Heart Failure Jay Shavadia
Definition Clinical syndrome characterized by: Symptoms: breathlessness at rest or on exercise, fatigue, tiredness or ankle swelling AND Signs: tachycardia, tachypnea, pulmonary rales, pleural effusion, raised JVP, peripheral edema, hepatomegaly AND Objective evidence of a structural or functional abnormality of the heart at rest: cardiomegaly, third heart sound, cardiac murmurs, echo abnormality, raised natriuretic peptides
Local epidemiology No population based studies on the incidence and prevalence of HF hospital based CVD accounts for 7-10% of all medical admissions in African hospitals, and HF contributed to 3-7% of these Majority of this data from preechocardiography era
HF ANNUAL INCIDENCES OF NEW CASES / 1000 (Framingham) 60 50 40 30 20 10 0 45-54yrs 55-64yrs 65-74yrs 75-84yrs 85-94yrs
Hospital Discharges for CHF
Mayosi et al Heart 2007, 12 clinical studies and 4 autopsy of the etiology of HF > 4500 patients from 8 countries identified
So why the fuss.?
HF PROGNOSIS Uniformly poor if underlying cause cannot be rectified. >50% HF patient die in 4 years. >50% severe HF die in 1 year. Poor long term prognosis even in asymptomatic LV dysfunction. >200 hospital admissions per 100,000 individuals per yr (NZ).
Survival rates (%) compared with CHF 1 year 2 years 3 years Breast cancer 88 80 72 Prostate cancer 75 64 55 Colon cancer 56 48 42 CHF 67 41 24
HF aims of management PREVENTION a) prevent/control disease leading to ventricular dysfunction b) prevent progression to HF if ventricular dysfunction established MORBIDITY- maintain /improve quality of life. MORTALITY - increase duration of life.
HF management Non - pharmacologic low salt diet, rest/exercise balance, stop smoking, alcohol restriction, fluid balance, drugs to avoid Pharmacologic (symptomatic, prognosis) - diuretics, ACEI / ARBs, betablockers, vasodilators
HF management Devices / Surgery - Revascularisation - ICD, CRT-D - Heart transplantation - Ventricular assist devices - Ultra filtration / haemodialysis - Myogenic transplantation strategies
Stage A Patients at High Risk for Developing Heart Failure
Patients at risk for HF HTN DM CAD Obesity Metabolic syndrome Exposure to cardiotoxins Family history of cardiomyopathy
Stage A Risk factor modification Non-invasive measurement of LV function Periodic evaluation for signs and symptoms of heart failure Ventricular rate control and sinus rhythm restoration
Stage B Patients with Asymptomatic LV Dysfunction
Stage B Previous MI LV remodeling Valve disease LVH
Acute infarct (hours) Infarct expansion (hours to days) Global remodeling (days to months)
Stage B Therapy Recommended Therapies: General Measures as advised for Stage A Drug therapy for all patients ACEI or ARBs Beta-Blockers ICDs in appropriate patients Coronary revascularization in appropriate patients Valve replacement or repair in appropriate patients
Stage C Patients with Past or Current Symptoms of Heart Failure
Stage C Therapy (Reduced LVEF with Symptoms) Recommended Therapies: General measures as advised for Stages A and B Drug therapy for all patients Diuretics for fluid retention ACEI Beta-blockers Drug therapy for selected patients Aldosterone Antagonists ARBs Digitalis Hydralazine/nitrates ICDs in appropriate patients Cardiac resynchronization in appropriate patients Exercise Testing and Training
Diuretics Loop NaK2Cl inhibitor diuresis Venodilator reduce RA and PCWP Transient afterload,? i/vascular RAS activation, use with vasodilators if BP allow
ACE-I Trials in Symptomatic HF Chronic HF Mortality % Mortality % ACE-I Control RR CONSENSUS 1 39 54 0.56 SOLVD Treatment 35 40 0.82 Post-MI IA ACE-I should be used in all patients with reduced EF, unless contraindicated or unable to tolerate them. SAVE 20 25 0.81 AIRE 17 23 0.73 TRACE 35 42 0.78 Avg mortality 21% 25% 16%
IA ACE inhibitors should be titrated to doses used in clinical trials, as tolerated, with concomitant up-titration of beta-blockers
Diuretics and ACEI Reduce the number of sacks on the wagon
Beta-blockers in HF Metoprolol XL IA carvedilol Beta-blockers (carvedilol and metoprolol XL) should be used in all stable patients with reduced EF, unless contraindicated bisoprolol
Betablockers in HF Limit the speed
RALES (Randomized Aldactone Evaluation Study) 1663 patients NYHA class III-IV 10% beta-blockers KCl discouraged Exclusion: K>5.0 or Cr>2.5 Spironolactone 25mg daily Drug held for K>6.0 or Cr>4.0 HR 0.70 IB Aldosterone antagonists may be added in selected patients with moderately severe to severe symptoms with low EF who can be carefully monitored for renal function and potassium p<0.001 Pitt et al. NEJM 1999:341:709.
