Dr Dinna Soon. Consultant Cardiologist, Department of Cardiology. GP symposium 2 April 2016

Transcription

1 Dr Dinna Soon Consultant Cardiologist, Department of Cardiology GP symposium 2 April 2016

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3 Case presentation 76 years old male, chronic smoker, hypertension, previous MI 3/7 SOB and chest tightness BP : 170/90 CVS- no murmur Chest -few wheeze ECG- sinus tachycardia, Q waves in anterior leads. CXR-?Cardiomegaly, hyper inflated lungs, increased bronchovascular markings. Normal initial lab results

4 Diagnostic Dilemma 1.ACS 2.Acute exacerbation of COPD 3. Acute PE 4. Acute Heart Failure (LVF) Aspirin + Bronchodilator + Clexane + Diuretic ( ABCD treatment)

5 More information Orthopnoea, PND Cold peripheries, leg swelling, fine inspiratory crackles at lung bases, JVP elevated 6cm S3 Gallop BNP markedly elevated ECHO- Dilated LV, severe LV systolic dysfunction- EF 20%

6 Organs that may be involved in development of shortness of breath Nervous and Musculoskeletal system: Brain tumour/stroke Muscle disorders Systemic illness: Anaemia Hyperthroidism Renal failure/liver failure Heart: Heart failure Angina equivalent Lungs: Asthma/COPD/Emphysema Pneumonia Pneumothorax Cancer Pulmonary embolism Asbestosis/ systemic illness (Rheumatoid arthritis) Biykem Bozkurt, and Douglas L. Mann Circulation. 2003;108:e11-e13

7 Heart Failure A complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood -American Heart Association and American College of Cardiology Hunt SA et al.2009.circulation.2009;119(14):e391-e479

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9 Accuracy of Initial Evaluation Findings in Diagnosing Heart Failure Ruling in Heart Failure Michael K. Am Fam Physician.2012;85(12):

10 Framingham Diagnostic Criteria for Heart Failure Major Criteria Paroxysmal nocturnal dyspnea/orthopnoea Neck vein distension Rales Cardiomegaly Acute pulmonary oedema S3 gallop Hepatojugular reflux Minor Criteria Ankle edema Dyspnea on exertion Hepatomegaly Nocturnal cough Pleural effusion Tachycardia (>120 beats per minute) Heart failure is diagnosed when 2 major criteria or 1 major and 2 minor criteria are met Patrick A. McKee et al. The Natural History of Congestive Heart Failure: The Framingham Study.N Engl J Med 1971; 285:

11 To validate Framingham diagnostic criteria using echocardiography as the reference standard to diagnose heart failure Framingham clinical criteria - very sensitive for systolic HF (92% compared with 89% for diastolic HF) and moderately specific (79%) Absence of the Framingham clinical criteria rules out the diagnosis of HF However the presence of these criteria do not necessarily confirm the diagnosis, which may be based in echocardiography Journal of Evaluation in Clinical Practice.2009;15(1):55-61

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13 BNP & NT-pro BNP Secreted by atria and ventricles in response to stretching or increased wall tension 1 Normal BNP/NT-pro BNP effectively rules out HF 2 (high negative predictive value) No HF Further evaluation HF BNP < 100 (NNV 96%) > 400 Levels in pg/ml NT-pro BNP <400 (NNP99%) > Chen WC. Biomarkers in heart failure.heart 2010;96(4): Balion C et al. Evid Rep Technol Assess 2006;(142) Han-Na Kim et al. Natriuretic Peptide testing in HF.Circulation 2011;123:

14 WHO ARE AT RISK?

15 Risk Factors for Heart Failure Coronary artery disease Hypertension (LVH) Valvular heart disease Alcoholism Infection (viral) Diabetes Congenital heart defects Other: Obesity Age Smoking Obstructive Sleep Apnea

