Heart Failure with Reduced EF. Dino Recchia, MD, FACC, FHFSA

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1 Heart Failure with Reduced EF Dino Recchia, MD, FACC, FHFSA

2 Heart Failure HF is the end phenotype of almost all CV disorders Complex clinical syndrome resulting from any structural or functional impairment of ventricular filling or ejection of blood Cardinal manifestations are dyspnea, fatigue, limited exercise tolerance, and fluid retention HF is a clinical diagnosis not defined by EF or BNP level ACC/AHA Guidelines for Management of Heart Failure 2013

3 Stable HF HF Reduced EF HFrEF Systolic HF EF < 50% HF Mid Range EF HFmEF EF 40-50% HF Preserved EF HFpEF Diastolic HF EF > 50% Decompensated HF Advanced HF

4 Prevalence of Heart Failure 6,000,000 Age>65 3,500,000 Age<65 2,300,000 2,500, Adapted from Heidenreich et al Circ Heart Failure 2013

5 HF is Cardiac Cancer N= 56,658 Mamas at el Eur J Heart Fail 2017

6 Prevalence of Non-Cardiac Comorbidities in HF 41% 30% 29% 15% 11% CHRONIC KIDNEY DISEASE ANEMIA DIABETES COPD STROKE Van Deursen et al Eur J Heart Fail 2013

7 Stages of Heart Failure Stage A Stage B Stage C Stage D At risk Structural heart disease without HF symptoms Structural heart disease with prior or current HF symptoms Advanced HF

8 STOP-HF Trial Stage A patients at risk for HF had screening BNP level Randomized to PCP knowing result or not knowing result If BNP < 50 -> usual care If BNP > 50 -> echo + collaborative care with cardiologist All pts had echo at end of study Endpoint was composite: Systolic or diastolic dysfunction HF MI TIA/CVA N=1,374 Ledwidge et al JAMA 2013

9 HFmEF is not benign EF >50%, no HF EF 40-50%, no HF EF <40%, no HF EF <50%, + HF

10 Systolic Heart Failure - HFrEF Eccentric Structural Remodeling: Post MI leading to HFrEF Injury / Disease Acute Remodeling (hours to days) Chronic Remodeling (days to months) Jessup and Brozena, NEJM 2003: 348:

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12 Goals of Treatment in HFrEF Guideline Directed Management & Therapy (GDMT) Improve Outcomes Reduce Congestion

13 Guideline Directed Management & Therapy (GDMT) Hospice Transplant Mechanical Circulatory Support Consider Implantable Monitoring Device Consider Ivabradine Evaluate for Iron Deficiency Implantable Defibrillator +/- CRT Cardiac Rehabilitation - Exercise ACEI/ARB/ARNI, HF Specific BB, Aldosterone Antagonist +/- Loop Diuretic HF Self Care Strategies

14 HF Self Care Strategies Medication compliance 50% of HF pts take >10 meds Medication compliance is 50-80% Dietary Na + restriction ( mg) Fluid restriction (2 liters) Especially if hyponatremic or recurrent decompensations Daily weights Instructions on how to weigh and the target range 2-4 lb wt gain in 1 week triples risk for hospitalization Specific instructions on when to call and what to do

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16 Decompensation without Weight Gain Volume Accumulation vs Redistribution Venous system holds 2/3 blood volume and is 30x more compliant than arterial system Veins have 5-fold more adrenergic receptors than arteries Changes in venous capacitance may auto transfuse volume leading to HF decompensation without volume accumulation or weight change.

17 Exercise Training in HF EF does not always correlate with degree of impairment Additional contributors to reduced exercise capacity: Impaired vasoreactivity Abnormal skeletal muscle energy metabolism Functional iron deficiency Exercise training can increase peak VO 2 up to 25% Cardiac rehab now a covered benefit for Medicare pts with EF <35% and stable HF

18 Change in Odds of 24-month Mortality ACEI/ARB ACEI/ARB + Beta Blocker ACEI/ARB + Beta Blocker + ICD -38% -63% Additive effect of GDMT -76% Adapted from Fonarow et al J Am Heart Assoc 2012 IMPROVE HF Registry

19 Response to GDMT

20 New Concept in HF Treatment Neprilysin inhibition

21 PARADIGM-HF Trial Sacubitril/valsartan

22 PARADIGM-HF Outcome Time to First Occurrence of CV Death or HF Hospitalization RRR 20% ARR 4.7% NNT 21 McMurray et al NEJM 2014

23 ARNI in HF More angioedema and hypotension than ARB ARNI will raise BNP levels average 40 pg/ml. No effect on NT pro-bnp Potential for increased Alzheimer's risk unclear Unanswered questions: Use in pts on low-dose ACE/ARB Value in ACEI/ARB naive pts Hospitalized HF HF complicating MI HFpEF If all eligible pts in US were switched to ARNI from ACE/ARB estimated 28,000 lives saved annually.

24 Diuretics in HF Double edged sword Relive congestion and improve symptoms Activate the RAAS and SNS which worsens HF progression Can either worsen or improve renal function Braking phenomenon and structural changes in kidney due to chronic therapy lead to diuretic resistance Many pts leave hospital after HF admission still congested

25 Plasma Refill Rate Extracellular Volume Intravascular Volume Edema Effusion Ascites Plasma Refill Rate ml/hr Blood Vessels 5-6 L Plasma Volume Loss ml/hr L Excess PRR declines as euvolemia approaches ml/hr Diuresis

26 Diuretics in HF Aldosterone antagonists (spironolactone, eplerenone) Modestly enhance diuresis Reduce risk of hypokalemia Improve survival Which loop to use? Bumetanide and torsemide have better bioavailability and more potent effect than furosemide Torsemide has longest half life Studies suggest torsemide associated with lower mortality and readmission rates

27 Cardiorenal Syndrome Nephrologist Cardiologist

28 ICD in HFrEF 50% DNR pts have ICD shock function programmed on. 1 in 3 patients receive painful shocks just before death.

29 Advanced HF

30 Stage D HF HF symptoms at rest Frequent hospitalizations Inability to tolerate GDMT RV failure Cardiorenal syndrome Cardiac cachexia

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32 Annual Demand vs Supply 670,000 New cases of HF 25,000 appropriate candidates for transplant 2,500 hearts available

33 Mechanical Circulatory Support - LVAD Bridge to transplant Bridge to life Bridge to decision Bridge to recovery

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35 Stage D Heart Failure 87% 76% 2 yr Survival 70% 61% 10% Transplant LVAD BTT LVAD BTD LVAD DT Medical Rx Teuteberg et al JACC:Heart Failure 2013

36 End of Life Issues Trajectory of Disease Cancer Heart Failure Frailty

37 Hospice in Heart Failure 60% HF pts hospitalized within 30 days of death Hospice use before death in HF < 20% Roller coaster pattern of disease can inspire false hope Patients prediction of their survival averages 3 years longer than predicted Physicians incorrectly predict end of life wishes 1 in 4 times Identifying goals of care involves the art of medicine

38 Shifting Deaths to Hospice Setting Munson HF Program Deaths in Hospice 65% 51% 54% 39% 41%

39 Thank You