Heart Failure. Sandra Keavey, DHSc, PAC, DFAAPA

Transcription

1 Heart Failure Sandra Keavey, DHSc, PAC, DFAAPA

2 Defined Heart failure (HF) is a common clinical syndrome resulting from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. HF may be caused by disease of the myocardium, pericardium, endocardium, heart valves, vessels, or by metabolic disorders

3 Epidemiology-Magnitude Heart failure disproportionately affects the older population. Approximately 80% of all cases of heart failure in the United States occur in persons aged 65 years and older. In the older population, heart failure accounts for more hospital admissions than any other single condition. Following hospitalization for heart failure, nearly half are readmitted within 6 months.

4 Epidemiology-Prevalence Prevalence. About 5.1 million people in the United States have heart failure. One in 9 deaths in 2009 included heart failure as contributing cause. About half of people who develop heart failure die within 5 years of diagnosis. 25% of all heart failure patients are re-admitted to the hospital within 30 days. 50% of all heart failure patients are re-admitted to the hospital within 6 months.

5 Systolic vs Diastolic There are two common types of heart failure

6 Systolic HF Systolic HF is the most common type of HF Now referred to as HFrEF Heart Failure reduced Ejection Fraction The heart is weak and enlarged. The muscle of the left ventricle loses some of its ability to contract or shorten.

7 Diastolic HF Diastolic HF is not an isolated disorder of diastole; there are widespread abnormalities of both systolic and diastolic function that become more apparent with exercise. Heart Failure Preserved Ejection Fraction-HFpEF also seen in the literature is HFNEF, where N is normal. It is characterized by a stiff left ventricle with decreased relaxation, decreased compliance, increased filling pressure in the setting of normal LV dimensions. There is raised LV end-diastolic pressure, end-systolic pressure, diastolic dysfunction, pulmonary capillary wedge pressure and pulmonary artery systolic pressure.

8 Types of Heart Failure High output heart failure Low cardiac output syndrome Right heart failure Left heart failure Biventricular failure Diastolic dysfunction Bounding pulses, wide pulse pressure, accentuated heart sounds, peripheral vasodilatation, increased cardiac output and ejection fraction, moderate four-chamber enlargement Fatigue, loss of lean body mass, prerenal azotemia, peripheral vasoconstriction, reduced left or right contractility Dependent edema, jugular venous distention, right atrial and ventricular dilatation, reduced right-sided contractility Dyspnea, pulmonary vascular congestion, reduced left-sided contractility Dyspnea, dependent edema, jugular venous distention, pulmonary vascular congestion, bilateral reduced contractility Normal myocardial contractility, left ventricular volume, and ejection fraction; impaired myocardial relaxation; diminished early diastolic filling

9 Types of Heart Failure High output heart failure Low cardiac output syndrome Right heart failure Left heart failure Biventricular failure Diastolic dysfunction High output heart failure occurs when the demand for blood exceeds the capacity of an otherwise normal heart to meet the demand. This type of heart failure may occur in patients with severe anemia, AV malformations with shunting of blood, or hyperthyroidism. Patients have fatigue and loss of lean muscle mass as their most prominent symptoms, but they also may have dyspnea, impaired renal function, or altered mental status. Characterized by peripheral edema Characterized by pulmonary congestion. Both systemic and pulmonary congestion are present in patients with biventricular heart failure. The treatment of diastolic heart failure is less well defined than the treatment of systolic heart failure. None of the treatment recommendations have been validated by randomized controlled trials.

10 Conditions That Contribute to HF Coronary heart disease the most common cause of HF due to systolic dysfunction in Western countries. Cigarette smoking Increases BP, decreases exercise tolerance and increases the tendency for blood to clot. Obesity-approximately 11 percent of cases of HF in men and 14 percent in women are attributable to obesity alone. Diabetes from microvascular dysfunction and increased fatty acid utilization and decreased NO bioavailability. Valvular heart disease- an increasingly common cause of HF at older ages, with calcific aortic stenosis being the most common disorder requiring surgery.

