Download Congestive Heart Failure

Congestive Heart Failure:
It’s not just about bilateral
lower extremity swelling
Cruff Renard, MD
Senior Internal Medicine Resident
Montefiore Medical Center, Bronx NY
Definition
Inability for the heart to pump
sufficient blood to meet the body’s
needs
CO = SV x HR
CO= Cardiac output; SV = Stroke Volume; HR= Heart rate
Epidemiology
• 5 millions american live with heart
failure (NIHLB)
• Most frequent cause of hospitalization
in patient above 65 year old
• Soweto Heart Study(2008): mean age
55 and 57% were women
Risks
Factors
• Hypertension
• Diabetes, HLD and CAD
• Anemia
• Pregnancy
• Valvular disease +++
• Cardio-toxic substance use: ETOH,
Cocaine
• Thyroid disorder
Diagnosis
What symptoms and signs should
prompt clinicians to consider the
diagnosis of heart failure?
Diagnosis
Asymptomatic
Treating asymptomatic patient with LV
dysfunction can delay onset of HF
Goldberg LH et al. Circulation 2006 Jun 20;113(24)2851-60. PMID 16785351
Diagnosis
• dyspnea and PND
• fatigue
• exercise intolerance
• Fluid retention: pulm congestion and
edema
• cough
Diagnosis (physical)
• Elevated blood pressure
• Elevated JVP, Hepato-jugular reflux
• Cardiac murmur
• Third heart sound
• LE edema
Classification (NYHA)
• NYHA class I (mild): Patient has asymptomatic left ventricular dysfunction.
Normal physical activity does not cause undue fatigue, palpitation or
shortness of breath
• NYHA class II (mild): Patient has fatigue, palpitation, or shortness of breath
with normal physical activity
• NYHA class III (moderate): Patient has shortness of breath with minimal
activity, including usual activity of daily living
• NYHA class IV (severe): Patient has shortness of breath at rest and is
unable to perform any physical activity without discomfort. Physical activity
of any kind increases discomfort
Stages (ACC/AHA)
•
What are the types of heart failure
and how should clinicians distinguish
them?
Types of Heart
Failure
• Dilated Cardiomyopathy
• Hypertrophic
• Restrictive CM
• Systolic HF VS HF with preserved EF
What tests should clinicians consider
in the evaluation of patients with
suspected heart failure?
Heart Failure: work
up
• Chest X-ray: cardiomegaly,
pulmonary
congestion, pHTN, underlying lung
diseases, pericardial or/and pleural
effusion
• EKG: arrhythmia, LVH, ischemic heart
disease
• CBC : anemia, signs of infections
• Blood chemistry and TFTs
• 2D Echo
Treatment
What are the key points of the
updated heart failure guidelines?
HFSA 2010 Practice Guideline (12.3, Table 12.3)
Acute Decompensated Heart Failure (ADHF)—
Treatment Goals for Hospitalized Patients
• Improve symptoms, especially congestion and low-output symptoms
• Optimize volume status
• Identify etiology
• Identify precipitating factors
• Optimize chronic oral therapy; minimize side effects
• Identify who might benefit from revascularization
• Education patients concerning medication and HF self-assessment
• Consider enrollment in a disease management program
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Treatment
(Monitoring)
• Frequent vitals signs (BP, HR, RR,
Temp, O2Sat)
• Input/Output+++
• Daily Weight +++
• Twice daily or daily physical exam
HFSA 2010 Practice Guideline
HF RISK Factor Treatment Goals
Risk Factor
•
•
•
•
•
•
•
•
Goal
Hypertension
Generally <130/80
Inactivity
20-30 min. aerobic 3-5 x wk
Obesity
Weight reduction <30 BMI
Alcohol
Men ≤ 2 drinks/day, women ≤1
Smoking
Cessation
Dietary Sodium
Maximum 2-3 g/day
Diabetes
ADA guidelines
Hyperlipidemia
NCEP guidelines
Treatment
Loop diuretic
Loop diuretic : furosemide/torsemide ideally IV.
Decrease fluid overload.
Kaplan–Meier Curves for the Clinical Composite End Point of Death,
Rehospitalization, or Emergency Department Visit.
Felker GM et al. N Engl J Med 2011;364:797-805
Mean Change in Serum Creatinine Level.
Felker GM et al. N Engl J Med 2011;364:797-805
ACE Inhibitors in Heart Failure:
From Asymptomatic LVD to Severe HF
SOLVD Prevention
(Asymptomatic LVD)
CONSENSUS
Heart Failure)
20%
death or HF hosp.
40%
mortality at 6 mos.
