CLINCIAL APPLICATION OF GUIDELINES IN HEART FAILURE

Transcription

1 CLINCIAL APPLICATION OF GUIDELINES IN HEART FAILURE SSC Journée d Automne 25 novembre 2010 Dr. Charles Seydoux, spéc. FMH en médecine interne et en cardiologie, Lausanne Dr. Claudia Bösch, Oberärztin Herzinsuffizienz & Transplantation, Inselspital, Bern

2 Clinical case scenario A.G. ( ), 1963 No CV history in the past Active smoker No medical treatment 169 cm, 71 kg, BMI 25

3 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), 1963 No CV history in the past Active smoker No medical treatment 169 cm, 71 kg, BMI : Chest pain on exertion over past 2 months Acute chest pain in the morning 144 (nitrates) admitted to rural primary care hospital: normal clinical examination, no more chest pain ECG:

4 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), 1963 ECG in ER, 3 hours after onset of symptoms:

5 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE What next?

6 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), 1963 ECG: acute anterior myocardial infarction : Thrombolytic therapy in primary care hospital (Rapilysin (r-pa), ASS 250mg, Clopidogrel 600mg) - max CK rise up to 5400, Troponin ECG post-lysis:

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8 2010

9 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), 1963 Course of hospitalization: symptom-free on ambulation, no signs of congestion, BP 100/65mmHg, HR 90bpm, SaO2 96% on room air Transthoracic echocardiography on day 2: LVEF 30-35% akinetic apex hypokinetic anterior and septal mid-wall no significant valve pathologies

10 What next? a) Medical treatment for heart failure (non-invasive strategy) b) Functional testing (DSE, MPI, cmri, treadmill?), only if angina -> cath c) Cath directly d) Discharge, review in 3 months, then decide if further investigations needed

11 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : Coronary Angiography

12 Now what?

13 BUT:.

14 Evidence: treatment for persistent infarct-related occluded artery after MI Late Open artery hypothesis, 1993: Post-MI patency of IRA independent predictor of - lower incidence of death, -HF, - recurrent MI occluded IRA open IRA BRAVE-2 (beyond 12 hrs (12-48) reperfusion alternative evaluation trial) 2005: -final infarct size smaller in PCI group: 8% vs 13%

15 On the other hand. DECOPI (Desobstruction Coronaire en Post- Infarctus), 2004 LVEF 5% higher in invasive group after 6 mo more patent arteries in PCI 83 vs 34% restenosis 49% in PTCA ( ) NO DIFFERENCE IN CLINICAL OUTCOMES, HIGHER COST THAN MEDICAL OAT (occluded artery trial), 2006 no sign. benefit from IRA opening in absence of viable or ischemic myocardium

16 What do the most recent guidelines (2010) recommend?

17 ESC 2010 Lit 88: salvage in late PCI, Busk Lit 89: BRAVE 2 Lit 90: DECOPI Lit 91: OAT

18 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : Coronary angiography: LAD occlusion-> PCI with DES LV EF 30-35% after STEMI, late reperfusion (d 4), AP CCS 1, NYHA I-II, BP 100/75mmHg, HR 80bpm, BNP 420, creatinin150 umol/l medical treatment:?

19 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), 1963 Treatment at discharge: Aspirin 100 mg Plavix 75 mg Lisinopril 5 mg Beloc Zoc 50 mg Pravastatine 40 mg Nexium 40 mg..

20 ESC 2008

21 high risk pts

22 ESC STEMI 2008 ACE-Inhibitor post-mi

23 ACE-Inhibitor and HF 159 Challenging the dogma of high target doses in.., Archives of Cardiovascular Disease 2009, F. Follath

24 Betablocker post-mi BMJ 1999

25 Lack of superior efficacy of high vs moderate-to-low dose betablocker : MERIT-HF subgroup analysis (JACC 2002) => more not always better

26 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : stable, no congestion, atypical angina, NYHA II-III TTE: LVEF 25-30%, anterior infarct, moderate MR BP 95/65mmHg, HR 65bpm, Crea 160umol/L, BNP 1000 ECG:

27 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : stable, no congestion, atypical angina, NYHA II-III TTE: LVEF 25-30%, anterior infarct, moderate MR BP 95/65mmHg, HR 65bpm, Crea 160umol/L, BNP 1000

28 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : stable, no congestion, atypical angina, NYHA II-III TTE: LVEF What 25-30%, anterior next? infarct, moderate MR BP 95/65mmHg, HR 65bpm, Crea 160umol/L, BNP 1000 ECG: nc SR, Q wave anterior, QRS 90ms Current medication: Lisinopril 5 mg Beloc Zoc 50 mg Pravastatine 40 mg Aspirin 100 mg Plavix 75 mg Nexium 40 mg

