Heart Failure Medical and Surgical Treatment
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1 Heart Failure Medical and Surgical Treatment Daniel S. Yip, M.D. Medical Director, Heart Failure and Transplantation Mayo Clinic Second Annual Lakeland Regional Health Cardiovascular Symposium February 10, MFMER slide-1
2 Burden of Heart Failure Prevalence 5.7 million Americans >20-years old Lifetime risk at age 40-1:9 men, 1:6 women Incidence >825,000 new cases/year Morbidity million office visits 6.5 million hospital days annually More than 1 million hospital discharges Most frequent cause of hospitalization (>65 yrs) $9 billion hospital costs (71% total health expen) Mortality 20% 10-year survival in patients with symptoms 50% diagnosed die within 5 years 11% 30-day inpatient hospital mortality American Heart Association Heart Disease and Stroke Statistics Update 2017 MFMER slide-2
3 Risk Factors for Heart Failure Coronary Artery Disease Hypertension Diabetes Age Gender and Ethnicity Obesity Arrhythmias 2017 MFMER slide-3
4 Treatment Lifestyle modification Risk factor modification Diet Fluid Limitation Monitoring weight daily Exercise 2017 MFMER slide-4
5 Treatment Medications shown to improve survival hydralazine plus isosorbide dinitrate angiotensin converting enzyme (ACE) inhibitors β-blockers (carvedilol, metoprolol succinate, bisoprolol) spironolactone angiotensin receptor blocker (ARB) sacubitril-valsartan (Entresto) * * Limited Data 2017 MFMER slide-5
6 Angiotensin-Neprilysin Inhibition Neprilysin, a neutral endopeptidase, degrades several endogenous vasoactive peptides, including natriuretic peptides, bradykinin, and adrenomedullin. Inhibition of neprilysin increases the levels of these substances, countering the neurohormonal over-activation that contributes to vasoconstriction, sodium retention, and maladaptive Vardeny et al. JACC: Heart Failure 2014;2(6): MFMER slide-6
7 2017 MFMER slide-7
8 PARADIGM-HF McMurray et al. NEJM MFMER slide-8
9 PARADIGM-HF McMurray et al. NEJM MFMER slide-9
10 Dosage of LCZ696 (Entresto) ENTRESTO is contraindicated with concomitant use of an angiotensin-converting enzyme (ACE) inhibitor. If switching from an ACE inhibitor to ENTRESTO allow a washout period of 36 hours between administration of the two drugs Patients previously taking an ACE inhibitor or ARB: The recommended starting dose of ENTRESTO is 49/51 mg twice-daily Patients not taking an ACE inhibitor or ARB or previously taking low Doses of these agents: The recommended starting dose of ENTRESTO is 24/26 mg twice-daily Double the dose of ENTRESTO after 2 to 4 weeks to the target maintenance dose of 97/103 mg twice daily, as tolerated 2017 MFMER slide-10
11 ARNI 2017 MFMER slide-11
12 Treatment Medications shown to improve symptoms diuretics digoxin ivabradine (Corlanor) * * Limited Data 2017 MFMER slide-12
13 Ivabradine (Corlanor) 2017 MFMER slide-13
14 Ivabradine is a specific inhibitor of the I f current in the sinoatrial node Symptomatic heart failure and a left-ventricular ejection fraction of 35% or lower, were in sinus rhythm with heart rate 70 beats per min or higher, had a hospitalization for HF within the previous 12 months and were on stable background therapy including a betablocker when tolerated Swedberg et al. Lancet 2010; 376: MFMER slide-14
15 Mean heart rate during the study in the total study population Swedberg et al. Lancet 2010; 376: MFMER slide-15
16 Kaplan-Meier cumulative event curves for the primary composite endpoint of cardiovascular death or hospital admission for worsening heart failure RR 18% Swedberg et al. Lancet 2010; 376: MFMER slide-16
