Heart Failure Guidelines For your Daily Practice

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1 Heart Failure Guidelines For your Daily Practice Juan M. Aranda, Jr., MD, FACC, FHFSA Professor of Medicine Director of Heart Failure and Cardiac Transplantation University of Florida College of Medicine

2 Heart Failure in Latin America Latin American countries experiencing a large-scale epidemic of heart failure risk factors Patients admitted to public hospitals (younger, more illiterate, noncompliance before admission, less BB, ACE inhibitor use, length of stay, mortality) compared to private hospitals (Lack of Access) jj Heart failure with preserved ejection fraction (HFpEF) accounts for 20 to 45% of hospitalized patients with decompensated HF No substantial financial support for development of clinical trials specific for Latin American countries J Am Coll Cardiol 2013; 62: and Am J Cardiol 2011; 108:

3 The Reality of Heart Failure in Latin America Bocchi, EA, et al. J Am Coll Cardiol 2013; 62:

4

5 Characteristics of Patients with HFpEF and Patients with HFrEF Jessup M and Brozena S, N Engl J Med 2003;348: = occasionally associated with ++ = often associated with +++ = usually associated with 0 = not associated with

6 CRITERIA 1 Symptoms ± Symptoms ± Symptoms ± Signs Signs Signs 2 LVEF < 40% LVEF 40-49% LVEF 50% BNP At least one additional criterion: 1. Relevant structural heart disease (LVH/LAE) 2. Diastolic dysfunction Ponikowski P. Eur Heart J. 2016;37:

7 Pathophysiology of HFpEF Borlaug B. Circ J. 2014;78:20-32

8 Kaplan-Meier Plots of Two Components of the Primary Outcome: Time to Confirmed Death of Cardiovascular Causes and Time to the First Confirmed Hospitalization for Heart Failure (TOPCAT) Pitt B, et al. New Engl J Med 2014; 370:

9 TOPCAT: Exploratory Post-hoc Analysis Placebo vs Spironolactone by Geographic Region Placebo US, Canada, Argentina, Brazil HR = 0.82 ( ) Spironolactone Interaction P = Spironolactione Russia, Rep Georgia HR = 1.10 ( ) Placebo Pfeffer MA et al. Circulation. 2015;131:34-42.

10 de Denus S, et al. N Engl J Med 2017; 376:

11 Recommendations for Stage C HFpEF Yancy CW, et al. J Am Coll Cardiol 2017; doi: /j.jacc

12 ARBs, Nitrates, Phosphodiesterase-5, and Nutritional Supplements in Patients with HFpEF Yancy CW, et al. J Am Coll Cardiol 2017; doi: /j.jacc

13 If you had to have heart failure, would you rather have: Systolic Heart Failure? OR Heart Failure with Preserved EF

14 Clinical Course of Systolic Heart Failure Latin America: 1 million HF hospitalization, LOS 4 to 10 days JACC HF 2013, Circulation 2012, 125:

15 Classification of Patients Presenting with Acutely Decompensated Heart Failure Yancy CW, et al. Circulation 2013; 128:

16 Inpatient mortality from ADHERE Registry Based on admission BUN, creatinine and BP < BUN 43 (n=32220) 2.88% (n=24469) 8.35% (n=67640) < SBP 115 (n=2,702) < SBP 115 (n=6697) 5.67% (n=3882) 2.31% (n=20820) < 13.23% (n-1270) 15.30% (n-1863) Cr 2.75 (n-1862) 19.76% (n-592) 5.63% (n-4834) Analysis of patients in the National Acute Decompensated Heart Failure National Registry (ADHERE) BUN=blood urea nitrogen, Cr=serum creatinine, SBP-systolic blood pressure Fonarow GC et al. J Cardiac Fail 2003;9(suppl 1):S79.

17 Initial Management of a Patient with Acute Heart Failure Pinikowski P, et al. Eur J Heart Fail 2016; 18:

18 Factors Triggering Acute Heart Failure Ponikowski P, et al. Eur Heart J 2016; 37:

19 Recommendations for Therapies in the Hospitalized HF Patient Yancy CW, et al. Circulation 2013; 128:

20 Typical 6-Day HF Journey Day 1 Day 2 Day 5 Day 6 Admission Most of day in ER Diuretic regimen not established until evening Diuresis begins Patient feels better Wants to go home Discharge Patient converted to PO meds Feels better Still volume overloaded

21 Heart Failure Admission S Y M P T O M S Background: Congestion and Symptoms in Heart Failure Pulmonary and systemic congestion Increased filling pressures (Most discharged HF patients) Abnormal LV function