11 Impact of Stress IMPAIRED RESPONSE TO STRESS Patients with heart failure have particular difficulty in tolerating certain types of hemodynamic stresses: Atrial fibrillation poorly tolerated Sinus tachycardia also not well tolerated. Elevations in systemic blood pressure that worsen myocardial relaxation Ischemia resulting in worsening of diastolic function

12 Hypertension Hypertension increases the risk of HF at all ages. Data from the Framingham Heart Study found that, after age 40, the lifetime risk of developing HF was twice as high in subjects with a blood pressure 160/100 mmhg compared to <140/90 mmhg The risk of developing HF increases with the degree of blood pressure elevation. Even moderate elevations contribute to risk in the long term.

13 The average blood pressure of hypertensive candidates for HF in the Framingham Study was 150/90 Chronic hypertension is the most common cause of diastolic dysfunction and failure. It leads to left ventricular hypertrophy and increased connective tissue content, both of which decrease cardiac compliance.

14 Conditions That HF Contributes to Atrial Fibrillation (Afib) -As the ventricle stiffens and develops higher end-diastolic pressures, the atria are distended and stressed; often resulting in Afib. Atrial fibrillation with uncontrolled rate worsens HF symptoms Loss of atrial contraction worsens symptoms of HF, because patients with diastolic dysfunction often are dependent on the atrial kick of the left ventricle LV hypertrophy is a prominent feature of evolving HF. Each method of demonstrating LV hypertrophy (ECG, chest film, or echocardiogram) independently predicts HF. As a result, persons having any combination of them have a greater risk than those with any one alone.

15 QUIZ

16 Of the HF cases that occur in the United States what percentage occurs in those 65 years and older? A. 20% B. 50% C. 60% D. 80%

17 Of the HF cases that occur in the United States what percentage occurs in those 65 years and older? A. 20% B. 50% C. 60% D. 80%

18 In Western countries the most common cause of HF due to systolic dysfunction is caused by. A. Cigarette smoking B. Coronary artery disease C. Obesity D. Valvular heart disease

19 In Western countries the most common cause of HF due to systolic dysfunction is caused by. A. Cigarette smoking B. Coronary artery disease C. Obesity D. Valvular heart disease

20 Which of the following conditions is made worse by heart failure? A. Chronic hypertension B. Diabetes C. Atrial fibrillation D. Valvular heart disease

21 Which of the following conditions is made worse by heart failure? A. Chronic hypertension B. Diabetes C. Atrial fibrillation D. Valvular heart disease

22 Diagnosis HF is a clinical syndrome with multiple causes. The likelihood of HF is increased in those patients with older age, history of coronary artery disease or myocardial infarction, and using a loop diuretic. The approach to the patient with suspected HF includes the history and physical examination, and diagnostic tests to help establish the diagnosis. These will also indicate acuity and severity.

23 Signs and Symptoms Excess fluid causes dyspnea, orthopnea, edema, pain from hepatic congestion, and abdominal distention from ascites. A reduction in cardiac output causes fatigue and weakness that is most pronounced with exertion. A fall in cardiac output, leading to alterations in renal function, due in part to activation of the sodium-retaining renin-angiotensin-aldosterone and sympathetic nervous systems.

24 Symptoms-Acute HF Acute and subacute presentations (days to weeks) are characterized primarily by shortness of breath, at rest and/or with exertion. Also common are orthopnea, paroxysmal nocturnal dyspnea, and, with right HF, right upper quadrant discomfort due to acute hepatic congestion. Patients with atrial and/or ventricular tachyarrhythmias may complain of palpitations. This may be accompanied by lightheadedness.

25 Symptoms-Chronic HF When HF develops over months patients differ in that fatigue, anorexia, abdominal distension, and peripheral edema may be more pronounced than dyspnea. The anorexia is secondary to several factors including poor perfusion of the splanchnic circulation, bowel edema, and nausea induced by hepatic congestion. Over time, pulmonary venous capacitance accommodates to the chronic state of volume overload, leading to less or no fluid accumulation in the alveoli, despite the increase in total lung water.

26 All HF Patients may report. Fatigue and/or weakness Dyspnea, orthopnea. Dry, hacking cough or cough productive of frothy or blood-tinged sputum Restlessness, change in mental status Decreased urine output during day, nocturia Dizziness, syncope

27 Think HF if Dyspnea-Nearly all patients with heart failure present with dyspnea. The absence of dyspnea makes heart failure highly unlikely (sensitivity: greater than 95 percent) Heart failure is present in only about 30 percent of patients who present with dyspnea in the primary care setting. Jugular venous distention, displacement of cardiac apical pulsation, or a gallop rhythm is present the presence of cardiomegaly or pulmonary vascular congestion is seen on the chest radiograph. Anterior Q waves or left bundle branch block is seen on an electrocardiogram.

