Download End stage CHF

End stage Systolic Heart Failure
Treatment Options
Mr GJ, 48/M
• Dilated Cardiomyopathy (2008)
• L4-5 canal stenosis/sciatica ( on disability pension
since 2005)
• Smoker 30 pack yrs ,quit 2 weeks ago
• Marijuana use
• Heavy alcohol intake, quit 3 yrs ago
• Lives alone( wife died with cancer a year ago)
• Worked many jobs, last one in horticulture and
many other physical jobs
• Currently inpatient at JHH
1. Decompensated CHF( with Hypotension but not
needing Ionotropes)
2. Acute Renal Failure (Cr 366)
3. Atrial Arrhythmia
4. Pulmonary Embolism
Clinically recovered well and close to his baseline
health
• Known to cardiology team since 09/2008, first
reviewed in the clinic for pre op cardiac
evaluation
• Noted to have LBBB, No evidence of CHF
clinically
• Reviewed again in op clinic with
Echocardiogram results(03/2009): Dilated
Cardiomyopathy EF of 25-30%
• Initiated heart failure therapy
Current medications
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Warfarin (new)
Thiamine 100mg tds
Sotolol 40mg BD(New)
Epleronone 25mg OD
Frusemide 120mg TDS
Hydrochlorothiazide 25mg Alt days
Bisoprolol and Irbesartan(stopped during the
current inpatient admission)
ECG
Echo pictures
Echo picutures
• 12 months after initiation of heart failure
meds, given his Age/ EF 11% / Abn ECG(
LBBB,QRS 168) referred to AICD/Biven
pacemaker placement
• 03/2010: Procedure was long and difficult LV
lead could not be placed (RA and RV lead in
place)
3 Admissions with decompensated CHF in last 3
years including the current admission( Prev
acute admission to this was in 2009)
? Compliance may be an issue
Treatment
Correction of systemic factors
Inappropriate medications
Superimposed infection
Anemia
Uncontrolled diabetes
Thyroid dysfunction
Electrolyte disorders
Patient-related factors
Medication noncompliance
Dietary indiscretion
Alcohol consumption
Substance abuse
Cardiovascular factors
Superimposed ischemia /infarction
Uncontrolled hypertension
Unrecognized primary valvular disease
Worsening secondary mitral regurgitation
New onset or uncontrolled atrial fibrillation
Excessive tachycardia
Pulmonary embolism
Treatment
Digoxin
only safe and effective oral positive inotropic agent
Safety is related to Serum concentration levels
Ionotropes
Inotropic use in ADHF
• Phosphodiesterase inhibitors: Milrinone
• Calcium sensitising agents: Levosimendan
• B receptor agonists: Dobutamine
Levosimendan
Several studies showed improved Short-term
hemodynamic effects(Eur Heart J. 2006, J Am
Coll Cardiol. 2000, and others)
Long term effects less well established
Lower mortality in the Levosimendan when
compared to Dobutamine (Lancet. 2002 LIDO
study)
Vasodilator Therapy in ADHF with
Nesiritide
RCT in 7000 pts (N Engl J Med. 2011;365(1):32)
No change in mortality or re hospitalisation
rates, so NOT recommended routine use in
broad population of patients
Device Therapy
Given unsuccessful Coronary sinus lead
placement
Role for attempting Epicardial lead placement
Safe and reliable technique and should be
considered as an equal alternative ,(European
Journal of Cardio-thoracic Surgery2005)
Heart Transplantation
• Is he a candidate of HT?
General Criteria
• A history of repeated hospitalizations for HF
• Escalation in the intensity of medical therapy
• A reproducible VO2max of less than 14 mL/kg
per min
Heart failure and Pulmonary
Embolism
Thromboembolic events in CHF 1.5 to 2.7 per
100 patient-years
Risk factors
• Severity of myocardial dysfunction
• Thrombus that protrudes into the left
ventricular cavity
• Atrial fibrillation
Treatment
Anticoagulation with Warfarin
?Need to Thrombolysis in the setting of acute
hemodynamic compromise
Role of prophylactic anticoagulation in severe
CHF
Growth Hormone Treatment in
Chronic HF
• IGF-I directly causes cardiomyocyte
hypertrophy, augment myocardial contractility
myofilament sensitization to Calcium, and
retardation of cardiomyocyte apoptosis
• Meta-Analysis (J Clin Endocrinol Metab 2007)
Improves several relevant cardiovascular
parameters
• To be confirmed by a large RCT on
hemodynamic, morphological, and functional
parameters