29%
death or new HF
31%
mortality at 1 year
27%
study
mortality at end of
SOLVD Treatment
(Chronic Heart Failure)
16%
mortality
(Severe
No difference in incidence of
sudden cardiac death
SOLVD Investigators. N Engl J Med 1992;327:685-91
SOLVD Investigators. N Engl J Med 1991;325:293-302
CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35
HFSA 2010 Practice Guideline (7.2)
Pharmacologic Therapy: Substitutes for ACEI
It is recommended that other therapy be substituted for ACE
inhibitors in the following circumstances:
 In patients who cannot tolerate ACE inhibitors due to cough,
ARBs are recommended.
Strength of Evidence = A
 The combination of hydralazine and an oral nitrate
considered in such patients not tolerating ARBs.
may be
Strength of Evidence = C
 Patients intolerant to ACE inhibitors from hyperkalemia or renal
insufficiency are likely to experience the same side effects with
ARBs. In these cases, the combination of hydralazine and an oral
nitrate should be considered.
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.6, 7.7)
Pharmacologic Therapy: Beta Blockers
Beta blockers shown to be effective in clinical trials
are recommended for symptomatic and
asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A
Beta blockers are recommended as routine therapy
for asymptomatic patients with an LVEF ≤ 40%.
 Post MI
Strength of Evidence = B
 Non Post-MI
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Effect of Beta Blockade on Outcome
in Patients With HF and Post-MI LVD
HF Severity
Target
Dose (mg)
Outcome
Study
Drug
US Carvedilol1
carvedilol
mild/
moderate
6.2525 BID
↓48% disease progression
(p= .007)
CIBIS-II2
bisoprolol
moderate/
severe
10 QD
↓34% mortality (p <.0001)
MERIT-HF3
metoprolol
succinate
mild/
moderate
200 QD
↓34% mortality (p = .0062)
COPERNICUS4
carvedilol
severe
25 BID
↓35% mortality (p = .0014)
CAPRICORN5
carvedilol
post-MI LVD 25 BID
1Colucci
↓23% mortality (p =.031)
WS et al. Circulation 1196;94:2800-6. 2CIBIS II Investigators. Lancet 1999;353:9-13.
3MERIT-HF Study Group. Lancet 1999;353:2001-7. 4Packer M et al. N Engl J Med 2001;344
1651-8. 5The CAPRICORN Investigators. Lancet 2001;357:1385-90.
HFSA 2010 Practice Guideline
Pharmacologic Therapy: Beta Blocker Overview*
General considerations Initiate at low doses
Up-titrate gradually, generally no sooner than at 2 week
intervals
Use target doses shown to be effective in clinical trials
Aim to achieve target dose in 8-12 weeks
Maintain at maximum tolerated dose
If symptoms worsen or Adjust dose of diuretic or concomitant vasoactive med.
Continue titration to target after symptoms return to
other side effects
baseline
appear
If up-titration continues Prolong titration interval
Reduce target dose
to be difficult
Consider referral to a HF specialist
*Consult language of specific recommendations
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Beta Blockers
Used in Clinical Trials
Generic Name
Trade Name
Initial
Dose
Bisoprolol
Zebeta
Carvedilol
Daily
Target Dose
Mean Dose in
Clinical Trials
1.25 mg qd
10 mg qd
8.6 mg/day
Coreg
3.125 mg bid
25 mg bid
37 mg/day
Carvedilol
Coreg CR
10 mg qd
80 mg qd
Metoprolol
succinate
CR/XL
Toprol XL
12.5-25 mg qd
200 mg qd
159 mg/day
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.3)
Pharmacologic Therapy: Angiotensin
Receptor Blockers
ARBs are recommended for routine
administration to symptomatic and
asymptomatic patients with an
LVEF ≤ 40% who are intolerant to
ACE inhibitors for reasons other than
hyperkalemia or renal insufficiency.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ARBS in Patients Not Taking ACE Inhibitors: ValHeFT & CHARM-Alternative
CHARM-Alternative
Valsartan
Placebo
p = 0.017
CV Death or HF Hosp %
Survival %
Val-HeFT
Placebo
Candesartan
HR 0.77, p = 0.0004
Months
Months
Maggioni AP et al. JACC 2002;40:1422-4
Granger CB et al. Lancet 2003;362:772-6
HFSA 2010 Practice Guideline (7.14-7.15)
Pharmacologic Therapy:
Aldosterone Antagonists
An aldosterone antagonist is recommended
for patients on standard therapy, including
diuretics, who have:
 NYHA class IV HF (or class III, previously class IV) HF from
reduced LVEF (≤ 35%)
One should be considered in patients postMI with clinical HF or diabetes and an LVEF
< 40% who are on standard therapy,
including an ACE inhibitor
(or
ARB)
Strength of
Evidence
= A and a
beta blocker.
