Management of Heart Failure from diagnosis to the grave. Richard Lawrance Consultant Cardiologist - WMH

Transcription

1 Management of Heart Failure from diagnosis to the grave Richard Lawrance Consultant Cardiologist - WMH

2 Case Presentation 55y man Breathless Ex tolerance 100yds on flat, limited by SOB No chest pain Borderline hypertension Obst sleep apnoea Diabetic O/E Overweight + BP154/88, P 90 reg 4 th HS JVP obscured by fat Oedema to mid thighs

3 H

4 H

5 H Hypertension Diabetes HF.just a personal perspective!

6

7 ..from diagnosis to the grave Can we predict those who might develop HF? If we can would any intervention help?

8 The Saint Vincents Screening To Prevent Heart Failure (STOP-HF) Study A Multicentre, Prospective, Randomised, Controlled Trial of Natriuretic Peptide Based Screening And Collaborative Care To Reduce The Prevalence of Left Ventricular Dysfunction and Heart Failure STOP-HF Investigators St. Vincent s / St. Michael s Hospitals and Collaborative GP Group Dublin, Ireland

9 STOP-HF Inclusion / Exclusion Entry Criteria (> 40yrs) with Hypertension Hyperlipidemia Diabetes Vascular disease Arrhythmia Obesity Excluded Known LVSD or HF Life-threatening illness Refusal / inability to give informed consent Primary End Point Prevalence of heart failure (hospitalized) and asymptomatic left ventricular dysfunction Systolic Dysfunction: LVEF < 50% Diastolic Dysfunction: E / e prime > 15 Secondary End Point Hospitalization for Cardiovascular Events (Time to event and Event rate) Heart Failure, Arrhythmia, Myocardial Infarction, Unstable angina, CVA, TIA, Peripheral Thrombosis, PE

10 STOP-HF Intervention Routine PCP care Annual BNP not available to clinicians At least annual review by PCP Cardiology review only if requested by PCP NP-directed care In addition to routine PCP care Annual BNP in all If BNP >50pg/ml at any time Shared-care Cardiology review Echo-Doppler Other CV investigations CV nurse coaching Regular Cardiology follow-up

11 Endpoint MACE Event Rate Event Rate OR 0.54 p=0.001 vs. Control CONCLUSION: Reduced the rates of left ventricular dysfunction, heart failure, and emergency hospitalizations for major cardiovascular events with NPbased screening Number of events per 1,000 patient years Stroke/TIA PE/DVT MI Heart Failure Arrhythmia 0 Control Intervention N=71 (10.5%) N=51 (7.3%)

12 55y man Breathless Going back to our case Case Presentation Ex tolerance 100yds on flat, limited by SOB No chest pain Borderline hypertension Obst sleep apnoea Diabetic O/E Overweight + BP154/88, P 90 reg 4 th HS JVP obscured by fat Oedema to mid thighs

13 Clinical Case Presentation Initial investigations CXR and ECG Basic spirometry normal Echo showed mild concentric LVH, EF 55%, dilated LA 48mm, mild to moderate MR

14

15

16

17 Mineralocorticoid Receptor Antagonists

18 Mineralocorticoid Receptor Antagonists in LV systolic dysfunction RALES Study NYHA class III / IV Significantly reduced all-cause mortality in spironolactone group compared with placebo (35 vs. 46%, relative risk reduction 30%, p<0.001) Significantly more gynaecomastia with spiro (p<0.001) EPHESUS Study HF post-mi Significantly reduced all-cause mortality with Epleronone, RRR 15% Significantly reduced CV death / hospitalisation, RRR 13% EMPHASIS Study NYHA II patients Significant reduction in CV death / HF hospitalisations with epleronone, (25.9% vs 18.3%, RRR 37%) 32% RRR in death for worsening HF 42% RRR in HF hospitalisations

19

20 RATIONALE - HF mortality remains high -RAS inhibition works in HF - Aliskiren inhibits RAS so it has to be good in HF pts, doesn t it?

21

22 RED-HF Trial Reduction of Events with Darbepoetin alfa in Heart Failure Trial Assess efficacy and safety of Darbepoetin alfa treatment on mortality and morbidity in heart failure subjects with symptomatic left ventricular systolic dysfunction and anaemia Darbepoetin alfa glycoprotein that stimulates erythropoietin, a hormone released from the kidney that develops red blood cells and produces hemoglobin

23 Results / Conclusion Negative result 2,278 pts Hb improved No improvement in HF admissions Excess of thromboembolic events in treated group Hb is marker of poor prognosis in HF rather than a therapeutic target

24

25

26

27 LV Function in Patients with First Admission for Heart Failure in ALLHAT 37% 45% EF<40% EF 40-49% 18% EF>50% HF BY EF LEVEL >60% had EF>40% N=1399

28 Survival in HF-PEF hasn t changed 1.0 Surviving p= Years No. at risk Owan et al, NEJM, 2006

29 Causes of diastolic dysfunction? pressure overload Results in Left Ventricular Hypertrophy

30 Causes of diastolic dysfunction? Diabetes Mellitus Diabetic foot and eye disease

31 Causes of diastolic dysfunction?

32 LA size and mortality post-mi 50% 2-year mortality LA size also predicts: Heart Failure Stroke AF onset 10% Normal Increasing LA volume >50ml/m2

