Heart Failure Update. Bibiana Cujec MD May 2015

Heart Failure Update Bibiana Cujec MD May 2015

Disclosures Participation in clinical trial GUIDE IT (BNP in management of HF)

Plan Review of new trials/ccs guidelines Management of heart failure: cases Stage D heart failure Mechanical circulatory support End of life care

Classifying Heart Failure Ejection fraction % Diagnosis in patients with clinical heart failure >50 HF with preserved ejection fraction (HFpEF) 41 49 HF with borderline preserved ejection fraction <40 HF with reduced ejection fraction (HFrEF)

From: 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019 Figure Legend:

DIET Approach to the Patient With Heart Failure Diagnose Etiology Severity (LV dysfunction) Initiate Diuretic/ACE inhibitor -blocker Spironolactone Digoxin Educate Diet Exercise Lifestyle CV Risk Titrate Optimize ACE inhibitor Optimize -blocker 6

Non Pharmacologic Management and Education Symptom/weight management self diuretic titration Avoid excessive fluid intake (consider 1.5 2L/day) Salt restriction (<1.5g/day benefit not clear) Modest alcohol use (none in alcoholic cardiomyopathy) Avoid smoking/illicit drugs Reinforce importance of exercise (cardiac rehab) Understand medication benefits/risks When travelling, carry medical history/medication list Immunization Sexual activity safe in stable patients (limited by symptoms) Consider treatment of sleep disordered breathing if present Be aware of psychosocial problems associated with HF McMurray et al, Eur Heart J, 2012

Case 1 75 year old man Anterior MI 15 years ago. Type 2 DM, hypertension, dyslipidemia. Dyspnea NYHA class III. Orthopnea. PND BP 100/74, HR 100, O2 sat= 92% JVP 15 cm>sa. 3+ leg edema ECG: SR 90 bpm. LBBB Creatinine 150 umol/l,egfr 45 ml/min. Hb 115 g/l Echocardiogram: LVEF 25%. Moderate mitral regurgitation How should he be managed? Furosemide 40 80 mg daily, ACE I, spironolactone 25 mg daily. Start beta blocker once edema improves

HFrEF What if? Develops gout: colchicine or prednisone. No NSAID Develops atrial fibrillation: Anticoagulate Develops pneumonia and creatinine increases to 200 umol/l : Stop diuretics and hold ACE I Worsening fluid overload: Increase furosemide and add metolazone

Case 2 75 year old woman obese (BMI 40 kg/m2), hypertension, diabetes, CKD stage 3 Dyspnea NYHA class III BP 180/70, HR 120 JVP elevated, 3+ leg edema EKG: atrial fibrillation Echocardiogram: LVEF 50%. Severe LA enlargement How should she be managed? Furosemide, control HTN and ventricular rate, anticoagulate

From: 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019

BNP in HF RECOMMENDATION We suggest that measurement of BNP or NTproBNP in patients hospitalized for HF should be considered before discharge, because of the prognostic value of these biomarkers in predicting rehospitalization and mortality (Strong Recommendation; Moderate Quality Evidence). CanJCardiol 2015;31:3-16

Figure 3 BNP and management of HF CCS Heart Failure guidelines 2014

Figure 1 Mechanisms of anemia in HF Canadian Journal of Cardiology 2015 31, 3-16DOI: (10.1016/j.cjca.2014.10.022) CCS Heart Failure guidelines 2014

Anemia in HF RECOMMENDATIONS We suggest that for patients with documented iron deficiency, oral or intravenous iron supplement be initiated to improve functional capacity. (Weak Recommendation; Low Quality Evidence). We recommend erythropoiesis stimulating agents not be routinely used to treat anemia in HF. (Strong Recommendation; High Quality Evidence). Limit transfusions to Hb <80 g/l CanJCardiol 31(2015)3 16

PARADIGM HF 8442 patients with NYHA class II,III,IV LVEF < 40% Randomized to LCZ696 200 mg BID or enalapril 10 mg BID LCZ696 200 mg = Valsartan 160 mg and sacubitril (neprilysin inhibitor) Neprilysin inhibition increases natriuretic peptides (ANP,BNP), bradykinin, adrenomedulin Vasodilatation Natriuresis NEJM 2014;371:993 1004

Angiotensin Neprilysin Inhibition versus Enalapril in Heart Failure PARADIGM-HF Study terminated after 27 mos because of 20% mortality reduction McMurray JJV et al. N Engl J Med 2014;371:993-1004

Numbers of Patients with Heart Failure Who Would Need to Be Treated to Reduce Any Cause Mortality in Seven Clinical Trials. Jessup M. N Engl J Med 2014;371:1062 1064.

