5 Important Things to Know About Heart Failure. Kia Afshar, MD

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1 5 Important Things to Know About Heart Failure Kia Afshar, MD

2 Disclosures I have no conflicts of interest to disclose I will not be discussing any off label medications and/or devices

3 Objectives 1) Understand certain relationships between heart failure and renal dysfunction 2) To recognize the two broad categories of heart failure presentations 3) Realize that ejection fraction is not the end-allbe-all of heart failure management 4) Understand the importance of reaching goal doses of heart failure treatments 5) Recognize the signs that your patient needs an advanced heart failure specialist

4 What is Heart Failure? 1. A clinical syndrome characterized by Inability to provide sufficient cardiac output to meet tissue demands At normal ventricular filling pressures... Packer M, Cohn JN, eds. Consensus recommendations for the management of heart failure. Am J Cardiol 1999;83(2A):1-38A )

5 Chronic Systolic Dysfunction Defined as ejection fraction (EF) < 50% Decreased stroke volume and effective arterial pressure results in compensatory neurohormonal activation Neurohormonal activation is initially important to maintain BP and CO but eventually results in deleterious myocardial changes and remodeling which increases morbidity and mortality.

6 How to think about Systolic HF: 1. Hemodynamic 2. Neurohumoral 3. Remodeling

7 Most common Ischemic (most common in Western world) idiopathic/nonischemic dilated cardiomyopathy (NIDCM) hypertensive (long standing) valvular (severe AR, severe AS, severe MR) (relatively common) Familial hemochromatosis amyloidosis sarcoidosis viral myocarditis Giant cell myocarditis drugs - chemotherapy, alcohol, cocaine peripartum anomalous coronary arteries tachycardia induced cardiomyopathy (more common than you think) stress cardiomyopathy (takotsubo's) radiation treatment (causes coronary disease, pericardial, valvular, and muscular disease) HIV cardiomyopathy septic shock Cardiomyopathies (relatively rare) high-output heart failure constriction restriction rheumatic myocarditis hypereosinophilic (rare) endocardial fibroelastosis (rare) pheochromocytoma (rare) PVC induced (rare) LBBB induced chronic RV pacing (rare) LV noncompaction (rare) glycogen storage disease (very rare) Fabry's (very rare) Friedreich's ataxia (very rare) duschenne (very rare) carcinoid (rare)

8 Heart Failure Paradigm (HFrEF vs HFpEF)

9 Heart Failure Paradigm (HFrEF vs HFpEF) Low EF Normal EF Ischemic Non-ischemic

10 Chronic Systolic Dysfunction Goals 1) Identify underlying cause 2) Improved quality of life (e.g. improve symptoms, decrease hospitalizations, increase functional status) 3) Increase length of life (i.e. decrease mortality)

11 Chronic Systolic Dysfunction Goals 1) Identify underlying cause 2) Improved quality of life (e.g. improve symptoms, decrease hospitalizations, increase functional status) 3) Increase length of life (i.e. decrease mortality)

12 Ischemic idiopathic/viral hypertensive Valvular Familial hemochromatosis amyloidosis sarcoidosis Giant cell myocarditis drugs - chemotherapy, alcohol, cocaine peripartum anomalous coronary arteries tachycardia induced cardiomyopathy stress cardiomyopathy (takotsubo's) radiation treatment HIV cardiomyopathy septic shock high-output heart failure constriction restriction rheumatic myocarditis Hypereosinophilic endocardial fibroelastosis Pheochromocytoma PVC induced LBBB induced chronic RV pacing LV noncompaction glycogen storage disease Fabry s Friedreich's ataxia Duschenne Carcinoid Chaga s Low EF Normal EF Ischemic Non-ischemic

13 Ischemic idiopathic/viral hypertensive Valvular Familial hemochromatosis amyloidosis sarcoidosis Giant cell myocarditis drugs - chemotherapy, alcohol, cocaine peripartum anomalous coronary arteries tachycardia induced cardiomyopathy stress cardiomyopathy (takotsubo's) radiation treatment HIV cardiomyopathy septic shock high-output heart failure constriction restriction rheumatic myocarditis Hypereosinophilic endocardial fibroelastosis Pheochromocytoma PVC induced LBBB induced chronic RV pacing LV noncompaction glycogen storage disease Fabry s Friedreich's ataxia Duschenne Carcinoid Chaga s Low EF Normal EF Ischemic Non-ischemic

14 Important Thing # 1 The best way to manage heart failure is to know the TRUE underlying cause. Treat every case as if you are Sherlock Holmes. Idiopathic and viral should be diagnoses of exclusion once you exhausted your brain s ability to figure out a cause

15 Chronic Systolic Dysfunction Goals 1) Identify underlying cause 2) Improved quality of life (e.g. improve symptoms, decrease hospitalizations, increase functional status) 3) Increase length of life (i.e. decrease mortality)

