8:30-10:30 WS #4: Cardiology :00-13:00 WS #11: Cardiology 101 (Repeated)

Transcription

1 Professor Ralph Stewart Cardiologist Auckland City Hospital Green Lane Cardiovascular Research Unit Auckland Heart Group Fiona Stewart Cardiologist Green Lane Hospital National Women's Hospital Professor Rob Doughty Heart Foundation Chair Heart Health University of Auckland Ivor Gerber Cardiologist Auckland Heart Group Auckland City Hospital 8:30-10:30 WS #4: Cardiology :00-13:00 WS #11: Cardiology 101 (Repeated)

2 Heart Failure Professor Rob Doughty Heart Foundation Chair of Heart Health Auckland Heart Group, The University of Auckland And Green Lane Cardiovascular Service, Auckland City Hospital A

3 How is heart failure diagnosed? Where does an echo fit in assessment of a patient with heart failure? What your patient can do beyond drug therapy What else can help your patient with worsening heart failure?

4 Case 1 57 yr old male Prior anterior MI 6 months ago Primary stent (2 hour delay) Uncomplicated recovery Echo LVEF 45%, anterior wall hypokinesis Discharged Cilazapril 1mg, metoprolol CR 23.75mg, atorvastatin 80mg, aspirin and ticagrelor

5 Presents 4 months later to you Progressive decline in exercise, short of breath BP 130/80, JVP 4cm, bibasal crackles, weight 4 kg increase over 2-3 weeks, bilateral ankle oedema Diagnosis?

6 HF: Diagnosis / Definition HF is defined, clinically, as a syndrome in which patients have typical symptoms (e.g. breathlessness, ankle swelling, and fatigue) and signs (e.g. elevated jugular venous pressure, pulmonary crackles, and displaced apex beat) resulting from an abnormality of cardiac structure or function McMurray et al. EHJ 2012; 33:1787

7 Heart Failure Diagnosis: MICE Rule Individual data from 5 prospective HF diagnostic studies in primary care MICE : Male, Infarction, Crepitations, Edema Male HR 1.91 ( ) Infarction HR 5.38 ( ) Crepitations HR 5.26 ( ) Edema HR 2.76 ( ) Refer directly for echo Roalfe AK et al. Euro J Heart Failure 2012:14;

8 Repeat echocardiogram: Moderate LV dilatation LVEF 25%, severe LV impairment

9 Left Ventricular Ejection Fraction Commonly measured on echocardiography Important for assessment of patient with HF LV Ejection Fraction 10% 20% 30% 40% 50% 60% 70% 80% Severe Moderate Mild Normal LV systolic impairment HF can occur in setting of normal LVEF

10 Clinical Heart Failure 35 yr old male No prior medical Hx Hospitalised with HF Class IV symptoms Clinical signs HF AF 82 yr old female HTN, T2DM Hospitalised with HF Class IV symptoms Clinical signs HF AF

11 Clinical Heart Failure 35 yr old male No prior medical Hx Hospitalised with HF Class IV symptoms Clinical signs HF AF Severe LV dilatation, LVEF 15% 82 yr old female HBP, T2DM Hospitalised with HF Class IV symptoms Clinical signs HF AF Normal LV size, LVEF 65%, moderate LVH

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13 Case 2 76 yrs old male COPD, prior MI, hypertension, T2DM Increasing dyspnoea during winter Clinical assessment uncertain cause... NT-proBNP 48pmol/l (Creatinine 120micromol/L)

14 BNP / NT-ProBNP H 2 N 1 Pro-BNP COOH Cardiomyocyte H 2 N 1 NT-pro-BNP BNP Peripheral Circulation Roche Elecsys COOH H 2 N 108 COOH Biosite Triage Adapted from Lam et al, JACC 2007; 49:1193

15 Recommendations Brain natriuretic peptide assists in the diagnosis of patients presenting with symptoms of suspected heart failure. Level of evidence II: Grade of Recommendation A Clinical Practice Points BNP-32 and NT-proBNP are both useful tests to aid clinical decision-making in patients presenting with symptoms of suspected heart failure. Suggested values for BNP are as follows: Heart failure unlikely Heart failure likely (Rule out test) (Rule NTproBNP in or confirm test) BNP-32 <100 pg/ml >500 pg/ml (approx 30 pmol/l) (approx 145 pmol/l) NT-proBNP Rule out HF if < 35 pmol/l <300 pg/ml (approx 35 pmol/l) Recommended age-adjusted optimal cut points: Age <50yrs: 450 pg/ml ( 50 pmol/l) Age yrs: 900 pg/ml ( 100 pmol/l) Age >75 yrs: 800 pg/ml ( 210 pmol/l) Rule in HF use age-related cut-offs: < 50yrs > 50 pmol/l yrs > 100 pmol/l > 75 yrs > 210 pmol/l

