Cardiac Investigation In Heart Failure

1,289 views

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,289
On SlideShare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
91
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • If we turn back to evidence-based data for just a moment. All of you are aware of this study, COMPANION trail, published in NEJM showing that patients with CRT or CRT D who met the study criteria here had a significant reduction in primary outcomes including mortality and HF hosp from any causes and secondary endpoints including any death.
  • About a year later, a CARE HF study published in NEJM actually showed the same thing for survival benefit of the CRT.
  • Not only survival benefits of CRT, functional benefits including …. Have been demonstrated in many literatures.
  • Not only CRT, but also ICD has survival benefit in selected patients with HF. Data from SCD heft has clearly shown that ICD therapy significantly reduce mortality compared with placebo.
  • Cardiac Investigation In Heart Failure

    1. 1. Cardiac Investigation in Heart Failure What Internist Needs to know Sarinya Puwanant, MD, FASE
    2. 3. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare disease and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul>
    3. 4. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare disease and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul>
    4. 5. Assessment of CAD in HF <ul><li>Is the patient a potential revascularization candidate? </li></ul><ul><li>Recommendations linked to proof that revasc alters outcomes. </li></ul>EST Perfusion Stress Echo
    5. 6. Get Angiogram First <ul><li>Angina (I) </li></ul><ul><li>Atypical Chest Pain (IIa) </li></ul><ul><li>Known CAD + No chest pain (IIa) </li></ul><ul><li>Suspected CAD with Chest pain (IIa) </li></ul>
    6. 7. Stress Test, Viability, Perfusion Study <ul><li>Known CAD (extent) (IIa) </li></ul><ul><li>Diagnostic CAD (IIb) </li></ul>
    7. 8. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare disease and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul>
    8. 9. <ul><li>Spotty Disease </li></ul><ul><li>Sensitivity 50% </li></ul><ul><li>False negative 40% </li></ul>
    9. 10. <ul><li>No specific Rx even immunosuppressive Rx does not improved outcomes </li></ul><ul><li>Giant Cell Myocarditis </li></ul><ul><li>Trial Immunosuppressive </li></ul><ul><li>LVAD </li></ul><ul><li>OHTx </li></ul><ul><li>GCM- Young, Female, rapid deterioration (VT, CHB, rapid drop of EF) </li></ul>
    10. 11. Biopsy is useful for <ul><li>Confirm diagnosis (Strongly suspected) </li></ul><ul><li>Altered management </li></ul><ul><ul><li>Anthracycline toxicity </li></ul></ul><ul><ul><li>Affect Suitability for OHTX ( Amyloid) </li></ul></ul><ul><ul><li>GCM </li></ul></ul>
    11. 12. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare disease and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul>
    12. 13. B-Natriuretic Peptide in HF <ul><li>Physiology </li></ul><ul><li>Caveats of Natriuretic Peptide </li></ul><ul><li>Clinical Utility of Natriuretic Peptide and </li></ul><ul><li>Landmark Trials </li></ul><ul><li>When should we order Natriuretic Peptide? </li></ul>
