Management of Acute Heart Failure

Transcription

1 Management of Acute Heart Failure Uri Elkayam, MD Professor of Medicine University of Southern California School of Medicine Los Angeles, California

2 ADHF Treatments Goals.2 Improve symptoms. Optimize volume status. Identify etiology. Identify and address precipitating factors. Optimize chronic drug therapy.

3 Proenkephalin in Acute Heart Failure Ng LL et al JACC 2017;69:56 In recent years, many advances have been made in the management of chronic heart failure. However, the understanding and treatment of acute heart failure has remained incomplete and broadly unchanged during this period.

4 Oxygen Therapy and /or Ventilatory Support 2016 ESC Guidelines Oxygen therapy is recommended in patients with AHF and SpO2 <90% or PaO2<60 mmhg. Class I level C

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6 Oxygen Therapy and /or Ventilatory Support 2016 ESC Guidelines Noninvasive CPAP or BIPAP should be considered in patients with respiratory distress (RR > 25/min, SpO2 <90%). Class IIa, level B.

7 AHF - Treatment Diuretics/Ultrafiltation. Vasodilators. Inodilators..

8 AHA/ACC guidelines 2013 Patients with volume overload 8 Should be treated with intravenous loop diuretics to reduce morbidity (Level of Evidence: B)

9 AHA/ACC guidelines The initial IV dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. (Class 1, Level of Evidence: B)

10 The DOSE Study

11 DOSE Trial - Design 2-by-2 factorial design. Low dose vs. high dose. IV bolus Q 12 h vs. continuous IV infusion.

12 DOSE Trial - Design Low-dose: total daily oral dose. (80mg=80mg) High dose: 2.5 X total daily oral dose (80mg=200mg)

13 Bolus vs. Continuous Results over 72 hours Parameters Bolus Continuous P value AUC for dyspnea 4456± ± Change in weight (Lb.) -6.8± ± Net fluid loss (ml) 4237± ± Chang in NTproBNP (pg/ml) -1316± ± Higher bolus dose 592 mg vs 480 mg / 72 hours (p=0.06) Bolus required more frequent dose adjustment

14 COMPARATIVE EFFECT ON URINE OUTPUT Ng T, Elkayam U et al J CV Pharm Therapy 2012 N=160 N=42 N=40 Continuous infusion furosemide Furosemide + metolazone Continuous infusion Bumetanide

15 Change in Scr and outcome Parameters Low dose High dose P value Increase in Scr > 0.3 mg/dl 14% 23% 0.04 Median length of stay (days) Alive and out of the hospital (days)

16 Diuretic Strategies for ADHF Felker GM et al NEJM 2011;364:797 16

17 Increased Scr During Successful Treatment of Volume Overload What is the Clinical significance?

18 Primary end points Change in Scr and weight at 96 hours after enrollment CARRESS HF Study Design 18 Patients Hospitalized for AHF with Worsening of renal function and Volume overload. Randomized to diuretics or ultrafiltration

19 Goal: 3-5 L/day

20 20 CARRESS HF

21 CARRESS HF

22 CARRESS - HF Mortality Mortality and HF hospitalization P=0.465 P=

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24 24 Among patients with advanced decompensated HF, baseline and D/C renal insufficiency impact outcome more than WRF

25 Is WRF a n ominous prognostic sign inpatients with ADHF? Metra M et al Circ Heart Fail 2012 ;5:54 Variable Multivariable HR P VALUE + WRF + CONGESTION WRF + CONGESTION WRF CONGESTION WRF congestion Ref N=599

26 26 J Cardiac Fail 2011;17:993 31% of 903 patients with ADHF developed 20% increased GFR (IRF). IRF was associated with greater incidence of post discharge WRF and increased mortality (HR 1.3, p=0.011)

27 Effect of IRF vs. WRF on Outcome Brisco MA et al J Cardiac Failure Oct 2016 These data should further motivate clinicians to critically evaluate changes in serum creatinine during the treatment of ADHF in the context of the overall clinical status.

28 Many Patients Have Little or No Weight Loss During Hospitalization 35 33% 30 24% Patients (%) % 6% 13% 15% 3% 2% 0 < to to to -5-5 to 0 0 to 5 5 to 10 >10 Change in weight (lbs) Fonarow GC. Rev Cardiovasc Med. 2003;4(suppl 7):S21-S30.

29 Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Coiro S et al EuJ Heart Fail 2015;17:

30 Diuretic Resistance When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics or b. addition of a second (eg, thiazide) diuretic. (Class IIa, Level of Evidence: B).

31 COMPARATIVE EFFECT ON URINE OUTPUT Ng T, Elkayam U et al J CV Pharm Therapy 2012 N=160 N=42 N=40 Continuous infusion furosemide Furosemide + metolazone Continuous infusion Bumetanide

32 AHF - Treatment Diuretics/Ultrafiltation. Vasodilators. Inodilators.

33 AHA/ACC Practice Guidelines 2013: Vasodilators CLASS IIb If symptomatic hypotension is absent, IV NTG, nitroprusside, or nesiritide may be considered an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acutely decompensated HF. (Level of Evidence: A)

34 IV Vasodilators in the Treatment of ADHF Parameters Nitroprusside Nitroglycerin Nesiritide Prospective studies in HF Hemodynamic effect Need for dose titration Tolerance Effect on coronary blood flow Effect on ischemia NA Effect on urine output NA Effect on neurohormones Vascular resistance Evidence of symptomatic improvement +

35 IV NTG in the Treatment of ADHF: Relationship Between Dose and Effect on PCWP Elkayam U et al. Am J Cardiol. 2004;93:

36 AHF - Treatment Diuretics/Ultrafiltation. Vasodilators. Inodilators.

37 In-Hospital Mortality in Pts With ADHF Receiving Vasoactive Meds ADHERE Registry * NTG (6055) vs MIL (1660) NTG (5713) vs DOB (3478) 0.59* 0.46* 0.47* NES (4663) vs MIL (1534) NES (4270) vs DOB (3301) 0.94 NES (4402) vs NTG (5668) 1.27* DOB (3656) vs MIL(1496) *Risk factor and propensity score-adjusted odds ratios. Abraham WT et al. J Am Coll Cardiol. 2005;46:57-64.

38 HFSA Practice Guidelines 2006: Inotropes Inotropes (milrinone or dobutamine) may be considered in patients with diminished peripheral perfusion or end organ dysfunction (low output), particularly those with symptomatic hypotension despite adequate filling pressure, who do not tolerate or fail to improve with IV vasodilator therapy or in whom severe symptomatic hypotension precludes use of vasodilators (C).

39 Management of Acute Heart Failure Take Home Points O2 supplement to patients with hypoxemia SpO2 < 90%. Intravenous loop diuretics at high dose 2.5 x daily dose. Continuous better than bolus. Not all WRF during treatment are bad, the goal is to treat congestion.

40 Management of Acute Heart Failure Take Home Points Up titrate IV NTG to dose >150 mcg/min. Use Inotropes only when signs of poor perfusion (Low BP with WRF, confusion) and high filling pressure not to chase low CO.