Sara O. Weiss, MD Director, Heart Failure Services Virginia Mason Medical Center September 8, 2012 Disclosure: Dr. Weiss has no significant financial interest in any of the products or manufacturers mentioned.
Outline Background Lifestyle Interventions Medical Therapy
Magnitude of the Problem HF is common: Increasing in prevalence 5.8 million Americans; 23 million worldwide Lifetime likelihood of developing HF: 20% over age 40 HF is expensive: $30 billion dollars (2010) HF is deadly: 20% mortality at 1 yr Heart Disease and Stroke Statistics--2010 Update: A Report From the American Heart Association; Circulation 2010
Prevalence and Incidence Prevalence of heart failure by sex and age (National Health and Nutrition Examination Survey: 2005 2008). Incidence of heart failure (heart failure based on physician review of medical records and strict diagnostic criteria) by age and sex (Framingham Heart Study: 1980 2003). Roger V L et al. Circulation 2011;123:e18-e209 Roger V L et al. Circulation 2011;123:e18-e209 Copyright American Heart Association Copyright American Heart Association
Prognosis Redfield et al. Circulation 1998; 98; 2282
Pathophysiology Hemodynamic Model Inadequate pump function Poor forward flow Unable to explain the progressive nature Negative Remodeling Neurohormonal Dysregulation Architectural distortion
Complex Neurohormonal Effects in Heart Failure Myocardial Insult Increased Load and Increased Wall Stress Reduced System Performance Activation of RAAS and SNS Altered Gene Expression Growth Remodeling Ischemia Energy Depletion Cytokine Expression Fetal Gene Program ANP, BNP LVH Abnormal Ca 2+ Handling Ventricular Dyssynchrony Necrosis Fibrosis Apoptosis Cell Death Organ Failure
Etiology Coronary Artery Dz Non-Ischemic Causes Hypertension EtOH Valvular disease Obesity Diabetes Tobacco Abuse Chemotherapy Viral Myocarditis Post-partum Hypertrophic CM Gheorghiade M, Bonow RO. Circulation 1998;97:282-289.
Diagnostic Pearls CLINICAL DIAGNOSIS Based on signs and symptoms Orthopnea, PND, weight gain Elevated JVD LE edema, ascites Supportive Testing ECHO CXR EKG Stress testing or angiogram
Diagnotic Pearls BNP Pearls One time measurement Should not be used to adjust diuretics Lower in obese pts Increased with age Increased in women Increased in CKD Troponin Frequently elevated in HF Low grade (ie. < 2.0) Flat Poor prognostic indicator
Lifestyle Modification Salt restriction 2000 mg/24 hr Fluid restriction 2000 cc/24 hr Daily Weight Log Call if weight increased 3 lbs in 1 day 5 lbs overall
Pharmacologic Therapy Diuretics Ace inhibitors/arb Beta blockers Aldosterone antagonists Hydralazine/Nitrates Digoxin
Diuretic Pearls Furosemide 6 hr half-life Variable oral bioavailability Torsemide & bumetinide Almost 100% oral bioavailability Ethacrynic Acid No sulfa moiety Furosemide IV Furosemide PO Torsemide PO/IV Bumetinide PO/IV 20 mg 40 mg 20 mg 1 mg
Thiazide Synergy Chlorothiazide IV Metolazone Hydrochlorothiazide Chlorthalidone
Ace Inhibitors/ARBs Afterload reduction Antagonize RAAS Reduce hospitalizations Improve survival SOLVD Investigators NEJM 1991; 325: 293
AceI Pearls AceI first line Cough more common in women Fear not! Hypotension Hyperkalemia Renal insufficiency
Mortality Beta Blockers MERIT-HF 1 COPERNICUS 2 1.0 b -blocker 1.0 b -blocker 0.8 Placebo 0.8 Placebo 0.6 Risk 34% 0.6 Risk 35 % P=0.0062 P<0.00013 0 1 2 Metop Succ: n=1990 Placebo: n=2001 0 1 2 Time (years) Carvedilol: n=1156 Placebo: n=1133 1. MERIT-HF Study Group. Lancet 1999;353:2001-2007. 2. Packer M, et al. N Engl J Med 2001;344:1651-1658.
