Heart Failure. GP Update Refresher 18 th January 2018

Transcription

1 GP Update Refresher 18 th January 2018 Heart Failure Dr. Alexander Lyon Senior Lecturer and Consultant Cardiologist Clinical Lead in Cardio-Oncology Royal Brompton Hospital, London UK President of British Cardio-Oncology Society Heart Failure Association of the ESC Board Member Chair of HFA Cardio-Oncology Study Group of ESC Cardiology advisor to Macmillan Cancer

2 Overview What is heart failure? Causes of heart failure Presentation, assessment and diagnosis HFrEF and HFpEF Co-morbidities Treatment Acute Heart Failure Monitoring

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4 What is Heart Failure?

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7 Heart Failure is a Syndrome NOT a Disease!

8 *most common Causes of Heart Failure 1.Myocardial disease* 2.Valve disease 3.Arrhythmias 4.Pericardial disease 5.Congenital heart disease

9 Myocardial diseases 1. Coronary artery disease: Myocardial Infarction Ischaemia/hibernation/stunning 2. Dilated Cardiomyopathy (DCM): Idiopathic Viral Genetic (familial) Post-partum Hypertension Alcohol Chemotherapy 3. Hypertrophic Cardiomyopathy (HCM or HOCM or ASH) 4. Restrictive Cardiomyopathy 5. Arrhythmic right ventricular cardiomyopathy(arvc) 6. Drugs/Toxins 7. Other or unknown

10 Heart Failure is a big problem 26 millions adults worldwide with HF 1 Growing problem Survivorship following MI and cancer Ageing population 17-45% pts hospitalised with HF die within 12 months % mortality during HHF 1 HHF = hospitalisation with heart failure * From White Paper on Heart Failure: Preventing disease and death worldwide ESC HFA 2014

11 Evolving Heart Failure Population

12 Cardio-Oncology Heart disease in cancer patients Similar risk factors More potent treatments Increasing cancer survivors Mission: Preventing the cancer patient of today becoming the cardiac patient of tomorrow

13 Diagnostic algorithm for a diagnosis of heart failure Piotr Ponikowski et al. Eur Heart J 2016;37:

14 ECG in heart failure Heart rate Heart rhythm Old heart attacks Thickened heart muscle (hypertrophy) Conduction disease (bundle branch block)

15 Echocardiography Normal Heart Failure

16 Contrast Cardiac MRI Late Gadolinium Enhancement Normal Positive LGE Heart Attack

17 Myocardial Fibrosis in Dilated Cardiomyopathy

18 New classification of Heart Failure based upon Left Ventricular Ejection Fraction Structural cardiac remodelling Left atrial dilatation and/or Left ventricular hypertrophy Functional diastolic dysfunction Elevated E/E

19 Normal vs HFpEF

20 Who develops HFpEF?

21 Co-Morbidities Cardiac Arrhythmias Atrial fibrillation VF and sudden death Mitral valve leak Coronary disease Angina Stroke Diabetes Non-cardiac Renal failure Anaemia Iron deficiency Depression Gout Sleep-disordered breathing Erectile dysfunction Co-existing chronic airways disease (COPD) Cancer

22 New recommendations regarding co-morbidities Piotr Ponikowski et al. Eur Heart J 2016;37:

23 Total number of non-cardiac co-morbidities Braunstein JB et al. JACC 2003; 42:

24 Heart failure patients have fears and anxiety about mortality The cause of death is equal between clinical worsening and sudden death, leaving HF patients uncertain about both when and how they could die 1 HF patients are often fearful of death during times of new symptoms or symptom exacerbation 2 16% are afraid of dying during deterioration 1 4% have this fear very often 1 Fear of death does not change significantly during the 6 months after HF deterioration 1 Fear of death and anxiety/depression are correlated 1 1. Stromberg & Jaarsma. Eur J Heart Fail 2008;10(6): Abshire et al. J Clin Nurs 2015;24(21 22):

25 EMPHASIS-HF Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure 2737 patients, 55 years, NYHA class II, with CV hospitalization within 6 months (or elevated BNP/NT pro BNP) and LVEF 0.30 (or 0.35 if QRS duration >130msec. Followed for a median of 21 months >25% of patients with MILD symptoms experience CV death or HF hospitalization within 3 years Zannad et al. NEJM 2011;364:11-21

