Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
ACUTE HEART FAILURE AFTER MYOCARDIAL INFARCTION Nurkić Midhat MD PhD FESC • In most patients with heart failure due to left ventricular systolic dysfunction, the underlying cause is coronary heart disease • To reduce progression to heart failure in a patient with acute myocardial infarction, it is important to achieve the earliest possible reperfusion, whether by thrombolysis or primary percutaneous coronary intervention ACUTE HEART FAILURE Sudden development of a large myocardial infarction or rupture of a cardiac valve in a patient who previously was entirely well LV Remodelling Post MI Acute infarction (hours) Infarct expansion (hours to days) Global remodelling (days to months) • Acute heart failure (AHF) is the one of the most common disorders encountered in medical practice, and is associated with a high mortality and morbidity rate despite contemporary therapy Heart Failure after Acute MI Cumulative HF (%) 30 25 20 15 10 5 0 0 30 Days 1 2 3 4 5 6 Years 7 8 9 10 Time Kannel et al, 1979 Apical 4 chamber view: End diastole LV Remodelling Post Anteroseptal MI 1 week EDV: 137 ml ESV: 80 ml EF: 41% 3 months EDV: 189 ml ESV: 146 ml EF: 23% Sharpe N. 2000 Heart failure • Clinical syndrome that may result from any structural or functional cardiac disorder that impairs the pumping ability of the heart • It not only reduces life expectancy but is associated with symptoms of breathlessness, fluid retention and fatigue that markedly impair quality of life Pathologic Progression of CV Disease Sudden Death Coronary artery disease Hypertension Diabetes Myocardial injury Pathologic remodeling Low ejection fraction Death Cardiomyopathy Pump failure Valvular disease • Neurohormonal stimulation • Endothelial dysfunction • Myocardial toxicity Adapted from Cohn JN. N Engl J Med. 1996;335:490–498. Symptoms: Dyspnea Fatigue Edema Chronic heart failure Explosive Increase in HF AHA.Heart Disease and Stroke Statistics – 2005 Update • 1979 – 2002: Hospital discharges from HF rose from 377,000 to 970,000 per year • 1992 – 2002: Deaths increased 35.3% • Number of patients with HF is expected to double in 30 years Similarities Between Acute MI and Acute Decompensated HF in the US Incidence Acute MI ADHF 1 million per year 1 million per year 3–4% 3–4% 2% 10% Clearly defined (coronary thrombosis) Uncertain Beneficial Minimal/no benefit or deleterious compared with placebo Many Level A None Mortality In-hospital After discharge (60–90 d) Pathophysiological target(s) Clinical benefits of interventions in published clinical trials ACC/AHA recommendations (Gheorghiade M, et al. Circulation 2005;112:3958-68) Natural History of Chronic and Acute Heart Failure Normal heart Chronic heart failure 5 million in the US 10 million in Europe Initial myocardial injury Heart Viability Death What if fluid overload causes progressive HF? First ADHF episode: Pulmonary edema ER admission Later ADHF episodes: Rescue therapy ICU admission Initial phase Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G. Last year Mechanism of Worsening HF with Renal Dysfunction Renal dysfunction (Schrier RW. JACC 2006;47:1-8) Current Treatment of Heart Failure Acutely Decompensated Heart Failure (ADHF) ♥ How to predict mortality? ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ What do these patients look like? How do you know how much to diurese? Is BNP useful in judging diuresis? How to use diuretics What do you do when the creatinine increases? Is ultrafiltration useful? ACE-inhibitors or beta-blockers first? Should beta-blockers be started in hospital? When should you use intravenous therapy? Predictors of InHospital Mortality Fonarow, G. C. et al. JAMA 2005;293:572-580. Copyright restrictions may apply. Heart Failure Risk Scoring System Lee, D. S. et al. JAMA 2003;290:2581-2587. Mortality Rates in Acutely Decompensated Heart Failure by Risk Score Lee, D. S. et al. JAMA 2003;290:2581-2587. They’re Sicker Than We Think Mortality risk after 1st hospitalization for ADHF: (Age, male gender, ischemia and decreased LVEF worsen prognosis) •In-hospital: 3% •30-day: 7.9% •One year: 30% •Five years: 60% Baker, DW et al. Am Heart J 2003; 146(2): 258-64 Ho KK, et al. Circulation 1993; 88(1): 107-15 Jong P, et al. Arch Int Med 2002; 162(15) 1689-94 Narang R ,et al. Eur Heart J 1996; 17(9) 1390-1403 Comparative Five Year Mortality • Adenocarcinoma of the colon (IIIB): 36% • COPD (FEV1 30-39% predicted): 53% • ESRD (dialysis-dependent): 60-80% Current Treatment of Heart Failure Acutely Decompensated Heart Failure (ADHF) ♥ How to predict mortality? ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ What do these patients look like? How do you know how much to diurese? Is BNP useful in judging diuresis? How to use diuretics What do you do when the creatinine increases? Is ultrafiltration useful? ACE-inhibitors or beta-blockers first? Should beta-blockers be started in hospital? When should you use intravenous therapy? Congestion in HF: Most Admitted Patients are “Wet” 100% Admitted Patients (%) 90% 89% 74% 80% 67% 70% 65% 60% 50% 34% 40% 30% 20% 10% 0% Any Dyspnea Pulmonary Congestion (CXR) Rales Peripheral Edema (ADHERE Registry. 3rd Qtr 2003 National Benchmark Report.) < at Rest Dyspnea Time Course of Events Preceding ADHF Hospitalization (-89 to -1) ePAD (19) Thoracic Impedance (15) SDAAM (16) (-25 to -5) (-21 to ?) Dyspnea (8-9) Edema, Cough, Fatigue (7) Cough (10) Weight gain (11) Days I -90 Dyspnea (3) Edema (12) II I -25 I I I I -20 I I I I I I -15 I I I I I I -10 I I I I I -5 I I I I I 0 Admission I I I I 5 I I I I I 10 Rapid Assessment of Hemodynamic Status Congestion at Rest NO Low Perfusion at Rest N O Y E S YES Signs/Symptoms of Congestion: Orthopnea / PND JV Distension Hepatomegaly Edema Rales (rare in chronic heart failure) Elevated est. PA systolic( loud P2 and RV lift) Valsalva square wave Abdominojugular reflux S3 Possible Evidence of Low Perfusion: Narrow pulse pressure Cool extremities Sleepy / obtunded Hypotension with ACE inhibitor Low serum sodium Renal Dysfunction (one cause) Elevated LFTs Pulsus alternans Rapid Assessment of Hemodynamic Status Congestion at Rest NO Low Perfusion at Rest N O Y E S Warm & Dry YES Warm & Wet 67% Cold & Dry 5% Cold & Wet 28% Nohria,J Cardiac Failure 2000;6:64 Potential Endpoints of Therapy in ADHF • • • • • • • Resting symptoms JVD Rales Edema PCW or Cardiac Output BNP Echo (mitral regurgitation or PA pressure) (Drazner M, et al. J Heart Lung Tx 1999;1126. Rosario, et al. JACC 1998;1819-24. Johnson, et al. Ciruclation 1998 [abstract]) Is the Swan-Ganz Catheter Useful in the Patient with Acute Decompensated HF? NO (Stevenson, et al. JAMA 2005;294:1625-1633) Early Response of PCW but not CI Predicts Subsequent Mortality in Advanced Heart Failure Total Mortality Risk% Total Mortality Risk% 60 60 50 50 PCW > 16 mmHg 40 30 40 Cardiac Index > 2.6 L/min-M2 30 199 PCW < 16 mmHg 20 20 Cardiac Index < 2.6 L/min/M2 236 10 257 10 P=0.001 0 0 6 12 Months 18 24 0 220 0 6 P=NS 12 Months 18 24 Final hemodynamic measurement in 456 advanced HF patients after tailored vasodilator therapy (Fonarow G Circulation 1994;90:I-488) Current Treatment of Heart Failure Acutely Decompensated Heart Failure (ADHF) ♥ How to predict mortality? ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ What do these patients look like? How do you know how much to diurese? Is BNP useful in judging diuresis? How to use diuretics What do you do when the creatinine increases? Is ultrafiltration useful? ACE-inhibitors or beta-blockers first? Should beta-blockers be started in hospital? When should you use intravenous therapy? BNP is Increased with HF and Systolic or Diastolic Dysfunction Maisel AS, et al. JACC 2003;41:2010 BNP Levels Pre-discharge Predict Mortality and Readmisssion (Logeart D, et al. JACC 20042;40:976-82) Current Treatment of Heart Failure Acutely Decompensated Heart Failure (ADHF) ♥ How to predict mortality? ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ What do these patients look like? How do you know how much to diurese? Is BNP useful in judging diuresis? How to use diuretics What do you do when the creatinine increases? Is ultrafiltration useful? ACE-inhibitors or beta-blockers first? Should beta-blockers be started in hospital? When should you use intravenous therapy? Sodium Reabsorption Sites in the Nephron 70% Proximal Tubule 5% Distal Tubule Glomerulus 20% Loop of Henle Collecting Tubule Loop Diuretics Thiazide Diuretics 1-4% Ceiling Doses of Loop Diuretics (mg) Furosemide bumetanide torsemicle IV po IV po IV po moderate 80 80 2-3 2-3 20-50 20-50 severe 200 240 8-10 8-10 50-100 50-100 40 80-160 1 1 10-20 10-20 40-80 160240 2-3 2-3 20-50 20-50 Renal Insufficiency Cirrhosis with normal GFR CHF with normal GFR (Adapted from Brater C. New Engl J Med 1999) Bioavailability of Loop Diuretics 100% - 80% - 50% - 10% furosemide torsemide bumetanide Current Treatment of Heart Failure Acutely Decompensated Heart Failure (ADHF) ♥ How to predict mortality? ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ What do these patients look like? How do you know how much to diurese? Is BNP useful in judging diuresis? How to use diuretics What do you do when the creatinine increases? Is ultrafiltration useful? ACE-inhibitors or beta-blockers first? Should beta-blockers be started in hospital? When should you use intravenous therapy? Baseline Renal Dysfunction and Worsening Renal Function (WRF) are Additive in Predicting Mortality in HF Patients Predictors of WRF were thiazide diuretics, increased BUN, and vascular disease And a fall in sCr of > 0.3 mg/dL was associated with improved mortality sCreatinine ≤1.2 WRF (>0.3mg/dL) no 1.2-2.0 ≥2.0 ≤1.2 1.2-2.0 ≥2.0 no no yes yes yes (de Silva, R. et al. Eur Heart J 2006 27:569-581) What to do when the creatinine begins to increase? • Check volume status • Check blood pressure (especially at peak onset of vasodilators) • Restrict sodium intake (and water if hyponatremic) • Check for renal problems (obstructions, prooteinuria, interstitial nephritis) • Consider vasodilators or inotropes • Consider ultrafiltration Ultrafiltration Improved Weight Loss But Not Symptoms End points Ultrafiltration Diuresis p n 83 84 •Weight loss, primary end point 5.0 (mean kg) 3.1 0.001 •Dyspnea score, primary end point (mean) 6.4 6.1 0.35 •Net fluid loss (mean L) 4.6 3.3 0.001 •K<3.5 mEq/L (%) 1 12 0.018 •Need for vasoactive drugs (%) 3 13 0.015 48 hours Costanzo MR. American College of Cardiology 2006 Scientific Sessions; March 12, 2006; Atlanta, GA. Ultrafiltration Decreased Rehospitalization End points Ultrafiltration Diuresis p 90 days •Rehospitalization (%) 18 32 0.022 •Rehospitalization days (mean) 1.4 3.8 0.022 •Unscheduled office/ED visits (%) 21 44 0.009 Costanzo MR. American College of Cardiology 2006 Scientific Sessions; March 12, 2006; Atlanta, GA. Current Treatment of Heart Failure Acutely Decompensated Heart Failure (ADHF) ♥ How to predict mortality? ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ What do these patients look like? How do you know how much to diurese? Is BNP useful in judging diuresis? How to use diuretics What do you do when the creatinine increases? Is ultrafiltration useful? ACE-inhibitors or beta-blockers first? Should beta-blockers be started in hospital? When should you use intravenous therapy? ACE-inhibitor or Beta-blocker First? CIBIS-III (Willenheimer R, et al. Circulation 2005;112:2426-2435) ACE-inhibitor or Beta-blocker First? CIBIS-III Bisoprolol first Enalapril first (HR 0.94, CI = 077-1.16, = = 0.0.019 for noninferiority) (Willenheimer R, et al. Circulation 2005;112:2426-2435) ACE-inhibitor or Beta-blocker First? CIBIS-III Bisoprolol first Enalapril first Survival (HR 0.88, CI = 0.63-1.22, p = 0.44) (Willenheimer R, et al. Circulation 2005;112:2426-2435) ACE-inhibitor or Beta-blocker First? CIBIS-III Enalapril first Freedom from hospitaliz ation for worsening HF Bisoprolol first (HR = 1.25, CI = 0.87-1.81, p = 0.23) (Willenheimer R, et al. Circulation 2005;112:2426-2435) Current Treatment of Heart Failure Acutely Decompensated Heart Failure (ADHF) ♥ How to predict mortality? ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ ♥ What do these patients look like? How do you know how much to diurese? Is BNP useful in judging diuresis? How to use diuretics What do you do when the creatinine increases? Is ultrafiltration useful? ACE-inhibitors or beta-blockers first? Should beta-blockers be started in hospital? When should you use intravenous therapy? Goals in the Treatment of the Patient with Acutely Decompensated HF Diuretics Nesiritide Milrinone Improve symptoms yes (+++) yes (+) ? Decrease mortality ? ?(↑) ?(↑) yes no no ? no no yes no(↑) no(↑) Decrease hospitalization Duration Repeat hospitalization Decreased costs