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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!