Download Heart Failure Update

Heart Failure Update
Bibiana Cujec MD
May 2015
Disclosures
Participation in clinical trial
• GUIDE‐IT (BNP in management of HF)
Plan
• Review of new trials/CCS guidelines
• Management of heart failure: cases
• Stage D heart failure
– Mechanical circulatory support
– End of life care
Classifying Heart Failure
Ejection fraction %
Diagnosis in patients with clinical heart failure
>50
HF with preserved ejection fraction (HFpEF)
41‐49
HF with borderline preserved ejection fraction
<40
HF with reduced ejection fraction (HFrEF)
From: 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019
Figure Legend:
DIET Approach to the Patient With
Heart Failure
• Diagnose
• Educate
– Etiology
– Severity (LV
dysfunction)
–
–
–
–
• Initiate
–
–
–
–
Diuretic/ACE inhibitor
-blocker
Spironolactone
Digoxin
Diet
Exercise
Lifestyle
CV Risk
• Titrate
– Optimize ACE inhibitor
– Optimize -blocker
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Non‐Pharmacologic Management and Education
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Symptom/weight management‐self diuretic titration
Avoid excessive fluid intake (consider 1.5‐2L/day)
Salt restriction (<1.5g/day‐benefit not clear)
Modest alcohol use (none in alcoholic cardiomyopathy)
Avoid smoking/illicit drugs
Reinforce importance of exercise (cardiac rehab)
Understand medication benefits/risks
When travelling, carry medical history/medication list
Immunization
Sexual activity safe in stable patients (limited by symptoms)
Consider treatment of sleep disordered breathing if present
Be aware of psychosocial problems associated with HF
McMurray et al, Eur Heart J, 2012
Case 1
• 75 year old man
• Anterior MI 15 years ago. Type 2 DM, hypertension, dyslipidemia.
• Dyspnea NYHA class III. Orthopnea. PND
• BP 100/74, HR 100, O2 sat= 92%
• JVP 15 cm>SA. 3+ leg edema
• ECG: SR 90 bpm. LBBB
• Creatinine 150 umol/L,eGFR 45 ml/min. Hb 115 g/L
• Echocardiogram: LVEF 25%. Moderate mitral regurgitation
• How should he be managed?
• Furosemide 40‐80 mg daily, ACE‐I, spironolactone 25 mg daily. Start beta‐blocker once edema improves
HFrEF
• What if ?
– Develops gout: colchicine or prednisone. No NSAID
– Develops atrial fibrillation: Anticoagulate
– Develops pneumonia and creatinine increases to 200 umol/L : Stop diuretics and hold ACE‐I
– Worsening fluid overload: Increase furosemide and add metolazone
Case 2
• 75 year old woman obese (BMI 40 kg/m2), hypertension, diabetes, CKD stage 3
• Dyspnea NYHA class III
• BP 180/70, HR 120 JVP elevated, 3+ leg edema
• EKG: atrial fibrillation
• Echocardiogram: LVEF 50%. Severe LA enlargement
• How should she be managed? – Furosemide, control HTN and ventricular rate, anticoagulate
From: 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2013;62(16):e147-e239. doi:10.1016/j.jacc.2013.05.019
BNP in HF
RECOMMENDATION
We suggest that measurement of BNP or NT‐
proBNP in patients hospitalized for HF should be considered before discharge, because of the prognostic value of these biomarkers in predicting rehospitalization and mortality (Strong Recommendation; Moderate‐Quality Evidence). CanJCardiol 2015;31:3-16
Figure 3 BNP and management of HF
CCS Heart Failure guidelines 2014
Figure 1 Mechanisms of anemia in HF
CCS Heart Failure guidelines 2014
Canadian Journal of Cardiology 2015 31, 3-16DOI: (10.1016/j.cjca.2014.10.022)
Anemia in HF
RECOMMENDATIONS • We suggest that for patients with documented iron deficiency, oral or intravenous iron supplement be initiated to improve functional capacity. (Weak Recommendation; Low‐Quality Evidence). • We recommend erythropoiesis stimulating agents not be routinely used to treat anemia in HF. (Strong Recommendation; High‐Quality Evidence). Limit transfusions to Hb <80 g/L
CanJCardiol 31(2015)3‐16
PARADIGM‐HF
• 8442 patients with NYHA class II,III,IV
• LVEF < 40%
• Randomized to LCZ696 200 mg BID or enalapril 10 mg BID
• LCZ696 200 mg = Valsartan 160 mg and sacubitril (neprilysin inhibitor)
• Neprilysin inhibition increases natriuretic peptides (ANP,BNP), bradykinin, adrenomedulin
– Vasodilatation
– Natriuresis
NEJM 2014;371:993‐1004
Angiotensin–Neprilysin Inhibition versus Enalapril in Heart Failure
PARADIGM-HF
Study terminated after 27 mos because of 20% mortality reduction
McMurray JJV et al. N Engl J Med 2014;371:993-1004
Numbers of Patients with Heart Failure Who Would Need to Be Treated to Reduce Any‐Cause Mortality in Seven Clinical Trials.