    13. 14. B-Natriuretic Peptide in HF <ul><li>Physiology </li></ul><ul><li>Caveats of Natriuretic Peptide </li></ul><ul><li>Clinical Utility of Natriuretic Peptide and </li></ul><ul><li>Landmark Trials </li></ul><ul><li>When should we order Natriuretic Peptide? </li></ul>
    14. 15. BNP Release <ul><li>Atrial stretch </li></ul><ul><li> Not always = pressure </li></ul><ul><li>i.e., tamponade </li></ul><ul><li>Increased LV wall stress </li></ul>
    15. 16. ProBNP NT-ProBNP BNP Pre-ProBNP -In-active -Half Life 90 min -Active -Half Life 20 min
    16. 17. B-Natriuretic Peptide in HF <ul><li>Physiology </li></ul><ul><li>Caveat S of Natriuretic Peptide </li></ul><ul><li>Clinical Utility of Natriuretic Peptide and </li></ul><ul><li>Landmark Trials </li></ul><ul><li>When should we order Natriuretic Peptide? </li></ul>
    17. 18. <ul><li>High BNP </li></ul><ul><li>Elderly </li></ul><ul><li>Female </li></ul><ul><li>Pulmonary Emboli </li></ul><ul><li>Renal Failure </li></ul><ul><li>H/o HF w/ undiagnosed dyspnea </li></ul><ul><li>Anemia </li></ul><ul><li>Hyperthyroid (NT) </li></ul>Low BNP Tamponade Constriction Obesity –NPR-C 400 pg/ml pg/ml-se 87, sp 76 NT 1200 pg/ml-se 89, sp 72
    18. 19. B-Natriuretic Peptide in HF <ul><li>Physiology </li></ul><ul><li>Caveat of Natriuretic Peptide </li></ul><ul><li>Clinical Utility of Natriuretic Peptide </li></ul><ul><li>and Landmark Trials </li></ul><ul><li>When should we order Natriuretic Peptide? </li></ul>
    19. 20. Clinical Utility of Natriuretic Peptide in Heart Failure <ul><li>1. Diagnosis  Ruling out </li></ul><ul><li>2. Risk Stratification </li></ul><ul><li>3. Screening Cardiac Dysfunction </li></ul><ul><li>4. Guiding Management of Heart Failure </li></ul>
    20. 21. Clinical Utility of Natriuretic Peptide in Heart Failure <ul><li>1. Diagnosis  Ruling out </li></ul><ul><li>2. Risk Stratification </li></ul><ul><li>3. Screening Cardiac Dysfunction </li></ul><ul><li>4. Guiding Management of Heart Failure </li></ul>
    21. 22. Clinical Utility of Natriuretic Peptide in Heart Failure <ul><li>Confirm or Rule out HF Diagnosis </li></ul><ul><li>Ambiguous signs and symptoms </li></ul><ul><li>Acute Setting </li></ul>
    22. 23. BNP Cut – Off Maisel. N Engl J Med 2002;347:161-7 BNP Study N=1586
    23. 24. References Ranges BNP (pg/ml) <ul><li>767 Subjects w/o CV diseases or LV dysfunction (5 th -95 th percentile) </li></ul><ul><li>Age 45-54 55-64 65-75 74-83 </li></ul><ul><li>Female 8-73 10-93 13-120 16-155 </li></ul><ul><li>Male 4-40 5-52 7-67 9-86 </li></ul>Redfield JACC 2002
    24. 25. NT-Pro BNP Cut - Off PRIDE STUDY N=600 Am J Cardiol 2005;95:948
    25. 26. Pro-NT BNP Cut - Off Januzzi EHJ 2006:27:330 The International Collaborative of NT-proBNP Study N=1256
    26. 27. Preserved EF HF - BNP Sub-study JACC 2003; 41:2010 –7
    27. 28. BASEL STUDY <ul><li>N=452, ER w/ acute dyspnea, Biosite Essay </li></ul><ul><li>2 Diagnostic strategies- BNP and no BNP </li></ul><ul><li>BNP group </li></ul><ul><li>- Less need for hospitalization (75% vs. 85%, p< 0.05) </li></ul><ul><li>- Less need for intensive care (15 vs. 24%, p<0.05) </li></ul><ul><li>- Rapid time to discharge (8 vs. 11 days, p<0.05) </li></ul><ul><li>- Less total cost of treatment (5410 $ vs. 7264$, p<0.05) </li></ul><ul><li>- Similar 30- day mortality </li></ul>
