Download what`s new in heart failure – eric orme, md

What’s New in Heart Failure
• Recognize and treat before
symptomatic HF
• HFpEF vs HFrEF
• OMT/GDMT
• Treatment of HFrEF
• Advanced therapies
defibrillators, CRT, transplant
• End of life issues
HF is a clinical syndrome characterized
by typical symptoms that may be
accompanied by signs caused by a
structural or functional cardiac
abnormality, resulting in a reduced
cardiac output and/or elevated
intracardiac pressures at rest or during
stress.
Terminology: (historical and
based on measurement of LVEF)
HFrEF < 40%
HFpEF > 50%
HFmrEF 40-49%
Differentiation of patients based on LVEF is
important due to differing underlying etiologies,
demographics, comorbidities and response to
therapies
Diagnosis of HFpEF is more challenging
than the diagnosis of HFrEF
• LV is not dilated, instead typically LVH and LAE and
signs of increased filling pressures are present
• Impaired LV filling (diastolic dysfunction) best
determined by complicated echo criteria
• Not all HFpEF is due to diastolic dysfunction
PAH
Valvular HD
• Non cardiac pathology may mimic or exacerbate HF
(anemia, CKD, liver disease, obesity,
OSA/OHS, COPD)
Epidemiology
• 1-2% of Adult population
• ≥ 10% of those >70 years old
• 1/6 of patients > 65 years with DOE
will have unrecognized HF(mainly HFpEF)
• Patients with HFpEF are older, more often
women, HTN, AF
Diagnosis of HFpEF
Signs and Symptoms overlap with HFrEF
• LVEF ≥ 50%
• Increased BNP
• Relevant structural heart disease
LVH, LAE
Diastolic Dysfunction Echo Parameters
mitral inflow velocities
mitral annular motion
LA volume
TR velocities
Naturetic Peptides
BNP < 100
NT-pro BNP < 300
• Negative predictive valves are high
• Positive predictive valves are lower
• Common triggers of increased BNP besides HF:
AF, CKD, PE, Pulmonary HTN, COPD, Sepsis,
CVA, Anemia, cirrhosis, cancer chemo Rx, HTN
• Obesity may lead to a low BNP
Diuretic Therapy: Clinical
Considerations
• Use in all patients with vascular congestion and
continue in most patients with prior vascular
congestion
• Torsemide has better absorption and longer
duration
• Hypotension and Azotemia- slow down the
diuresis
Don’t stop as long as patient remains
asymptomatic with mild to moderate decrease
in BP (~90 mmHg) or increase in creat (>2)
Diuretic Therapy continued
• With advanced HF medication absorption
decreases
Add metolazone for “sequential nephron
blockade”, IV option
• Remember magnesium supplementation
• Fluid retention unresponsive to increasing
diuretic therapy with declining BP and azotemia =
ominous sign
ACEI Clinical Considerations
• In clinical practice majority of HF patients receive suboptimal
doses
• Preferred over ARB’s because of greater experience and
weight of evidence as to effectiveness
• Contraindications: angioedema, anuric RF, pregnancy
• Caution: hypotension (syst BP <80-90)
creatinine > 3mg ldl, serum K+ >5.5, bilateral RAS
• No difference between available ACEI’s as to effects on
symptoms or survival
• NSAI can block favorable effects
Beta blockers- Clinical
Considerations
• Carvedilol, metoprolol succinate, bisoprolol,
nebivolol
• ACEI and Bbl are complementary and can be
started together in the stable HF patient
• Do not delay the addition of Bbl in the stable patient
because of failure to reach higher target ACEI dose.
• Start at low dose and gradually up titrate
• Metoprolol succinate causes less abrupt
hypotension and bradycardia than carvedilol
Mineralocarticoid Receptor Antagonist
(MRA)
Spironolactone, Eplerenone
Benefit: Maintenance of higher serum K+
Blockade of harmful aldosterone effects
Clinical Considerations:
• Avoid other K+ sparing diuretics (amiloride,
triamterene)
• Do not use if GFR ≤ 30ml/min
• GFR 30-50ml/min, initial does 12.5mg/day
• If K+ ≥ 5.5, stop
• Avoid NSAI, K+ containing salt substitute
Angiotensin Receptor Neprilysin
Inhibitor (ARNI) Sacubitril/Valvsartan =
Entresto
• Neprilysin inactivates various vasodilating and
naturetic hormones
• Sacubitril increases vasoactive and naturetic
hormones, decreasing after load and increasing
diuresis
• Valsartan ARB
• Paradigm- HF
Reduced CV mortality and hospitalization in HF
patients as well as reduced all cause mortality
compared to a proven dose of ACEI (enalapril)
Sacubitril / Valsartan
Clinical Considerations
• Replace ACEI as first line Rx or use in those
who remain symptomatic despite OMT?
• Contraindicated concomitant ACEI/ARB (stop
for 36hrs prior) Pregnancy, angioedema,
aliskrien in diabetic
• Caution- elderly, volume depletion (decrease
diuretic does), CKD, NSAI, lithium
Ivabradine (Corlanor)
• HR reduction is a potential therapeutic target
in HFrEF
• Ivabradine slows HR by inhibition of If
channel in SAN
• SHIFT- Ivabradine reduced composite of CV
death or hospital admission for worsening
HF, benefits were associated with reduced
HR.
Ivabradine (Corlanor)
Clinical Considerations:
• Of possible use in HFrEF in SR with HR ≥70 bpm on
maximum tolerated Bbl
• Not a substitute for Bbl
• Not to be used in AF
• Side effects: bradycardia, conduction abnormalities,
HTN, AF, visual effects
Hydralazine- Isosorbide Dinitrate (H-ISDN)
• No clear evidence of benefit in all patients
with HFrEF
• Black patients (African decent)
H-ISDN reduced mortality and HF
hospitalization
• Consider in symptomatic HFrEF patients who
are ACEI/ARB intolerant
Digoxin
• Effect on mortality and hospitalization- unclear
• Patients with AF and HFrEF digoxin may be
useful to slow VR when other therapies not
available
• Digoxin provides symptom relief (but not
mortality benefit), thus digoxin should not be
used in asymptomatic patients in SR
• Symptomatic patients on OMT, addition of
digoxin is reasonable
Medications to avoid in HFrEF
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Glitazones
NSAI
Diltiazem/verapamil
Addition of an ARB to an ACEI
Prevention of SCD-ICD Indications
Cardiac Resynchronization
Therapy
Treatment of HFpEF
• Diuretics for vascular congestion
(MRA may be of benefit)
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Control of HTN
Maintenance/restoration of SR
Rate Control /AC if in AF
Exercise training is the only intervention
shown to improve exercise capacity and QOL
• Treat contributing factors and comorbidities
HTN, lung disease, OSA, CAD, AF, CKD,
obesity, DM