Jessup M. N Engl J Med 2014;371:1062‐1064.
ARB/Neprilysin inhibitor
RECOMMENDATIONS
We recommend that in patients with mild to moderate HF, an EF < 40%, an elevated BNP level or hospitalization for HF in the past 12 months, a serum potassium < 5.2 mmol/L, and an eGFR > 30 mL/min and treated with appropriate doses of guideline‐directed medical therapy should be treated with LCZ696 in place of an ACE inhibitor or an angiotensin receptor blocker, with close surveillance of serum potassium and creatinine
(Conditional Recommendation; High‐ Quality Evidence). CanJCardiol 31(2015);3‐16
TOPCAT: Spironolactone in HFpEF
• 3445 patients with LVEF > 45%
• Randomized to spironolactone 15‐45 mg daily versus placebo
• Followed for 3.3 years
• Primary outcome CV death, aborted cardiac arrest and HF hospitalizations: no difference (18.6% versus 20.4% placebo)
• Hospitalization for HF (12% versus 14.2%) decreased (p = .04) but higher creatinine and hyperkalemia (18% vs 9%)
• NEnglJMed 2014;370:1383‐92
Spironolactone in HFpEF
RECOMMENDATION We suggest that in individuals with HFpEF, an increased NP level, serum potassium < 5.0 mmol/L, and an estimated glomerular filtration rate (eGFR) > 30 mL/min, a mineralocorticoid receptor antagonist like spironolactone should be considered, with close surveillance of serum potassium and creatinine (Weak Recommendation; Low‐Quality Evidence). CanJCardiol 31(2015) 3‐16
Ivabradine in HF
• Slows sinus rate by inhibiting funny inward (If) current in SA node –mixed Na‐K inward current
• SHIFT (Lancet 2010; 376:875‐885)
– 6558 patients, LVEF < 35%, sinus rhythm, recent hosp admission
– Randomized to ivabradine 7.5 mg BID or placebo
– 22 months follow‐up
– Fewer HF hosp admissions (16% vs 21%, HR .74, p<.0001)
– Fewer deaths from HF (3% vs 5%, HR .74, p=.014)
• April 2015: FDA approved for stable patients with HFrEF, HR >70 bpm, on maximally tolerated beta‐
blocker to decrease hospitalization rate
Cardiac Resynchronization Pacemakers
CRT: Who is a candidate?
• Patients with heart failure who are in NYHA class II‐IV
• QRS duration of >130 msec and LBBB
• LVEF < 35%
• Sinus rhythm
• on ACE‐I and beta‐blocker (optimal heart failure medical therapy)
• Absence of chronic kidney disease (GFR > 30 ml/min)
• CCS guidelines 2013
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Cardiac resynchronization: What is the benefit?
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Improved exercise tolerance
Improved LV ejection fraction
Less functional mitral regurgitation
Improved survival
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Implantable Cardioverter Defibrillator
Approx. 50% of HF patients die
from “sudden
death” (VT/VF)
ICD: Bottom Line
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↓20% death
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Benefit almost exclusively >6 months post‐revasc
Cost
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1% implant deaths
4% lead problems
6% device malfxn
Shocking:
 Inappropriate shock 39%
 Increasd risk of HF hospitalization post shock
Primary Prevention (CCS, 2012)
 Ischemic
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> 1 month post MI/3 months post revascularization
EF≤30%
EF≤35%, NYHA II‐III
Non‐Ischemic:
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> 9 month on OMT
NYHA II‐III
EF <35% Contraindicated NYHA IV and not VAD/transplant candidate
McKelvie et al, Can J Cardiol, 2013
Heart Failure Clinics
• Frequent telephone follow‐up by nurses
• Decreases need for ED visits and hospitalizations
• Consider referring patients NYHA class III‐
IV with multiple co‐
morbidities
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Mechanical circulatory support
Stage D heart failure: Bridge to transplant or destination therapy
ROADMAP: Long term LVAD in ambulatory heart failure
• Observational study of 97 patients with LVAD and 103 patients with optimal medical therapy. NYHA class III‐IV LVEF< 25%
• 12 months survival : 80% LVAD versus 64% medical therapy (p<.05). Better QoL and 6 min walk
• LVAD patients had more strokes (9.6% versus 2%) and bleeding (47% versus 1%) – ISHLT 2015 Scientific Sessions Nice April 2015
Would you be surprised if this patient
died in the next year?
• Personal directive
with naming of health
agent/POA/will
• Goals of care (green
sleeve) designation—
signed by physician
• Focus on symptom
management:
inactivate ICD, titrate
beta-blocker, stop
statin
End of life and heart rhythm devices—
patient information
• Turning off the shocking action of ICD will not
cause death
• It is not legally or morally wrong to stop any
medical treatment if it no longer serves your
needs (ie no longer likely to result in meaningful
or long term prolongation of life).
• Not suicide or euthanasia
• Allowing nature to take its course rather than
trying to stay alive by repeated shocks
Heart Rhythm Society 2011
https://myhealth.alberta.ca/Alberta/Pages/advance-care-planning-conversationmatters.aspx
Questions?
• [email protected]