 17% 26 31% Beta-Blockers 34% 9 41% Aldosterone Antagonists 30% 6 35% Nitrates/Hydralazine 43% 7 33%
- 31. 2013 ACCF/AHA Guideline for the Management of Heart Failure
- 32. ACC/AHA Guidelines 2013 ā¢ Indicated for symptomatic or asymptomatic EF ā¤40%. ā¢ Use agents and target doses used in clinical trials. ā¢ Initiate when relatively euvolemic, off IV vasoactive agents and prior to hospital d/c. ā¢ Titrate upward every 2 to 4 weeks as long as stable. ā¢ Most trials held titration for HR <60 or SBP <90. ā¢ Adjust other agents if dyspnea, BP, or weight gain occur in order to titrate to target doses. Use of Beta Blockers in HFrEF
- 33. Drug Initial Daily Dose(s) Maximum Doses(s) Mean Doses Achieved in Clinical Trials Beta Blockers Bisoprolol 1.25 mg qd 10 mg qd 8.6 mg/d Carvedilol 3.125 mg bid 50 mg bid 37 mg/d Carvedilol CR 10 mg qd 80 mg qd --------- Metoprolol succinate extended release (metoprolol CR/XL) 12.5 - 25 mg qd 200 mg qd 159 mg/d 2013 ACCF/AHA Guideline for the Management of Heart Failure Which Beta Blocker; How Much?
- 34. Drug Initial Daily Dose(s) Maximum Doses(s) Mean Doses Achieved in Clinical Trials ACE Inhibitors Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d Enalapril 2.5 mg twice 10 to 20 mg twice 16.6 mg/d Fosinopril 5 to 10 mg once 40 mg once --------- Lisinopril 2.5 to 5 mg once 20 to 40 mg once 32.5 to 35.0 mg/d Perindopril 2 mg once 8 to 16 mg once --------- Quinapril 5 mg twice 20 mg twice --------- Ramipril 1.25 to 2.5 mg once 10 mg once --------- Trandolapril 1 mg once 4 mg once --------- 2013 ACCF/AHA Guideline for the Management of Heart Failure Which ACE I; How Much?
- 35. ACC/AHA Guidelines 2013 ā¢ ARBs are recommended in patients with HFrEF who are ACE inhibitor-intolerant (cough +/- angioedema), unless contraindicated, to reduce morbidity and mortality. ā¢ ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors as first-line therapy for patients with HFrEF, especially for patients already taking ARBs for other indications ā¢ Addition of an ARB may be considered in persistently symptomatic patients with HFrEF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated. ACE I or ARB or Both?
- 36. ACC/AHA Guidelines 2013 Drug Initial Daily Dose(s) Maximum Doses(s) Mean Doses Achieved in Clinical Trials ARBs Candesartan 4-8 mg qd 32 mg qd 24mg/d Losartan 25-50 mg qd 50 to 100 mg qd 129 mg/d Valsartan 20-40 mg BID 160 mg bid 254 mg/d Which ARB; How Much?
- 37. ā¢ Aldosterone receptor antagonists [or mineralocorticoid receptor antagonists (MRA)] are recommended in patients with NYHA class II- IV and who have LVEF of < 35%. ā¢ Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. ā¢ Creatinine should be < 2.5 mg/dL or less in men or < 2.0 mg/dL in women (or eGFR >30 mL/min/1.73m2) and potassium < 5.0 mEq/L. ā¢ Careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation, within 7-10 days after initiation and followed thereafter to minimize risk of hyperkalemia and renal insufficiency. Aldosterone Antagonists
- 38. Drug Initial Daily Dose(s) Maximum Doses(s) Mean Doses Achieved in Clinical Trials Aldosterone Antagonists Spironolactone 12.5 to 25 mg qd 25 mg qd 26 mg/d Eplerenone 25 mg qd 50 mg qd 42.6 mg/d ā¢ Eplerenone is a more specific aldosterone receptor antagonist; it can be used if spironolactone causes gynecomastia or breast pain. ā¢ It causes the same effects on potassium and renal function as spironolactone. Aldosterone Antagonists
- 39. ā¢ HDZ/ISDN combincation is recommended for African Americans with NYHA class IIIāIV HFrEF receiving optimal therapy with ACE inhibitors and beta blockers. ā¢ HDZ/ISDN can be useful to reduce morbidity or mortality in patients with current or prior symptomatic HFrEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated. Nitrate/Hydralazine (ISDN/HDZ)
- 40. ā¢ Digoxin can be beneficial in patients with HFrEF and sinus rhythm to decrease hospitalizations for HF: consider adding if on other therapy and still symptomatic ā¢ Digoxin can be used in HF patients with atrial fibrillation to help rate control ā¢ **Dose: 0.125 -0.25 mg qd depending on renal function (levels not for dosing but for toxicity) ā¢ **Interaction with amiodarone, which ā Digoxin levels Digitalis
