Download Leonardo Macias, MD Presbyterian Heart Group October.2015

Heart Failure
A practical approach
From recognition to diagnosis and management
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None
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Identify the distinguishing characteristics of
both ischemic and non-ischemic heart failure
Define both the pharmacological as well as
non-pharmacological modalities of therapy
for the treatment of heart failure
Explore the newest available therapies for the
treatment of heart failure.
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Definition
Prevalence
Etiology
Classification
Initial Evaluation
Pharmacological and Non pharmacological
Interventions
New Therapies in Heart Failure
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HF is a complex clinical syndrome that results
from any structural or functional impairment
of ventricular filling or ejection of blood
 The cardinal manifestations of HF
▪ Dyspnea and fatigue
▪ Fluid retention, which may lead to pulmonary and/or
splanchnic congestion and/or peripheral edema.
 Clinical Diagnosis
▪ Heart Failure does not equal cardiomyopathy of LV
dysfunction
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An estimated 5.7 million Americans aged ≥20 years have heart failure (HF),
and 870,000 new cases occur annually1
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Prevalence of HF is projected to increase 46% from 2012 to 2030, resulting
in >8 million people ≥18 years of age with HF2
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Approximately half of patients presenting with symptoms of HF have
reduced LVEF (≤40%)3
Definite HFrEF
(LVEF <35%, <40%, and ≤40%)1
50%
Definite HFpEF
Uncertain
(LVEF 40-50%)1 (LVEF >40%, >45%, >50%, and ≥55%)3
14%
36%
 Heart failure costs the nation
an estimated
$32 billion each year.
Proportion
of patients
HFpEF: heart failure with preserved ejection fraction; LVEF: left ventricular ejection fraction
1. AHA Heart Disease and Stroke Statistics – 2015 Update. Circulation. 2015;131:e29-e322.
2. Heidenreich PA, et al. Circ Heart Fail. 2013;6:606-619.
6
3. McMurray JJ, et al. Eur Heart J. 2012;33(14):1787-1847.
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Ischemic Cardiomyopathy
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Non-Ischemic Cardiomyopathy
 Structural Heart Disease
 Myocarditis/Inflammatory
 Familial
 Peripartum
 Endocrine and Metabolic disorders
 Iron overload
 Toxic
 Amyloidosis
 Tachycardia mediated
 Sarcoidosis
cardiomyopathy
 Stress (Takotsubo)
Heart Failure with reduced ejection fraction
(HFrEF) EF ≤ 40 %
II. Heart Failure with preserved ejection
fraction (HFpEF) EF ≥ 50 %
I. HFpEF, borderline EF 41-49 %
Edema/Shortness of breath + LVEF > 50 % does not equal
II. HFpEF, improved
> 40%
Heart Failure with preserved EF
I.
2013 ACC/AHA Guideline for the Management of Heart Failure
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Hypertension
 Single most important modifiable risk factor
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Diabetes Mellitus
 Clinical diabetes mellitus markedly increases the likelihood
of developing HF in patients without structural heart disease
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Metabolic Syndrome
 (abdominal adiposity, hypertriglyceridemia, low high
density lipoprotein, hypertension, and fasting
hyperglycemia)
 Prevalence 20 % ≥ 20 years of age and 40% > 40 years of
age
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Atherosclerotic Disease
 Coronary, cerebral or peripheral disease
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Hypertension remains the most important
cause of HFpEF, with a prevalence of 60% to
89%
Older women
Obesity
CAD
Diabetes mellitus
Atrial fibrillation
Hyperlipidemia
ACCF/AHA Stages of HF
NYHA Functional Classification
A
At high risk for HF but without
structural heart disease or symptoms
of HF
B
Structural heart disease but without
signs or symptoms of HF
I
Structural heart disease with prior or
current symptoms of HF
I
C
None
II
III
D
Refractory HF requiring specialized
interventions
Symptom Terminology
IV
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF
Asymptomatic
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF
Asymptomatic
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF
Mild
Marked limitation of physical activity.