ARB/Neprilysin inhibitor RECOMMENDATIONS We recommend that in patients with mild to moderate HF, an EF < 40%, an elevated BNP level or hospitalization for HF in the past 12 months, a serum potassium < 5.2 mmol/l, and an egfr > 30 ml/min and treated with appropriate doses of guideline directed medical therapy should be treated with LCZ696 in place of an ACE inhibitor or an angiotensin receptor blocker, with close surveillance of serum potassium and creatinine (Conditional Recommendation; High Quality Evidence). CanJCardiol 31(2015);3 16

TOPCAT: Spironolactone in HFpEF 3445 patients with LVEF > 45% Randomized to spironolactone 15 45 mg daily versus placebo Followed for 3.3 years Primary outcome CV death, aborted cardiac arrest and HF hospitalizations: no difference (18.6% versus 20.4% placebo) Hospitalization for HF (12% versus 14.2%) decreased (p =.04) but higher creatinine and hyperkalemia (18% vs 9%) NEnglJMed 2014;370:1383 92

Spironolactone in HFpEF RECOMMENDATION We suggest that in individuals with HFpEF, an increased NP level, serum potassium < 5.0 mmol/l, and an estimated glomerular filtration rate (egfr) > 30 ml/min, a mineralocorticoid receptor antagonist like spironolactone should be considered, with close surveillance of serum potassium and creatinine (Weak Recommendation; Low Quality Evidence). CanJCardiol 31(2015) 3 16

Ivabradine in HF Slows sinus rate by inhibiting funny inward (I f ) current in SA node mixed Na K inward current SHIFT (Lancet 2010; 376:875 885) 6558 patients, LVEF < 35%, sinus rhythm, recent hosp admission Randomized to ivabradine 7.5 mg BID or placebo 22 months follow up Fewer HF hosp admissions (16% vs 21%, HR.74, p<.0001) Fewer deaths from HF (3% vs 5%, HR.74, p=.014) April 2015: FDA approved for stable patients with HFrEF, HR >70 bpm, on maximally tolerated betablocker to decrease hospitalization rate

Cardiac Resynchronization Pacemakers

CRT: Who is a candidate? Patients with heart failure who are in NYHA class II IV QRS duration of >130 msec and LBBB LVEF < 35% Sinus rhythm on ACE I and beta blocker (optimal heart failure medical therapy) Absence of chronic kidney disease (GFR > 30 ml/min) CCS guidelines 2013 24

Cardiac resynchronization: What is the benefit? Improved exercise tolerance Improved LV ejection fraction Less functional mitral regurgitation Improved survival 25

Implantable Cardioverter Defibrillator Approx. 50% of HF patients die from sudden death (VT/VF)

ICD: Bottom Line 20% death Cost Benefit almost exclusively >6 months post revasc 1% implant deaths 4% lead problems 6% device malfxn Shocking: Inappropriate shock 39% Increasd risk of HF hospitalization post shock Contraindicated NYHA IV and not VAD/transplant candidate Primary Prevention (CCS, 2012) Ischemic > 1 month post MI/3 months post revascularization EF 30% EF 35%, NYHA II III Non Ischemic: > 9 month on OMT NYHA II III EF <35% McKelvie et al, Can J Cardiol, 2013

Heart Failure Clinics Frequent telephone follow up by nurses Decreases need for ED visits and hospitalizations Consider referring patients NYHA class III IV with multiple comorbidities 28

Mechanical circulatory support Stage D heart failure: Bridge to transplant or destination therapy

ROADMAP: Long term LVAD in ambulatory heart failure Observational study of 97 patients with LVAD and 103 patients with optimal medical therapy. NYHA class III IV LVEF< 25% 12 months survival : 80% LVAD versus 64% medical therapy (p<.05). Better QoL and 6 min walk LVAD patients had more strokes (9.6% versus 2%) and bleeding (47% versus 1%) ISHLT 2015 Scientific Sessions Nice April 2015

Would you be surprised if this patient died in the next year? Personal directive with naming of health agent/poa/will Goals of care (green sleeve) designation signed by physician Focus on symptom management: inactivate ICD, titrate beta-blocker, stop statin

End of life and heart rhythm devices patient information Turning off the shocking action of ICD will not cause death It is not legally or morally wrong to stop any medical treatment if it no longer serves your needs (ie no longer likely to result in meaningful or long term prolongation of life). Not suicide or euthanasia Allowing nature to take its course rather than trying to stay alive by repeated shocks Heart Rhythm Society 2011

https://myhealth.alberta.ca/alberta/pages/advance-care-planning-conversationmatters.aspx

Questions? bibiana.cujec@albertahealthservices.ca