26 Heart Failure Treatments

27 New therapeutic algorithm for symptomatic heart failure with reduced ejection fraction Piotr Ponikowski et al. Eur Heart J 2016;37:

28 ACE I, BB and MRA still cornerstone for treating HFrEF ACE Inhibitors Enalapril 20mg BD Ramipril 5mg BD Lisinopril 20mg OD Betablockers Carvedilol 25mg BD Bisoprolol 10mg OD Nebivolol 10mg OD Aldosterone antagonists Spironolactone 25mg OD* Eplerenone 50mg OD *can be increased to 50mg OD Piotr Ponikowski et al. Eur Heart J 2016;37:

29 The arrival of ARNI Entresto (LCZ696) = Angiotensin receptor antagonist and neprilysin inhibitor (ARNI)

30 PARADIGM-HF

31 PARADIGM-HF: Results ARR 4.7% RRR 20% Components of 1 o Endpoint Outcome LCZ696 (n=4187) Enalapril (n=4212) Hazard ratio* (95% CI) Absolute Risk Reduction p-value Death from CV causes 558 (13.3) 693 (16.5) 0.80 ( ) 3.2% <0.001 First HF hospitalization 537 (12.8) 658 (15.6) 0.79 ( ) 2.8% <0.001

32 Benefits observed across age groups Pardeep S. Jhund et al. Eur Heart J 2015;36:

33 Hypotension with Sacubitril-Valsartan (Entresto) common

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36 Real World Experience Early days Some HF patients very keen to have it Low BP most common SE Slower uptitration strategies Review loop diuretic dose GPs generally supportive Actual number of eligible patients modest Uptitration strategies Remember to stop ACE I Blockbuster culture

37 Biventricular Pacemakers for Cardiac Failure

38 New recommendations of what to avoid in HF patients Piotr Ponikowski et al. Eur Heart J 2016;37:

39 Acute Heart Failure

40 Patient journey with heart failure Recurrent hospitalization

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42 UK National HF Audit Acute hospital HF admission data UK National HF Audit ~ 67,000-81,500 admissions per annum ~9% in hospital mortality ~24% mortality at 1 year

43 UK National HF Audit Acute hospital HF admission data

44 UK National HF Audit Acute hospital HF admission data

45 UK National HF Audit Acute hospital HF admission data

46 Getting the basics right Cardiology FU HF nurse No Cardiology FU No HF nurse Post code lottery: 3 fold difference in mortality Specialist care in top performing hospital vs non-specialist care in poor performing hospital UK National Heart Failure Audit 2014

47 Royal Brompton Hospital Acute Heart Failure Audit 2016 In-Hospital Mortality (%) NICOR Overall Cardiology Ward In-hospital mortality

48 Warning signs

49 Death due to HF (%) Proportion of death due to heart failure is comparable across the NYHA II IV classes 1 The overall mortality due to HF ranges from 1.8% to 5.3% over 27 months Deaths due to HF Total deaths I II III IV NYHA Class HF, heart failure; NYHA, New York Heart Association. 1. Desai et al. Eur Heart J 2015;36:

50 Importance of Clinical Worsening of Heart Failure Treated in the Outpatient Setting Mortality (%) after a first event or in patients with no event. Naoki Okumura et al Circulation (23):

51 Heart Failure Nurse Specialists reduce Unplanned HF Hospitalisations and are Cost Effective

52 Unmet Needs: Monitoring Can we prevent hospitalisation? Strategies: Primary care Secondary care Specialist nurses Remote telemonitoring

53 Remote Monitoring Can we predict and prevent hospitalisation?

54 Unmet Needs: Remote Monitoring Can we prevent hospitalization

55 New home heart failure monitor

56 Preventing unscheduled HF admissions Monitoring 6 monthly reviews Rate, rhythm, medication Uptitrate evidence based therapy in HF patients with low EF to target doses ACE Inhibitors Betablockers (licensed for HF) Aldosterone antagonists Sacubitril-Valsartan Ivabradine CRT pacemakers Integrated care with specialist HF nurses and Cardiology HF service Coordinating 1 o and 2 o care Identify high risk groups Previous admission Diuretic dose increases High BNP or NTproBNP Renal dysfunction Low albumin Palliative Care

57 Dr. Alexander Lyon Senior Lecturer and Consultant Cardiologist Royal Brompton Hospital, London Tel: Mobile: Fax: