Introduction to Heart Failure. Mauricio Velez, M.D. Transplant Cardiologist APACVS 2018 April 5-7 Miami, FL

Transcription

1 Introduction to Heart Failure Mauricio Velez, M.D. Transplant Cardiologist APACVS 2018 April 5-7 Miami, FL

2 Disclosures No relevant financial relationships to disclose

3 Objectives and Outline Define heart failure and its public health significance Describe different classifications of HF Review the diagnostic evaluation of HF patients Discuss principles of guideline-directed management of chronic HF Recognize special considerations for treatment of patients hospitalized with HF

4 Definition of HF Heart failure is a complex disease that is the result of cardiac injury that impairs the heart s ability to eject or fill with blood This manifests with typical symptoms: Fatigue and shortness of breath that limit the patient s ability to exercise Fluid retention that can cause elevated jugular venous pressure, pulmonary or peripheral edema Symptoms can vary if HF is acute or chronic HF patients can have preserved or reduced ejection fraction (EF) Yancy C et al. J Am Coll Cardiol 2013;62:

5 Epidemiology of HF Over 5 million Americans suffer from HF at present 650,000 new cases annually Over 1 million hospital visits every year 20% of Americans older than 40 years will develop HF HF incidence is about 20 per 1000 people years old HF incidence rises with age and is greater than 80 per 1000 people 85 years old or older Djousse L et al. JAMA 2009;302: Go AS et al. Circulation 2013;127:e6-245 Curtis LH et al. Arch Intern Med 2008;168:

6 Risk Factors for the Development of HF Risk Factor Prevalence among cases (%) Overall (n=962) Women (n=517) Men (n=445) Time From RF to HF Onset in years, median (25 th -75 th percentile) Coronary artery disease ( ) Hypertension ( ) Diabetes (5-18.6) Obesity ( ) Ever smoker Dunlay SM C et al. Am J Med 2009;122:

7 Pathophysiology of HF MI HTN Arrhythmias Valve disease Diabetes Toxins Sympathetic NS Renin-Angiotensin- Aldosterone System Natriuretic Peptide System Mann DL et al. Circulation 2005;111:

8 Natural History of HF ONSET SUDDEN DEATH DECOMPENSATIONS PUMP FAIL Allen LA et al. Circulation 2012;125:

9 Hospital Discharges for HF by Gender (US ) 1.1M 720k CMS

10 Roger VL et al. JAMA 2004;292: HF 5-year Mortality 5-year mortality: 50% 5-year mortality: 46%

11 Classification of HF Based on EF Heart failure with reduced ejection fraction (HFrEF) Heart failure with preserved ejection fraction (HFpEF) HFpEF-borderline HFpEF-improved Based on symptom severity upon assessment NYHA class I-IV Based on disease progression ACCF/AHA Stages A-D Yancy C et al. J Am Coll Cardiol 2013;62:

12 Classification of HF by EF Classification EF (%) Description 1. HF with reduced EF (HFrEF) 40 Systolic HF. Most available clinical trials include patients with HFrEF 2. HF with preserved EF (HFpEF) 50 Diastolic HF. No known effective therapies a. HFpEF-borderline New intermediate group. Appear to be more similar to HFpEF b. HFpEF-improved >40 Patients with reduced EF who have improvement who may have different characteristics to HFrEF and HFpEF Yancy C et al. J Am Coll Cardiol 2013;62:

13 Classification of HF by Symptom Severity NYHA Class Description Class I No limitation of physical activity. Ordinary activity does not cause HF symptoms Class II Slight limitation of physical activity. Comfortable at rest, but ordinary activity results in HF symptoms Class III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes HF symptoms Class IV Unable to carry out any physical activity without HF symptoms or symptoms of HF at rest The Criteria Committee of the NY Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9 th Ed. Boston: Little & Brown; 1994

14 Classification of HF by Disease Stage ACCF/AHA Stage Description Stage A At high risk for HF but without structural heart disease or HF symptoms Stage B Structural heart disease is present but never had HF symptoms Stage C Structural heart disease present with HF symptoms now or in the past Stage D Refractory HF symptoms requiring advanced therapies Hunt SA et al. J Am Coll Cardiol 2009;53:e1-90

