HEART FAILURE IN WOMEN. Marian Limacher, MD Division of Cardiovascular Medicine University of Florida

Transcription

1 HEART FAILURE IN WOMEN Marian Limacher, MD Division of Cardiovascular Medicine University of Florida

2 Outline Epidemiology Clinical Overview Why HF is such a challenge State of the Field Heart Failure Adjudication What we have What we don t have What we will have

3 Epidemiology 1-2% of adults have HF 2.5 M women have HF, 1/3 of all disease related mortality in American women is due to HF Lifetime Risk: 20% for Americans > 40y/o Prevalence > 10% age 70 and older Mortality: 50% 5 year 5-7% community patients; after hospitalization 50% over next 2 years Medicare patients 30 day 10-12% Women survive longer, but Lower quality of life Significantly higher annual increase in hospitalization rates

4 HF Statistics Over 1 M hospital discharges per year with primary diagnosis of heart failure Over age 60: 10% men; 8% women > 3M physician visits per year 2010: direct and indirect costs $39.2 B Lifetime cost per individual patient $110,000/year 75% for inpatient care 30 day readmission rate 20-25%

5 Deaths attributable to cardiovascular disease (United States: 2010) Coronary Heart Disease 48.2% Heart Failure 7.3% Stroke 16.4% Go A et al. Circulation 2014;129:e28-e292 Copyright American Heart Association, Inc. All rights reserved.

6 Prevalence of Heart Failure by sex and age National Health and Nutrition Examination Survey: Go A et al. Circulation 2014;129:e28-e292 Copyright American Heart Association, Inc. All rights reserved.

7 Hospital discharges for heart failure by sex (United States: ) Go A et al. Circulation 2014;129:e28-e292 Copyright American Heart Association, Inc. All rights reserved.

8 Definition of Heart Failure (HF) Heart Failure is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. ACCF/AHA Guidelines The cardinal manifestations are Dyspnea and fatigue Fluid retention Congestive Heart Failure Acute or chronic HF with evidence of sodium and water retention No longer a preferred term

9 Heart Failure Syndrome Symptoms are non-discriminating Signs result from retention of sodium and water, which then may be absent in patients on treatment (diuretics, etc.) Or caused by non-cardiac conditions (renal failure, volume overload, pulmonary disease) Or may have multiple etiologies >> Identifying the underlying cardiac cause is central to the diagnosis

10 Etiologies of Heart Failure Left ventricular systolic dysfunction Diastolic dysfunction Valve dysfunction Pericardial disease Endocardial disease Rhythm abnormalities Conduction abnormalities

11 Using Ejection Fraction EF = stroke volume/end diastolic volume Stroke volume = end diastolic volume end systolic volume Normal EF > 50 or 55 EF is well established in HF Lower values reduce survival Most clinical trials use EF for selection Reduced EF (HFREF), usually means EF < 35 or 40 formerly systolic HF HF with preserved EF (HFPEF), HF syndrome with EF >50 Usually diagnosis of exclusion (no findings of COPD, anemia, etc.) Most have evidence of diastolic dysfunction, usually by echo/doppler parameters

12 Images pathies/dcm/severe%20dcm%20case.html

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14 ACCF/AHA Guideline 2013 Classification EF (%) Description I. Heart failure with reduced ejection fraction (HFREF) II. Heart failure with preserved ejection fraction (HFPEF) a. HFPEF, borderline 41 to 49 Also referred to as systolic HF. RCTs have mainly enrolled patients with HFREF, and it is only in these patients that efficacious therapies have been demonstrated to date. Also referred to as diastolic HF. The diagnosis of HFPEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. Characteristics, treatment patterns, and outcomes appear similar to those of patients with HFPEF. b. HFPEF, improved >40 Yancy et al. JACC 2013;15: Subset of patients with HFPEF previously had HFREF. These patients may be clinically distinct from those with persistently PEF or REF

15 New York Heart Association (NYHA) Functional Classification Class I No limitation of physical activity. Ordinary physical activity does not cause undue breathlessness, fatigue, or palpitations Class II Class III Class IV Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in undue breathlessness, fatigue, or palpitations Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in undue breathlessness, fatigue, or palpitations Unable to carry on any physical activity without discomfort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased

16 ACCF/AHA Stages of HF Stage Definition NYHA Class A B C D A high risk for HF but without structural heart disease or symptoms of HF Structural heart disease but without signs or symptoms of HF Structural heart disease with prior or current symptoms of HF Refractory HF requiring specialized interventions I I I, II, III, IV IV Yancy et al. JACC 2013;15:

17 ACCF/AHA Stages and 5 yr Mortality Stage Mortality A 97% B 96% C 75% D 20% Yancy et al. JACC 2013;15:

18 HF Risk Factors Increased BMI Abdominal fat accumulation Elevated fasting blood glucose Elevated systolic blood pressure Elevated apolipoprotein B/apo A ratio Cigarette smoking Framingham B-type natriuretic peptide Urinary albumin:creatinine ratio Elevated serum γ-glutamyl transferase Higher hematocrit

19 HF Risk Factors ARIC Elevated white blood cell count CRP Albuminuria HbA1c (without DM) Cardiac troponin PVCs Socioeconomic status MESA N-T pro BNP MRI LV mass index

20 Acute Decompensated Heart Failure New onset of severe HF or sudden intensification of chronic HF = most common cause of hospital admission Contributing factors Development of dysrhythmias (including AF) Acute coronary syndrome Rapid increase in need for increased cardiac output (infection, anemia, pulmonary embolus in setting of chronic HF Discontinuation of treatment for chronic heart failure Progression of underlying disease ADHERE (Acute Decompensated Heart Failure Registry) prognostic risk model

21 ADHERE model increased mortality Elevated BUN Lower systolic BP Low sodium Older age Elevated creatinine Dyspnea at rest Absent chronic beta-blocker use JACC : 76-84

22 ADHERE model increased mortality Elevated BUN >37 md/dl Lower systolic BP < 125 mmhg Low sodium Older age Elevated creatinine Dyspnea at rest Absent chronic beta-blocker use For both PEF and REF JACC : 76-84

23 Readmission Rate Figure 2 Kaplan Meier Estimate: readmission-free survival estimates for patients with HFpEF and HFrEF. Rene Quiroz, Gheorghe Doros, Peter Shaw, Chang-seng Liang, Diane F. Gauthier, Flora Sam Comparison of Characteristics and Outcomes of Patients With Heart Failure Preserved Ejection Fraction Versus Reduced Left Ventricular Ejection Fraction in an Urban Cohort The American Journal of Cardiology, Volume 113, Issue 4, 2014,

24 Mortality Figure 3 Kaplan Meier Estimate: survival estimates for patients with HFpEF and HFrEF. Rene Quiroz, Gheorghe Doros, Peter Shaw, Chang-seng Liang, Diane F. Gauthier, Flora Sam The American Journal of Cardiology, Volume 113, Issue 4, 2014,

25 Predictors of HF readmission and mortality Variable Readmission HR (95% CI) P value Mortality HR (95% CI) P value HFPEF 1.14 ( ) ( ) Age 1.04 ( ) <0.001 Women 0.85 ( ) Systolic BP 0.99 ( ) <0.001 Black race 0.71 ( ) <0.001 MDRD est GFR 0.99 ( ) BUN ( ) ARB at D/C ( ) < ( ) β blocker at D/C 0.66 ( ) Aldo inh. at D/C ( ) ( ) Hgb 1.04 ( ) ( ) Pulse ( ) ( ) Quiroz Am J Cardiol 2014; 113:

26 The Adjudication Room

27 WHI Adjudication Central adjudicators Training period paired with experienced adjudicator Periodic conference calls to discuss challenging cases and achieve consensus Ongoing Quality assessment random dual coding for accuracy and reliability WHI primary outcomes are coded on forms No patient level measurements or test results are recorded Especially problematic for HF

28 Form 121 Ver WHI OS + CT (98-05)

29 Form 121 Ver WHI Ext 1 ( ) HF not adjudicated

30 Form 121 Ver EXT 2 ( )

31 But now abstracted by UNC ARIC process All participants randomized in HT and all Black and Hispanic ppts in WHI Re-abstracting all HF cases WHI and ES1 retrospectively Continuing to code ES2 Will record pertinent variables EF Labs ECGs Opportunities for more meaningful assessment of WHI HF Able to code HFREF and HFPEF Ideas are welcome

32 The Challenge If the incidence of new cases of HF were to remain at the present level of 1% per year in persons age >65 years, with the expected aging of the population, by 2050 there would be >1 million new cases per year in the United States. While the war to reduce the toll of CVD, broadly considered, must continue, the battle to control HF has now moved to the center stage of this war. This battle will be long and difficult, and because the enemy has many faces, it will have to be fought simultaneously on multiple fronts and with many different weapons. E. Braunwald, JACC Heart Failure 2013