    28. 29. Clinical Utility of Natriuretic Peptide in Heart Failure <ul><li>Confirm or Rule out HF Diagnosis </li></ul><ul><li>Ambiguous signs and symptoms </li></ul><ul><li>Non - Acute Setting </li></ul>
    29. 30. Clinical Utility of Natriuretic Peptide in Diagnosis of Heart Failure in Non-Acute Setting <ul><li>Class II a , Level of evidence C </li></ul><ul><li>Skeptical, various cut-off values (80-300 pg/ml) </li></ul><ul><li>Lack of good prospective randomized control trials </li></ul><ul><li>Presently, NT pro-BNP improved HF diagnostic accuracy (21 vs. 8%, p<0.002). Number needed to Dx =7 </li></ul><ul><li>Great impact on ruling out HF </li></ul><ul><li>L ower cut-off compared to those in acute setting </li></ul>
    30. 31. Zaphirio European Journal of Heart Failure 7 (2005) 537– 541 N=306 ESC HF criteria
    31. 32. Nielsen et al. The European Journal of Heart Failure 6 (2004) 63–70 NT-pro BNP <17 pg/ml Age >=50 NT-pro BNP <11 pg/ml Age >=50 N= 345, ESC HF Dx Sens 95% Spect 68% PPV 54% NPV 97%
    32. 33. <ul><li>N=558, Chronic stable systolic HF </li></ul><ul><li>Asymptomatic (n=60)  BNP 5-572 pg/ml, median 147 </li></ul><ul><li>Symptomatic (n=498)  21% had BNP <100 pg/ml </li></ul>
    33. 34. r=0.32 r=0.69 <ul><li>Weak correlation of BNP and PCWP in ICU pts with LV dysfx - Circulation . 2004;109:2432-2439 </li></ul><ul><li>Poor correlation of BNP, pro BNP and LVEDP (r=0.05-0.08) </li></ul><ul><li>- Am Heart J 2006; 152:107126 </li></ul>
    34. 35. Clinical Utility of Natriuretic Peptide in Heart Failure <ul><li>1. Diagnosis  Ruling out </li></ul><ul><li>2. Risk Stratification </li></ul><ul><li>3. Screening Cardiac Dysfunction </li></ul><ul><li>4. Guiding Management of Heart Failure </li></ul>
    35. 36. Risk Stratification <ul><li>Provide robust prognostic information </li></ul><ul><li>- Normal Population </li></ul><ul><li>- ACS </li></ul><ul><li>- CAD </li></ul><ul><li>- CRT </li></ul><ul><li>- HF </li></ul><ul><li>- PE </li></ul><ul><li>for both BNP and proBNP </li></ul><ul><li>for both absolute values and delta values on F/U </li></ul><ul><li>Provide incremental prognostic information </li></ul><ul><li>Lack of clear clinical utility of guiding of clinical management </li></ul>
    36. 37. ( Circulation . 2003;107:1278-1283.) N=4300 HF patients Valheft Study
    37. 38. <ul><li>N= 72, NYHA class 3-4 </li></ul><ul><li>Last BNP strongly associate combine endpoints </li></ul><ul><li>(death, re-HF hospitalization) </li></ul><ul><li>BNP @ DC = strong predictor of re-admission </li></ul>J Am Coll Cardiol 2001;37:386 –91
    38. 39. Clinical Utility of Natriuretic Peptide in Heart Failure <ul><li>1. Diagnosis  Ruling out </li></ul><ul><li>2. Risk Stratification </li></ul><ul><li>3. Screening Cardiac Dysfunction </li></ul><ul><li>4. Guiding Management of Heart Failure </li></ul>
    39. 40. Screening for Cardiac Dysfunction CV Risk Factors As ymptomatic LV dysfx Overt Heart Failure Advanced/Terminal Heart Failure AHA/ACC Stage A B C D ?