Comfortable at rest, but less than
ordinary activity causes symptoms of HF
Moderate
Unable to carry on any physical activity without
symptoms of HF, or symptoms of HF at rest
Yancy CW et al. J Am Coll Cardiol 2013; 62:e147-e239. Mosterd A, Hoes AW. Heart. 2007;93:1137-1146
ACCF, American College of Cardiology Foundation; AHA, American Heart Association; HF, heart failure; NYHA, New York
Heart Association
Severe
 With each acute event, myocardial injury may contribute to progressive LV dysfunction
 Increasing frequency of acute events with disease progression leads to high rates of hospitalization and
increased risk of mortality, 50% of people diagnosed with HF, 75 years of age, will die within 5 years
Clinical status
NYHA
classification
of HF
patients
Compensated
NYHA I
Episode of acute
decompensation
NYHA II
NYHA III
NYHA IV
Death as an “end stage” of disease
Chronically
decompensated
Acutely
decompensated
Disease Progression
Gheorghiade M, et al. Am J Cardiol. 2005;96:11G-17G. Muntwyler J, et al. Eur Heart J. 2002;23:1861-1866. Ahmed A, et al. J.Card Fail 2008;14:211-228. Gheorghiade M, Pang PS.
J Am Coll Cardiol. 2009;53:557-573. McCullough PA, et al. J Am Coll Cardiol 2002;39:60-69. McMurray JJ, et al. Eur Heart J. 2012;33(14):1787-1847. Mozaffarian D, et al. Circulation.
2015;e29-e322. Roger V, et al. JAMA. 2004;292:344-350. EntrestoTM (sacubitril/valsartan) [full prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp.; July
2015.
Death
 With each acute event, myocardial injury may contribute to progressive LV dysfunction
 Increasing frequency of acute events with disease progression leads to high rates of hospitalization and
increased risk of mortality50% of people diagnosed with HF, 75 years of age, will die within 5 years
NYHA
classification
% of HF
patients
Compensated
NYHA I
NYHA II
NYHA III
NYHA IV
Clinical status
Death as part of an acute decompensation
Episode of acute
decompensation
Chronically
decompensated
Sudden death at any timepoint
• 45% of CV deaths due to sudden death
• 26% of CV deaths due to pump failure
Acutely
decompensated
Death-----------------------------------------------------------------------Disease Progression
Gheorghiade M, et al. Am J Cardiol. 2005;96:11G-17G. Muntwyler J, et al. Eur Heart J. 2002;23:1861-1866. Ahmed A, et al. J.Card Fail 2008;14:211-228. Gheorghiade M, Pang PS.
J Am Coll Cardiol. 2009;53:557-573. McCullough PA, et al. J Am Coll Cardiol 2002;39:60-69. McMurray JJ, et al. Eur Heart J. 2012;33(14):1787-1847. Mozaffarian D, et al. Circulation.
2015;e29-e322. Roger V, et al. JAMA. 2004;292:344-350. EntrestoTM (sacubitril/valsartan) [full prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp.; July
2015.
Death
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Despite enormous efforts in research,
only small prolongations in survival have
been achieved with new therapeutic
approaches
The mortality rate in patients with
HFrEF remains high despite the
advent of new therapies
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Study (yr)
Patients with HFrEF (LVEF <50%)
1.0
1987–1991
1992–1996
1997–2001
Survival
0.8
0.6
SOLVD-T1
(1991)
RALES2
(1999)
Intervention
⬇ Mortality
Enalapril
16% risk reduction all-cause
mortality; 18% risk reduction CV
death
Spironolactone
30% risk reduction all-cause
mortality; 31% risk reduction CV
death
0.4
MERIT-HF4
(1999)
Metoprolol
CR/XL
34% risk reduction all-cause
mortality
0.2
BEST5
(2001)
Bucindolol
NS difference
COPERNICUS6
(2001)
Carvedilol
35% lower risk of all-cause death
p=0.005
0
0
1
2
3
Year
HF, heart failure; HFrEF, heart failure reduced ejection fraction
Owan et al. N Engl J Med 2006;355:251–9
4
5
EMPHASIS7
(2011)
Eplerenone
24% risk reduction all-cause
mortality
1. SOLVD Investigators. N Engl J Med. 1991;325:293-302; 2. Pitt et al. N Engl J Med.
1999;341:709-17; 3. Herlitz et al. J Cardiac Failure. 2002;8-14; 4. MERIT-HF Study Group.