16 Evaluation for IHD Warranted in patients with HF, especially if angina is present, given that CAD is the cause for HF in approximately two-thirds of the patients 1 Coronary angiography has been shown to improve symptoms and survival in patients with angina and reduced ejection fraction 2 1.Ghoerghiade M et al. Chronic HF in US: a manifestation of CAD. Circulation.1998;97(3): Hunt SA et al.2009 focused update incorporated into the ACC/AHA 2005 guidelines for diagnosis and management of HF in adults.circulation.2009;119(14):e391-e479

17 Identify alternative/reversible causes and treat Suspected Heart Failure Framingham criteria not met OR Normal BNP MK et al. American Family Physician.2012;85(12):

18 Referral and approach to care NICE (UK) GUIDELINES Refer patients to the specialist multidisciplinary heart failure team in the following situations: Initial diagnosis of heart failure Management of severe heart failure (NHYA III-IV) Heart failure not responding to treatment Heart failure due to valve disease Patient who is pregnant or planning to get pregnant NICE UK 2010 Chronic HF in adults

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24 Current therapies are unable to fully address neurohormonal imbalance in Heart Failure: ENTRESTO is a new alternative to an ACEI or ARBs in patients with HFrEF 1 SNS β-blockers NP system NPRs NPs Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy Neprilysin inhibitors INACTIVE FRAGMENTS HF SYMPTOMS & PROGRESSION ENTRESTO Epinephrine Norepinephrine RAAS Ang II α 1, β 1, β 2 receptors Vasoconstriction RAAS activity Vasopressin Heart rate Contractility AT 1 R Vasoconstriction Blood pressure Sympathetic tone Aldosterone Hypertrophy Fibrosis RAAS inhibitors (ACEI, ARB, MRA) Entresto: enhancement of natriuretic and other vasoactive peptides, with simultaneous RAAS suppression 1. McMurray et al. Eur J Heart Fail 2013;15: Figure references: Levin et al. N Engl J Med 1998;339:321 8 Nathisuwan & Talbert. Pharmacotherapy 2002;22:27 42 Kemp & Conte. Cardiovascular Pathology 2012; Schrier & Abraham. N Engl J Med 2009;341:577 85

25 NEJM SEP ;11

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27 PARADIGM-HF: Efficacy of ENTRESTO over Enalapril % reduction in CV death or HF hospitalization P<0.001 % reduction in HF hospitalization P<0.001 % reduction in CV mortality P< % reduction in all-cause mortality p<0.001 LCZ696 superior to enalapril in reducing symptoms and physical limitations of HF (indicated by KCCQ score)

28 Impact of ENTRESTO in improving QoL in HF Patients Significantly fewer patients treated with Entresto had a 5-point deterioration in KCCQ scores at Month 8, compared with enalapril and the effect was consistent for all subdomains of KCCQ; also the effect was consistent at Months 8, 12 and Death imputed as zero. The analysis included all patients with at least one KCCQ data point KCCQ, Kansas City Cardiomyopathy Questionnaire

29 Summary Heart failure is primarily a clinical diagnosis. The initial evaluation of patients with SOB/suspected HF should include a history and physical examination, laboratory assessment, CXR and ECG. ECHO can confirm the diagnosis. A displaced cardiac apex, a third heart sound, and CXR findings of pulmonary venous congestion or interstitial edema are good predictors to rule in the diagnosis of HF

30 Systolic heart failure can be effectively ruled out with a normal B-type natriuretic peptide or N-terminal pro-b-type natriuretic peptide level Systolic heart failure can be effectively ruled out when Framingham criteria are not met. Current treatments (beta-blocker, ACEi/ARB, MRA) mainly focus on blocking the detrimental effects of neurohormonal activation, and largely ignore the physiological compensatory effect of the natriuretic peptide system. Inhibition of neprilysin (ARNI) results in an increase in the activity of natriuretic peptides and other vasoactive peptides that can potentially exert favourable long-term compensatory effects.

31 THANK YOU

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