WHEN TO REFER FOR ADVANCED HEART FAILURE THERAPIES
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1 WHEN TO REFER FOR ADVANCED HEART FAILURE THERAPIES Mrudula R Munagala, M.D., FACC CO- Director Heart Failure & Circulatory Support Program OklahomaHeart.com
2 Heart Failure Prevalence Heart Failure affects 6.4 Million Americans 250, 000 patients die of heart failure each year 1Rosamond, W, Flegal K, Furie K, et al. Heart Disease and Stroke Statistics 2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25-e146. 2Adams KF, Zannad F. Clinical definition and epidemiology of advanced heart failure. Am Heart J 1998;135:S204-S Russell, SD, Miller L, Pagani F. Advanced Heart Failure: A Call to Action. Circulation Publication Pending
3 Mortality of Heart Failure Rose EA, et al. Long-term mechanical left ventricular assistance for end-stage heart failure. N Engl J Med Nov 15;345(20):
4 Survival after HFHospitalization S etoguchi et al. Am Heart J 2007
5
6 Stages of heart Failure
7 Co-existing Comorbidities OSA Obesity Thyroid diseases Diabetes Mellitus Hypertension Anemia Vitamin deficiency
8 Stage C Revascularization ICD CRT-D Valvular heart disease
9 Advanced HeartFailure Yancy et al ACC/AHA Guideline for the Management of Heart Failure. Circulation June 5, 2013
10 Refractory heart failure Vicious cycle Progressive cardiac remodeling Deterioration of renal function End-organ compromise Progressive disease despite optimal medical therapy Recurrent hospitalizations Limit of neurohormonal and cytokine blockade may have been reached Mann DL. Circulation 2004;109:
11 When is it Refractory Recurrent hospitalizations Intolerance to previously tolerated medications Progressive decline in clinical symptoms Persistent hypotension End-organ dysfunction (cardio-renal syndrome, worsening LFTs or synthetic function of liver and tissue hypoxemia) Hyponatremia Persistent decline in functional status Resting symptoms
12 END STAGE HEAT FAILURE Persistence of symptoms that limit daily life (NYHA class III or IV symptoms) despite receiving maximal tolerated guideline directed optimal medical therapy Corresponds to stage D heart failure Advanced heart failure therapy options Feldman, Clin. Cardiol. 2008;31, 7,
13 STAGE D HEART FAILURE THERAPEUTIC OPTIONS Heart Transplant Limited by donor hearts Mechanical Circulatory support Inotrope therapy Bridge vs palliative Palliative care Hospice Interventional heart failure therapies Mitra clip, TAVR & CCM Reconstructive surgeries Batista, DOR & cardiac Sleeves
14 Clinical Course of HeartFailure Circulation 2012, 125:
15 RiskAssessment Cleland, J. G.F. et al. J Am Coll Cardiol 2009;53:
16 Modifiers for Profiles Temporary circulatory support (TCS) A (arrhythmi a) Frequent Flyer (FF) Possible profiles to modify 1, 2 & 3 Any profile 3 (at home) 4, 5 & 6
17
18 Outcomes based on INTERMACs profile
19 WHEN IS THE RIGHT TIME??
20 NYHA class distribution
21 Mortality in CHF
22 Prognostication NYHA Class 1 Year Mortality I 5-10% II-III 15-30% IV 50-60%
23 Risk stratify INTERMACs Leitz-Miller score Columbia scoring Apache II Seattle Heart Failure Score
24 Predictors of poor operative outcome Age Female Prior CV surgery Pre existing RV failure Coagulopathy End organ failure Renal Liver Respiratory
25 Multivariable Models: SeattleModel
26
27
28 Profiles associated with high Mortality RL Kormos, AD Althouse, etal., Use of Classification & Regression Trees to Identify Patient Profiles Associated with High Risk of Implant Mortality ISHLT 2016
29 What did we derive Patients with renal dysfunction Patients with RV dysfunction Patients with high CVP Older patients with significant comorbidities Patients with persistent hyponatremia Recurrent hospitalizations
30 ADHERE CART ANALYSIS 263 hospitals 33,046 hospitalizations Validated with 32,229 hospitalizations J AMA Feb 2;293(5):572-80
31 WHO GETS LVAD LVEF < 25% NYHA class IIIb to IV On maximal medical therapy (for 60days out of last 90 days) Inotrope dependent for > 2 weeks IABP dependent for > 7 days Peal VO2 < 14 ml/kg/mt Life expectancy < 2 years due to heart failure Refractory cardiogenic shock
32 Cardiopulmonary exercise testing Symptom limited exercise test Measures airflow, SpO2, expired oxygen and CO2 Measures peak oxygen consumption Cardiac reserve
33 PeakVO2: With / Without BetaBlockers Circulation. 2005;111:
34 Mortality in CHF Patients Peak VO 2 >14 ml/kg/min: 1-yr survival 94% 2-yr survival 84% Peak VO 2 14 ml/kg/min: 1-yr survival 47% 2-yr survival 32% Mancini et al; Circulation 83: 778; 1991.
35 Parameters that can be used Functional 6 minute walk distance Cardiopulmonary exercise testing Imaging LVEF (alone is not predictive) End diastolic Volumes (LVEDV and LVESV) LVEDD TAPSE and TASV Degree of regurgitations (MR and TR) Right heart catheterization PA sat CVP/PCWP
36
37 CRT Negative and non responders Ypenburg, C. et al. J Am Coll Cardiol 2009;53:
38 Do we need to wait until it is Refractory to refer??? Recurrent hospitalizations Intolerance to previously tolerated medications Progressive decline in clinical symptoms Persistent hypotension End-organ dysfunction (cardio-renal syndrome, worsening LFTs or synthetic function of liver and tissue hypoxemia) Hyponatremia Persistent decline in functional status Resting symptoms
39
40 WHY IS THIS IMPORTANT??
41 Refer when Higher doses of diuretics Hyponatremia Persistent elevation of BNP If you have to reduce doses of Beta blockers, ACEI, ARB or Entresto Persistent hyponatremia Hyperkalemia alternating with hypokalemia Elevated BUN and Cr ration Worsening renal function Any patient with persistent LV systolic dysfunction LVEF < 30% (especially with dilated LVs)
42 Refer When. LVEDD > 6.5 cm Persistent hypotension (SBP ~ 90s) Recurrent hospitalizations ( 2) hospitalizations or ED visits for HF in the past year Not able to walk < 1 block Difficulty in carrying out daily routine Any significant decline from previous functional status Recurrent ICD discharges Weight loss cardiac cachexia
43
44 Risk Benefit balance Infection Nutrional status Albumin and prealbimin Hemorrhage Coagulopathy RV failure RVSWI CVP/PCWP ratio LFTs and bilirubin Arrhythmias Renal failure
45
46 Advanced Heart Failure Referral to specialized HF programs Mechanical circulatory support Cardiac transplant End-of-life planning Option to inactivate defibrillator
47
Ramani GV et al. Mayo Clin Proc 2010;85:180-95
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