Dr Emma Copsey Consultant Cardiologist Glenfield Hospital 28 th September 2017

Transcription

1 Dr Emma Copsey Consultant Cardiologist Glenfield Hospital 28 th September 2017

2 Educational Objectives Objectives To review the GIM & Cardiology syllabus for HF To review the new nomenclature/classification for HF Broad overview of HFpEF Clinical Cases CME Questions Questions

3 GIM Syllabus HF related to 3 sections: 1. Managing long term conditions and promoting self care 2. Symptom based competences/emergency presentations breathlessness (p51-52) 3. System specific competencies CV medicine, Heart Failure (p86-88)

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5 HF: Medical Mx & Interventional Therapy Establishing a diagnosis Knowledge of relevant Ix and Mx Knowledge of prognosis and likely response to therapy

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7 Scope of the Problem HFpEF most common type of HF in patients >65yrs Impact as great as HFrEF, with similar hospitalisation rates, substantial mortality Understanding of pathophysiology incomplete, optimal treatment undefined HFpEF prevalence increasing Challenging clinical syndrome

8 Scope of the Problem HF in England: 400,000 emergency admissions/yr 10-15% die in hospital >20% surviving admission die within 12 months ~50% of those with HF have preserved EF (HFpEF) Non-CV hospital readmissions and mortality are more common in HFpEF than HFrEF

9 Trends of HF Burden

10 Cause of Death In HFpEF Vs HFrEF

11 Defining HFpEF Uncertanties re definition, diagnosis and pathophysiology EF 50% in current guidelines, but some trials use >45% A clinical judgement Dyspnoea common but neither sensitive nor specific. Hallmark is exaggerated rise in PCWP and PA pressure during exercise and failure of LVED volume to rise during exercise. A heterogeneous group of disorders

12 Pathophysiology HFpEF initially termed diastolic HF but only some have diastolic dysfunction Oxidative stress and inflammatory process Distinct cellular & interstitial characteristics

13 Systemic Nature of HFpEF Comorbidities actively contribute to development of HFpEF. Hypertension strong risk factor, 80-90% of pts have it Advanced age, high prevalence of common co-morbidities: Hypertension Diabetes Obesity AF Pro-inflammatory state that results in systemic arterial and microvascular dysfunction Excess adipose tissue pro-inflammatory. 85% of elderly HFpEF pts are overweight or obese

14 ESC HF Definitions by EF

15 ESC HF Definitions by EF

16 Diagnosing HF

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18 NICE Guidance BNP & Referral Suspected HF and previous MI refer pt for urgent echo & specialist assessment within 2/52 If symptoms and signs of HF without MI: If BNP >400pg/ml or NT-proBNP >2000, echo & specialist within 2/52 BNP pg/ml or NT-proBNP , echo & specialist within 6/52 A normal BNP/NT-proBNP excludes the diagnosis without the need for echo

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20 Natriuretic Peptides Secreted by myocardium in response to stretch Induce: natriuresis/diuresis, vasodilatation, inhibition of SNS and RAAS NP testing high negative predictive value, so used primarily as a rule out test for HF BNP concentrations have a strong, independent association with an adverse prognosis & are predictive of in-hospital mortality independent of EF

21 Natriuretic Peptides A raised BNP is not diagnostic of HF. Other causes: ACS Heart Muscle Disease eg LVH VHD AF Myocarditis Cardiac surgery Advancing age (>70) Anaemia Renal/Liver Failure Pulmonary: OSA, pneumonia, Pul HTN, PE, hypoxia, COPD Sepsis Lower levels can be observed in: Obesity (BMI >35) Those treated with diuretics, ACE- I, BB, MRAs

22 Initial Investigations Bloods: FBC, U+Es, LFTs, albumin, TSH, ferritin, glucose, serum & urine protein electrophoresis, CK, BNP ECG: may give clues to aetiology of HF eg IHD, hypertension. ~1/4-1/3 of HF pts have AF at presentation CXR: Useful if suspecting pulmonary oedema or to exclude other causes of breathlessness

23 Structural and Functional Abnormalities in HFpEF Structural: LVH, LA dilatation Doppler: E/e ratio, abnormal mitral inflow Biomarkers: BNP/NT-proBNP (>100/400 respectively) Rhythm: AF Invasive haemodynamics: LVEDP

24 NICE 2014 Acute HF Diagnosis Use a single measurement of serum natriuretic peptides- BNP or NT-proBNP and the following thresholds to rule out the diagnosis of heart failure: BNP <100 ng/litre NT-proBNP <300 ng/litre. In people presenting with new suspected acute HF with raised natriuretic peptide levels, perform echocardiography to establish presence/absence of cardiac abnormalities. Consider performing transthoracic 2D echocardiography within 48 hours of admission to guide early specialist management.

25 NICE Quality Standard Acute HF DEC 2015 Statement 1. Adults presenting to hospital with new suspected acute HF have a single measurement of natriuretic peptide. Statement 2. Adults admitted to hospital with new suspected acute HF and raised natriuretic peptide levels have an echo within 48 hours of admission. Statement 3. Adults admitted to hospital with acute heart failure have input within 24 hours of admission from a dedicated specialist heart failure team.

26 Pharmacological Treatment What do current ESC Guidelines say? Acknowledge lack of evidence Recommend diuretics Focus on management of underlying conditions Hypertension Myocardial ischaemia Control HR Preserve SR No Rx shown to convincingly morbidity/mortality

27 TOPCAT Trial Sprinolactone Vs Placebo US, Brazil, Argentina, Russia, Georgia EF> 45% Recent hospital admission with HF or BNP +HF Sx No difference in primary outcome of death or hospitalisation for HF Subgroup analysis in Americas showed some benefit on the basis of BNP level

28 Exercise in HFpEF Looked at in small trials Lower physical activity levels associated with incidence of HFpEF Exercise training causes reverse remodelling of atrium Effects of exercise training: meta analysis: Improved peak O2 uptake Improved 6 min walk test Improved Minnesota HF questionnaire 1-3 months exercise training can improve QOL and mental/social improvement

29 Case 1 RT, 80 yr old male PC: Peripheral oedema Nurse concerned about oedema when went for leg dressing change Worsening oedema despite increased diuretic dose 1/52 ago Orthopnoea

30 Case 1 PMH AF COPD OSA Hypercholesterolaemia Fatty Liver Gastric Ulcer Prostate Ca Hypothyroidism DH Bisoprolol 5mg od Spironolactone 50mg od Atorvastatin 40mg od Apixiban 5mg od Omeprazole 20mg od Levothyroxine 25mcg od Fostair, atrovent, ventolin inhalers NKDA

31 Case 1-SH Ex-smoker ~30 units alcohol/week (previously heavier) Independent ADLs

32 Case 1-Examination Obs: Afebrile, p90 bpm, BP 105/56, sats 95% on air, RR 17, BM 6.5 Clinically jaundiced JVP, HS Normal Chest Clear Pitting oedema to thighs Umbilical hernia, hepatomegaly

33 Case 1-Investigations ECG: 90bpm AF, RBBB CXR: Lungs clear Bloods: Hb 114, WCC 11.4, MCV 115, plt 213 Na 122, K 3.9, Ur 10.0, Cr 134, egfr 48 Alb 30, ALP 248, ALT 59, Bili 169 INR 1.4, PT 16.2 BNP TSH 9.1

34 Clinical Impression/Plan Δ Decompensated HF Hepatic Congestion? 1⁰ Hepatic Pathology Plan Frusemide 240mg IV/24hrs Echo AbdoU/S Blood Culture Haematinics

35 Case 1-Echo Poor views, scanned in chair LV function appears reasonable Dilated atria Dilated and impaired RV function

36 Case 1-Progress Weight on admission 19/ kg In 8 days lost 9kg, now 110kg Still on IV frusemide 240mg/24hrs Levothyroxine 50mcg od 18/9 22/9 26/9 Na K Ur egfr ALP ALT Bili

37 Case 2 70 yr old Female PC: Oedema Planned admission for?tavi Worsening oedema, SOB stable, mobility Known severe AS, not suitable for surgical AVR

