Download advanced heart failure

Terapia non Chirurgica del Paziente con
Scompenso Cardiaco Avanzato
Metodi di valutazione della
sincronizzazione
ventricolare e loro
affidabilità
G. Lupi, ASL IV Chiavarese
G Lupi, Dipartimento di Cardiologia ASL III Genovese
ADVANCED HEART FAILURE
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treatments are inherently limited
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morbidity is typically progressive
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survival is often short.
ADVANCED HEART FAILURE
• Repeated hospitalizations for heart failure
• Intolerance or reduction of doses of
neurohormonal antagonists
• Escalation of diuretics
• Development of end-organ dysfunction,
malnutrition (or cardiac cachexia)
• Refractory arrhythmias with or without device
shocks
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‘a pattern of clinical characteristics should
suggest that a patient has become refractory to
traditional therapies’
Fang Et Al 2015
Non Surgical Theraphy
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Medical therapy (GDMT) dosed appropriately
Cardiac resynchronization therapy (CRT)
Arrhythmia management
Volume status optimization
Inotrope infusion
Medical therapy (GDMT)
• ….Critical to the definition of ACHF is
persistence of severe symptoms, functional
limitation and cardiac dysfunction despite
optimal therapy
Metra et Al 2007
ADVANCED HEART FAILURE
‘The first step in the assessment is to confirm
that the patient's conventional heart failure
management has been maximized and that
reversible factors (eg, ischemia, alcohol) have
been addressed…. Comorbidities …should also be
addressed’
Fang Et Al 2015
GUIDELINE RECOMMENDED MEDICAL
THERAPY
• There is evidence that neurohormonal
antagonists are administered at lower rates
and at lower doses in patients with more
severe HF
• This may have a detrimental effect on
prognosis
Komajda et Al EHJ 2005
GUIDELINE RECOMMENDED MEDICAL
THERAPY
• It is important to make every attempt to
initiate and up-titrate all indicated
medications to the doses shown to be
effective.
Metra et Al 2007
• An often underappreciated indicator of
advanced heart failure is the lack of response
to or intolerance of heart failure therapies.
Fang Et Al 2015
Stevenson L et Al 2007
CRT
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many stage D heart failure patients do not match
clinical trial populations owing to age or
comorbidities
CRT implantation in patients not likely to improve
is associated with several risks, including
procedural risks, device infection, risk of delay in
transplantation referral, and cost
Although CRT has strong evidence of benefit in
HFrEF, patients with advanced heart failure have
accounted for only ∼4% of the patients in CRT
clinical trials.
Primary time to all-cause
death or hospitalization.
Time to all-cause death or HF
hospitalization.
Circulation 2007
ICD
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An implantable cardioverter-defibrillator (ICD)
may abort death, but it does not improve
symptoms.
an ICD will not necessarily improve quality of
life and is not disease modifying
guidelines do not support the use of an ICD if
overall survival is estimated to be <1 year
Volume status optimization
• ‘When symptoms dominate the picture, they are primarily
symptoms of congestion… ‘
•‘Many patients considered to have refractory heart failure can
return to a reasonable level of comfort and function when fluid
balance is restored and maintained’
Stevenson EJHF 2015
DIURETIC RESISTANCE
ter Maaten, J. M. et al. (2014) Diuretic response in acute heart failure—pathophysiology, evaluation, and therapy
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2014.215
Figure 2 Mechanisms of loop diuretic resistance
An approach to treating patients with acute heart failure who are diuretic resistant
ter Maaten, J. M. et al. (2014) Diuretic response in acute heart failure—pathophysiology, evaluation, and therapy
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2014.215
How HSS alters renal and cardiac
hemodynamics
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instantaneous mobilization of extravascular fluid into the
intravascular space through the osmotic action of HSS
reduction in systemic vascular resistance through
baroreceptor reflex .
increased cardiac output, renal blood flow and enhanced
organ perfusion.
therapeutic furosemide concentration in renal tubules
along with the continued delivery of sodium.
•“The results of this meta-analysis demonstrate that in patients
with advanced CHF concomitant hypertonic saline
administration improved weight loss, preserved renal function,
and decreased length of hospitalization, mortality and heart
failure rehospitalization.”
ULTRAFILTRATION
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Ultrafiltration may represent a more rapid and
physiologic method of fluid removal than
diuretic therapy
Associated with a longer clinical stabilization
and a lower rehospitalization rate
ULTRAFILTRATION
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Concerns about the safety of ultrafiltration
Procedural-associated serious adverse events
could potentially offset clinical benefit and
hinder its widespread use.
Only when all diuretic strategies are
unsuccessful, ultrafiltration or other renal
replacement strategies are considered as
reasonable alternatives
ULTRAFILTRATION
Ultrafiltration
•Main questions:
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When patients with congestion may benefit the most from
Ultrafiltration?
When they should be treated with such an approach as a firstline therapy?
CUORE TRIAL
prospective, randomized, unblinded study
 ultrafiltration vs standard medical treatment in patients with
large fluid overload due to congestive HF.
Exclusion criteria:
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contraindications to anticoagulation
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severe renal insufficiency (serum creatinine >3.0 mg/dL)
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acute pulmonary edema or cardiogenic shock
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CUORE TRIAL
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Session duration and the ultrafiltration rate (100-500 mL/h)
left to the discretion of the treating physician
Fluid removal of > 2 liters (recommended not to exceed 75% of
the estimated initial weight increase)
intravenous dosage of diuretics started before randomization
unchanged unless required by the clinical condition
CUORE TRIAL
ULTRAFILTRATION
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If used late during hospitalization, in patients who had already
developed acute kidney injury, as in (CARRESS-HF), no
advantage from ultrafiltration
Early treatment with ultrafiltration in hospitalized HF patients
with hypervolemia (UNLOAD and CUORE) is associated with
significant reduction of rehospitalizations for HF
Prudential recommendation of incomplete (<75% of
estimated body weight gain) and slowly obtained fluid removal
Volume Status Optimization
•Once optimal fluid status has been restored, maintenance
of fluid balance is the challenge.
•No solid bases of evidence on the best way to do this.
•No current information to guide therapy in patients for
whom diuresis to the level of symptom relief is repeatedly
accompanied by progressive worsening of renal function
ESPERIENZA AMBULATORIO
INFERMIERISTICO
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216 VISITE
57 PAZIENTI
22 CASI IPERIDRATAZIONE ASINTOMATICA
4 CASI DISIDRATAZIONE
11 CASI VALUTAZIONE INF NON CONFERMATA
DAL MEDICO ATTRAVERSO ULTERIORI
ACCERTAMENTI
Intermittent or continuous use of
dobutamine and phosphodiesterase
inhibitors
• two focused meta-analyses
• traditional inotropic drugs did not show any
patient benefits
Inotrope Infusion
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Nieminem et Al Int J Cardiol 2014
AIM OF INOTROPIC THERAPY
•Patients listed for heart transplantation or waiting for VAD
implantation :
•preservation of organ function (e.g., renal and hepatic function)
as a bridging measure
•Patients who are not eligible (palliative)
•stabilisation and well-being of the patients and their avoidance
of re-hospitalisation.
LEVOSIMENDAN
LEVOSIMENDAN
Esperienza della Cardiologia di SESTRI P
• BRIDGE THERAPY
• 5 PAZIENTI
• PALLIATIVE THERAPY
• 8 PAZIENTI
• 2 impianto LVAD
• 1 Trapianto
• 1 Uscito dalla lista per
miglioramento
• 1 deceduto in lista
•
• 3 IN TRATTAMENTO
• 5 DECEDUTI
•(MEDIANA SOPRAVVIVENZA
6 MESI RANGE 4-9)
SURVIVAL IN INOTROPES
• Optimally treated patients in the Investigation
of Non–Transplant-Eligible Patients Who Are
Inotrope Dependent (INTREPID) trial had
survival rates of 22% at 6 months and 11% at 1
year
Fang 2015
Quando non c'è più niente da fare, c'è ancora molto da fare
Aging is frequently accompanied by the comorbid conditions of frailty and
malnutrition, which are important predictors of outcome with heart failure
and affect the feasibility of advanced heart failure therapies.
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depressed patients have decreased
medication adherence, worse health status,
increased health care utilization, and
increased mortality.
Cognitive impairment is also a predictor of
mortality in heart failure and may affect a
patient's self-care ability, thereby limiting
therapies for stage D heart failure.
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there is not enough evidence to conclude that
CRT implantation in stage D heart failure is
inappropriate, the decision should be factored
into the overall goals and plan of care for each
patient
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In one series, 545 of 729 CRT patients met ≥3
cardiac criteria for heart transplantation. 64 The
observed 92% and 77% survival rates at 1 and 3
years, respectively, rivaled or exceeded expected
transplantation outcomes
In a subset of patients with ambulatory New York
Heart Association (NYHA) functional class IV heart
failure enrolled in the Comparison of Medical
Therapy, Pacing, and Defibrillation in Heart Failure
(COMPANION) trial, CRT and CRT-defibrillator
therapy delayed the time to all-cause mortality
and hospitalization with a trend for improvement
in survival.
Diuretic resistance
Diuretic therapy
ter Maaten, J. M. et al. (2014) Diuretic response in acute heart failure—pathophysiology, evaluation, and therapy
Nat. Rev. Cardiol. doi:10.1038/nrcardio.2014.215
DIURETIC RESISTANCE

Advanced heart failure is characterized by
increasing inability to meet the metabolic
demands of end organs and skeletal muscle,
resulting in renal and hepatic insufficiency and
reduction in functional capacity, cachexia, and
fatigue. End-organ dysfunction increases the
mortality associated with heart failure and can
potentially preclude application of advanced
heart failure therapies.
•If a major goal is to treat the symptoms, therapies should be
reviewed in that context.
•ACEI and beta blockers have clearly been shown to impact
disease progression and survival, but benefit on current
symptoms has been very difficult to demonstrate