Acute Heart Failure 2017

Transcription

1 Acute Heart Failure 2017

2 Acute Heart Failure 2017 Heart Failure Definitions HFrEF, HFmrEF. EFpEF Acute Decompensated Heart Failure De Novo presentation Decompensation of Chronic Heart Failure Longer Term Mortality Reduction

3 How frequently do you see a Heart Failure Presentation on your medical intake in 2017? 1:2 patients 1:5 patients 1:10 patients 1:20 patients 1:30 patients

4 Of Those Heart Failure Presentation on your medical intake, what proportion are first presentations? 10% 20% 30% patients 50% patients >50% patients

5 From those of you who are not cardiologists, would you be responsible for the management of these patients beyond the first 24 hours? YES NO

6 Epidemiology Most frequent cause of acute hospitalisation in over 60 s 5% of all medical admissions Mean stay days 50% readmitted within 6 months Prognosis worse than for all common cancers except lung cancer

7 EuroHeart Failure Survey II Nieminen et al European Heart Journal 2006

8 EuroHeart Failure Survey II % Acute de Novo 37.1 Acute DeCompensated HF Nieminen et al European Heart Journal 2006

9 EuroHeart Failure Survey II Nieminen et al European Heart Journal 2006

10 Survival (%) Survival (%) Five-Year Survival Post Hospitalisation Month of follow-up Women Breast MI Bowel Ovarian Heart Failure Lung Men Month of follow-up MI Bladder Prostate Bowel Heart Failure Lung

11 Prognosis The physician who cannot inform his patient what would be the probable issue of his complaint [ ] is not qualified to prescribe any rational treatment for its cure. Hippocrates [ BC]. Preliminary Discourse. Classics of Medicine Library; Birmingham, England, 1985, p. 18

12 From those of you who are not cardiologists, would you be responsible for the care of these patients beyond the first 24hrs? YES NO

13 Treatment of HFpEF/HFmrEF

14 Helsinki-Zurich AHF Study (n=312) Rudiger A. at al Eur J Heart Fail 2005 Jun;7(4):662-70

15 Helsinki-Zurich AHF Study Rudiger A. at al Eur J Heart Fail 2005 Jun;7(4):662-70

16 Perna ER et al. AM Heart J. 2002;143:814

17 EuroHeart Failure Survey II Unpublished data ESC 2005 Stockholm

18 EuroHeart Failure Survey II Unpublished data ESC 2005 Stockholm

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22 Acute Management

23 Short- and long-term outcomes End point Dyspnea at 24 h, >mild improvement (%) in the SURVIVE trial Levosimendan, n=664 Dobutamine, n= All-cause mortality at 31 days (%) p All-cause mortality at 180 days (%)* Cardiovascular mortality at 180 days (%) Mean out-of-hospital days alive at 180 days Mebazaa A et al. JAMA 2007; 297:

24 Acute Heart Failure Serelaxin Bioengineered relaxin 2 RELAX-AHF-2 n= hr IV Serelaxin vs. placebo No difference in mortality/worsening HF Ultratide Analogue of Urodilatin TRUE-HF n= hr IV Ultratide vs placebo Less HF events first 48hr but no other no net benefit at 120hr, 30d and Fup (median 27/12)

25 Jugular Venous Pressure

26 LW Stevenson et al JACC 2003

27 Dry+warm Wet+warm Wet+cold LW Stevenson et al JACC 2003

28 Diuretics iv Nitrates ACE/ARB B-blockers Diuretics LW Stevenson et al JACC 2003

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30 Comorbidity

31 Stabilised Acute Phase

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35 Percentage 1 year Current Treatments Dramatically Reduced Mortality Solvd-T (1991) CIBISII + MERIT-HF(1999) Placebo group Active treatment group McMurray Heart 1999; 82(suppl 4): IV14-22

36 CIBIS III Trial

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39 Entresto or Sacubitril/ Valsartan combination

40 Entresto or Sacubitril/ Valsartan combination

41 NICOR National Heart Failure Audit

42 Non-drug Strategies

43 Left bundle branch block

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47 Cardiac Venous Anatomy

48 meters 6-Minute Walk (m) = + 23 % p = BiV-NoP 200 Baseline Rando CO1 CO2 12 months NoP-BiV

49 QOL (Minnesota LWHF ) = - 32 % p = BiV-NoP NoP-BiV 65 Baseline Rando CO1 CO2 12 months

50 Event-free Survival 1.00 HR 0.64 (95% CI 0.48 to 0.85) CRT Medical Therapy P = Number at risk CRT Medical Therapy Days Clealand et al N Engl J Med 2005;352:

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52 Incremental Cost per Life-Year Saved Number-Needed-to-Treat (NNT) to Save One Life MUSTT (5 year) MADIT (2.4 year) MADIT II (3 year) AVID (3 year) SCDHeFT (5 year) SAVE (3.5 year) Merit-HF (1 year) 4S (6 year) Camm J, Klein H, Nisam S. European Heart Journal. doi: /eurheart/eji166; 2006

53 Heart Failure 2017 From: Survival following a diagnosis of heart failure in primary care Fam Pract. 2017;34(2): doi: /fampra/cmw145

54 Heart Failure 2017 European Journal of Heart Failure Volume 17, Issue 3, pages , 9 MAR 2015 DOI: /ejhf.250

55 Conclusions De Novo presenting heart failure patients have a much higher early mortality than chronic heart failure admissions Risk stratification once again guides therapy Over use of loop diuretics will prevent the utilisation of prognostically important therapies

56 Questions?

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