17 Kaplan-Meier cumulative event curves for (A) death from heart failure and (B) all-cause death RR 26% Swedberg et al. Lancet 2010; 376: MFMER slide-17
18 Effect of Ivabradine on LV Remodeling and Function LVESVI ml/m ml/m2 p= Baseline Month 8 56 Baseline Baseline 54 Ivabradine 8 mos 8 mos Placebo Tardif et al. ESC EHJ MFMER slide-18
19 Effect of Ivabradine on LV Remodeling and Function LVEF % 2.4 p= Baseline Baseline 8 mos 8 mos Tardif et al. ESC EHJ MFMER slide-19
20 IVABRADINE 2017 MFMER slide-20
21 Treatment Device Treatment Continuous positive airway pressure (CPAP) for sleep apnea Implantable cardioverter defibrillator (ICD) Biventricular pacing Resynchronization Therapy (CRT) 2017 MFMER slide-21
22 Treatment Surgical Treatment Mitral Valve Repair Other valvular replacement Coronary Artery Bypass Grafting Left Ventricular Assist Device (LVAD) Cardiac Transplantation 2017 MFMER slide-22
23 SURVIVAL (Years) Heart Transplant: Gold-Standard 1967 (1 week) Dr. Shumway Dr. Barnard Louis Washkanski
24 100 Adult and Pediatric Heart Transplants Kaplan-Meier Survival (Transplants: January 1982 June 2015) Median survival = 10.7 years; Median survival conditional on surviving to 1 year = 13.3 years 75 Survival (%) 50 N = 118, Years JHLT Oct; 35(10): MFMER slide-24
25 Adult and Pediatric Heart Transplants Recipient Age Distribution by Era % of transplants (N=57,185) (N=40,500) /2015 (N=28,210) p< Recipient Age JHLT Oct; 35(10): MFMER slide-25
26 Limited Donors For Heart Transplantation Number Patients on Transplant Wait List Patients Transplanted Year Number of Wait List Additions Number of Heart Transplants Adapted from: MFMER slide-26
27 Adult Heart Transplants % of Patients Bridged with Mechanical Circulatory Support* 60 (Transplants: January 2000 December 2014) 50 % of Patients Year of Transplant 2016 * LVAD, RVAD, TAH, ECMO JHLT Oct; 35(10): MFMER slide-27
28 HeartMate II HeartWare 2017 MFMER slide-28
29 LVAD Function 2017 MFMER slide-29
30 Pump Function 2017 MFMER slide-30
31 Actuarial Survival INTERMACS ± 4% 55 ± 7% 80% INTERMACS CF LVAD 69% 58 ± 5% PF LVAD REMATCH, Medical Arm: 25% IMPROVEMENTS with: - DEVICES - MANAGEMENT LESS ADVANCED Illness (Patient Selection) 24 ± 11%
32 Definitions for Advanced Heart Failure HF Association of European Society of Cardiology Severe HF symptoms (NYHA Class III/IV) Episodes of volume overload and/or low resting CO Objective evidence of myocardial dysfunction Echo, cath, BNP/NT-proBNP Poor objective function capacity Inability to exercise 6 minute walk test <300m Peak VO2<12-14 ml/kg/min More than one HF hospitalization in past 6 months Persistence of above despite optimal medical therapy 2017 MFMER slide-32
33 Conclusions Landscape of Advanced HF has changed due to emerging therapies Transplant remains the gold-standard therapy VAD therapies are undergoing increased implementation as device technology improves Increasing evidence that placement of VAD earlier in advanced heart failure is associated with better outcomes Simple clues to identify advanced HF > 1 rehospitalization/ed visit within 6 months of admission Unable to tolerate evidence based heart failure therapy (ACE/BBL) Low SBP, renal insufficiency Persistent congestion, dyspnea, NYHA Class III/IV symptoms 2017 MFMER slide-33
34 Thank you (904) MFMER slide-34
35 Questions & Discussion 2017 MFMER slide-35
36 Mayo Clinic Locations 2017 MFMER slide-36
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