Beta Blocker Pearls Euvolemic patients only Not all beta blockers are created equally Carvedilol Metoprolol Succinate (not metop tartate) Bisoprolol Fear not the bradycardia and hypotension! High dose is better than low dose
Mortality (%) Lancet 2003; 362:7-13 COMET 40 30 20 10 Metoprolol tartate Carvedilol hazard ratio 0.83, 95% CI 0.74-0.93, p=0.0017 Number at risk 0 1 2 3 4 5 Time (years) Carvedilol 1511 1367 1259 1155 1002 383 Metop tart 1518 1359 1234 1105 933 352
Probability of Survival Aldosterone Antagonists Spironolactone Eplerenone 1.00 0.95 0.90 0.85 0.80 0.75 0.70 0.65 0.60 0.55 0.50 0.45 RALES Placebo Spironolactone 27% mortality P<.001 0.00 0 3 6 9 12 15 18 21 24 27 30 33 36 Months Pitt B et al. N Engl J Med. 1999;341:709 717.
Aldosterone Antagonist Pearls Weak diuretics Beware of hyperkalemia! Decrease/discontinue potassium supplementation Check levels frequently Contraindicated in renal insufficiency Women: Cr > 2.0 Men: Cr > 2.5
Hydralazine/Nitrates Potent vasodilator afterload reduction Increase NO formation VHeFT 1991 Hydralazine/ISDN v. enalapril Subgroup analysis of AA pts AHeft 2004
Hydralazine/Nitrate Pearls Must be used in combination TID dosing is difficult Rebound tachycardia Use with beta blockers
Event rate at 37 months (%) Cardiac Glycosides: Digoxin 40 P= 0.06 P= 0.001 Digoxin Placebo 30 20 10 0 Mortality HF hospitalization Digitalis Investigators. N Engl J Med 1997;336:525-533.
M ortality Ra Digoxin Pearls Narrow therapeutic window! DIG Trial Mortality Rates in Men by Trough Renal clearance Level Measured decreased 1 Month in elderly After Randomization in women Target level: 0.5-1.0 Figure 2 1.0 0.9 0.8 0.7 0.6 0.5 n = 1171 digoxin 2639 placebo Placebo Crude Rate Risk Adjusted Rate, digoxin 0.4 0.3 0.2 0.1 0.0 Crude Rate, digoxin 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 > = 2.0 Serum D igoxin Concentration
Percent of Patients Utilization of Evidence-based HF Therapies at University Hospitals 69 29 19 b- ACE Inhibitors Blockers Spironolactone University Hospital Consortium HF Registry: 33 centers, 1239 patients, Year 2000. Outpatient regimen before HF hospitalization in patients with Stage C HF. Presented by Dr. Fonarow at the Heart Failure Society of America Satellite Symposium, September 23, 2002. Unpublished data courtesy of Dr. G. Fonarow, UCLA Medical Center.
Common Problems Inadequate access to care Non-adherence to HF teaching: Salt restriction Daily weights Recognition of symptoms Co-morbidities Polypharmacy Financial concerns Cognitive and functional limitations Inadequate social support Anxiety and depression
HF Program at VM Multi-disciplinary clinic 2 physicians 2 ARNPs 3 nurses Social worker Palliative care team Pharmacist EP and cath lab support Goals: Decrease re-admissions Improved patient education Improved quality of life Lower costs Provide a service: patients medical community
Stage v. NYHA Class ACC/AHA HF Stage 1 NYHA Functional Class 2 A At high risk for heart failure but without structural heart disease or symptoms of heart failure (ie: patients with HTN or CAD) B Structural heart disease but without symptoms of heart failure C Structural heart disease with prior or current symptoms of heart failure I Asymptomatic II Symptomatic with moderate exertion III Symptomatic with minimal exertion D Refractory heart failure requiring specialized interventions IV Symptomatic at rest 1 Hunt SA et al. J Am Coll Cardiol. 2001;38:2101 2113. 2 New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al.jama.2002;287:890 897.
Device Therapy ICD LVEF < 35% Optimal medical management X 3 months CRT or BiV Optimal medical management QRS duration 120 msec NYHA class 2-4 symptoms