    40. 41. Screening for Cardiac Dysfunction Approach 1 – Post MI w/o overt HF Approach 2- Other Population Olmsted Higher BNP, higher LV abn. <ul><li>Inconclusive data (vary ranges, cost effectiveness) </li></ul><ul><li>Pro and Con </li></ul><ul><li>Class II b </li></ul><ul><li>Still not warranted/recommended </li></ul>
    41. 42. LV diastolic dysfunction N=294 Circulation . 2002;105:595-601
    42. 43. Clinical Utility of Natriuretic Peptide in Heart Failure <ul><li>1. Diagnosis  Ruling out </li></ul><ul><li>2. Risk Stratification </li></ul><ul><li>3. Screening Cardiac Dysfunction </li></ul><ul><li>4. Guiding Management of Heart Failure </li></ul>
    43. 44. N=220 NYHA 2-3 LVEF <45% BNP <100 = target Median 15 months FU JACC 2007;49:1733–9
    44. 46. Clinical Utility of Natriuretic Peptide in Heart Failure <ul><li>? Track changes in Clinical Status </li></ul>
    45. 47. Track changes in Risk and Clinical Status <ul><li>BNP falls rapidly after diuretics </li></ul><ul><li>BNP correlates w/ functional status in OPD pts. </li></ul>- Independent of hemodynamic status - vary widely - Lag period? - High intra-individual variability
    46. 48. <ul><li>Pre DC BNP is superior to Admission BNP in predicting of </li></ul><ul><li>death, HF hospitalization in pts with acute LVF </li></ul><ul><li>BNP is not a perfect surrogate for intravascular volume </li></ul><ul><li>Driving down BNP at all costs may be potentially harmful </li></ul><ul><li>NT pro-BNP comes down slower than BNP </li></ul><ul><li>What is optimal level? </li></ul><ul><li>Therefore … at best this is an unproven concept </li></ul>
    47. 49. B-Natriuretic Peptide in HF <ul><li>Physiology </li></ul><ul><li>Caveats of Natriuretic Peptide </li></ul><ul><li>Clinical Utility of Natriuretic Peptide and </li></ul><ul><li>Landmark Trials </li></ul><ul><li>When should we order Natriuretic Peptide? </li></ul>
    48. 50. When Should we order BNP/NT- proBNP ? <ul><li>To exclude or diagnose HF patients presented with acute dyspnea and ambiguous signs and symptoms of HF (Ruling out > Diagnose) </li></ul><ul><li>To exclude HF in patient presented with non-acute dyspnea and ambiguous signs and symptoms of HF in some patients (not routine !) </li></ul><ul><li>To assess risk stratification if needed in selected patients (not routine !) </li></ul>Adapted from Tang Circulation July 31, 2007
    49. 51. Not Recommend ordering BNP/NT-PBNP : <ul><li>Routine BNP/NT-pro BNP testing for screening of asymptomatic LV dysfunction </li></ul><ul><li>Routine blood biomarker testing for the sole purpose of risk stratification in patients with HF </li></ul><ul><li>Routine blood BNP or NT-proBNP testing for making specific therapeutic decisions for patients with acute or chronic heart failure </li></ul><ul><li>(Reasons: still emerging but incomplete data as well as intra- and inter-individual variations) </li></ul>Adapted from Tang Circulation July 31, 2007
    50. 52. Have to ask before interpretation <ul><li>NT pro BNP vs. BNP? </li></ul><ul><li>What kind of essay? </li></ul><ul><li>Research [Shionogi®] vs. Commercial [Abbots ® , Biosite ® ] </li></ul><ul><li>Any factors affecting BNP/ pro BNP level? </li></ul><ul><li>Is ordering physician clever ? Why did he/she order? </li></ul>
    51. 53. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare diseases and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul>
