Management of Advanced Systolic Heart Failure. Robert W. Hull MD FACC Associate Professor of Medicine West Virginia University

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1 Management of Advanced Systolic Heart Failure Robert W. Hull MD FACC Associate Professor of Medicine West Virginia University

2 American College of Cardiology Foundation (ACCF) American Heart Association (AHA) Physician Consortium for Performance Improvement (PCPI )

3 Stages of Congestive Heart Failure

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5 A Depiction Of The Clinical Course Of Heart Failure With Associated Types And Intensities Of Available Therapies. Allen L A et al. Circulation 2012;125: Copyright American Heart Association

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8 Renal Function During Heart Failure Management Worsening renal function (WRF) defined most liberally in studies as rise in creatinine 0.2 mg/dl Acute kidney injury (AKI) defined by American Heart Association scientific statement as creatinine rise of 0.5 mg/dl if creatinine < 2.0 mg/dl or rise of 1.0 mg/dl if creatinine > 2.0

9 Cardiorenal Syndromes Congestive heart failure with: Worsening renal function ( >25% increase in creatinine or BUN during treatment for acute decompensation) Difficulty in diuresis without worsening renal function ACE-inhibitor intolerance due to hypotension or hyperkalemia in severe heart failure Chronic renal insufficiency complicating heart failure therapy

10 Clinical Approach to Cardiorenal Syndromes Hypovolemic High central venous pressure Vasoconstricted Normal SVR with poor LV performance +/or low blood pressure Vasodilated

11 Physical Assessment Exam Weight Blood pressure, JVP Pulmonary edema, hepatic congestion, ascites, peripheral edema Peripheral perfusion (warm or cold feet) Echo Estimate of RA pressure Estimate of SVR Estimate of cardiac output/ci Pulmonary artery catheterization CVP, SVR, C.O.

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13 Cardiac Output = VTI x Area of Outflow Tract x Heart Rate 8cm/sec x 3cm x 80 beats/min = 1920 ml/min, 1.9 L/min

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15 Echo Estimation of SVR Mean arterial pressure: (systolic BP + twice diastolic pressure) / 3 Right atrial pressure estimation from Echo Cardiac output estimation from Echo SVR= (mean arterial pressure-mean RA pressure)x 80/CO

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19 Concept of Plasma Refill Rate in ADHF Diuretics to increase sodium loss and decrease venous pressures Redefining the Therapeutic Objective in Decompensated Heart Failure: Hemoconcentration as a Surrogate for Plasma Refill Rate Boyle and Sbotka J Card Failure May 2006

20 Concept of Plasma Refill Rate in ADHF Continued diuresis

21 Clinical Approach to Cardiorenal Syndromes

22 Hypovolemic Cardiorenal Syndrome Volume depleted with low CVP with low cardiac output and normal or increased SVR Etiologies include overdiuresis or intercurrent illness causing volume loss MUST fluid resuscitate and hold diuretics

23 High CVP Cardiorenal Syndrome Volume overloaded (high CVP) with normal cardiac output and SVR CVP typically > mm Hg MUST continue diuresis to normalize CVP Hemoconcentration correlates with improved prognosis

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25 Vasocontricted Cardiorenal Syndrome Euvolemic or hypervolemic (CVP normal or elevated) with reduced cardiac output and elevated SVR (often > 1800) Cold feet ACE-inhibitors and vasodilators to reduce SVR If hypotension develops, may require inotropic support

26 Normal SVR Cardiorenal Syndrome Low cardiac output and or BP results in reduced renal perfusion- BAD PUMP Inotropes and often pressors LVAD

27 Vasodilated Cardiorenal Syndrome Cardiac output can be normal but BP and SVR are low, often < 500; warm feet Stop ACE-inh, initiate pressors (AVP) with or without inotropes Exclude sepsis

28 Profiles Of The Cardiorenal Syndrome J. Thomas Heywood. The Cardiorenal Syndrome: A Clinician s Guide to Pathophysiology and Management CRS due to: Fluid Status CO CI SVR Treatment Too Dry!!! Dry Low Nml or high Fluids, stop diuretics Too Wet!!! (high CVP) Wet Nml Nml Continuous diuretic infusion, distal tubular diuretic, ultrafiltration Too Clamped Down!!! Wet or Nml Low High ACEI, Nitroprusside, Nesiritide, Relaxin Vasodilated!!! Nml or wet Nml or high Low Stop ACEI, Pressors, Vasopressin Inotropes, VAD No Pump!!! Wet or Nml Low Nml Inotropes, Vasopressors Balloon Pump LVAD Intrinsic Renal /Diuretic Resistance Wet Nml Nml Continuous diuretic infusion, distal tubular diuretic, ultrafiltration

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30 DIURETIC OPTIMIZATION STRATEGIES EVALUATION IN ACUTE HEART FAILURE (DOSE) G. Michael Felker, MD, MHS, FACC Christopher M. O Connor, MD, FACC on behalf of the NHLBI Heart Failure Clinical Research Network

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32 Secondary Endpoints: Low Vs. High Intensification Low High P value Dyspnea VAS AUC at 72 hours % free from congestion at 72 hrs 11% 18% Change in weight at 72 hrs -5.3 lbs -8.2 lbs Net volume loss at 72 hrs 3575 ml 4899 ml <0.001 % Treatment failure 37% 40% 0.56 % with Cr increase > 0.3 mg/dl at 72 hrs 14% 23% Length of stay, days (median)

33 Creatinine (mg/dl) Changes In Creatinine Over Time*: High Vs. Low 1.8 p = Low High p = p = 0.28 p = 0.07 p = 0.85 p = Time (days) *P values are for change in creatinine from baseline

34 Concept of Plasma Refill Rate in ADHF Continued diuresis

35 Figure 1. Admission-to-discharge percentage change in GFR grouped by presence or absence of hemoconcentration. Testani J M et al. Circulation 2010;122: Copyright American Heart Association

36 Figure 2. Survival curves grouped by presence or absence of hemoconcentration after adjustment for baseline characteristics. Testani J M et al. Circulation 2010;122: Copyright American Heart Association

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40 Original Article Ultrafiltration in Decompensated Heart Failure with Cardiorenal Syndrome Bradley A. Bart, M.D., Steven R. Goldsmith, M.D., Kerry L. Lee, Ph.D., Michael M. Givertz, M.D., Christopher M. O'Connor, M.D., David A. Bull, M.D., Margaret M. Redfield, M.D., Anita Deswal, M.D., M.P.H., Jean L. Rouleau, M.D., Martin M. LeWinter, M.D., Elizabeth O. Ofili, M.D., M.P.H., Lynne W. Stevenson, M.D., Marc J. Semigran, M.D., G. Michael Felker, M.D., Horng H. Chen, M.D., Adrian F. Hernandez, M.D., Kevin J. Anstrom, Ph.D., Steven E. McNulty, M.S., Eric J. Velazquez, M.D., Jenny C. Ibarra, R.N., M.S.N., Alice M. Mascette, M.D., Eugene Braunwald, M.D., for the Heart Failure Clinical Research Network N Engl J Med Volume 367(24): December 13, 2012

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43 Management Strategies Long Term Cardiac transplantation Left Ventricular Assist Device (LVAD) Palliation with or without continuous inotrope infusion

44 Palliation Allen L A et al. Circulation 2012;125: Copyright American Heart Association

45 Keys to the Future Earlier Identification and Intervention