29 J Am Coll Cardiol 2005;46:

30 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : stable, no congestion, atypical angina, NYHA II-III TTE: LVEF 25-30%, anterior infarct, moderate MR BP 95/65mmHg, HR 65bpm, Crea 160umol/L, BNP 1000 ECG: ncsr, QRS 90 msec, Q V1-V3 Medication: Lisinopril 5 mg Beloc Zoc 50 mg Pravastatine 40 mg Aspirin 100 mg Plavix 75 mg Nexium 40 mg Aldactone 25mg, then Digoxin 0.250mg ( ng/ml) What next?

31 ESC 2008 MADIT II: all cause mort 20% vs 14.2% SCD-HeFT

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33 The superiority of CRT was driven by a 41% reduction in the risk of heart failure events

34 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : Defibrillator implantation for primary prevention : NYHA III-IV, orthopnea, NPD, no angina BP 80/60 mmhg, HR 62bpm, no signs of heart failure Creatinine 200umol/L, BNP 2010, Na 128, K 4.5 ECG: SR, QRS 90 msec, infarct V1-V3

35 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : Defibrillator implantation for primary prevention : NYHA III-IV, orthopnea, NPD, no angina BP 80/60 mmhg, HR 62bpm, no signs of heart failure Creatinine 200umol/L, BNP 2010, Na 128, K 4.5 ECG: SR, QRS 90 msec, infarct V1-V3 Medication: Lisinopril 5 mg Beloc Zoc 50 mg Pravastatine 40 mg Aspirin 100 mg Plavix 75 mg Nexium 40 mg Aldactone 25mg Digoxin 0.250mg What next?

36 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : Defibrillator implantation for primary prevention : NYHA III-IV, orthopnea, NPD, no angina BP 80/60 mmhg, HR 62bpm, no signs of heart failure Creatinine 200umol/L, BNP 2010, Na 128, K 4.5 ECG: SR, QRS 90 msec, infarct V1-V3 Medical treatment: reduction of BB from 50 to 25 mg/d

37 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : Defibrillator implantation for primary prevention : NYHA III-IV, orthopnea, NPD, no angina BP 80/60 mmhg, HR 62bpm, no signs of heart failure Creatinine 200umol/L, BNP 2010, Na 128, K 4.5 ECG: SR, QRS 90 msec, infarct V1-V3 Medical treatment: reduction of BB from 50 to 25 mg/d What next? : NYHA II-III, feels better, no signs of HF, 115/75, HR 70/ ECG: sinus rhythm, QRS 100ms Creatinine 165umol/L, Urea 20, BNP 1900, Na 129, K 4.9

38 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE A.G. ( ), : acute anterior myocardial infarction, PCI to LAD : Defibrillator implantation for primary prevention : NYHA III-IV, orthopnea, NPD, no angina BP 80/60 mmhg, HR 62bpm, no signs of heart failure Creatinine 200umol/L, BNP 2010, Na 128, K 4.5 ECG: SR, QRS 100 msec, infarct V1-V3 Medical treatment: reduction of BB from 50 to 25 mg/d : NYHA II-III, feels better, no signs of HF, 115/75, HR 70/ ECG: sinus rhythm, QRS 100ms Creatinine 165umol/L, Urea 20, BNP 1900, Na 129, K 4.9 CPET: VO2 max 13.2 ml/min/kg

39 End-stage heart failure

40 CLINICAL APPLICATION OF GUIDELINES IN HEART FAILURE

41 Stage D heart failure: evaluation of cardiac transplantation Hunt et al focused update ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults. J Am Coll Cardiol. 2009

42 Evaluation for cardiac transplantation: Scoring ) ) Aaronson,, Mancini. Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation. Circulation 1997;95: Listing Criteria for Heart Transplantation: ISHLT Guidelines for the Care of Cardiac Transplant Candidates, 2006

43 VAD example: Typ Heart Mate II by Thoratec High-speed ( rpm), blood flow up to 10 liters/min axial flow, rotary blood pump, non-pulsatile, 375g, 4cmx6cm, titanium.

44 Ventricular assist device Bridge to decision Bridge to recovery Bridge to transplant Bridge to bridge (destination) Listing Criteria for Heart Transplantation: ISHLT Guidelines for the Care of Cardiac Transplant Candidates, 2006

45 Improved survival in patients with VAD therapy EACTS, 2008 Early = Mid = Late= Outcomes dramatically improved

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