Download Modern Management of Heart Failure

Modern Management of Heart
Failure
Dr Amanda Varnava
Consultant Cardiologist
Watford General Hospital
&
Imperial College Healthcare Trust
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 ex tolerance
3rd Heart sound
Fatigue
Assessment of SOB
• ECG /CXR or BNP abnormal >
• Echo
• Additionally
– Non invasive testing for ischaemia
– Angiogram
– MRI
Measurement BNP in CHF
Accurately identifies CHF 81-97% of
patients
Levels > 100 (sens 90% & spec 76%)
Levels vary according to age and gender
BNP < 100
BNP 100-400 BNP > 400
CHF
unlikely
Uncertain
diagnosis
CHF very
likely
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
Heart Failure Therapies
ACEIns
•
•
•
•
Inhibit RAS at multiple sites
Start low, go slow
Probably class effect
Side effects related to kinin production
(cough in 5-10%) and angioedema (1%) >
common in Chinese and Blacks
• Continue unless > 50% rise in Cr above
baseline/ Cr >350 / K> 5.9
ACEIn titration
Drug
Starting dose
Target dose
Lisinopril
2.5 or 5mg od
30 or 35mg od
Ramipril
2.5mg od
5mg bd or 10mg od
Perindopril
2mg od
4mg od
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 does not support combination of
ACEIn + ARB
 Blockers
• Inhibit adverse 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
β blocker titration
Drug
Starting dose
Target dose
Carvedilol
3.125mg bd
25mg or 50mg bd
Bisoprolol
1.25mg od
10mg od
Aldosterone antagonists
• Compensate for RAS escape with ACEIn
• RALES study provided 30%mortality in
NYHA III/IV
• EPHESUS study showed 20% mortality
post MI pts 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
• Use when ACEIn contraindicated (RF)
Diuretics
• Often first line agent
• Treat volume overload
• Symptomatic relief, but no clear prognostic
benefit
Digoxin
• No prognostic benefit
• Can improve quality of life
• Use in pts with persistent symptoms despite
standard Rx
• Caution post MI / ongoing ischaemia
Polyunsatureated fatty acids
GISSI study
– n-3 polyunsaturated fatty acids (PUFA) vs
placebo in > 7000 heart failure pts
– Small, but signif reduction in mortality (27%
vs 29%, HR 0.9, p= 0.04)
Current GP prescribing practices in UK
•
•
•
•
163 practices from 2001-06 with 9311 pts
Loop diuretics 79%
ACE In or ARB 71% (35% to target)
β blocker 36% (11% to target)
Non pharmacological
intervention
Implications of myocardial viability (MV)
MV - revascularised
MV – med Px
No MV – med Px
No MV - revascularised
Senior et al. J Am Coll Cardiol 1999;33:1848-54
Cardiac resynchronisation therapy
CRT (biventricular pacing)
• As add on Rx it
improves QOL, Ex Tol
and hospitalisation
• Recent trials have also
shown 20-30%
mortality
CRT indications
• Third of pts in NYHA III/IV have QRS>120ms (=
electrical dysynchrony)
• However, 40% pts do not benefit thus need echo
evidence of mechanical dysynchrony to further
select pts
Thus for pts with:
• Persistent symptoms, in SR with wide QRS and
echo dysynchrony
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
 Blockers
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 epleronone
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
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
Lifestyle & rehab
• Exercise
Aerobic and resistive ideally within rehab programme
• Diet
Wt reduction, salt and fluid restriction (daily wts)
• Stopping smoking
• Alcohol
– Cessation if causative/ moderate if unrelated
• Vaccination
Pneumococcal and annual influenza
• Air travel
Safe in most pts
Clinical Review
Interval dependent on status but not > 6 monthly
• Clinical review
– Fluid status
– Functional capacity
– Cardiac rhythm
• Medication review
• Bloods
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
NICE guidelines for specialist
referral
•
•
•
•
•
•
CCF not related systolic dysfunction
Co-morbidities (COPD, CRF, An, Gout)
Angina
Arrhythmias (inc AF)
Women planning pregnancy
Severe or very symptomatic heart failure
Specialist referral
• Confirm diagnosis
• Invasive assessment to diagnose underlying
aetiology and Rx
• Addition of beta-blockers and/or
spironolactone
• Management of difficult / deteriorating
cases
• Consideration of device therapy
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
Cardiac failure services available
at West Herts
• Routine outpatients for specialist opinion and
invasive investigation
• Emergency assessment in A+E with BNP
• Specialist heart failure nurse service with
consultant supervision (WGH & HH)
• Specialist cardiac failure device clinic
Thank You