EPHESUS: Eplerenone for LV Dysfunction after MI Selective aldosterone blocker in 6632 patients Post-MI day 3-14, EF<40%, and CHF Exclusion: Cr>2.5, K>5.0 IB Median follow-up 16 months Addition of an aldosterone antagonist in patients after an acute MI, with HF signs and symptoms, and an EF<40% Rate of death from cardiovascular causes or hospitalization or cardiovascular events Pitt et al. NEJM 2003;348:1309.
Hydralazine/Isordil Study V-Heft I V-Heft II RR at 2 years IIbC Combination Hydralazine/isordil hydralazine/isordil may be reasonable vs. in placebo patients with low EF and current or prior symptoms who Hydralazine/isordil cannot be given ACEI or ARB because vs. enalapril of renal insufficiency or intolerance 34 (p=0.028) 28 (p=0.016) IIaA Addition of hydralazine/isordil is reasonable AA-Heft in patients with low EF who are already on ACEI and beta-blocker who have persistent symptoms Taylor et al. NEJM 2004;351:2049.
Digoxin: Improvement in symptoms but not survival Digitalis investigation group 6800 patients EF<45% Past or current symptoms of HF On ACEI and diuretics Death or hospitalization for worsening HF IIaB Digitalis can be beneficial in patients with low EF and current or prior symptoms to decrease hospitalizations for HF All-cause mortality NEJM 1997;336:525.
Digitalis compounds Like a carrot placed in front of the donkey
ICDs for secondary prevention IA: an ICD is recommended for survivors of cardiac arrest, VF or hemodynamically unstable VT who have low EF and current or prior symptoms
ICDs for primary prevention MADIT II 1232 patients EF<30% Prior MI Conventional tx vs. ICD Death from any cause was the primary endpoint IA An ICD is recommended for patients with an ischemic cardiomyopathy who are at least 40d post MI, LVEF<30%, NYHA class HR II-IV 0.69 on optimal medical therapy with an p=0.016 expected survival of >1 year Moss et al. NEJM 2002;346:12.
CRT: Cardiac Resynchronization Therapy
CRT: Cardiac Resynchronization Therapy MIRACLE EF<35% QRS>130ms IA Patients with EF<35%, NSR, NYHA III-IV despite optimal medical management who have a QRS>120ms should receive resynchronization therapy unless contraindicated Endpoints: death or hospitalization for CHF CRT reduces all-cause mortality but not sudden death. Abraham et al. NEJM 2002;346:24.
Stage C Therapy (Reduced LVEF with Symptoms) Unproven/Not Recommended Drugs and Interventions for HF Nutritional Supplements Hormonal Therapies Intermittent Intravenous Positive Inotropic Therapy
Additional recommendations Diuretics and salt restriction for fluid retention Routine exercise NSAIDS and calcium-channel blockers should be avoided Routine combination of ACE-I, ARB and aldosterone antagonist is not recommended
Bi-v pacing if sxs Hydralazine/nitrate or ARB if BP allows + sxs Digoxin to reduce hospitalizations Aldosterone antagonists in select patient ICD Diuretics for fluid retention Beta Blocker ACE-I (or ARB if ACE intolerant) Regular exercise program Sodium restriction
Stage D Patients with Refractory End-Stage HF
Stage D Limited options High mortality Frequent hospitalizations Consume tremendous resources for care
Stage D Heart Failure Options Heart transplant Chronic inotropes Permanent device Experimental surgery/drugs Compassionate End-of-life care/ hospice
Heart Failure Pearls Use IV Lasix (instead of oral) for inpatients Lowers pulmonary pressures, rapid symptom relief Be aggressive in patients with normal EF, good BP and normal renal function Go slowly in patients with HCM, cor pulmonale, severe AS and low EF Preload dependent Closely monitor renal function Don t be afraid of beta-blockers
Heart Failure Pearls Titrate up quickly on ACE-I, ARB and hydralazine/isordil while inpatient Titrate up slowly on beta-blockers as an outpatient Rate control is critical Stay ahead on electrolyte replacement Check weights, I/Os, telemetry on patients daily Review the echo with a friendly cardiology fellow Review fluid, salt restrictions and medication compliance with patients at each outpatient visit
Questions?