Heart Failure. Guillaume Jondeau Hôpital Bichat, Paris, France

Size: px

Start display at page:

Download "Heart Failure. Guillaume Jondeau Hôpital Bichat, Paris, France"

Homer Young
6 years ago
Views:

1 Heart Failure Guillaume Jondeau Hôpital Bichat, Paris, France

2 Epidemiology Importance of PEF Europe

3 I-PREFER study. Abstract: 2835 Prevalence of HF Preserved LV systolic Function older (65 vs 62 y, p<0.001), female (50% vs 28%, p<0.001) obese (39% vs 27%, p<0.001) HTN (78% vs 53%, p<0.001), AF (29% vs 24%, p=0.03) less AMI (21% vs 44%, 10 0 Middle east Latin America Africa p<0.001)

7 Diagnosis of the disease Unusual use of echography

Ultrasonographic detection of pleural effusion (US-PE) P1654 83

652±456 days, 1826 visits 77 visits : high possibility of worsening HF

6% [95%CI 65.6-85.5%] specificity 98.6% [95%CI 98.0-99.

8 Ultrasonographic detection of pleural effusion (US-PE) P ambulatory HF patients (39% men, aged 77±12 years) mean follow-up of 652±456 days, 1826 visits 77 visits : high possibility of worsening HF 1749 : low possibility of worsening HF US-PE sensitivity 76.6% [95%CI %] specificity 98.6% [95%CI %] positive predictive value 71.1% [95%CI %] negative predictive value 99.0% [95%CI %]

9 Comet tail

11 Ultrasound lung comets as prognostic determinant in heart disease N ,102 consecutive in-patients (aged 69±12 years, 751 males) ULC score : n of ULC from 28 scanning sites on anterior and lateral right and left hemithoraxes, from the 2d to the 5th intercostal. Diagnosis at admission stable angina (n = 219, 20%), acute coronary syndrome (n = 216, 19%), primary (n = 74, 6%) or ischaemic CMP (n = 132, 12%), valvular heart disease (n = 134, 12%), arrhythmias (n = 154, 14%), other (n = 173, 17%). On multivariate analysis, ULC > 30 ( [HR] 2.17; 95% [CI] ) provided additional prognostic information on age (HR 1.02; CI ), diabetes mellitus (HR 1.47; CI ), NYHA class (HR 1.28; CI ).

12 Pathophysiology Importance of the RA pressure

Liver function tests and hemodynamics in end-stage heart failure patients P1652 186 end-stage HF 57±10 years, 77% male, at

Predominantly cholestatic enzyme pattern 60 50 RAP the only independent predictor of T-Bil (r=0.37; p=0.028) and GGT (r=0.

13 Liver function tests and hemodynamics in end-stage heart failure patients P end-stage HF 57±10 years, 77% male, at time of listing for heart transplantation between 1997 and Predominantly cholestatic enzyme pattern RAP the only independent predictor of T-Bil (r=0.37; p=0.028) and GGT (r=0.44; p=0.006) in a stepwise multiple regression analysis CI not correlated with cholestatic enzymes nor transaminases T Bil GGT A LP A ST % patients w ith increase value

perfusion pressure systemic arterial pressure pressure in renal

14 renal failure = filtration rate 1) Altered kidney Comorbidity diabetes, age, Cardiogenic shock 2) perfusion gradient 2a) perfusion pressure systemic arterial pressure pressure in renal artery Selective vasoconstriction Arterial stenosis 2b) venous pressure 2b 2a 1

15 Domman JACC

16 Pronostication of the patients

17 Tubular damage and outcome in chronic heart failure N pts from the GISSI-HF trial Pronostic value of egfr (chronic kidney disease) albuminuria Tubular damage (3 increased): Kidney Injury Molecule 1 (KIM-1), N-acetyl-beta-D-glucosaminidase (NAG) Neutrophil Gelatinase Associated Lipocalin (NGAL)

patients referred for heart transplantation in the era of device

54±12 years; ICD: 244; CRT: 30; CRT-D: 108; none: 333 follow-up of

LVAD HFSS effective in discriminating patients into low, medium and

transplant patients with HFSS medium to high risk HFSS (unchanged)

18 patients referred for heart transplantation in the era of device therapy P CHF patients referred for heart transplantation 54±12 years; ICD: 244; CRT: 30; CRT-D: 108; none: 333 follow-up of 962±912 days, 354 patients died or received urgent heart transplant or LVAD HFSS effective in discriminating patients into low, medium and highrisk groups in all device groups peak VO2 did not discriminated between low (> 14) and medium (10.1 to 14 ml/min/kg) risk in device patients The recommendation to transplant patients with HFSS medium to high risk HFSS (unchanged) with ICD and/or CRT, a peak VO2 10 but not 14 ml/min/kg may now identify the high risk group which should be considered for transplantation

19 therapy

Kayexalate 25 meq/d extra K excretion: K plasma level 6.5 5.5; 4 3.

