Acute Heart Failure 2017
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1 Acute Heart Failure 2017
2 Acute Heart Failure 2017 Heart Failure Definitions HFrEF, HFmrEF. EFpEF Acute Decompensated Heart Failure De Novo presentation Decompensation of Chronic Heart Failure Longer Term Mortality Reduction
3 How frequently do you see a Heart Failure Presentation on your medical intake in 2017? 1:2 patients 1:5 patients 1:10 patients 1:20 patients 1:30 patients
4 Of Those Heart Failure Presentation on your medical intake, what proportion are first presentations? 10% 20% 30% patients 50% patients >50% patients
5 From those of you who are not cardiologists, would you be responsible for the management of these patients beyond the first 24 hours? YES NO
6 Epidemiology Most frequent cause of acute hospitalisation in over 60 s 5% of all medical admissions Mean stay days 50% readmitted within 6 months Prognosis worse than for all common cancers except lung cancer
7 EuroHeart Failure Survey II Nieminen et al European Heart Journal 2006
8 EuroHeart Failure Survey II % Acute de Novo 37.1 Acute DeCompensated HF Nieminen et al European Heart Journal 2006
9 EuroHeart Failure Survey II Nieminen et al European Heart Journal 2006
10 Survival (%) Survival (%) Five-Year Survival Post Hospitalisation Month of follow-up Women Breast MI Bowel Ovarian Heart Failure Lung Men Month of follow-up MI Bladder Prostate Bowel Heart Failure Lung
11 Prognosis The physician who cannot inform his patient what would be the probable issue of his complaint [ ] is not qualified to prescribe any rational treatment for its cure. Hippocrates [ BC]. Preliminary Discourse. Classics of Medicine Library; Birmingham, England, 1985, p. 18
12 From those of you who are not cardiologists, would you be responsible for the care of these patients beyond the first 24hrs? YES NO
13 Treatment of HFpEF/HFmrEF
14 Helsinki-Zurich AHF Study (n=312) Rudiger A. at al Eur J Heart Fail 2005 Jun;7(4):662-70
15 Helsinki-Zurich AHF Study Rudiger A. at al Eur J Heart Fail 2005 Jun;7(4):662-70
16 Perna ER et al. AM Heart J. 2002;143:814
17 EuroHeart Failure Survey II Unpublished data ESC 2005 Stockholm
18 EuroHeart Failure Survey II Unpublished data ESC 2005 Stockholm
19
20
21
22 Acute Management
23 Short- and long-term outcomes End point Dyspnea at 24 h, >mild improvement (%) in the SURVIVE trial Levosimendan, n=664 Dobutamine, n= All-cause mortality at 31 days (%) p All-cause mortality at 180 days (%)* Cardiovascular mortality at 180 days (%) Mean out-of-hospital days alive at 180 days Mebazaa A et al. JAMA 2007; 297:
24 Acute Heart Failure Serelaxin Bioengineered relaxin 2 RELAX-AHF-2 n= hr IV Serelaxin vs. placebo No difference in mortality/worsening HF Ultratide Analogue of Urodilatin TRUE-HF n= hr IV Ultratide vs placebo Less HF events first 48hr but no other no net benefit at 120hr, 30d and Fup (median 27/12)
25 Jugular Venous Pressure
26 LW Stevenson et al JACC 2003
27 Dry+warm Wet+warm Wet+cold LW Stevenson et al JACC 2003
28 Diuretics iv Nitrates ACE/ARB B-blockers Diuretics LW Stevenson et al JACC 2003
29
30 Comorbidity
31 Stabilised Acute Phase
32
33
34
35 Percentage 1 year Current Treatments Dramatically Reduced Mortality Solvd-T (1991) CIBISII + MERIT-HF(1999) Placebo group Active treatment group McMurray Heart 1999; 82(suppl 4): IV14-22
36 CIBIS III Trial
37
38
39 Entresto or Sacubitril/ Valsartan combination
40 Entresto or Sacubitril/ Valsartan combination
41 NICOR National Heart Failure Audit
42 Non-drug Strategies
43 Left bundle branch block
44
45
46
47 Cardiac Venous Anatomy
48 meters 6-Minute Walk (m) = + 23 % p = BiV-NoP 200 Baseline Rando CO1 CO2 12 months NoP-BiV
49 QOL (Minnesota LWHF ) = - 32 % p = BiV-NoP NoP-BiV 65 Baseline Rando CO1 CO2 12 months
50 Event-free Survival 1.00 HR 0.64 (95% CI 0.48 to 0.85) CRT Medical Therapy P = Number at risk CRT Medical Therapy Days Clealand et al N Engl J Med 2005;352:
51
52 Incremental Cost per Life-Year Saved Number-Needed-to-Treat (NNT) to Save One Life MUSTT (5 year) MADIT (2.4 year) MADIT II (3 year) AVID (3 year) SCDHeFT (5 year) SAVE (3.5 year) Merit-HF (1 year) 4S (6 year) Camm J, Klein H, Nisam S. European Heart Journal. doi: /eurheart/eji166; 2006
53 Heart Failure 2017 From: Survival following a diagnosis of heart failure in primary care Fam Pract. 2017;34(2): doi: /fampra/cmw145
54 Heart Failure 2017 European Journal of Heart Failure Volume 17, Issue 3, pages , 9 MAR 2015 DOI: /ejhf.250
55 Conclusions De Novo presenting heart failure patients have a much higher early mortality than chronic heart failure admissions Risk stratification once again guides therapy Over use of loop diuretics will prevent the utilisation of prognostically important therapies
56 Questions?
57
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