16 Chronic Systolic Dysfunction Management 60 1 Year Mortality (EF < 35%, NYHA III-IV)

17 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT

18 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT

19

20 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT

21 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT

22 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT

23 Chronic Systolic Dysfunction Admissions/deaths in Canada in the months after the RALES trial was published.

24 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT

25 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT

26 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT

27 Chronic Systolic Dysfunction Management Diuretics, digoxin 1 Year Mortality (EF < 35%, NYHA III-IV) % ACE inhibitors ACE + BB ACE + BB + ACE + BB + ACE + BB + spironolactone spironolactone+ spironolactone+ ICD ICD+ CRT 10 15%

28 Important Thing # 2 Heart Failure medications (at goal doses used in clinic trials) increase quality and quantity of life. Don t be afraid of slight increase in creatinine when using ACE inhibitors, likely beneficial! Aldosterone antagonists need diligent K+ monitoring, if you cant, don t use them.

29 Case # 1

30 HF consult for fear to diurese due to ARF

31 HF consult for fear to diurese due to ARF 40 year old man with 2 months of DOE, abdominal distension, and weight gain. Came to the ED due to difficulty breathing. Exam showed obese gentleman in NAD. JVD to angle of jaw sitting upright, 1+ bilateral edema to thighs. Warm extremities. Regular, no S3 or S4 appreciated. Echocardiogram showed no significant valvular lesions, mild RV dysfunction, LVIDD of 6.8cm, LVEF of 25% with global hypokinesis.

32

33 HF consult for fear to diurese due to ARF

34 HF consult for fear to diurese due to ARF

35 Case # 2

36 HF consult on 1/20/15 for increasing Cr with diuresis 59 year old man with 2 months of DOE, abdominal distension, and lb weight gain.

37

38 HF consult on 1/20/15 for increasing Cr with diuresis 59 year old man with 2 months of DOE, abdominal distension, and lb weight gain.

39 HF consult on 1/20/15 for increasing Cr with diuresis 59 year old man with 2 months of DOE, abdominal distension, and lb weight gain.

40 HF consult on 1/20/15 for increasing Cr with diuresis

41 A rising BUN / Cr does not always mean that you need to slow down/stop your diuresis. If there is significant venous congestion, patients can get renal venous congestion which reduces their net renal perfusion pressure and raises the creatinine. In these cases with aggressive diuresis the creatinine often will come down. THE KEY: ACCURATE ASSESSMENT OF FLUID STATUS If you can t tell by the JVP and/or the patient is not responding predictably then you may have to put in a Swan-Ganz catheter to assess hemodynamics.

42 Heart Failure and Worsening Renal Function

43 Heart Failure and Worsening Renal Function 70 NORMAL PATIENT: Mean Arterial Pressure: 70mmHg

44 Heart Failure and Worsening Renal Function 5 70 NORMAL PATIENT: Mean Arterial Pressure: RAP/Renal Vein Pressure: 70mmHg 5mmHg

45 Heart Failure and Worsening Renal Function 70 65mmHg 5 NORMAL PATIENT: Mean Arterial Pressure: RAP/Renal Vein Pressure: 70mmHg 5mmHg Renal Perfusion Pressure: 70 5 = 65mmHg

46 Heart Failure and Worsening Renal Function 65 DECOMPENSATED HEART FAILURE PATIENT: Mean Arterial Pressure: 65mmHg

47 Heart Failure and Worsening Renal Function DECOMPENSATED HEART FAILURE PATIENT: Mean Arterial Pressure: RAP/Renal Vein Pressure: 65mmHg 20mmHg

48 Heart Failure and Worsening Renal Function 65 45mmHg 20 DECOMPENSATED HEART FAILURE PATIENT: Mean Arterial Pressure: RAP/Renal Vein Pressure: 65mmHg 20mmHg Renal Perfusion Pressure: = 45mmHg

49 Heart Failure and Worsening Renal Function MAP NORMAL PATIENT: MAP - RAP RAP Mean Arterial Pressure: RAP/Renal Vein Pressure: 70mmHg 5mmHg Renal Perfusion Pressure: 70 5 = 65mmHg DECOMPENSATED HEART FAILURE PATIENT: Mean Arterial Pressure: RAP/Renal Vein Pressure: 65mmHg 20mmHg Renal Perfusion Pressure: = 45mmHg

50 Heart Failure and Worsening Renal Function CVP Cardiac Index SBP PCWP

51 Heart Failure and Worsening Renal Function Low CVP High CVP

52 Important Thing # 3 A rising BUN/creatinine does not mean the patient is dry and/or that you cannot diurese a hypervolemic patient If there is significant venous congestion, patients can get renal venous congestion which reduces their net renal perfusion pressure and raises the creatinine. In these cases with aggressive diuresis the creatinine often will come down. THE KEY: ACCURATE ASSESSMENT OF FLUID STATUS

