Download Management of Heart Failure for individual patients

Optimizing Treatment Of
Heart Failure for individual
patients
By
Prof. Mansoor Ahmad FRCP
Consultant Cardiologist
Introduction
A clinical syndrome characterized by
progressive weakening of the heart as a pump,
causing complex changes in processes at
systemic, organ and cellular levels, finally
leading to premature myocardial cell death. This
leads to salt and water retention with classical
symptoms and physical signs.
Heart failure
• Prevalence of symptomatic HF 0.4-2.0%,
6-10% in people over 65 years
• Disease of the elderly (mean age > 70 years)
• Prevalence is rising
• Bad prognosis: 5-year survival rate < 50%
• Mortality (even if age adjusted) is increasing
Laszlo L. Tornoci, Inst. Pathophysiology, Semmelweis University
Prognosis
• Annual mortality rate depends on patients
symptoms and LV function
• 5% in patients with mild symptoms and
mild ↓ in LV function
• 30% to 50% in patient with advances LV
dysfunction and severe symptoms
• 40% – 50% of death is due to SCD
Causes of heart failure
• Underlying (true) causes
• Precipitating causes (which make the
clinical condition worse, ‘decompensate’
the patient)
Underlying causes
•
•
•
•
•
Ischemic heart disease
Hypertension
Valvular heart disease
Cardiomyopathies
Other
Precipitating causes 1.
Increased workload
•Increased cardiac output
–metabolic need
(fever, infection,
hyperthyroidism)
–volume overload
(renal failure, high sodium intake)
•Pressure overload
–high BP
–pulmonary embolism
Precipitating causes 2.
Same workload, but weaker heart
•
•
•
•
Cardiac ischemia
Decreased efficiency (arrhythmias)
Drug effect
Endocarditis, myocarditis
Precipitating causes 3
• Drugs
•
•
•
•
•
•
Non Steroidal Anti Inflammatory Drugs
Steroids
IV fluids
Hydralazine
Beta blockers
Angioedema
Summary of drug therapy
drug
control
fluid
retention
alleviate
symptom
s
prolong
survival
diuretic
++
+
?
ACE
inhibitor
+
+
++
-blocker*
 (0)
 (+)
++
digitalis
+
++
0
*:
long term effects are in parentheses
Heart failure
•
•
•
•
Treatment is evidence based eg.
CONSENSUS 1987 (ACEI)
CHARM 2004 (ARB)
MERIT HF and COPERNICUS (beta
blocker)
MERIT-HF and COPERNICUS: Severe Heart Failure
Number of Patients to
Treat 1 Year
in Order to Save One Life
 MERIT-HF:
 COPERNICUS:
13
15
COPERNICUS
Inclusion Criteria Defining Heart Failure
EF <0.25 within 6 months prior to randomization
Symptoms of dyspnea and/or fatigue at rest or on
minimal exertion for at least 2 months
No pulmonary rales and no ascites at
randomization
No or only trace (minimal) oedema of the
peripheral limbs at randomization (patients with
mild oedema may be enrolled if the oedema is
due to a venous disorder)
Heart failure?
• Most of the studies use highly selected
patients.
• On an average 12 to 20% of patients are
selected out of total screened.
• Where do the rest of the patients fit??
Intolerance to drugs
• Approximately 15% withdrawal rate for 
blocker.
MERIT-HF
Severe Heart Failure (NYHA III/IV and EF<0.25)
25
Placebo
Metoprolol CR/XL
20
15
10
5
0
All cause
No. of
withdraw
als
p=0.027
86/62
Adverse
events
p=0.012
66/42
Wosening
CHF
p=0.018
34/18
Goldstein S et al, JACC 2001;38:932-8
MERIT-HF and COPERNICUS: Severe Heart Failure
Yearly Withdrawal Rate of
Study Medicine
Placebo
MERIT-HF1
COPERNICUS
21.7%
18.5%
Meto
CR/XL
15.5%
14.8%
Δ
-31%
-23%
p-value
0.027
0.02
Goldstein S et al, JACC 2001;38:932-8
Packer et al, NEJM 2001;344:1651-8
Heart failure
• A variety of patients are seen in day to day
practice who will not fit completely for the
prescribed GUIDELINES.
•
Blood Pressure levels
• Patients with low Blood Pressure levels
tend to tolerate ACE inhibitor, Angiotensin
Receptor Blocker and  blocker less well.
MERIT-HF
Severe Heart Failure (NYHA III/IV and EF<0.25)
Baseline Blood Pressure and Heart Rate
Variable
CR/XL
Systolic blood pressure
Diastolic blood pressure
Heart rate
Placebo
n=396
124
77
85
Meto
n=399
125
77
85
Goldstein S et al, JACC 2001;38:932-8
MERIT-HF and COPERNICUS: Severe Heart Failure
Baseline Blood Pressure and Heart Rate
Variable
SBP
DBP
HR
MERIT-HF1
Placebo
n=396
124
77
85
Meto CR/XL
n=399 n=1133
125
77
85
COPERNICUS
Placebo Carvedilol
n=1156
123
76
80
123
76
80
Chronic Obstructive Airway
Disease
 blocker
Chronic kidney disease
• Caution with ACE inhibitor and
Angiotensin Receptor Blocker.
• BP control
Hyperkalemia
• Hyperkalemia is the commonest reason
for temporary pacing.
• ACE inhibitor
• Angiotensin Receptor Blocker
• Spiranolactone
• Possibly  blocker.
Heart failure
•
•
•
•
Maintain symptomatic control
Control fluid retension
Use diuretics
Serum potassium.
Heart failure
• Add ACE inhibitors/ Angiotensin Receptor
blocker early
• Build up the dose over weeks if blood
pressure is low
• Watch out for
• cough (upto 20%)
• Serum potassium
• Serum creatinine
Heart failure
• Add beta blocker after the fluid overload is
controlled
• Build up the dose slowly
• Watch out for brochospasm, worsening
failure??
Heart failure
• Use digoxin appropriately and cautiously
• Main indication is Fast Atrial Fibrillation
with failure
• Serum potassium
• Toxicity
DIAL: Randomized Trial of
Telephonic Intervention in Chronic
Heart Failure
DIAL: primary endpoint: all-cause mortality/heart
failure hospitalizations
DIAL: heart failure hospitalization
Summary
• Tailor treatment to individual needs of
thepatients
• Dosage to tolerability levels
• Support care as much as possible
• Advise on possible precipitating factors
eg. Flu vaccination in autumn for COAD
patients
Summary
• Treat cause whenever possible eg.
Revascularization, Valve replacement.
• Control arrythmias
• Close watch on patients even if they are well, as
Sudden Cardiac Death is common in all
• CRT and ICD in appropriate cases (both clinical
and financial)
• Transplant
• Artificial heart