16 Clinical Evaluation Brain Natriuretic Peptide Systematic review 20 studies assessing diagnostic accuracy of peptides in HF BNP is a useful first line test for the diagnosis of HF: rule out test JA Doust et al. Arch Intern Med 2004;164:1978 Cost: $50 per test

17 Case 2 76 yrs old male COPD, prior MI, hypertension, T2DM Increasing dyspnoea during winter Clinical assessment uncertain cause... NT-proBNP 48pmol/l Age cut-offs < 50 years NT-proBNP < 50pmol/L years NT-proBNP < 100pmol/L ** >75yrs NT-proBNP < 210pmol/L

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19 Case 3 45 yr old man Dilated cardiomyopathy, severe LV impairment Obesity CKD - creatinine 200micromol/L Cilazapril 5mg daily, carvedilol 25mg bid Frusemide 160mg bid, spironolactone 25mg Attendance variable

20 2-3 kg weight increase No major change in symptoms What to do?

21 2-3 kg weight increase No major change in symptoms What to do? Excess fluid intake, high salt food

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23 Goals of Patient Resource Focus on NZ population Simple accurate information Promote maintenance of health Promote self management Can be used by patients and all providers

24 Patient Self-Management

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26 Case 4 57 year old man 10 years ago STEMI and subsequent CABG Comorbidities arthritis, IGT, gout, prior DVT Xs alcohol Heart failure 18 months ago LVEF 40%, old MI Creatinine 87, egfr 79ml/min LDL 1.9mmol/L

27 Cilazapril 5mg daily Metoprolol 95mg daily Spironolactone 25mg daily Frusemide 80mg daily Aspirin 100mg daily Atorvastatin 80mg daily Allopurinol 300mg daily

28 Current Pharmacotherapy Loop diuretic ACE inhibitor or Angiotensin receptor blocker (ARB) Beta-blocker Spironolactone +/- nitrate +/- warfarin (AF) Aspirin, statin Other drug therapies

29 Intermittent worsening HF Why? What will you consider?

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32 Aims of Treatment of HF Improve symptoms, quality of life Improve exercise tolerance Improve LV function Decrease hospital admissions Improve survival End of life care

33 Case 4 Repeat echo LVEF 20% ECG Left bundle branch block What other therapies should we consider in this man?

34 Implantable Defibrillators Small devices like pacemakers Deliver electric shock to terminate ventricular arrhythmias Improve survival in patients with heart failure

35 Implantable Defibrillators Established role in primary prevention of sudden cardiac death in chronic heart failure SCD-HeFT Trial. G Bardy et al. NEJM 2005;352: Indications: Patients with heart failure with LVEF <30% despite optimal medical therapy and stable class II symptoms

36 Biventricular Pacing LBBB common in HF patients Dyssynchrony between ventricles Biventricular pacing Pace right and left ventricle Improved cardiac output, quality of life and decreased mortality Indications: Patients with heart failure with LVEF <35% and class III/IV symptoms despite optimal medical therapy

37 Case 5 35 yr old man HTN and T2DM Hospitalised with new onset HF, and cellulitis lower leg AF LVEF 35%, moderate LV impairment Diagnosis dilated cardiomyopathy

38 Discharged on Friday 5pm, with bloods arranged for early next week with FU with his GP Medications on discharge Dabigatran 150mg bid Cilazapril 5mg daily Frusemide 120mg daily Spironolactone 25mg daily Carvedilol 6.25 mg daily

39 Bloods come back Wednesday Creatinine 330micromol/L (prev 145) Potassium 5.4mmol/L Hb 118 What will you do?

40 You do see him urgently.. BP 117/50 (previously approx 160) Weight 6 kg less than on discharge Below target weight Not drinking much each day

41 Increase oral fluids Withhold ACEi and spironolactone Withhold dabigatran Repeat bloods 1/7

42 Case 6 78 year old Samoan man Comorbidities: prior GI bleeds, T2DM, exsmoker, chronic renal failure Creatinine 190umol/L Heart Failure diagnosed 2010 Out of hospital VF arrest 2012 Implantable defibrillator for secondary prevention following resuscitated sudden death

43 Frusemide mg daily Cilazapril 2.5mg daily Carvedilol 6.25mg am, 12.5 mg pm Amiodarone 200mg daily Simvastatin 40mg daily Gliclazide 80mg daily Metformin 500mg bid Omeprazole 40mg daily

44 progressive heart failure and renal failure worsening HF over a weekend shock from his ICD in your clinic What to do?

45 Don t panic ECG rhythm Management of worsening HF and decision whether requires hospitalisation

46 End-Stage Heart Failure Issues to consider Symptom control ICD turned off Patient and relatives counselling Palliative care