Download Issues in Heart Failure

The Treatment of Advanced
Heart Failure
Shiva Roy FRACP
POWH Nov 2000
Heart Failure: where are we now?
 CCF
is a major health problem
» 400,000 new cases / yr in USA
» 300,000 Australians affected
 Care
is expensive
» 70% of costs relate to hospitalisation
» $1.1 billion/year inpatient costs in Australia
» commonest hospital DRG in USA in pts > 65 yrs
 High
mortality & readmission rates
» > 40% readmissions / year after index admission
Heart Failure
Definition
“The situation when the heart is
incapable of maintaining a cardiac output
adequate to accommodate metabolic
requirements and the venous return”
E. Braunwald
Chronic CCF: Evolution of stages
Normal
1
Asymptomatic
LV dysfunction
2
Symptoms on
exercise
•LV dysfunction = CCF
•Symptoms may not be
proportional to extent
of LV dysfunction
3
Symptoms with
minor exertion
4
Symptoms at
rest
Assessment of Heart Failure

Diagnosis
» symptoms often more useful than signs
» CXR, ECG helpful
» echocardiography is essential

Exclusion of treatable causes
»
»
»
»
»
»
ischaemia
valvular lesions
uncontrolled HT
thyrotoxicosis
arrhythmias
anaemia
Determinants of Cardiac Output
CONTRACTILITY
AFTERLOAD
PRELOAD
STROKE VOLUME
•Synergy of LV contraction
•Valvular competence
HEART RATE
CARDIAC OUTPUT
Pharmacological Therapy
Drug Class
ACE-I
Diuretics
Digoxin
ß-blockers
Spironolactone
Amlodipine
A2 receptor blockers
(if ACE-Inhibitor cough)
NYHA
1-4
2-4
2-4
2-3
3-4
2-4
2-4
Mortality
Symptoms
( )
?
?
ACE Inhibitors




Alters balance between vasoconstrictive, salt
retaining, hypertrophic properties of angiotensin II
and, the vasodilatory and natriuretic properties of
bradykinin.
Morbidity and mortality data from large trials in
spectrum of LVF make ACE inhibitors mandatory
(SAVE, SOLVD, CONCENSUS, AIRE…)
? High dose – ATLAS study
HOPE – reduced Cardiac death, CVA, & non fatal MI
in ramipril treated pts with documented vascular
disease but no heart failure
Aldosterone antagonists
 Aldosterone
causes Na retention, K/Mg loss,
myocardial fibrosis, baroreceptor dysfunction,
catechol augmentation and ventricular
arrhythmogenicity.
 RALES demonstrated 30% reduction in all
cause mortality, and in hospitalisation in
spironolactone (md 26mg) treated pts with
NYHA III & IV heart failure
 Well tolerated with conventional therapy.
Angiotensin receptor antagonists





High levels of Angiotensin II predict poor outcome,
and ACE inhibition of bradykinin metabolism may
induce cough.
Unexpected benefit of Losartan in ELITE, not
confirmed in ELITE II
Adverse outcome with Candesartan v Enalapril in
RESOLVD
Val- HeFT (class II and III)standard triple Rx v
combination Rx, and VALIANT – valsartan v Captopril
V combination post MI
Current role of AII R blockers is in ACE I intolerant pts
and as adjunct to conventional therapy.
Sympathetic activation in CCF






B Blockers ? Contraindicated
Down regulation of B1 AR’s due to high catechol
levels with failing myocardium.
US Carvedilol heart failure study 65% decrease
mortality, ANZHF 24% NS reduction in mortality.
COPERNICUS – favourable carvedilol effect in severe
HF.
B1 selective blockers Metoprolol (CR) – MERIT-HF
3991 pts, FC II-IV, 34% decrease in CV mortality,
41% decrease in SCD with similar results for
Bisoprolol – CIBIS II.
COMET – Carvedilol or Metoprolol European Trial…
Therapy of Heart Failure
Comprehensive care is essential
» pharmacological management
» treatment of arrhythmias: esp AF
» lifestyle: Na+ & fluid restriction, weight
loss, cessation of smoking, alcohol
» exercise
» management of co-morbidities:
depression, sleep apnoea
» vaccination against respiratory pathogens
Diastolic Heart Failure

Stiffening of the ventricle
» Poor filling, need for higher than normal filling pressures
» Small fluid shifts often poorly tolerated
» Difficult balance between pulmonary congestion and
systemic hypotension


Often accompanies systolic heart failure
Isolated diastolic failure:
Common causes
Hypertension
Ischaemia
Uncommon causes
Hypertrophic cardiomyopathy
Infiltration
Isolated Diastolic Heart Failure
Management is difficult!
 treat
the underlying cause
 lower the HR, improve relaxation:
ß-blocker or verapamil
 atrial fibrillation: attempt restoration of
sinus rhythm
 ACE-inhibitors, spironolactone: may
cause regression of hypertrophy
 cautious use of diuretics
 digoxin unhelpful
Biventricular Pacing
 DCM
with IVCD is associated with significant
interventricular dyssynchrony
 BV pacing may promote a coordinated
ventricular pattern of contraction.
 Symptomatic benefit demonstrated to date.
Surgery for Heart Failure
Conventional
revascularisation
valve replacement or repair
transplantation
mechanical ‘bridge’ to transplant
cardiomyoplasty
LV reduction surgery
permanent mechanical heart
xenotransplantation
Investigational
Heart Transplantation
Indications
•End stage heart failure, NYHA class 3-4,
no further therapeutic options
•Poor LV function alone is not an indication
in the absence of significant symptoms
Contraindications
•Severe systemic disease limiting survival
•Active infection
•Irreversible pulmonary hypertension
•Adverse psycho-social factors
Heart Transplantation 1982 - 1999
Actuarial Survival
Years post Heart Transplant
ISHLTx Reg 2000
Heart Transplantation
Australian Transplants
120

100

80

60

40
20

0
'84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99
Year
Disadvantages:
Donor shortage
Long waiting times
10-20% mortality
on waiting list
Risks of immunosuppression
Risk of rejection:
acute & chronic
Evolution in VAD Support
Thoratec in Intensive Care
Thoratec on
the ward
Novacor out of
hospital
Case 1
 40
yr old female lawyer, N Coast
 30 cigarettes daily, Hypertension
 Severe chest pain, nausea, diaphoresis
 Refused thrombolysis
 Medical therapy
Case 2
 77
yr old female
 Independent with medical therapy for
ischemic cardiomyopathy and hypertension
 Known moderate LV impairment (EF ~40%)
 Sudden onset of increasing breathlessness
 No chest pain
Case 3
 19
yr old indigenous Australian
 22 wks pregnant
 Intermittent palpitations
 Increasing dyspnoea and peripheral oedema
Case 4
 70
yr old surgeon
 Sudden dyspnoea after driving off 1st tee
 Previously well with no CV history
 Loud apical PSM on auscultation with
pulmonary oedema
Case 5
 24
yr old Chinese basketballer
 ?Deteriorating physical fitness
Case 6
 43
yr old radio presenter
 ESRF secondary to wegeners
granulomatosus, x3/wk HD
 Hypertensive
 Inceasingly dyspnoeic
Heart Failure 2000: Therapeutic Options
Medical Therapy
ACE-Inhibitors
Spironolactone
Angio-II blockers
diuretics
High risk
conventional
surgery
Bi-ventricular
pacing?
Left Ventricular
reduction surgery?
digoxin
Exercise
CPAP
Myoplasty?
ß-blockers
Surgical Therapy
Transplantation
Xenografts?
Tolerance?
LVADs
Total
artificial
heart?