Download Principles of systolic heart failure

Systolic Heart Failure
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Some terminologies
► Systolic dysfunction:
contractility.
presence of impaired LV
 There maybe substantial discordance between symptoms
and the degree of LV dysfunction.
► NYHA class:
 Most commonly used classification system to describe
symptoms, though the definition is vague and physicians
can disagree about what class they will assign to a
particular patient.
 Class I: no limitations
 Class II: no limitations with ordinary activity
 Class III: limitations with ordinary activity.
 Class IV: symptoms at rest
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Etiologies
► Important to identify reversible causes.
► Most common etiology in the United States are due to
hypertension and coronary artery disease.
► Important reversible causes which can be treated
includes valvular disease, toxins (alcohol,
adriamycin…etc), metabolic derangements (thyroid
disease, high-output failure due to anemia…etc).
► Other causes include viral, peripartum, idiopathic…etc.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Initial Assessment
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clinical assessment is addressed in detail later on in the talk.
Common laboratory assessment includes:
 CBC (assess anemia), BMP (lytes and renal function), LFTs (assess
hepatic congestion), TFTs (assess reversible cause), BNP (confirm
diagnosis and assess severity).
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Echoardiogram is very useful- gives detailed information about
structure/function
Pursue work-up for cardiac ischemia in patients with risk factors
via ETT (with imaging) or cardiac catheterization.
 Cardiac ischemia is very common reversible cause of cardiomyopathy
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2008
Biopsy of the heart muscle rarely needed as it rarely influences
treatment.
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Assessment and Treatment of
Acute Decompensated Heart
failure
(what we deal with on the inpatient
service)
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Assessment
► Needs to assess whether
the patient have signs
and symptoms of low
output, congestion, or
both to formulate a plan
for treatment
2008
Warm/dry
Warm/wet
(most common
presentation,
needs diuresis)
Cold/dry
Cold/wet
(over-diuresed)
(end-staged, may
need inotrope
and/or other
therapies)
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Signs, symptoms, and labs
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Low output
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Congestion
Fatigue
Dizziness
Low blood pressure
Low pulse pressure
Lower than baseline weight
Cool extremities on exam
Oliguria/ azotemia
 Higher than baseline weight
 Left sided congestion:
► Dypsnea, orthopnea
► Rales, s3 (in
patients with
advanced heart failure, often
don’t hear rales).
 Right sided congestion:
► Anorexia (from bowel edema)
► JVD, ascites, edema
► Increase LFTs
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Diuretics
► Given for symptom control and not expected to
improve survival
 Aldosterone antagonists are an exception
► Patients in heart failure are less responsive to diuretics
compared to a normal person because:
 Low cardiac output means less delivery of the drugs to the
kidneys
 Activation of the renal-angiotensin-aldosternone system
results in higher sodium absorption
 Flow dependent hypertrophy of the distal tubules
 Often have concomitant renal insufficiency
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Diuretics
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Loop diuretics are the mainstay:
 For furosemide (the most common drug used), the starting dose is
20-40mg PO, the max dose is around 200mg.
 If the initial dose is ineffective, double the dose and try again.
Much less effective to try the same dose several hours later.
 Adding thiazide diuretics greatly potentiates diuresis (but low K).
 Oral furosemide has about 50% bioavailability and is sometimes
erratically absorbed
Worse when patients have substantial right sided failure and bowel edema
► IV lasix often preferred in acute exacerbation
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 lasix 20mg IV equals 40mg PO…etc
 Lasix gtt can results in greater fluid removal and less ototoxicity.
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Bumetanide and torsemide are alternative oral regiments that have more
reliable oral absorption.
 Bumetanide to lasix ratio is 40:1 in those with normal kidney, 20:1 in those
with abnormal kiney.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Diuretics
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In patients with edema, interstitial fluid is quickly mobilized to the
vasculature and there is no “ceiling” per se for rate of diuresis
 Needs to be careful about electrolyte abnormalities…etc.
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Generally expect diuresis to decrease pre-load and hence cardiac output,
however, sometimes the opposite occur (Cr improves after diuresis), some
explanations are:
 In patients with markedly dilated ventricle and substantial MR as a consequence,
diuresis may shrink the ventricle and improve MR.
 Decrease wall stress by decreasing the diameter of the ventricle
 On the “plateau” portion of the Starling curve
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Effect of diuretics is maximal on the 1st dose and gradually wears off over 2
weeks. Afterwards, the medicine will maintain but no longer reduce weight.
 Likewise, electrolyte abnormalities also reach their steady- state at this time. No
need to re-check electrolytes unless the clinical situation changes.
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2008
Diuretics are generally continued indefinitely.
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
How a dilated ventricle begets more MR
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Intravenous Inotropes
used in people who are stage III-IV and refractory to other
therapies (the patient is cold and wet) as palliative measures or
bridge to other treatment (like tranpslant or LVAD).
► Acute hemodynamic improvement but chronic administration
(at least oral forms) leads to increased mortality.
► Dobutamine (dose of 5mcg/kg/min and up)- beta 1 agonist, can
cause tachycardia
► Milrinone (dose of 0.325mcg/kg/min and up)phosphodiesterase inhibitor. Can cause hypotension and
arrhythmias. Can be used with a beta-blocker
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2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
How to prevent future
exacerbations?
