Advanced Heart Failure Management Dr Andrew Hannah Consultant Cardiologist Aberdeen Royal Infirmary
Grading of heart failure
Mr WY age 73 3/12 dyspnoea, fatigue and some ankle oedema PMH: hypertension 10 yrs, hyperchol, anterior MI 2006, PCI to LAD and occluded RCA 2006, severe LVSD last echo 2009 DH: aspirin, simva 40, ramipril 10mg, carvedilol 12.5mgbd, frusemide 80mg/day Ex smoker little alcohol OE: SR 90 BP 105/65 JVP raised, mild oedema, chest few creps, no murmurs Renal function normal, FBC normal CXR cardiomegaly,? Mild oedema What next?
Next steps Educate regarding fluid intake, weight monitoring Increase frusemide to 120mg/day Add spironolactone Watch U+Es: check 1 week, 4 weeks and 3 monthly Anything else? Refer cardiology
RALES: All-Cause Mortality NYHA III-IV Probability of survival 1.00 0.95 0.90 0.85 0.80 0.75 0.70 0.65 0.60 0.55 Placebo + ACE inhibitor + loop diuretic ± digitalis Risk reduction 30% 95% CI (18%-40%) p < 0.001 Aldosterone receptor antagonist + ACE inhibitor + loop diuretic ± digitalis 0.50 0.45 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
Spironolactone or eplerenone Monitor U+Es carefully after introduction U+Es at 1 week, 2-4 weeks then 3 monthly (usually do not start if creat >170ish) K+ >5.5 but <6 reduce dose, if concomitant worsening renal function then stop. And start at lower dose once renal fx stabilised Beware inter-current illness: especially with renal impairment Advice patients who develop D+V or anorexia to stop spiro and seek medical/hfsn review
Why refer to cardiology? NYHA III with LBBB Suitable for CRT +/- ICD Even if less symptomatic consider ICD
Cardiac resynchronisation therapy (CRT) the theory In patients with CHF and LBBB not only is there poor LV contraction but dyssynchronous contraction Cardiac resynchronisation therapy can improve these factors and increase cardiac performance Biventricular pacing
CRT (cardiac resynchronisation therapy): Biventricular pacemaker
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Which patients should be considered for CRT? NYHA III-IV despite maximum (tolerated) medical therapy Evidence of conduction abnormalities (QRS >120ms:ideally LBBB) No major co-morbidity likely to be fatal in next 6-12 months or likely to be major contributor to poor QOL/SOB Age is not a contraindication
Issues regarding CRTs/ICDs CRT: 2+hours procedure, ICD 1hour Small risk of pneumothorax/tamponade Risk of infection, 1 in 40 cases failure to insert LV lead ICD: no driving for 1 month if primary prev, nil for 6months if scndry prev. Appropriate shock no driving 6months Inappropriate shocks no driving for up to 6months Box site pain sometimes, psychological problems
Mrs DP age 78 Increasing breathlessness 1 month, ankle odema to mid shin Known LVSD, hypertension, type II diabetes Carvedilol 6.25mgbd, ramipril 10mg, spiron 25mg, frus 80mg, aspirin, simvastatin Pulse 105, BP 110/60, jvp raised, peripheral odema, s1s2 no murmurs, dull bibasally but chest otherwise clear K+ 4.7, U12, cr 135, Hb 125 What next? ECG
ECG important in decompensated HF
What do you now want to achieve?...what dug changes? Warfarin and stop aspirin Increase frusemide Improve rate control how? But increasing carvedilol when pt in overt HF may be risky Add digoxin 125ug/day (perhaps give 250-500ug loading x2) Review in 1 week
1 week later VR 80, BP 110/65, odema better, feels less breathless What next? Increase carvedilol 12.5 bd Review 1 week
1 week later Feels better, no clinical HF U 12 cr 145 k 4.5 HR 62 What next? Stop digoxin and increase carv to 25mg bd
Patients (n) Mean Follow-up NYHA Class LVEF (%) Effects on all-cause mortality HF CIBIS 641 1.9yrs III-IV <40 All-cause mortality: 20% (p=0.22) CIBIS-II 2647 1.3yrs III-IV 35 All-cause mortality: 34% (p<0.0001) MERIT-HF 3991 1yr II IV 40 All-cause mortality: 34% (p=0.0062) US Carvedilol HF Study 1094 6.5mths II IV 35 All-cause mortality: 65% (p<0.001) COMET 3029 4.9yrs II-IV <35 All-cause mortality: 17%(p=0.0017) Post-MI HF CAPRICORN 1959 1.25yrs N/A <40 All-cause mortality: 23%(p=0.03)
ESC guidance 2010
Mr PD age 75 Recent admission with decompensated HF Severe LVSD, moderate functional MR, moderate pulmonary hypertension, moderate TR Narrow QRS, SR 90bpm K 5.0, u18, cr 205 Ramipril 2.5 bd, bumetanide 3mg bd, aspirin, simvastatin BP 92/65 JVP high, moderate peripheral odema, chest: small bibasal effusions but no crepitations Still NYHA III-IV
Reviewed by HFSN: yes What next? Add thiazide or increase loop diuretic BFZ useful if renal function reasonable Otherwise metolazone: 2.5mg every 2-3 days in primary care, U+Es 2x/week, watch K+, Na++ and renal function Not spironolactone: renal failure too poor
Must monitor closely: HFSN v helpful Slow improvement in odema nd dyspnoea over 2-3 weeks Hr 90, BP 95/60 U 24, cr 250, k 4.0 but stable Trace odema only Weight now static and 8kg less than pre-metolazone What next? Now try to commence carvediolol 3.125 bd Educate re side effects, daily weights, close monitoring, may need increased diuretics if starts to decompensate
Carvediolol in advanced CHF: COPERNICUS
Other drug options in advanced HF Digoxin in SR sometimes: perhaps can improve symptoms, rarely used now in UK Ivabradine: only if SR, HR >70 despite max tolerated dose of BB (decent option if cannot have BB at all eg significant asthma) ACEI/ARB intolerant due to renal failure: hydralazine and nitrate
Reducing re-admissions 30% re-admission rate for decompensated HF at 3 months HFSN review early post discharge GP review early post discharge Good patient education: self management, weights Optimise drug therapy Avoid stopping important drugs during decompensations esp betablockers Consider CRT devices in timely fashion
Which HF patients should be referred to cardiology? Probably the majority of patients with LVSD should have a cardiology evaluation at some point If diagnostic or aetiological doubt, particularly younger patients, as coronary angiography may be indicated Assessment for primary prevention ICD If angina present -? revascularisation Uncontrolled atrial fibrillation/flutter -? Tachycardia related cardiomyopathy If LBBB present: higher risk,? Suitable for CRT Syncope or presyncope:?vt,?needs ICD concerns over concomitant valvular dysfunction eg MR If difficulties establishing full medical therapy Difficulties controlling symptoms