53

54

55 Case # 3

56 Acute cardiogenic pulmonary edema (aka flash pulmonary edema )

57 Acute cardiogenic pulmonary edema (aka flash pulmonary edema ) Causes: Acute hypertension Acute mitral/aortic valve regurgitation Acute myocardial ischemia Acute left sided valvular obstruction (thrombosed prosthetic mitral valve, myxoma, HOCM physiology) Acute and aggressive volume loading Acute ventricular septal rupture

58 Acute cardiogenic pulmonary edema (aka flash pulmonary edema ) Causes: Acute hypertension Acute mitral/aortic valve regurgitation Acute myocardial ischemia Acute left sided valvular obstruction (thrombosed prosthetic mitral valve, myxoma, HOCM physiology) Acute and aggressive volume loading Acute ventricular septal rupture

59 Two Major Presentations of ADHF:

60 Two Major Presentations of ADHF: 1. Vascular Failure: Acute dyspnea, pulmonary edema, often due to acute hemodynamic

61 Acute cardiogenic pulmonary edema (aka flash pulmonary edema )

62 Two Major Presentations of ADHF: 2. Cardiac Failure: Gradual edematous decompensation

63

64 Chronic heart failure patients usually don t have crackles. Most decompensated HF patients don t have crackles Crackles may be absent in up to 80% of patients. These patients have increased lymphatic drainage and chronic perivascular compensation They generally don t have hypoxemia. With diuresis their shortness of breath and energy does however improve substantially. Up to 50% of patients may not have edema. GI symptoms: Abdominal discomfort, fullness or n/v It is not uncommon that we will be consulted for a pre-op eval for gall bladder surgery and discover the real problem is liver congestion from decompensated HF

65 Important Thing # 4 Acute cardiogenic pulmonary edema is an ACUTE pressure overload problem as opposed to CHRONIC decompensated heart failure which is a volume issue If you see flash pulmonary edema, aim for BP control first rather than reaching for diuretics. If BP is normal, investigate for other causes of acute hemodynamic changes

66 The Course of Heart Failure

67 Kaplan-Meier Survival by Era (Transplants: January June 2010) vs : p < vs /2010: p < vs /2010: p < Survival (%) (N = 25,138) (N = 37,193) /2010 (N = 24,021) 20 0 HALF-LIFE : 8.5 years; : 10.9 years; /2010: NA Years ISHLT 2012 J Heart Lung Transplant Oct; 31(10):

68 Heart Transplants Reported per Year Number of transplants ,255 2,352 2,991 3,508 3,801 4,464 4,679 4,646 4,851 4,761 4,755 4,630 4,538 4,281 3,995 3,858 3,836 3,726 3,650 3,610 3,709 3,772 3,777 3,745 3,774 3,892 ISHLT 2012 J Heart Lung Transplant Oct; 31(10): NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide

69 Left Ventricular Assist Devices (LVADs)

70 Improvements in Survival 100% 90% HEARTWARE 80% TRANSPLANT 70% 60% 50% 40% 30% 20% 10% HM II NATL HM II - UAHP POST-REMATCH LVAD REMATCH OMM REMATCH 0% Months post implant

71 Our Program s Outcomes (DT) 100% 90% 94% 95% 97% 90% 78% 80% 70% 60% 64% 67% 68% 58% 62% 50% 42% 40% 30% 20% 10% 0% Intermacs UAHP - All Devices NEJM UAHP - HM II

72 Evaluation Criteria Consider an evaluation when three of the following indications are present: Class III IV heart failure symptoms Inability to walk < 1 block without dyspnea Sodium < 136 meq/l BUN > 40 mg or Cr > 1.8 mg/dl ACE/ ARB/ BB intolerance Diuretic dose > 1.5 mg/kg/d 1 HF admit in the past 6 months No clinical improvement with CRT

73 Importance of Timing Goldilocks Effect Cleland JGF, et al. J Am Coll Cardiol. 2009;53:

74

75 Important Thing # 5 Heart transplantation is the gold standard treatment for advanced heart failure in eligible candidates. LVADs are becoming necessary to keep patients in good enough health in order to get heart transplantation safely LVADs can be used as destination therapy to improve quality/quantity of life Early referral is safer than late referral

76 Evaluation Criteria Consider an evaluation when three of the following indications are present: Class III IV heart failure symptoms Inability to walk < 1 block without dyspnea Sodium < 136 meq/l BUN > 40 mg or Cr > 1.8 mg/dl ACE/ ARB/ BB intolerance Diuretic dose > 1.5 mg/kg/d 1 HF admit in the past 6 months No clinical improvement with CRT

77 Heart Failure Team: Outpatient Appointments: MD-to-MD Line: HFMD (4363)

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