Latest therapies for patients with HF. Dr AIGUL BALTABAEVA PhD, FESC, FRCP RBHT & ASPH

Transcription

1 Latest therapies for patients with HF Dr AIGUL BALTABAEVA PhD, FESC, FRCP RBHT & ASPH

2 ESC HF Guidelines 2016

3 ESC HF Guidelines 2016: Pharmacological Treatments

4 Pathways blocked by ACE-I, ARB and NI

5 Effect of ARNI

6 PARADIGM-HF: ARNI vs Enalapril in HF

7 NICE: ARNI Appraisal

8 Recent trials of newer glucose-lowering agents have 8 been neutral on the primary CV outcome HR: 1.0 (95% CI: 0.89, 1.12) SAVOR-TIMI 53 HR: 0.98 (95% CI: 0.88, 1.09) TECOS HR: 0.96 (95% CI: UL 1.16) EXAMINE DPP-4 inhibitors* Lixisenatide Empagliflozin HR: 1.02 (95% CI: 0.89, 1.17) ELIXA EMPA-REG OUTCOME

9 Empagliflozin 9 Empagliflozin is a highly selective inhibitor of the sodium glucose cotransporter 2 (SGLT2) in the kidney Glucose reduction occurs by reducing renal glucose reabsorption and thus increasing urinary glucose excretion In patients with type 2 diabetes, empagliflozin leads to 1 : Significant reductions in HbA1c Weight loss Reductions in blood pressure without increases in heart rate

10 Adjusted mean (SE) HbA1c (%) Empagliflozin: HbA1c Placebo Empagliflozin 10 mg Empagliflozin 25 mg Week Placebo Empagliflozin 10 mg Empagliflozin 25 mg

11 Adjusted mean (SE) systolic blood pressure (mmhg) Empagliflozin: Systolic BP Placebo Empagliflozin 25 mg Empagliflozin 10 mg Week Placebo 2322 Empagliflozin 10 mg 2322 Empagliflozin 25 mg

12 CV death 12

13 CV death 13 Empagliflozin 10 mg HR 0.65 (95% CI 0.50, 0.85) p=0.0016

14 Hospitalisation for heart failure 14

15 ESC HF Guidelines 2016

16 Effective LV Pacing

17 CRT Correction of LV Dyssynchrony the Abolition of the Septal Flash Before CRT After CRT Septal Flash No Septal Flash Septal Flash No Septal Flash

18 HF: CRT Therapy J Gamble et al, Cardiostim, J B Van Rees et al, JACC, 2011

19 Failed LV lead 53 y old female Broad LBBB Normal coronaries CRT (PPM switched off) NYHA III

20 WiSE - European CE Mark 2015

21 ESC HF Guidelines 2016

22 HF: Effect of LV Remodelling Volume Overload Acute/ Chronic LV remodelling Development of MR

23 HF: Moderate-to-Severe MR Large Centre US Cohorts: 29% of HF, I/P with HF 74% Italian registry: 42% of HF, increases with age (>70 y.o.) Bursi et al, European Journal of Heart Failure, 2010

24 Surgical Correction of Severe MR Tribouilloy C et al, Circulation. 1999

25 Mitral Devices

26 Key design features of the MitraClip system Cobalt-chromium implant Polyester clip cover designed to promote tissue healing Independent capture of each leaflet for secure attachment MRI safe to 3 Tesla Preserved surgical options if needed

27 Advantages of the MitraClip procedure Catheter based delivery system: minimally invasive, Less trauma, Short hospital stay and recovery time No cardiopulmonary bypass No chest incision Controlled systematic procedure, with stable hemodynamics Precise positioning and accurate placement of the device MitraClip Real-time efficacy assessment

28 Edge-to-Edge & MitraClip Concepts Facilitates proper leaflet coaptation Mechanical solution to a mechanical problem Degenerative - Anchor flail and prolapsed leaflets (similar to chordal transfer/replacement) Functional - Coapts tethered leaflets to reduce time and force required to close valve Reduces LV volume overload by reducing MR Creates tissue bridge Limits dilatation of annulus Septal-lateral (anterior-posterior) dimension Supports durability of repair Restrains LV wall Limits LV dilatation Porcine model, 6M

29 EVEREST II: 5 Year Results

30 EVEREST II: HRR

31 Survival Post-procedure J Am Coll Cardiol Bhatia RS et al, NEJM, 2006

32 HF NYHA Class at Baseline, 1 & 12/12 F/U In high-risk patients with severe mitral regurgitation, percutaneous MitraClip therapy significantly improved NYHA functional class at 30 days and at 12 months relative to baseline (p < 0.001).

33 EII HRR: Clinical Results J Am Coll Cardiol. 2014;64(2):

34 87 y old male Hx of late presentation MI in cardiogenic shock and pulm. oedema, req. intubation and ventilation Long stay in CTITU complicated by LRTI Echo: Severe ischaemic MR PCI to LCx, mild reduction in MR NYHA III

35 MitraClip Procedure

36 MitraClip

37 Acute Effect of Mitral Clip

38 RBHT: MitraClip Programme Courtesy of Dr R. Smith, 2016

39 Conclusions Time Life New drugs have made convincing entrance to HF guidelines New drugs are being trialled and tested New approach is taken in device therapy New approach is taken in re-shaping the failing heart