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Aldosterone Antagonists in HF
Probability of Survival
RALES (Advanced HF)
EPHESUS (Post-MI)
Eplerenone
Spironolactone
Placebo
Placebo
RR = 0.70
P < 0.001
RR = 0.85
P < 0.008
Months
Pitt B. N Engl J Med 1999;341:709-17
Pitt B. N Engl J Med 2003;348:1309-21
HFSA 2010 Practice Guideline (7.16-7.18)
Aldosterone Antagonists and Renal Function
Aldosterone antagonists are not recommended when:
 Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
 Serum potassium> 5.0 mmol/L
 Therapy includes other potassium-sparing diuretics

Strength of Evidence = A
It is recommended that potassium be measured at baseline,
then 1 week, 1 month, and every 3 months
Strength of Evidence = A
Supplemental potassium is not recommended unless potassium
is < 4.0 mmol/L
Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.19)
Pharmacologic Therapy:
Hydralazine and Oral Nitrates
A combination of hydralazine and
isosorbide dinitrate is recommended as
part of standard therapy, in addition to
beta-blockers and ACE-inhibitors, for
African Americans with HF and reduced
LVEF:
 NYHA III or IV HF
Strength of Evidence = A
 NYHA II HF
Strength of Evidence = B
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
A-HeFT Outcomes
End point
Primary end point
composite score
ISDN-HDZN
(n=518)
Placebo
(n=532)
pvalue
-0.1
-0.5
0.01
6.2
10.2
0.02
1st HF hospitalization (%)
16.4
24.4
0.001
Change in quality-of-life
score at 6 months**
-5.5
-2.7
0.02
All-cause mortality (%)
Taylor AL et al. N Engl J Med 2004; 351;2049-57
Prevention
Treating Hypertension to Prevent HF
Aggressive blood
pressure control:
Decreases
risk of
new HF
by ~ 50%
56% in DM2
Lancet 1991;338:1281-5 (STOP-Hypertension
JAMA 1997;278:212-6 (SHEP)
UKPDS Group. UKPDS 38. BMJ 1998;317:703-713
Aggressive BP control in
patients with prior MI:
Decreases
risk of
new HF
by ~ 80%
HFSA 2010 Practice Guideline (3.3-3.4)
Prevention—ACEI and Beta Blockers
ACE inhibitors are recommended for prevention of HF in
patients at high risk for this syndrome, including those with:
 Coronary artery disease
 Peripheral vascular disease
 Stroke
 Diabetes and another major risk factor
Strength of Evidence = A
ACE inhibitors and beta blockers are recommended for all
patients with prior MI.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Management of Patients with Known
Atherosclerotic Disease But No HF
HOPE
Treatment with ACE
inhibitors decreases
the risk of CV death,
MI, stroke, or cardiac
arrest.
Placebo
Ramipril
22% rel. risk red. p < .001
EUROPA
Placebo
NEJM

2000;342:145-53 (HOPE)
2003;362:782-8 (EUROPA)
Lancet
Perindopril
20% rel. risk red. p = .0003
Treatment of Post-MI Patients with
Asymptomatic LV Dysfunction (LVEF ≤ 40%)
SAVE Study
Mortality
Rate
Placebo
 All-cause mortality ↓19%
Captopril
 CV mortality ↓21%
 HF development ↓37%
19% rel. risk reduction
p = 0.019
 Recurrent MI ↓25%
Years
Pfeffer et al. NEJM 1992;327:669-77
The Additional Value of Beta Blockers
Post-MI: CAPRICORN
Studied impact of beta blocker (carvedilol) on
post-MI patients with LVEF ≤ 40% already
receiving contemporary treatments, including
revascularization, anticoagulants, ASA, and
ACEI:
 All-cause mortality reduced (HR = 0.077; p = 0.03)
 CV mortality reduced (HR = 0.75; p = .024)
 Recurrent non-fatal MIs reduced (HR =.59; p = .014)
Dargie HJ. Lancet 2001;357:1385-90
A-HeFT Outcomes
End point
Primary end point
composite score
ISDN-HDZN
(n=518)
Placebo
(n=532)
pvalue
-0.1
-0.5
0.01
6.2
10.2
0.02
1st HF hospitalization (%)
16.4
24.4
0.001
Change in quality-of-life
score at 6 months**
-5.5
-2.7
0.02
All-cause mortality (%)
Taylor AL et al. N Engl J Med 2004; 351;2049-57
Treatment
(Multidisciplinary)
• Patient and family
• Physicians
• Nurses
• Social workers
• Nutritionist
• Health educators
• Pharmacist +++
Thank you!