33 A Practical approach to diagnosis of HFPEF Patient has clinical or radiographic evidence suggestive of heart failure. EF preserved ( 50% on echo) Major Criteria E/e >15 Invasive haemodynamics suggestive of raised PCWP or LVEDP Minor Criteria Raised BNP>200 AF Raised LV mass index Raised LA volume index 8 < E/e > 15 To clinch diagnosis need 1 major or 2 or more minor criteria

34 EVIDENCE BASE FOR DIASTOLIC HEART FAILURE

35 HF-PEF Current treatment targets and options LV volume & oedema: Diuretics, salt restriction, nitrates Rx HTN: Diuretics, CCB, BB, ACEI, ARB Reverse LVH: Most antihypertensives Prevent ischemia: BB, CA, nitrates Reduce HR, prevent AF: BB, rate lowering CA, ARB Bradycardia: Atrial Pacing Enhance relaxation: No current treatment Prevent vascular events: ACEI, ARB, BB What is the evidence?

36 Effects of verapamil in diastolic heart failure 20 patients - CHF > 3 months, LVEF >0.45, abnormal PFR (> 2.5 EDV/sec) B a s e l i n e P l a c e b o V e r a p a m i l Exercise time (minutes) * p < 0.01 v. placebo CHF score * p < 0.01 v. placebo B P V B P V Setaro et al Am J Cardiol 1990; 12: 981-6

37 Effects of propranolol in diastolic heart failure 158 elderly patients (mean 81 yrs) with NYHA II/III CHF, prior Q-wave MI (>6 mos), and LVEF 0.40 (mean 58%) Death Death or MI Incidence % p = p = n o p r o p r a n o l o l p r o p r a n o l o l Aronow et al, Am J Cardiol 1997; 2: 207-9

38

39 ALDO-DHF Aldosterone Receptor Blockade in Diastolic Heart Failure trial, Patients, all NHYA 2, fit enough to cycle and with good renal function received spironolactone for a year benefited with significantly improved diastolic function and ventricular remodeling as well as reduced levels of natriuretic peptides no apparent effect on NYHA class, exercise capacity, or patient quality of life in the trial. HOWEVER: Aldo-DHF is a study of early-phase diastolic dysfunction, very early diastolic heart failure many of the trial's patients had relatively low BNP levels Virtually no mortality in the trial Hopefully, the TOPCAT study will reveal more

40

41 Effect of Phosphodiesterase-5 Inhibition on Exercise Capacity and Clinical Status in Heart Failure with Preserved Ejection Fraction (RELAX) Phosphodiesterase type-5 (PDE-5) metabolizes nitric oxide (NO) and natriuretic peptide (NP) generated cgmp If PDE-5 is activated in HF; may limit beneficial NO and NP actions in the heart, vasculature and kidney Viagra in stiff hearts no clinical benefit seen

42

43

44

45

46 Case Presentation If there s not much effective treatment, how can I help you die well? Palliative care for HF

47 It is easier to die of Cancer than Heart or Renal failure John Hinton (Medical Attending Physician) 1963

48 Clinical Features Similarities to Cancer Dyspnoea Cachexia/weight loss Lethargy/poor mobility Pain Anxiety & depression Insomnia & confusion Postural Hypotension Jaundice More infections Polypharmacy Fear of the future O Brien et al. BMJ 1998

49 Clinical Features Differences From Cancer More oedema Predicting death more difficult Mistaken belief condition more benign than cancer No local pressure effects Less anaemia

50 Experience of Patients Lung Cancer Clearer trajectory able to plan for death Initially feel well but told you are ill Good understanding of diagnosis and prognosis Relatives anxious Swinging between hope and despair Cardiac Failure Gradual decline, acute deterioration, sudden death Feel ill but told you are well Little understanding of diagnosis and prognosis Relatives isolated and exhausted Daily grind of hopelessness (Murray 2002)

51 Experience of Patients Lung Cancer Cancer takes over life Treatment dominates life Feel worse on treatment Financial benefits accessible Services available in the community Care prioritised as cancer or terminal Cardiac Failure Much morbidity Shrinking social world Feel better on treatment Less access to financial benefits Services less available in the community Less priority as chronic illness

52 Prognostication Very difficult to prognosticate would I be surprised if?? Markers of poor prognosis (< 6 months) Sodium: mean of 164 days if < 137, 373 days if > 137 Liver failure, renal failure, delirium Unable to tolerate ACE-I due to bp NYHA Class 4 EF < 20% Frequent hospitalisations Cachexia (Hauptman 2005, Taylor 2003, Ward 2002

53 Heart Failure: New Ideas and Old Misconceptions New Ideas Relaxation or diastolic function important This can be assessed on Echo Left atrial volume index, LV mass and E/e will all start to appear on echo reports these all predict future events Old Misconceptions It s not all about Ejection Fraction Heart failure can be present even if EF is normal There are more chambers in the heart than just the LV! Diuretics / spironolactone and Cablockers may be of some use Uncertain role of ACE-I / ARB Watch this space for other potential Rxs