    52. 54. When should I screen for rare diseases and comorbidities? <ul><li>Anthracycline </li></ul><ul><li>Herceptin </li></ul><ul><li>Cyclophosphamide </li></ul><ul><li>Chloroquine </li></ul><ul><li>ETOH, Cocain </li></ul><ul><li>NSAIDS-Cox2 </li></ul><ul><li>XRT </li></ul><ul><li>Premature CAD </li></ul><ul><li>Valvular disease </li></ul><ul><li>CP </li></ul><ul><li>RCM </li></ul>
    53. 55. HF and systemic disease <ul><li>Recognize Clinical Clue </li></ul><ul><li>Routine screening not recommended if nothing suggested in clinical history </li></ul>Hemochromatosis HIV CNTD Amyloid Pheochromocytoma Familial CM
    54. 56. ROUTINE LAB: CBC, UA, BUN, Cr, Elyte BG, Lipid, LFT, TSH 12 lead EG CXR PA, lat
    55. 57. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare diseases and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul><ul><li>Hot Topic-Sleep and HF </li></ul>
    56. 58. When should I get metabolic stress testing ? <ul><li>Vo2 max < 14 ml/k/min or </li></ul><ul><li><50% age and sex matched </li></ul><ul><li>RER >=1.15 </li></ul><ul><li>Don’t do until medical Rx optimized. </li></ul>
    57. 59. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare diseases and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul><ul><li>Hot Topic-Sleep and HF </li></ul>
    58. 60. Heart Failure Diastolic dysfunction - LV filling pressure - Exercise/rest Systolic dysfunction Structural Abnormalities <ul><li>RV </li></ul><ul><li>Pericardial disease </li></ul>
    59. 61. E/e’ = 22 Mitral e’ = 5 cm/s Mitral E = 110 cm/s 110/5 Diastolic LV filling pressure ? Critical LM CAD LVEDP 28 mmHg
    60. 62. Estimation of LV Filling Pressure mLAP LVEDP PCWP
    61. 63. E / E’ ratio
    62. 64. M-LVDP vs. Groups Defied by Values of Septal E/E’ Ommen et al. Circulation 2000 110-103
    63. 65. Omens SR Circ 102: 10/10/2000
    64. 66. Septal vs. Lateral Omens SR Circ 102: 10/10/2000
    65. 68. Diastolic Dysfunction <ul><li>Lateral E/E’ >10 predicts LVEDP >12 mmHg </li></ul><ul><li>Sensitivity 91% </li></ul><ul><li>Specificity 81% </li></ul>Nagueh et al. JACC 1997; 30:1527-33
    66. 69. Correlations between PCWP and BNP vs. Mitral E/e’
    67. 70. Echocardiography is now able to estimated LV filling pressure under various conditions
    68. 71. RA pressure Note in intubated patients, IVC size is not reliable for RA pressure assessment (unless it is small). IVC ∆ with resp RA pressure <1.5 cm collapse 0-5 mmhg nl (1.5-2.5) >50% 5-10 nl <50% 11-15 >2.5 <50% 16-20 >2.5 no change >20
    69. 72. RVSP-RASP = Peak gradient TR= 85 mmHg RVSP = 85 + RASP = 85+5= 90 RV RA mRAP =5 mmHg
    70. 73. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare diseases and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul><ul><li>Hot Topic-Sleep and HF </li></ul>
    71. 74. Right Atrial Lead Right Ventricular Lead Left Ventricular Lead
    72. 75. COMPANION study N Engl J Med 2004;350:2140-50. (Death and hospitalization) (Death from any cause) <ul><li>NYHA class III </li></ul><ul><li>QRS 120 </li></ul><ul><li>PR 150 </li></ul><ul><li>LVEF < 35% </li></ul><ul><li>NSR </li></ul><ul><li>VDD pacing </li></ul>
    73. 76. CARE-HF N Engl J Med 2005;352:1539-49. <ul><li>NYHA class III </li></ul><ul><li>LVEF < 35% </li></ul><ul><li>QRS 120-149 plus echo criteria </li></ul><ul><li>LVEDD 30 mm </li></ul><ul><li>QRS > 149 </li></ul>