38 Case 2 PMH AF Asthma Morbid obesity Pulmonary Hypertension Severe AS SH Non-smoker No alcohol Usually Independent DH Warfarin Bisoprolol 7.5mg od Orlistat 120mg tds Salbutamol, salmeterol& clenil inhalers NKDA

39 Examination Findings Obs: BP 119/73, p60bpm, sats 97% on air JVP PSM & ESM Chest: AE Lt.base Pitting oedema to knees Abdominal wall ascites

40 Investigations Bloods: Hb 88, WCC 4.4, plt 100, INR 1.9 Na 137, K 4.5, Ur 10.5, Cr 97, egfr 52 ECG: 80bpm AF, RBBB CXR: Pulmonary oedema

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42 Impression / Plan Imp: Decompensated HF secondary to severe AS Plan: Frusemide 240mg IV/24hrs Daily weights TAVI MDT

43 Progress Weight on admission 181.3kg Lost 12kg in 10 days 19/9 21/9 25/9 26/9 Na K Ur egfr

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45 Question 1 The following statements describe heart failure with preserved ejection fraction. Which one is false? A. The most common form of HF in older adults B. Stable in prevalence despite population aging C. Most challenging clinical syndrome for the practicing clinician and basic research scientist D. Originally considered to be predominantly caused by diastolic dysfunction E. Typified by a broad range of cardiac and non-cardiac abnormalities and reduced reserve capacity in multiple organ systems

46 Question 2 Which statement is false? Compared to all CHF patients, HFpEF patients: A. Are less symptomatic B. Their mean NYHA class is lower C. Have a lower number of CHF symptoms per patient D. Have a lower rate for all individual symptoms except peripheral oedema E. Have a higher rate for all individual symptoms

47 Question 3 Which statement is true? To be satisfied according to the ESC current guidelines, the diagnosis of HFpEF requires: A. 3 Conditions: Symptoms typical of HF -signs typical of HF - normal or only mildly reduced LVEF B. 3 Conditions: Symptoms or signs typical of HF - normal or only mildly reduced LVEF - LV not dilated C. 4 Conditions: symptoms typical of HF - Signs typical of HF - Mildly reduced LVEF and LV not dilated - Relevant structural heart disease (LV hypertrophy/la enlargement) and/or diastolic dysfunction D. 4Conditions: symptoms typical of HF - Signs typical of HF - Normal or only mildly reduced LVEF and LV not dilated - Relevant structural heart disease (LV hypertrophy/la enlargement) and/or diastolic dysfunction E. 4Conditions: symptoms typical of HF - Signs typical of HF - Normal or only mildly reduced LVEF and LV not dilated - Relevant structural heart disease (LV hypertrophy/la enlargement).

48 Question 4 Which statement is true? In diagnostic criteria of HFpEF to date, preserved EF is currently taken as LV ejection fraction: A. 40% B. 45% C. 50% D. >50% E. 55%

49 Question 5 Which statement is true? The authors of the Olmsted County study report major changes in the epidemiology of HF in the last decade, with: A. A large increase in incidence B. A shift toward HFrEF C. An increase in mortality and rates D. A transition toward non-cardiovascular causes of hospitalisation E. A decreasing comorbidity burden in this elderly population of patients.

50 Question 6 In HFpEF, myocardial dysfunction and remodelling are driven by: A. Endothelial inflammation and oxidative stress B. Ischemia C. Infection D. Toxic agents E. None of the above

51 Question 7 According to a study by F Edelmannet al. (ClinRes Cardiol 2011), the total impact of comorbidities on NYHA in multivariate analyses is much stronger than the impact of a decrease in ejection fraction in HFrEF. A. 5% B. 10% C. 15% D. 20% E. 25%

52 Question 8 In patients with preserved EF, death is most commonly attributed to noncardiovascularcauses such as pulmonary disease and cancer, but at what percentage of all deaths? A. 32% B. 39% C. 42% D. 49% E. 69%

53 Question 9 According to the ESC Guidelines, only which drug is recommended in HFpEF? A. Diuretics B. Digoxin C. Ace inhibitors D. Angiotensin receptor blockers E. Ranolazine