- 41. Neprilysin as a Therapeutic Target Inactive fragments Neprilysin Natriuretic peptides Adrenomedullin Bradykinin Substance P (angiotensin II) ā¢ Neprilysin breaks down endogenous vasoactive peptides, including the natriuretic peptides ā¢ Inhibition of neprilysin potentiates the action of those peptides ā¢ Because angiotensin II is also a substrate for neprilysin, neprilysin inhibitors must be co-administered with a RAAS blocker ā¢ The combination of a neprilysin inhibitor and an ACEI is associated with unacceptably high rates of angioedema Corti R et al. Circulation. 2001;104:1856-1862. Sacubitril/Valsartan (LCZ696): Angiotensin ReceptorāNeprilysin Inhibitor (ARNI)
- 43. COR LOE Recommendation I B-R ACEI or ARB or ARNI in conjunction with Ī² blockers + MRA (where appropriate) is recommended for patients with chronic HFrEF to reduce morbidity and mortality I B-R In patients with chronic, symptomatic HFrEF NYHA class II or III who tolerate an ACEI or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality III B-R ARNI should NOT be administered concomitantly with ACEI or within 36 hours of last ACEI dose III C-EO ARNI should NOT be administered to patients with a history of angioedema 1. Yancy CW et al. J Am Coll Cardiol. 2016;68:1476-1488. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure COR LOE Recommendations IIa B-R Ivabradine can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA class II-III), stable, chronic HFrEF (LVEF ā¤35%) who are receiving GDMT, including a Ī² blocker at maximally tolerated dose, and who are in sinus rhythm with a heart rate ā„70 bpm at rest
- 44. Implantable Cardiac Defibrillators (ICD) ā¢ Sustained ventricular tachycardia is associated with sudden cardiac death in HF. ā¢ About one-third of mortality in HF is due to sudden cardiac death. ā¢ ICDs for primary prevention have been shown to improve survival in selected patients with HF
- 45. Indications for ICD Therapy ā¢ ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post- MI with LVEF ā¤35%, and NYHA class II or III symptoms on chronic GDMT, who are expected to live ā„1 year ā¢ ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post- MI with LVEF ā¤30%, and NYHA class I symptoms while receiving GDMT, who are expected to live ā„1 year ā¢ ** ICDs do not improve symptoms; most patients should be on GDMT; should have an expected life- expectancy of at least 1 year 2013 ACCF/AHA Guideline for the Management of Heart Failure
- 46. Cardiac Resynchronization Pacing: Consequences of a Prolonged QRS Delayed Ventricular Activation Delayed lateral wall contraction Disorganized ventricular contraction Decreased pumping efficiency Reduction in diastolic filling times Prolongation of the duration of mitral regurgitation Sinus node AV node Conduction block
- 47. ā¢ Intraventricular Activation ā¢ Organized ventricular activation sequence ā¢ Coordinated septal and freewall contraction ā¢ Improved pumping efficiency Mechanism: Ventricular Resynchronization Sinus node AV node Stimulation therapy Conduction block
- 48. Cardiac Resynchonization Rx (CRT) ā¢ LVEF < 35% ā¢ Greatest benefit in patients with sx HF with LBBB + QRS > 150 msec already on GDMT and in sinus rhythm ā¢ Can consider in patients with symptomatic HF with LBBB and QRS 120-149 msec ā¢ Can consider in symptomatic HF with non-LBBB and QRS > 150 msec ā¢ Can be considered in atrial fibrillation if ventricular pacing is needed and rate control will allow nearly 100% ventricular pacing with CRT 2013 ACCF/AHA Guideline for the Management of Heart Failure
- 51. ā¢ Definition of HF ā¢ Magnitude of the problem ā¢Symptoms & Signs of HF ā¢ Types of HF: HFpEF & HFrEF ā¢ Stages of HF and NYHA Functional Classification of HF ā¢ Management of Patients with HF: Initial work up Medical therapy Device Therapy Summary