    74. 79. Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure <ul><li>LVEF <=35% </li></ul><ul><li>QRS >=120 ms </li></ul><ul><li>Sinus rhythm </li></ul><ul><li>NYHA III or ambulatory IV </li></ul><ul><li>Optimal medical Rx </li></ul><ul><li>LVEF <=35% </li></ul><ul><li>QRS >=120 ms </li></ul><ul><li>AFib </li></ul><ul><li>NYHA III or ambulatory IV </li></ul><ul><li>Optimal medical Rx </li></ul><ul><li>LVEF <=35% </li></ul><ul><li>QRS >=120 ms </li></ul><ul><li>V pacing dependent </li></ul><ul><li>NYHA III or ambulatory IV </li></ul><ul><li>Optimal medical Rx </li></ul>I IIa IIb III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III A
    75. 80. Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure <ul><li>For patients with LVEF less than or equal to 35% with NYHA functional Class I or II symptoms who are receiving optimal recommended medical therapy and who are undergoing implantation of a permanent pacemaker and/or ICD with anticipated frequent ventricular pacing, CRT may be considered. </li></ul><ul><li>CRT is not indicated for asymptomatic patients with reduced LVEF in the absence of other indications for pacing. </li></ul><ul><li>CRT is not indicated for patients whose functional status and life expectancy are limited predominantly by chronic noncardiac conditions. </li></ul>I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III B I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III C
    76. 81. N Engl J Med 2005;352:225-37 N=2521 LVEF 35% NYHA class II
    77. 82. Evaluation /Investigation <ul><li>How do I assess CAD in HF ? </li></ul><ul><li>When should I do endomyocardial biopsy ? </li></ul><ul><li>When should I order BNP? </li></ul><ul><li>When should I screen for rare diseases and comorbidities? </li></ul><ul><li>When should I get metabolic stress testing ? </li></ul><ul><li>When should I use echo for guiding management? </li></ul><ul><li>When should I place CRT/ICD? </li></ul><ul><li>Hot Topic-Sleep and HF </li></ul>
    78. 83. Sleep and HF <ul><li>OSA </li></ul><ul><li>Central Apnea- Chyne stroke Resp </li></ul>
    79. 84. <ul><li>Sleep Disordered Breathing (SDB) </li></ul><ul><li>[Apnea-Hypopnea syndrome] </li></ul><ul><li>SDB – apnea or hypopnea </li></ul><ul><ul><ul><li>AH index (Apnea/hypopnea index) ง </li></ul></ul></ul><ul><ul><ul><ul><ul><li>5-15 Mild </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>>15 Moderate or severe </li></ul></ul></ul></ul></ul><ul><ul><ul><li>AH syndrome (SDB)  Daytime somnolence </li></ul></ul></ul>Sleep and HF
    80. 85. <ul><li>Polysomnogram </li></ul>Sleep and HF
    81. 86. <ul><li>General pop </li></ul><ul><ul><ul><li>SDB 24% men, 9% women </li></ul></ul></ul><ul><ul><ul><li>OSAH syndrome 4% male, 2 % female. </li></ul></ul></ul><ul><li>HF with low LVEF </li></ul><ul><ul><ul><li>Prevalence is higher </li></ul></ul></ul><ul><ul><ul><li>SDB = 51% </li></ul></ul></ul><ul><ul><ul><li>(78% CSA, 22% OSAH) </li></ul></ul></ul>Sleep and HF
    82. 87. <ul><li>CSA caused by HF </li></ul><ul><li>OSA caused HF </li></ul>Sleep and HF
    83. 88. <ul><li>OSAHS </li></ul><ul><ul><ul><li>Weight Loss </li></ul></ul></ul><ul><ul><ul><li>CPAP </li></ul></ul></ul><ul><li>CSR-CSA </li></ul><ul><ul><ul><li>Nocturnal O2 </li></ul></ul></ul><ul><ul><ul><li>CPAP needed? </li></ul></ul></ul><ul><ul><ul><li>Theophylline </li></ul></ul></ul><ul><ul><ul><li>ASV-Alternating servo ventilation </li></ul></ul></ul>Sleep and HF Rx

    ×