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Why did most patients get in the trouble in the 1st place?
 Dietary indiscretion
 Medication non-compliance
 Worsening underlying heart function
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Very important to elicit these information and modify
behavior/treat underlying cause.
Important to record baseline “dry weight” (in d/c summary,
clinic notes…etc) so we know (roughly) what to aim for if the
patient gets into trouble again
In general, in treatment of CHF patients
 Do not be afraid to diurese until they patient is dry even if it causes a
little bit of azotemia
 Do not be afraid of low blood pressure (SBP around 90 perfectly
acceptable) unless the patient is symptomatic.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Chronic Therapy for CHF
with proven efficacy
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
ACE- I
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Improves survival in all severities of
systolic heart failure, ranging from
asymptomatic left ventricular
dysfunction to moderate to severe
CHF (about 20%-30%).
If tolerated, the target dose should
be:
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In the SOLVD prevention trial of 4228 patients (83 percent
post-MI) with asymptomatic left ventricular dysfunction,
prophylactic administration of enalapril reduced the probability
of death or congestive heart failure (p<0.001). Data from The
SOLVD Investigators, N Engl J Med 1992; 327:685.
Enalapril 20mg BID
Captopril 50mg TID
Lisinopril 40mg qd
These relatively high doses were
used in successful trial.
Decreased mortality in patients with advanced NYHA class III or IV heart
failure after treatment with enalapril compared to placebo (p = 0.003). Data
from The CONSENSUS Trial Study Group, N Engl J Med 1987; 316:1429.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Beta-blockers
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Additional benefit on top of ACE-I
 Meta-analysis suggests another 20-30% reduction in mortality,
 Less information is available in patients with class IV CHF. However, the
COPERNICUS trials and subgroup analysis from MERIT-HF showed equivalent
benefit in those with class IV failure.
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Carvedilol vs Metoprolol?
 Carvedilol
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Alpha, beta1, beta2 blocker, results in greater reduction in BP
 Metoprolol
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Beta1 blocker. Better tolerated in hypotension. Use long-acting form in CHF
 COMET trial
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Compares coreg and metoprolol- use of coreg results in lower mortality but the dose of
coreg used maybe higher.
When/how to start?
 Start with care in patients with severe/decompensated CHF
 Usually start ACE-I 1st
 Start low, but target dose of coreg 25-50mg BID, Toprol 200mg qd
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Hydralazine and Nitrates
 Hydralazine 25mg PO TID and titrate up as tolerated, imdur
(40-120mg daily) or isosorbide dinitrate (40mg TID or QID)
 modest benefit in patients with CHF and is less effective
than ACE-I. JN, Johnson, G, Ziesche, S, et al, N Engl J Med 1991; 325:303
 Generally poor compliance due to the TID/QID dosing
 Arguably effective in African Americans who are already on
optimal therapy and can tolerate the regiment (A-HeFT).
This population maybe arguably less responsive to ACE-I
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In general, reasonable to use in:
 Patients who can’t tolerate ACE-I/ARBs
 Patients on other optimal CHF therapy with more blood
pressure to burn who remains symptomatic.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Aldosternone antagonists
Aldactone and eplerenone (less gynecomastia, a lot more
expensive)
► RALES trial- 30% reduction in mortality at 2 years in patients
with class IV CHF or class III CHF with class IV symptoms in the
previous 6 months.
► EPHESUS trial- 15% reduction in mortality in post-MI patients
with EF<40 and evidence of CHF or DM
► Benefits probably related to K sparing effects as well as
minerocorticoid blockade.
► Use in patients with moderate to severe CHF and reduced LVEF
with relatively normal Cr and low or normal K
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2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Digoxin
► Control symptoms,
does not prolong survival
 The DIG trial (dig vs placebo in patient otherwise receiving
optimal CHF therapy) shows reduced hospitalization but
no reduction in survival. (N Engl J Med 1997 Feb 20;336(8):525-33 )
 Some intriguing subgroup analysis (but take with grain of
salt, as they are just that):
► worse in women compare to men
► When serum concentraion is between
0.5 and 0.8ng/ml in
men, survival is improved compared to placebo. It is
significantly worsen when serum conc >1.2ng/ml.
 Generally, use in addition to optimal CHF therapy to treat
symptoms.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Devices
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ICD for primary prevention: (pts with CHF are at increased risk of
malignant arrhythmias):
 MADIT-II-ischemic cardiomyopathy and EF of <=30% has survival
benefit
 SCD-HeFT: class II-III CHF with EF <35% has survival benefit (HR 0.77)
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Biventricular PPM (for resynchronization therapy):
 Presence of interventricular conduction delay or bundle branch block
results in dysynchronous contraction and worsens cardiac output.
 For patients with wide QRS (>120ms), LVEF of <=35%, and class III- IV
CHF despite optimal medical therapy, there is symptomatic
improvement/survival benefit (CARE-HF and COMPANION)
 Some in the group above responds while others do not, no great
predictors of who would respond.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Stepwise treatment of CHF
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.