Surgery and device intervention for the elderly with heart failure: assessing the need. Devices and Technology for heart failure in 2011
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1 Surgery and device intervention for the elderly with heart failure: assessing the need Devices and Technology for heart failure in 2011 Assessing cardiovascular function / prognosis (in the elderly): composite scores - Better than VO 2 alone Selection for heart transplant or LVAD Lars H Lund Karolinska University Hospital Stockholm, Sweden Disclosures: Research grants: OrionPharma, AstraZeneca Consultant: AstraZeneca, StJude, Thoratec Lecture fees: AstraZeneca, OrionPharma, Vingmed/Thoratec, HeartWare, Astellas, Novartis
2 Peak VO 2 limitations: Derived before most evidence based therapies Less useful in women Influenced by age and body weight Requires reaching the ventilatory threshold, RER ? Attempts to improve: other data from the CPET: % predicted VO 2 VO 2 at ventilatory threshold Ventilatory efficiency VE/VCO 2 But still single variables: composite scores better
3 Heart Failure Survival Score: HFSS History Physical examination (continued) Age Heart rate Race (white vs nonwhite) 1 Body mass index Sex Jugular venous distension 1 Duration of CHF Rales 1 Cardiac arrest 1 Mitral regurgitation 1 Syncope 1 Tricuspid regurgitation 1 Embolic episode 1 S 1 3 Stroke 1 Hepatomegaly 1 Cause of CHF Laboratory data Ischemic cardiomyopathy 1 Electrocardiography Valvular cardiomyopathy 1 Rhythm Idiopathic cardiomyopathy 1 Normal sinus rhythm 1 Alcoholic cardiomyopathy 1 Atrial fibrillation or flutter 1 Hypertensive cardiomyopathy 1 Paced 1 Myocarditis 1 IVCD 1 NYHA class of CHF Q-wave infarction Angina 1 3 Chest roentgenogram Canadian Cardiovascular Society class of Cardiomegaly angina Myocardial 3 infarction in prior 6 months 1 3 Blood chemistries Coronary artery bypass grafting 3 Bicarbonate Internal cardioverter-defibrillator Blood urea nitrogen Permanent pacemaker 1 Creatinine Drug or alcohol abuse 1 Sodium Comorbid illnesses (modified Charlson's Aspartate aminotransferase index) AIDS 12 Radionuclide ventriculography Cerebrovascular disease 1 LVEF Chronic obstructive pulmonary disease 1 Cardiopulmonary exercise test Dementia 1 Peak oxygen consumption (peak VO 2 ) Diabetes with end-organ damage 1 Percent of maximal predicted peak VO 2 Diabetes without end-organ damage 1 Oxygen pulse Hemiplegia 1 Peak systolic blood pressure Leukemia 1 Peak heart rate Liver disease (mild) 1 Right heart catheterization Liver disease (moderate or severe) 1 Cardiac output Lymphoma 1 Cardiac index Peptic ulcer disease 1 Right atrial pressure Peripheral vascular disease 1 Pulmonary artery systolic pressure Renal disease (moderate or severe) 1 Pulmonary artery diastolic pressure Rheumatologic disease 1 Pulmonary artery mean pressure Solid tumor (metastatic) 1 PCWP Solid tumor (without metastases) 1 Pulmonary vascular resistance Physical examination Pulmonary vascular resistance index Systolic blood pressure Transpulmonary gradient Diastolic blood pressure Coronary angiography Mean blood pressure Three-vessel disease ( 70% diameter stenosis) or left main coronary artery disease ( 50% diameter stenosis) 3 Collected 80 variables and tested for univariate correlation to survival. Italics denotes independent prediction of survival with p<0.15 (40 variables). Underlined italics denotes inclusion in HFSS. Aaronson, Circ. 1997
4 7 variables selected for HFSS: - Best independent predictors - Weakly correlated with each other Represent different aspects of pathophysiology Ischemic cardiomyopathy - Resting heart rate - LVEF - Mean arterial BP - QRS > Peak VO 2 Serum sodium - Ischemia Sympathetic activation Systolic function Integrated measure Fibrosis and dyssynchrony Integrated measure Renin Angiotensin Aldosterone and ADH Aaronson, Circ. 1997
5 Derivation: Penn 73% 93% Validation: Columbia 88% 60% 43% 35% Good discrimination and calibration Low risk: no transplant Med and Hi risk: listed for transplant Aaronson, Circ. 1997
6 HFSS calculation for transplant and LVAD selection
7 Peak VO2 validated but HFSS better discrimination and calibration and better AUC of the ROC: Beta-blocker era Lund, AJC 2003 Serial evaluations Lund, AJC 2005 Women Green, AJC 2007 Elderly Parikh, AJC 2008 Different ethnic origins Goda, AJC 2009 With CRT / ICD therapy Goda, JHLT 2010
8 Modern era: CRT / ICD patients Peak VO2: Poor discrimination and calibration: HFSS: Good discrimination and calibration: Goda, JHLT 2010
9 DT-LVAD: age > 65 Peak VO2: Fair discrimination and calibration: HFSS: Good discrimination and calibration:
10 The HFSS better than the peak VO 2 alone for transplant and LVAD selection Also in the elderly But the HFSS still requires the peak VO2 DT-LVAD underutilized Tool for DT-LVAD referral Seattle Heart Failure Model: SHFM
11
12
13 Mostly HeartMate II Heartware HVAD Ketchum, JHLT 2010 Strueber, JACC 2011 But, not actuarial survival and SHFM derived in clinical trials, not in transplant or LVAD referred
14 ESC-HF 2011, Göteborg, Poster 301
15 Summary Assess prognosis to select for transplant and DT-LVAD Also in elderly Composite scores better than peak VO 2 alone HFSS extensively validated in Tx and LVAD referred SHFM does not require the peak VO 2 And has now been validated in Tx and LVAD referred Limitation: many Tx and LVAD are inotrope dependent - But should expand DT-LVAD to also ambulatory patients - To increase awareness in community: Still need easier referral criteria: Walk a block, walk one flight of stairs?
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