28 Differential Diagnosis Decreased Exercise Tolerance Myocardial ischemia Pulmonary disease Dyspnea Asthma COPD Interstitial lung disease Thromboembolus Fatigue Deconditioning Sleep apnea Depression Peripheral edema Venous thrombosis or insufficiency Renal sodium retention Drug side effect (eg, calcium channel blocker) Cirrhosis.

29 Physical Exam In a study by Mantz, et al, the physical finding of a displaced apical impulse had the best combination of sensitivity, specificity, and positive and negative predictive value of any physical sign of systolic HF. Other strong predictors were a gallop rhythm and elevated jugular venous pressure. Signs of low cardiac output

30 Physical Exams-Heart Sounds S3 Gallop Occurs in early diastole Occurs during passive LV filling May be normal at times Requires a very compliant LV Can be a sign of systolic CHF Low pitched murmur Left lateral decubitus position at the cardiac apex is best to hear. Heard with bell of the stethoscope FU***, I m screwed S4 Gallop Occurs in late diastole Occurs during active LV filling Almost always abnormal Requires a non-compliant LV Can be a sign of diastolic CHF Well, FU*** you

31 Signs of Low Cardiac Output Variations in B/P (may be increased because of compensatory vasoconstriction; may be decreased when compensatory mechanisms and pump fail) Tachycardia. Pulsus alternans (alternating strong and weak pulse) is virtually pathognomonic for severe HF An S 3 heart sound Abnormal breath sounds (e.g. crackles [rales], wheezes, diminished sounds, tachypnea Diminished or absent peripheral pulses Cool extremities Pallor or cyanosis of skin Capillary refill time greater than 3 seconds Edema

32 QUIZ

33 The third heart sound (S 3 ), is specific for increased left ventricular end-diastolic pressure and decreased left ventricular ejection fraction. A) True B) False

34 The third heart sound (S 3 ), is specific for increased left ventricular end-diastolic pressure and decreased left ventricular ejection fraction. A) True B) False Among physical findings, the Ventricular filling gallop, provides the best specificity (99%) for detecting HF.

35 In a patient who does not have shortness of breath during exertion, the diagnosis of HF can be ruled out with a sensitivity of. A) 24% B) 57% C) 84% D) 93%

36 In a patient who does not have shortness of breath during exertion, the diagnosis of HF can be ruled out with a sensitivity of. A) 24% B) 57% C) 84% D) 93% The absence of dyspnea upon exertion allows clinicians to rule out HF with a 84% sensitivity.

37 The presence of paroxysmal nocturnal dyspnea can assist in the diagnosis of HF, with a specificity rating of. A) 24% B) 57% C) 84% D) 93%

38 The presence of paroxysmal nocturnal dyspnea can assist in the diagnosis of HF, with a specificity rating of. A) 24% B) 57% C) 84% D) 93% Paroxysmal nocturnal dyspnea has a the highest specificity of any symptom of HF.

39 Diagnostic Testing EKG Lab testing Chest Xray Echocardiogram

40 EKG Most patients with heart failure (HF) due to systolic dysfunction have a significant abnormality on an electrocardiogram (ECG). A normal ECG makes systolic dysfunction unlikely (98 percent negative predictive value) The EKG may show an atrial fibrillation or acute ischemia or prior MI The ECG is particularly important for identifying evidence of acute or prior myocardial infarction or acute ischemia. Ischemia can cause or exacerbate HF or confuse the diagnosis initially.

41 EKG with LVH

42 Lab Testing CBC- anemia can exacerbate HF Serum electrolytes, blood urea nitrogen, and creatinine may indicate associated conditions. Hyponatremia generally indicates severe HF, though other causes should be considered Renal impairment can be caused by or contribute to HF Additionally baseline renal function is important when starting or adjusting diuretic regimens Liver function tests may be affected by hepatic congestion A1c/Fasting blood glucose to detect underlying diabetes mellitus.