20 Randomised Placebo Controlled, Parrallel Group, Multidose, to evaluate the effect of RLY5016 in Heart Failure Patients (PEARL HF) Polymer binds K+ in colon, no Na load, better tolerated that Kayexalate 25 meq/d extra K excretion: K plasma level ; patients (2 groups of 50 patients): 68 years, 60% males, BMI 28, CHF 4.5 years, LVEF 40%, egfr 80 ml/min 73% ACE + BB, 75% diuretic

21 PEARL HF 30g RLY5016 Placebo K baseline K 4 weeks * aldo 50 mg 90% 74%* GI side effect 21% 6%*

22 Systolic Heart failure treatment with the If inhibitor ivabradine Trial M. Komajda on behalf of the Investigators

$left ventricular ejection fraction$

23 Primary objective To evaluate whether the I f inhibitor ivabradine improves cardiovascular outcomes in patients with : 1. moderate to severe chronic heart failure 2. left ventricular ejection fraction 35% 3. heart rate 70 bpm and in sinus rhythm 4. the best possible recommended therapy

24 Study endpoints Primary composite endpoint Cardiovascular death Hospitalization for worsening heart failure Other endpoints All-cause / CV / HF death All-cause / CV / HF hospitalization Composite of CV death, hospitalization for HF or non-fatal MI NYHA class / Patient & Physician Global Assessment Swedberg K, et al. Eur J Heart Fail. 2010;12:75-81.

25 Patients and follow-up 7411 screened 6558 randomized 3268 to ivabradine 3290 to placebo Excluded: 27 Excluded: analysed 2 lost to follow-up 3264 analysed 1 lost to follow-up Median study duration: 22.9 months; maximum: 41.7 months Lancet. Online

Baseline characteristics Ivabradine 3241 Placebo 3264 Mean age, y 60.7 60.

26 Baseline characteristics Ivabradine 3241 Placebo 3264 Mean age, y Male, % Ischaemic aetiology, % NYHA II, % NYHA III/IV, % Previous MI, % Diabetes, % Hypertension, % Lancet. Online

27 Mean heart rate reduction Heart rate (bpm) 90 Mean ivabradine dose: 6.4 mg bid at 1 month Ivabradine Placebo 6.5 mg bid at 1 year weeks Months Lancet. Online

28 Primary composite endpoint Cumulative frequency (%) Ivabradine n=793 (14.5%PY) Placebo n=937 (17.7%PY) HR = 0.82 p< Ivabradine Placebo - 18% Months Lancet. Online

29 Hospitalization for heart failure Cumulative frequency (%) Ivabradine n=514 (9.4%PY) Placebo n=672 (12.7%PY) HR = 0.74 p< Ivabradine Placebo - 26% Months Lancet. Online

30 Cardiovascular death Cumulative frequency (%) 30 Ivabradine n=449 (7.5%PY) Placebo n=491 (8.3%PY) HR = 0.91 p=0.128 Ivabradine Placebo Months Lancet. Online

31 Effect of ivabradine on outcomes Endpoints Hazard ratio 95% CI p value Primary composite endpoint 0.82 [0.75;0.90] p< CV death 0.91 [0.80;1.03] p=0.128 Hospitalization for HF 0.74 [0.66;0.83] p< All-cause death 0.90 [0.80;1.02] p=0.092 Death from HF 0.74 [0.58;0.94] p=0.014 Hospitalization for any cause 0.89 [0.82;0.96] p=0.003 Hospitalization for CV reason 0.85 [0.78;0.92] p= Lancet. Online

32 Effect of ivabradine in prespecified subgroups Age <65 years 65 years Sex Male Female Beta-blockers No Yes Aetiology of heart failure Non-ischaemic Ischaemic NYHA class NYHA class II NYHA class III or IV Diabetes No Yes Hypertension No Yes Baseline heart rate <77 bpm 77 bpm Test for interaction p= Hazard ratio Favours ivabradine Favours placebo 1.5 Lancet. Online

39 Take home messages Importance of LVSPEF Echo: look at the lungs Importance of RA pressure: liver, kidney Prognosis: renal function Transplantation VO2 < 10 ml/kg/min Therapy Ivabradine (EF<35%, HR>>70, BB...) Update guidelines resynchro

Saudi Arabia February Pr Michel KOMAJDA. Université Pierre et Marie Curie Hospital Pitié Salpétrière

Saudi Arabia February Pr Michel KOMAJDA. Université Pierre et Marie Curie Hospital Pitié Salpétrière Prevention of Cardiovascular events with Ivabradine: The SHIFT Study Saudi Arabia February 2011 Pr Michel KOMAJDA Université Pierre et Marie Curie Hospital Pitié Salpétrière Paris FRANCE Declaration Of