15 Chronic HF Management by Disease Stage Hunt SA et al. J Am Coll Cardiol 2005;112:e

16 Evaluation of HF Patients HF is a purely clinical diagnosis Thorough history and physical examination should be obtained in all patients Assess severity of activity limitations (NYHA class) Presence of orthopnea HR, BP and changes in weight Assess jugular venous pressure and extent of edema Laboratory testing CBC Serum electrolytes and glucose BUN/creatinine Fasting lipids Liver function tests Thyroid function tests Yancy C et al. J Am Coll Cardiol 2013;62:

17 Evaluation of HF Patients 12-lead electrocardiogram Chest X-ray 2D echocardiogram with Doppler Follow up echocardiogram if: Significant changes in clinical status Suspected recovery after a clinical event Suspected recovery due to medical therapy To assess eligibility for device therapy Routine follow up echocardiograms are not recommended Cardiac MR is an alternative to echocardiography When CAD is suspected, non-invasive stress testing or coronary angiography is reasonable unless the patient is not a candidate for revascularization Yancy C et al. J Am Coll Cardiol 2013;62:

18 Biomarkers in HF BNP or NT-proBNP can be helpful when the cause of dyspnea is uncertain BNP or NT-proBNP should be checked to assess prognosis/disease severity Entresto can increase BNP, but not NT-proBNP Elevated Troponin T or I indicate poor prognosis in patients hospitalized with HF, even in the absence of acute coronary syndrome Soluble ST-2, galectin-3 and high-sensitivity troponin are markers of cardiac injury/fibrosis and are associated with risk of hospitalization and death Tang WH et al. Circulation 2003;108: Anand IS et al. Circulation 2003;107: Manzano-Fernandez S et al. Am J Cardiol 2011;107: Shah RV et al. Eur J Heart Fail 2010;12:

19 Biomarkers in Prevention, Diagnosis and Risk-Stratification of HF Yancy C et al. J Am Coll Cardiol 2017;70:

20 Principles of Chronic HF Management The treatment of HFrEF includes pharmacologic and nonpharmacologic components Pharmacologic treatment involves several medication classes which have combined effects that reduce HF mortality and morbidity The foundation of medical therapy are ACEi/ARBs and evidencebased beta-blockers Achieving guideline-directed doses of these medications is the primary goal of dose adjustment Non-pharmacologic treatments are just as important and include lifestyle modification/self-care behaviors and device-based therapies The treatment requirements change as disease progresses from Stage A to Stage D

21 Management of Chronic HF Evolves by Stage Jessup M et al. N Engl J Med 2003;348:

22 Classification of Recommendations and Levels of Evidence Yancy C et al. J Am Coll Cardiol 2017;70:

23 Pathophysiology of HF MI HTN Arrhythmias Valve disease Diabetes Toxins Neurohormones Sympathetic NS Renin-Angiotensin- Aldosterone System Natriuretic Peptide System Mann DL et al. Circulation 2005;111:

24 Management of Stage A Chronic HF Aggressive management of HF risk factors Hypertension and abnormal lipids should be treated according to current guidelines Diabetes, obesity and smoking should be treated as well Avoid cardiotoxic exposures as possible: alcohol, certain cancer therapies, radiation therapy to the chest Yancy C et al. J Am Coll Cardiol 2013;62:

25 Management of Stage B Chronic HF Patients with a history of MI, recent or remote, and a low EF, should be treated with ACEi/ARB or evidence-based beta-blockers to decrease the likelihood of HF onset Post-MI patients should be treated with statins to prevent HF In patients with LVH, hypertension should be treated according to current guidelines ACEi/ARB and evidence-based beta-blockers should be used in all patients with low EF to prevent HF An ICD is reasonable in post-mi patients without HF symptoms if they are at least 40 days post-mi, have an EF 30%, and are on guideline-directed medical therapy Yancy C et al. J Am Coll Cardiol 2013;62:

26 Management of Stage B Chronic HF Diltiazem, verapamil Yancy C et al. J Am Coll Cardiol 2013;62:

27 Management of Stage C Chronic HF Non-Pharmacologic Interventions Education on HF self-care behaviors Dietary sodium and fluid restriction Reduce congestive symptoms Compliance with medications and follow-up Reduce hospitalization risk Daily weight Early calls to healthcare providers with volume retention Exercise training and cardiac rehabilitation Improves functional capacity, quality of life and reduces mortality Yancy C et al. J Am Coll Cardiol 2017;70:

28 Mortality reduction (%) Management of Stage C Chronic HF Pharmacologic Interventions Enalapril(1) Carvedilol(2) Spironolactone(3) HZN/ISDN(4) Entresto (5) (1) N Engl J Med 1987;316: (2) N Engl J Med 2001;344: (3) N Engl J Med 1999;341: (4) N Engl J Med 2005;352: (5) N Engl J Med 2014;371:

29 Management of Stage C Chronic HF Yancy C et al. J Am Coll Cardiol 2013;62:

30 Entresto (Sacubitril-Valsartan) New drug class (ARNI) ARB (Valsartan) combined with neprilysin inhibitor (Sacubitril) Neprilysin breaks down BNP, bradykinin and other vasoactive peptides Use of Entresto resulted in further 20% reduction in HF mortality and HF hospitalization compared to enalapril Patients who can tolerate and ACEi or ARB should be transitioned to Entresto Discontinue ACEi/ARB for AT LEAST 36 HOURS before starting Entresto to decrease risk of angioedema Dosed 24/26 mg (50 mg), 49/51 mg (100 mg) and 97/103 mg (200 mg) tabs McMurray JJV et al. N Engl J Med 2014;371: Yancy C et al. J Am Coll Cardiol 2017;70:

31 Other Beneficial Drugs Digoxin Can be used in HFrEF to reduce HF hospitalizations Ivabradine Can be used in NYHA II-III HFrEF who are on GDMT, receiving a beta-blocker at maximally-tolerated dose, who remain in sinus rhythm with heart rate 70 bpm Omega-3 Fatty Acids May reduce mortality and cardiovascular hospitalizations Digitalis Investigation Group. N Engl J Med 1997;336: Tavazzi L et al. Lancet 2008;372: Swedverg K et al. Lancet 2010;376:

32 Guideline-Directed Management & Therapy of Stage C Chronic HF Yancy C et al. J Am Coll Cardiol 2017;71:

33 Guideline-Directed Management & Therapy ACEi/ARB/ARNI ACEi/ARB/ARNI Starting Dose Maximum Dose Mean Dose Achieved in Trial Captopril 6.25 mg TID 50 mg TID mg/day Enalapril 2.5 mg BID 10 to 20 mg BID 16.6 mg/day Lisinopril 2.5 to 5 mg Daily 20 to 40 mg Daily 32.5 to 35 mg/day Candesartan 4 to 8 mg Daily 32 mg Daily 24 mg/day Losartan 25 to 50 mg Daily 50 to 150 mg Daily 129 mg/day Valsartan 20 to 40 mg BID 160 mg BID 254 mg/day Entresto 50 to 100 mg BID 200 mg BID 375 mg/day N Engl J Med 1987;316: N Engl J Med 2001;344: N Engl J Med 1999;341: N Engl J Med 2005;352: N Engl J Med 2014;371:

34 Guideline-Directed Management & Therapy Beta-Blockers/HZN-ISDN/Aldo B BB/HZN-ISDN/Aldo B Starting Dose Maximum Dose Mean Dose Achieved in Trial Bisoprolol 1.25 mg Daily 10 mg Daily 8.6 mg/day Carvedilol mg BID 25 mg BID 37 mg/day Metoprolol Succinate 12.5 to 25 mg Daily 200 mg Daily 159 mg/day Hydralazine 25 to 50 mg TID 100 mg TID 175 mg/day Isosorbide Dinitrate 20 to 30 mg TID 40 mg TID 90 mg/day Spironolactone 12.5 to 25 mg BID 25 mg Daily or BID 26 mg/day Eplerenone 25 mg Daily 50 mg Daily 42.6 mg/day N Engl J Med 1987;316: N Engl J Med 2001;344: N Engl J Med 1999;341: N Engl J Med 2005;352: N Engl J Med 2014;371:

35 Recommendations for Medical Optimization Yancy C et al. J Am Coll Cardiol 2017;71:

36 ICDs and Cardiac Resynchronization Are Important Components of GDMT Moss AJ et al. N Engl J Med 2002;346: Abraham WT et al. N Engl J Med 2002;346: Moss AJ et al. N Engl J Med 1996;335:

37 Early Recognition of Stage D Heart Failure Repeated ( 2) hospitalizations or ED visits for HF in 1 year Progressive decline in renal function Weight loss with unknown cause (cardiac cachexia) Referral to HF specialist for consideration of candidacy for advanced therapies such as LVAD or cardiac transplantation Intolerance to ACEi/ARB/ARNI due to hypotension or worsening renal function Intolerance to beta-blockers due to hypotension or worsening HF Frequent SBP < 90 mmhg Dyspnea with bathing and dressing Unable to walk 1 block without dyspnea or fatigue High diuretic needs (i.e., > furosemide 160 mg/day) Progressive decline in serum sodium Frequent ICD shocks Yancy C et al. J Am Coll Cardiol 2013;62:

38 Acute-on-Chronic Heart Failure: The Hospitalized HF Patient Inability to maintain simultaneous optimal volume and perfusion status as determined by symptoms, signs or hemodynamic measures

39 Acute vs. Chronic Heart Failure Acute Heart Failure Hemodynamic derangement due to sudden ventricular dysfunction Chronic Heart Failure Progressive decline in ventricular function with hemodynamic adaptation

40 Acute vs. Acute-on-Chronic Heart Failure Truly Acute Major end-organ changes, minor LV dysfunction Signs/symptoms usually obvious Usually ischemic Acute-on-Chronic Variable end-organ changes, major LV dysfunction Signs/symptoms often subtle, misleading All etiologies

41 Precipitating Factors Medication/dietary non-adherence Acute coronary syndromes Arrhythmias Non-cardiac diseases COPD, renal failure, infections Pacemaker/ICD malfunction Recreational drugs and alcohol abuse Medication misadventures Disease progression

42 Principles of Management of Acute-on-Chronic Heart Failure Re-establish optimal volume status Intravenous diuretics Re-establish optimal end-organ perfusion Vasodilators or intravenous inotropes Reduction in beta-blocker dose Achieve all of the above simultaneously and as quickly as possible Achieve all of the above in a way that can be maintained in the outpatient setting

43 Principles of Management of Acute-on-Chronic Heart Failure Outpatient GDMT should be continued during the hospitalization in the absence of hypotension or other contraindications If the patient is not on beta-blockers, evidence-based beta-blockers can be started once volume status is normal and the patient is no longer on vasoactive drips When in doubt, do not hesitate to consult your heart failure cardiologist

44 Beta-blocker Caveats in Acute-on-Chronic Heart Failure Try to continue home dose if the patient has adequate perfusion Decrease by 50% if the patient has signs of poor perfusion Discontinue completely if the patient is in cardiogenic shock or requires vasoactive drips or mechanical support Avoid the urge to give beta-blockers for sinus tachycardia in patients with HFrEF

45 Summary HF is a major health problem that carries a high risk of 5-year mortality (~50%) About half of patients suffer from HFrEF and about half suffer from HFpEF NYHA class allows us to assign symptom severity -- class changes with clinical status ACCF/AHA stages reflect disease progression and are helpful in focusing treatment goals

46 Summary Evaluation of HF patients relies on a thorough history and physical examination Key labs assess organ function and prognosis Echocardiography should be obtained in all patients Follow up echocardiograms only in specific scenarios

47 Summary The management of chronic HF involves several drug classes aimed at neurohormones that influence HF progression Optimal medical therapy means that doses used in clinical trials have been achieved medications must be uptitrated over time Transition symptomatic patients who can tolerate ACEi/ARB to Entresto Patients with Stage D HF should be considered for LVAD/heart transplant

48 Summary Patients with acute-on-chronic heart failure are mainly treated with volume management and, if needed, vasodilators/inotropes Continue GDMT uninterrupted, if possible Beta-blockers should be started at low dose only after volume status is normal and the patient is stable off all drips No beta-blockers for sinus tachycardia in HFrEF

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