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Modern Management of heart Failure Dr Amanda Varnava Consultant Cardiologist Watford & St Mary’s Hospitals • • • • • • • • • Background What is HF? How to diagnose? 4 stages of HF and Rx of these stages Specific therapies Prognosis SCD and prevention HF with normal systolic function Who manages care? Background • Huge health costs $27 billion pa in US • Primarily a disease of the elderly • Incidence of 10/100 in those over 65yrs What is heart failure? Impaired ventricular filling and / or contraction Symptoms Signs Dyspnoea Fluid overload Impaired ext tolerance 3rd Heart sound Fatigue Assessment • • • • • ECG BNP Echo Non invasive testing for ischaemia Angiogram BNP assessment 3 questions we need addressed with echo • Is EF preserved? • Is LV structure and wall movement normal? • Are there other structural abnormalities? – Valvar disease – Atrial dilation – PA hypertension Stages of Heart Failure At risk At risk, but no evidence of structural disease or symptoms Frank Heart Failure Evidence of structural disease, but no symptoms Dyspnoea HT CAD MI Obesity Valvular disease FH CM Cardiotoxins ETOH 1º Prevention Structural disease with symptoms LVH ACEIn/ARB Fatigue Ex Tol ACEIn Blockers Spironolactone ±CRT Refractory symptoms NYHA IV despite max Rx Palliative care Or TX LVADs Stem cell Tx Primary prevention HT • Lifetime risk of HT is 75% • Optimal Rx of HT cuts in 1/2 the risk of HF DM • Females 3 x > likely to develop HF • ACEIn CAD • All MI pts should start on ACEIn and • If HF > Add epeleronone Management of asymptomatic pts Drugs • ACEIn delay onset of symptoms and improve mortality • No specific trials with ARBs • No trials with s, but ACC guidance suggests use esp in CAD Devices • MADIT II ICD trial supports use, but no’s huge thus not current practice Symptomatic patients • As with asymptomatic • In addition diuretics for fluid overload • Aldosterone antagonists Also • Na restriction • Withdraw NSAIDS, Ca antag • Exercise • Close F/U Refractory symptoms • Increased awareness of palliative care Where appropriate consider • Cardiac TX • LVADs • Stem cell Tx Heart Failure Therapies ACEIns • • • • Inhibit RAS at multiple sites Start low, go slow Probably class effect Side effects related to kinin production (cough ion 5-10%) and angioedema (1%) > common in Chinese and Blacks Angiotensin Receptor Blockers • Developed because of RAS “escape” with ACEIn and side effects • However, less well studied and some benefits may relate to kinin production • Thus alternative, not 1st line • Data is equivocal for ACEIn + ARB Blockers • Inhibit advrse effects of sympathetic NS • Trials with carvedilol, bisoprolol and LA metoprolol • Not class effect • Rx as soon as HF diagnosed • If pts on low dose ACEIn greater benefit to add’n of than ACEIn Aldosterone antagonists • Compensate for RAS escape with ACEIn • RALES study provided 30%mortality in NYHA III/IV • EPESUS study showed 20% mortality post MI with HF signs (eplerenone) • Thus in mod-severe HF or HF post MI Nitrate and Hydralazine • Less well tolerated • Trials show inferior to ACEIn • Subgroup analysis showed benefit in black pts when added to standard Rx Digoxin • No prognostic benefit • Can improve quality of life • Use in pts with persistent symptoms despite standard Rx • Caution post MI / ongoing ischaemia Cardiac resynchronisation therapy (CRT) • Third of pts in NYHA III/IV have QRS>120ms (+electrical dysynchrony) • Associated with suboptimal LV filling, prolonged MR and paradoxical septal motion • Pacing both ventricles improves contractility and reduces MR CRT cont’d • When added to optimal drug Rx improves QOL, Ex Tol and hopitalisation • Recent trials have also shown 20-30% mortality • However, many pts do not benefit thus other discriminators echo TDI used to select pts • Thus pts with persitent symptoms, wide QRS and echo dysynchrony Prognosis • Likelihood of survival can be reliably predicted for populations, but not individuals (death may be endstage HF or sudden) • Old prognostic models do not apply due to new drug Rx and devices • Annual mortality of 7% in those on Sudden cardiac death • Proportion with SCD is greater in those with less severe LVSD • ICD trials show risk reduction 23-30% in pts with EF<35% However, • Not within 1st 30 days post MI, no benefit within 1st year and most trials did not inc large no’s of elderly Heart failure with normal systolic function Differential causes of signs of HF with normal EF Incorrect diagnosis Incorrect assessment of LV function Restrictive Cardiomyopathy Pericardial constriction Episodic systolic dysfunction (ischaemia, arrhythmias) High output failure Diastolic dysfunction Management of diastolic dysfunction • • • • Few trials Resolve fluid overload Some data on ACEIn / ARBs Treat underlying condition Who should manage care? Once diagnosed and appropriate investigations completed Nurse led clinics GP or specialist run service? 1° care manage most pts If remain symptomatic or are complex then refer to specialists