22 High CVP Elevated Creatinine

23 Proposed Pathophysiology of Renal Venous Hypertension (Backward flow) Ross EA. J Cardiac Failure 2012;18:

24 Concept of Plasma Refill Rate in ADHF Diuretics to increase sodium loss and decrease venous pressures Intravascular volume Hydrostatic pressure declines Interstitial pressure + serum oncotic pressure exceeds luminal hydrostatic pressure Fluid is reabsorbed Redefining the Therapeutic Objective in Decompensated Heart Failure: Hemoconcentration as a Surrogate for Plasma Refill Rate Boyle and Sbotka J Card Failure May 2006

25 Recommendations for Hospital Discharge Yancy CW, et al. Circulation 2013; 128:

26 Components of Early Post-Discharge Follow-Up Gheorghiade, et al. J Am Col Cardiol 2013;

27 2017 ACC/AHA/HFSA Focused Update Biomarkers: Recommendations for Prognosis Yancy CW, et al. J Am Coll Cardiol 2017; doi: /j.jacc

28 Selected Potential Causes of Elevated Natriuretic Peptide Levels Yancey CW, et al. J Am Coll Cardiol 2017; 70:

29 Changes in BNP Levels and Pulmonary Artery Wedge Pressure During 1st 24 Hours of Treatment Kazanegra, et al. J Cardiac Fail;2001:7:21-9.

30 Anemia Recommendations Yancy CW, et al. J Am Coll Cardiol 2017; doi: /j.jacc

31 Sleep Disordered Breathing Yancy CW, et al. J Am Coll Cardiol 2017; doi: /j.jacc

32 Clinical Course of systolic Heart Failure Latin America: 1 million HF hospitalization, LOS 4 to 10 days JACC HF 2013, Circulation 2012, 125:

33 Treatment of HFrEF Stage C and D Yancey CW, et al. J Am Coll Cardiol 2017; 70:

34 CRT Responders (EF <35%, female, nonischemic) CRT Most benefit Class I QRS >150 msec, LBBB sinus, NYHA 2, 3, 4 Class IIa Class IIb QRS >150 msec, non LBBB, sinus, NYHA 3, 4, OR QRS 120 to 149, LBBB, NHYA 2, 3, 4, OR RV Pacing >40% QRS >150 msec, no LBBB, sinus, NYHA 2, OR QRS 120 to 149, no LBBB, sinus, NYHA 3, Ambulatory Class V Class III Most Benefit QRS <150 msec, no LBBB, NYHA 1, 2 No Benefit Ponikowski P. Eur Heart J. 2016;37:

35 Stevenson et al. Journal of Cardiac Failure, August 2006.

36 Prognostic Importance of Defibrillator Shocks in Patients with Heart Failure (SCD-HeFT) Poole JE, et al. N Engl J Med 2008;359:

37 6.2 Nonischemic Cardiomyopathy Al-Khatib SM, et al. Circulation 2017; epub ahead of print.

38 All-Cause Mortality After Each Subsequent Hospitalization for HF Setoguchi S, et al. Am Heart J 2007;154:

39 Multivariable Predictors of Hospitalization After HF Diagnosis Dunlay, S. M. et al. J Am Coll Cardiol 2009;54:

40 28% reduction in HF hospitalizations 20% reduction in CV death, HF hospitalizations 26% reduction in HF hospitalizations

41 Meta-Analysis of Remote Patient Monitoring Klersy, et al. JACC 2009;

42 Congestion Precedes Hospitalization Adamson PB et al. J Am Coll Cardiol. 2003; 41: 565

43 Clinical Course of Systolic Heart Failure Latin America: 1 million HF hospitalization, LOS 4 to 10 days JACC HF 2013, Circulation 2012, 125:

44 2017 ACC Expert Consensus Decision Pathway Referral to Advanced Heart Failure Specialist I NEED HELP I IV inotropes N NYHA IIIB/IV or BNP E End organ dysfunction E EF <35% D Defibrillator shocks H Hospitalization >1 E Edema despite escalating diuretic L Low BP, high HR P Prognostic medication downtitration of GDMT Yancey, et al. J Am Coll Cardiol 2017; 71:

45 Successful 2018 Treatment of Congestive Heart Failure = Complex Multidisciplinary Management Strategy HF Education Diet Cardiac Rehabilitation Heart Failure Clinics Less ER visits, Less hospitalizations, Better quality of life Home Telemonitoring Systems CHF Patient Cardiac Devices AICD CRT Compliance Medications ARNI ivabradine RAAS blockers Beta blocker Diuretics aldosterone blocker Digoxin

46 Treatment Algorithm for GDMT Including Novel Therapies HFrEF ACE/ARB and BB with Diuretic as Needed Yancey CW, et al. J Am Coll Cardiol 2018; 71:

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