43 Lab Testing Cardiac biomarkers Troponin T or I in patients with acute decompensated HF and/or suspected acute coronary syndrome. BNP (Brain Natriuretic Peptide) A natriuretic hormone released primarily from the heart, particularly the ventricles. A high BNP does not exclude other diseases processes such as pneumonia In some patients with acute decompensated HF elevated levels are not diagnostic. Some patients with severe chronic HF may have persistently elevated plasma levels.

44 BNP Right HF and pulmonary hypertension are associated with elevations in plasma BNP Plasma BNP levels tend to be lower in obese patients and are elevated in patients with renal failure, and some acute noncardiac illnesses such as sepsis. In patients receiving sacubitril-valsartan (Entresto) the plasma BNP levels may be artificially elevated.

45 Chest Xray The chest radiograph is a useful initial diagnostic test, particularly in the evaluation of patients who present with dyspnea, to differentiate HF from primary pulmonary disease Redistribution and cardiomegaly were the best predictors of increased preload and reduced ejection fraction, respectively but not a definitive diagnosis. HF findings include Cardiomegaly Cephalization of pulmonary vessels, Kerley B-lines Pleural effusions

46 Echocardiogram HFrEF is relatively easy to diagnose by echocardiography which demonstrates a dilated left ventricle with a reduced ejection fraction. Accurately and noninvasively provides a measure of ventricular function and identifies causes of structural heart disease. It can also detect and define the hemodynamic and morphologic changes in HF over time. Gives stroke volume (amount of blood ejected by the left ventricle in one contraction, usually 1 ml/kg) and cardiac output (stroke volume times heart rate).

47 Echocardiogram Evaluates Heart size Heart function or ejection fraction Presence of cardiac malformations Presence of ventricular aneurysms Presence of scars Valve morphology Presence of masses in the heart or on the valves Presence of pericardial fluid

48 Left Ventricular Function Hyperdynamic Normal Mild LV dysfunction Moderate LV dysfunction EF (%) > Chest wall R L

49 Echocardiography Currently, Doppler echocardiography is the primary tool for identifying abnormal diastolic function. It will identify diminished early diastolic filling and reduced ventricular compliance associated with diastolic dysfunction. The quality of the study is somewhat operator dependent.

50 NYHA HF Functional Classification System I - Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. no shortness of breath when walking, climbing stairs etc. II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances ( m). Comfortable only at rest. IV - Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

51 How ACE Inhibitors Help in HF As ACEI s dilate (or widen) the blood vessels to improve blood flow, which helps to decrease the amount of work the heart has to do. They also block some of the harmful substances in the blood (angiotensin) that are produced as a result of heart failure. Angiotensin is one of the most powerful vasoconstrictors (they narrow the blood vessels) in the body.

52 How ARBS help in HF Angiotensin II receptor blockers (ARBs) have the same effects on heart disease as ACE inhibitors, but work by a different mechanism. These heart drugs decrease certain chemicals that narrow the blood vessels, allowing blood to flow more easily through your body. They also decrease certain chemicals that cause salt and fluid build-up in the body.

53 How Diuretics help in HF Stimulate the kidneys to remove more water and salt (sodium) from the body. This can help relieve swelling that happens because of heart failure. The blood urea nitrogen and serum creatinine often rise during diuretic treatment of HF and careful monitoring of renal function and electrolytes is recommended. Several uncontrolled studies have found that higher diuretic doses are associated with worse outcomes, including mortality

54 How Diuretics help in HF Thiazide diuretics cause moderate increases in water excretion and are appropriate for long-term use. Potassium-sparing diuretics help your body retain the mineral potassium and are often prescribed in conjunction with the other two types of diuretics. Caution--Use of non-potassium sparing diuretics to treat HF has been associated with arrhythmic death

55 Diastolic HF Treatment Diuretic therapy is the mainstay of treatment for preventing pulmonary congestion, while beta blockers appear to be useful in preventing tachycardia and thereby prolonging left ventricular diastolic filling time. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers may be beneficial in patients with diastolic dysfunction, especially those with hypertension. The treatment of diastolic heart failure is less well defined than the treatment of systolic heart failure. None of the treatment recommendations have been validated by randomized controlled trials.

56 How Physical Activity Helps No surprise that those who consistently maintained a physical active lifestyle had the lowest incidence of HF. Increasing PA, even in middle age, can reduce the risk of subsequent heart failure. Clinicians should ask about exercise levels.