Lancet. 1999;353:2001-7; 5. Beta-Blocker Evaluation of Survival Trial Investigators. N Engl J
Med. 2001;344:1659-67; 6. Packer et al. N Engl J Med. 2001;344:1651-8; 7. Zannad et al. N
Engl J Med. 2011;364:11-21.
HISTORY
PHYSICAL EXAM
Severity and triggers of
dyspnea and fatigue
 Exercise capacity
 Physical activity
 Presence of chest pain
 Weight gain
 Peripheral edema/Ascites
 Duration of illness
 Change in appetite
 Palpitations
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Weight
 Blood pressure/Orthostatic
Changes
 JVD/HJR
 Extra Heart Sounds (s3)
 Rales, pleural effusion
 Hepatomegaly/Ascites
 Peripheral Edema
 LE temperature
LABORATORY
IMAGING
CBC with Diff
 Chem-10
 LFT’s
 Lipid Profile
 TSH
 NT-Pro BNP
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Chest Xray (2V)
Echocardiogram
ECG
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Echocardiogram report interpretation.
 HFpEF
▪ Grade I/Impaired relaxation Abnormality= Normal filling pressures.
▪ Grade II/Pseudonormal pattern= filling pressures
▪ Grade III/Restrictive pattern=  filling pressures
 Echocardiographic limitations to diagnosis.
▪ Clinical evaluation and risk profile for HFrEF
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Hypertension and lipid disorders should be
controlled in accordance with contemporary
guidelines to lower the risk of HF
Strict management of contributing
conditions
 Obesity, diabetes mellitus, tobacco use, and known
cardiotoxic agents, should be controlled or avoided.
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ACE (mortality reducing drug)
 In all patients with a reduced EF.
 ARB in ACE intolerance/allergy
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Beta blockers (mortality reducing drug)
 In all patients with a reduced EF
 Bisoprolol, carvedilol, and sustained release
metoprolol succinate
NON PHARMACOLOGICAL
Specific education to facilitate HF self-care
 Sodium restriction (<3 g/dl)
 CPAP, improve functional status in patients with HF and sleep
apnea
 Regular physical activity
 Cardiac Rehab
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From: 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary: A Report of the
American College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines
J Am Coll Cardiol. 2013;62(16):1495-1539. doi:10.1016/j.jacc.2013.05.020
Date of download: 8/30/2016
Copyright © The American College of Cardiology. All rights reserved.
Pharmacological Treatment for Stage C HFrEF: Recommendations
Recommendations for Renin-Angiotensin System Inhibition With ACE Inhibitor or ARB
COR
I
LOE
ARNI: B-R
Recommendations
In patients with chronic symptomatic HFrEF NYHA class II or III
who tolerate an ACE inhibitor or ARB, replacement by an ARNI
is recommended to further reduce morbidity and mortality.
*Dosing in clinical trials was based on the total amount of both components of sacubitril/valsartan, i.e., 24/26 mg, 49/51 mg, and
97/103 mg were referred to as 50 mg, 100 mg, and 200 mg, respectively.
Yancy CW, et.al. , 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update
of the 2013 ACCF/AHA Guideline for the Management of Heart Failure, Journal of the American College of Cardiology (2016),
doi: 10.1016/ j.jacc.2016.05.011.
Kaplan–Meier Curves PARADIGM-HF
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Aldosterone receptor antagonist
 NYHA class II–IV HF and who have LVEF of 35% or
less.
 Creatinine should be 2.5 mg/dL or less in men or
2.0 mg/dL or less in women, and potassium
should be less than 5.0 mEq/L. 2.
 Following an acute MI in patients who have LVEF
of 40% or less who develop symptoms of HF or
who have a history of diabetes mellitus.
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Hydralazine and nitrates
 African Americans with NYHA class III–IV HFrEF
receiving optimal therapy with ACE inhibitors and
beta blockers.
 Intolerance to ACE/ARB
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CardioMEMS
 Implantable PA sensor
 Ambulatory PA pressure monitoring
 NYHA class III patients and a HF hospitalization in
the last year.
PA Pressure Sensor on
Catheter Delivery System
4.5cm
120cm
Hospital and Patient Electronics
Unit
PA Pressure Database
Physician Access Via Secure Website
Actionable
Data