54 Question 10 Exercise training in chronic HF may improve symptoms and quality of life, via beneficial effects on: A. Endothelial function B. Central haemodynamics C. Inflammatory markers and neurohormonal activation D. Skeletal muscle structure and function E. All of the above

55 Question 1 The following statements describe heart failure with preserved ejection fraction. Which one is false? A. The most common form of HF in older adults B. Stable in prevalence despite population aging C. Most challenging clinical syndrome for the practicing clinician and basic research scientist D. Originally considered to be predominantly caused by diastolic dysfunction E. Typified by a broad range of cardiac and non-cardiac abnormalities and reduced reserve capacity in multiple organ systems

56 Question 2 Which statement is false? Compared to all CHF patients, HFpEF patients: A. Are less symptomatic B. Their mean NYHA class is lower C. Have a lower number of CHF symptoms per patient D. Have a lower rate for all individual symptoms except peripheral oedema E. Have a higher rate for all individual symptoms

57 Question 3 Which statement is true? To be satisfied according to the ESC current guidelines, the diagnosis of HFpEF requires: A. 3 Conditions: Symptoms typical of HF -signs typical of HF - normal or only mildly reduced LVEF B. 3 Conditions: Symptoms or signs typical of HF - normal or only mildly reduced LVEF - LV not dilated C. 4 Conditions: symptoms typical of HF - Signs typical of HF - Mildly reduced LVEF and LV not dilated - Relevant structural heart disease (LV hypertrophy/la enlargement) and/or diastolic dysfunction D. 4Conditions: symptoms typical of HF - Signs typical of HF - Normal or only mildly reduced LVEF and LV not dilated - Relevant structural heart disease (LV hypertrophy/la enlargement) and/or diastolic dysfunction E. 4Conditions: symptoms typical of HF - Signs typical of HF - Normal or only mildly reduced LVEF and LV not dilated - Relevant structural heart disease (LV hypertrophy/la enlargement).

58 Question 4 Which statement is true? In diagnostic criteria of HFpEF to date, preserved EF is currently taken as LV ejection fraction: A. 40% B. 45% C. 50% D. >50% E. 55%

59 Question 5 Which statement is true? The authors of the Olmsted County study report major changes in the epidemiology of HF in the last decade, with: A. A large increase in incidence B. A shift toward HFrEF C. An increase in mortality and rates D. A transition toward non-cardiovascular causes of hospitalisation E. A decreasing comorbidity burden in this elderly population of patients.

60 Question 6 In HFpEF, myocardial dysfunction and remodelling are driven by: A. Endothelial inflammation and oxidative stress B. Ischemia C. Infection D. Toxic agents E. None of the above

61 Question 7 According to a study by F Edelmannet al. (ClinRes Cardiol 2011), the total impact of comorbidities on NYHA in multivariate analyses is much stronger than the impact of a decrease in ejection fraction in HFrEF. A. 5% B. 10% C. 15% D. 20% E. 25%

62 Question 8 In patients with preserved EF, death is most commonly attributed to noncardiovascularcauses such as pulmonary disease and cancer, but at what percentage of all deaths? A. 32% B. 39% C. 42% D. 49% E. 69%

63 Question 9 According to the ESC Guidelines, only which drug is recommended in HFpEF? A. Diuretics B. Digoxin C. Ace inhibitors D. Angiotensin receptor blockers E. Ranolazine

64 Question 10 Exercise training in chronic HF may improve symptoms and quality of life, via beneficial effects on: A. Endothelial function B. Central haemodynamics C. Inflammatory markers and neurohormonal activation D. Skeletal muscle structure and function E. All of the above

65 Take Home Messages Prevalence within HF pts For diagnosis need 4 criteria: Signs & Symptoms of HF EF 50% + cardiac structural/functional abnormality HF has a poor prognosis ~1/3 die within 1 year Comorbidities common and actively contribute to development of HF No pharmacological approach to improve prognosis Diuretics to ease congestion Exercise training may improve QOL, exercise capacity and cardiac function