57 How Physical Activity Helps Each increase in physical activity of approximately 30 minutes of brisk walking four times per week was associated with a significant reduction in the risk of HF events. Recommend activity consistent with the CDC and American Heart Association guidelines of 150 minutes per week of moderately intense activity, such as brisk walking Or 75 minutes per week of more intense activity such as jogging or a combination of both.

58 Inpatient Management

59 Inpatient Management 1/10 Monitor oxygen saturation, vital signs, and cardiac rhythm Provide supplemental oxygen if hypoxic Fluid restriction, sodium restriction, Provide NIV (Noninvasive ventilation) as needed, unless immediate intubation is required or NIV is otherwise contraindicated Have airway management equipment readily available; etomidate is a good induction agent for rapid sequence intubation in ADHF (Acute decompensated heart failure)

60 Inpatient Management 2/10 Initiate diuretic therapy without delay to relieve congestion/fluid overload: Give IV loop diuretic furosemide 40 mg IV or torsemide 20 mg IV; or bumetanide 1 mg IV IV administration of loop diuretics results in prompt diuresis and relief of symptoms in most patients Higher doses are needed for patients taking diuretics chronically (eg, twice home dose) and in patients with renal dysfunction

61 Inpatient Management 3/10 Diuretics stimulate the the kidneys to remove water and salt (sodium). Diuretics clearly improve hemodynamics and symptoms of dyspnea and edema Higher diuretic doses are associated with worse outcomes Higher doses are also associated with more significant disease states.

62 Inpatient Management 4/10 Search for cause of ADHF (including: acute coronary syndrome, hypertension, arrhythmia, acute aortic or mitral regurgitation, aortic dissection, sepsis, renal failure, anemia, or drugs) and treat appropriately. Patients with acute decompensated HF and AF with rapid ventricular rate often require medication (eg, digoxin) to slow their heart rate Direct current cardioversion is indicated for patients with new onset AF and hemodynamic instability or refractory symptoms despite rate control. Obtain immediate cardiac surgery consultation for acute aortic or mitral regurgitation or ascending aortic dissection

63 Inpatient Management 5/10 For patients with adequate end-organ perfusion (eg, normal or elevated blood pressure) and signs of Acute Decompensated HF with fluid overload: If urgent afterload reduction is required, consider early vasodilator therapy: Give nitroprusside* for severe hypertension, or if acute aortic regurgitation or acute mitral regurgitation is present; titrate rapidly to effect (eg, start nitroprusside at 5 to 10 mcg/min and titrate up every five minutes as tolerated to a dose range of 5 to 400 mcg/min).

64 Inpatient Management 6/10 If response to diuretics is inadequate, give vasodilator to reduce preload: Give IV nitroglycerin in addition to diuretic therapy if persistent dyspnea or as a component of therapy in refractory HF and low cardiac output. Start nitroglycerin* infusion at 5 to 10 mcg/min Titrate every three to five minutes as needed and tolerated based upon mean arterial blood pressure or SBP to a dose range of 10 to 200 mcg/min.

65 Inpatient Management 7/10 For patients with known systolic HF (eg, documented low ejection fraction) presenting with signs of severe ADHF and cardiogenic shock, discontinue chronic beta bocker therapy and: Give an IV inotrope* (eg, dobutamine or milrinone) and/or mechanical support (eg, intraaortic balloon counter pulsation)

66 Inpatient Management 8/10 For patients with known diastolic HF (ie, preserved systolic function) presenting with signs of severe ADHF and cardiogenic shock: Treat for possible left ventricular outflow obstruction with a beta blocker, IV fluid (unless pulmonary edema is present) An IV vasopressor* (eg, phenylephrine or norepinephrine); do not give an inotrope or vasodilator (eg, dobutamine or milrinone). Obtain immediate echocardiogram as needed. Consider possibility of acute mitral or aortic regurgitation, or aortic dissection, and need for emergent surgical intervention.

67 Inpatient Management 9/10 For patients whose cardiac status is unknown but present with signs of severe ADHF (ie, pulmonary edema) and hypotension or signs of shock: Give an IV inotrope* (eg, dobutamine or milrinone), with or without an IV vasopressor (eg, norepinephrine) And assess need for mechanical support (eg, intraaortic balloon counter pulsation); Obtain immediate echocardiogram as needed.

68 Remember 10/10 Patients receiving vasodilator, vasopressor, or inotrope infusions require continuous noninvasive monitoring of blood pressure, heart rate and function, and oxygen saturation. This means ICU not just Telemetry. Treatment of patients with volume overload who have heart failure with a reduced ejection fraction (HFrEF) that has been unresponsive to diuretics should be guided by hemodynamics.

69 Hospital Discharge Criteria 1/2 Exacerbating factors addressed Near optimal volume status observed Transition from intravenous to oral diuretic Patient/family education, including discharge instructions Left ventricular ejection fraction (LVEF) documented Smoking cessation counseling initiated Near optimal pharmacologic therapy achieved, including ACE inhibitor and beta blocker (for patients with reduced LVEF), or intolerance documented

70 Hospital Discharge Criteria 2/2 Follow-up clinic visit scheduled, usually for 7 to 10 days Oral medication regimen stable for 24 hours No intravenous vasodilator or inotropic agent for 24 hours Ambulation before discharge to assess functional capacity after therapy (See Walk Test, next slide) Plans for post-discharge management (scale present in home, visiting nurse or telephone follow up generally no longer than three days after discharge) Referral for disease management, if available

71 Six Minute Walk Test The six-minute walk test (6MWT) measures the distance an individual is able to walk over a total of six minutes on a hard, flat surface. The goal is for the individual to walk as far as possible in six minutes. It is self-paced and the patient may rest as needed as they traverse back and forth along a marked walkway. Average distance walked: meters depending on the severity of heart disease Predicted six-minute walk distance in healthy elderly = 631 ± 93 meters

72 Quiz

73 In Acute Decompensated HF initiate diuretic therapy to relieve congestion/fluid overload: A. without delay B. after the BNP results comes back elevated C. after the CXR confirms heart failure. D. after the first set of troponins is negative.

74 In Acute Decompensated HF initiate diuretic therapy to relieve congestion/fluid overload: A. without delay B. after the BNP results comes back elevated C. after the CXR confirms heart failure. D. after the first set of troponins is negative.

75 In patients chronically on diuretics at home the initial dose if diuretic should be A. Same dose but given intravenously B. Twice the home dose given orally. C. Twice the home dose given intravenously D. Same dose as given at home.

76 In patients chronically on diuretics at home the initial dose if diuretic should be A. Same dose but given intravenously B. Twice the home dose given orally. C. Twice the home dose given intravenously D. Same dose as given at home.

77 Outpatient Management

78 Outpatient Treatment Heart failure is diagnosed in the outpatient setting following a similar algorithm. However as the patient is not acutely decompensated and assessment is without the same urgency nor is iv medication required. A comprehensive history and physical followed by appropriate labs and testing. Systematically assess risk factors. Order labs, an echocardiogram, CXR to confirm diagnosis and establish baseline data. Create an action plan for the patient to follow at home. Start a diuretic and schedule next appointment within 7-10 days.

79 Outpatient Treatment- FU Visits Review any previously ordered labs or testing. Systematically assess risk factors and co-morbid conditions. Monitor changes in weight, blood pressure, well being. Review patients diary. Discuss compliance with the action plan Discuss any problems with current medications. Consider need for adjustments in medication regimen. Consider need for adjustments in the action plan.

80 Outpatient Treatment Patient require education and support on Medications they are on and potential side effects Need for routine follow-up Daily self assessment Daily weights on the same scale. Daily BP monitoring Review the patient action plan

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83 Risk Factor Reduction In the Physician Health Study of 20,900 men the impact of healthy lifestyle habits was studied. normal body weight not smoking regular exercise [five or more times per week] moderate alcohol intake [5 to 14 drinks per week] consumption of breakfast cereals consumption of fruits and vegetables The study showed that there was a 21% overall risk. Addressing 4 of the 6 risk factors decreased the overall risk to 10%.

84 New Therapies

85 Ivabradine-New Drug Treatment Approved by the FDA April 15, 2015, to reduce hospitalizations from worsening heart failure. Specific heart-rate lowering drug that reduces myocardial oxygen demand, simultaneously improving oxygen supply. There are no negative inotropic or lusitropic (relaxation of cardiac muscle) effects Ventricular contractility is preserved and there are no major electrophysiological parameters unrelated to heart rate.

86 Valsartan/Sacubitril New Drug Treatment The first FDA approved (July 7, 2015) agent in the angiotensin receptor-neprilysin inhibitor (ARNI) class. Combination drug of the angiotensin-receptor blocker valsartan affixed to the neprilysin inhibitor sacubitril. Valsartan and Sacubitril bpth cause blood vessel dilation and reduction of ECF volume via sodium excretion. A significant reduction in cardiovascular death or heartfailure hospitalizations by 20% compared with treatment with the ACE inhibitor enalapril alone. Study criticized for lack of a valsartan head to head comparison and early termination.

87 New Device Therapy CardioMEMS HF System In the past year the FDA has approved use of an implantable device to monitor heart failure management via measurement of the pulmonary artery pressure. Approved for use in HF patients at a NYHA Class III-IV level. In a retrospective analysis of the CHAMPION clinical data for HFrEF patients already on guideline-directed medical therapy, pulmonary artery pressure guided management reduced HF hospitalization by 43% and mortality by 57% NYHA Class III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances ( m). Comfortable only at rest.

88 CardioMEMS HF System Indications The CardioMEMS HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. Contraindications The CardioMEMS HF System is contraindicated for patients with an inability to take dual antiplatelet or anticoagulants for one month post implant. Cautions Medical procedures including radiofrequency ablation, ionizing radiation, and diagnostic ultrasound can also be performed while the sensor is implanted if precautions are taken to avoid direct contact with the sensor.

89 CardioMEMS HF System Patients who are currently on chronic anticoagulant therapy should restart treatment after sensor implantation. Patients who are not currently being treated with chronic anticoagulant therapy should be placed on aspirin (81 mg or 325 mg) and clopidogrel (75 mg) daily for one month following the procedure. The PA Sensor is a permanent implant. After one month, the patient should continue aspirin therapy. Patients with a reduced ejection fraction should be on stable AHA/ACC guidelines based medical therapy prior to implant.

90 CardioMEMS HF System The PA Sensor is a permanently implanted in the distal pulmonary artery during a right heart catheterization. Is MRI compatible Pacemakers, ICDs, and Ventricular Assist Devices (VAD) can work in conjunction with the PA Sensor and will not affect the performance of the system. The sensor does not require removal before cremation.

91 CardioMEMS HF System No batteries required. Never needs to be removed. 7 mm long, 2 mm thick. Patient-initiated sensor readings are wirelessly transmitted to an external electronics unit.

92 Wearable Patch A wearable device capable of recording electrical and mechanical aspects of cardiac function. Goal is to identify compensated and decompensated HF states and to track the clinical course of the patients. Patients with compensated (outpatient) and decompensated (hospitalized) HF were fitted with a wearable ECG and seismocardiogram sensing patch. Wearable technologies recording cardiac function and machine learning algorithms can assess compensated and decompensated HF states by analyzing cardiac response to submaximal exercise.

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94 In Summary Cornerstones of Treatment Medication management. Anti-ischemic therapy Beta blockers Calcium channel blockers ACE inhibitors Angiotensin II receptor blockers Aldosterone antagonists Phosphodiesterase-5 inhibition Statins Routine and frequent follow-up Atrial fibrillation rate vs rhythm control Weight control Smoking cessation Daily patient self-monitoring with an action plan Diet with fruits and vegetables Moderate ETOH intake Regular exercise Patient education

95 References Centers for Disease Control Dr. Smith s EKG Blog (2015) Retrieved from Gutierrez, C., Blanchard, D.G. Diastolic Heart Failure: Challenges of Diagnosis and Treatment. Am Fam Physician Jun 1;69(11): Heart Failure Society of America

96 References Mant J, Doust J, Roalfe A, Barton P, Cowie MR, Glasziou P, Mant D, McManus RJ, Holder R, Deeks J, Fletcher K, Qume M, Sohanpal S, Sanders S, Hobbs FD. Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modeling of implications of different diagnostic strategies in primary care. Health Technol Assess Jul;13(32):1-207, iii. Masoudi, F.A., Havranek, E.P., Krumhold, H.M. The burden of chronic congestive heart failure in older persons: magnitude and implications for policy and research. Heart Fail Rev Jan;7(1):9-16. St. Jude Medical. Retrieved from UpToDate (2016).

97 Thank you.