Download New CHF Patient in my Office: What Should I Do?

New CHF Patient in my Office: What Should I Do?
Joseph Mishkin MD FACC
Advanced Heart Failure, Transplantation and Mechanical Circulatory Support
Disclosures
• No disclosures Clinical Presentation
• 38 year old man presents with 3 week history of abdominal discomfort, postprandial nausea, early satiety. Also reports fatigue, dyspnea and difficulty sleeping • Past Medical History
– GERD
– Irritable bowel syndrome
– Appendectomy
Additional History
• Medications
– Famotidine
– Ibuprofen as needed
• Social History
Non smoker
Occasional alcohol
Office manager
Father is medical malpractice attorney
– Married, 2 children
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• Family History
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Father MI age 77
Mother healthy age 75
Brother healthy age 35
Sister healthy age 42
Physical Examination
Appears tired, pale/ashen. No respiratory distress
Temp 97.9 F HR 122 BP 92/60 mmHg
Jugular venous distension present
Lungs clear
Tachycardic, 2/6 apical holosystolic murmur, third heart sound?
• Abdomen soft, mild RUQ tenderness, no rebound/guarding
• No edema, cool extremities
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Next Step in Management?
A) Referral to General Surgery to evaluate for cholecystectomy
B) Referral to GI for EGD
C) Rx for furosemide, carvedilol and digoxin; check some labs, follow up in 3 weeks
D) Outpatient Cardiology referral for a stress test
E) Inpatient admission for further evaluation and management
How to Recognize Heart Failure? • A syndrome caused by cardiac dysfunction
– Results from myocardial muscle dysfunction or loss – Characterized by left ventricular dilatation or hypertrophy – Neurohormonal and circulatory abnormalities leading to characteristic symptoms:  Fluid retention
 Shortness of breath
 Fatigue, especially on exertion • Left untreated, usually progressive • Severity of clinical symptoms may vary substantially during course of the disease process and may not correlate with changes in underlying cardiac function
HFSA Guidelines 2010
Braunwald. NEJM 2008
Clues From the History and Physical Examination
Features that increase the likelihood of heart failure: • Presence of paroxysmal nocturnal dyspnea (greater than 2‐fold likelihood) • Presence of an S3 (11 times greater likelihood)
• Bendopnea (shortness of breath when bending over)
– Indicative of elevated filling pressures
HFSA Guidelines 2010
Thibodeau, et al. JACC HF 2013
Definition of Heart Failure
Classification
Ejection
Fraction
Description
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
≤40%
Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
≥50%
Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline
41% to 49%
These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved
>40%
It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
Updated ACC Guidelines 2013
Heart Failure Patient Evaluation
• Assess clinical severity and functional limitation by history, physical examination, and determination of functional class*
• Assess cardiac structure and function
• Determine the etiology of HF
• Evaluate for coronary disease and myocardial ischemia
• Evaluate the risk of life threatening arrhythmia
• Identify any exacerbating factors for HF
• Identify co‐morbidities which influence therapy
• Identify barriers to adherence *Metrics to consider include the 6‐minute walk test,NYHA functional class
HFSA 2010 Practice Guideline Adapted from:
New York Heart Association Classes
• I: Ordinary physical • III: Comfortable at rest, activity does not cause but less than ordinary undue fatigue, activity causes fatigue, palpitation, or dyspnea palpitation, or dyspnea.
(shortness of breath).
• IV: Symptoms of cardiac • II: Comfortable at rest, insufficiency at rest. If but ordinary physical any physical activity is activity results in fatigue, undertaken, discomfort palpitations, or dyspnea.
is increased.
Objective Clinical Classification of Heart Failure Syndrome
A
L
B
C
How do you determine stability in a patient with suspected HF?
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•
•
History and physical
Laboratory assessment
Cardiac imaging
Biomarkers
HF Risk scores
Signs and Symptoms Necessitating More Urgent Evaluation
•
•
•
•
•
•
Hypotension
Tachycardia
Orthopnea, paroxysmal nocturnal dyspnea
Syncope
Unstable angina
Unintentional weight loss/early satiety
Biomarkers and Diagnosis
Maisel, et al. NEJM 2002
Biomarkers and Prognosis
‐Val‐HeFT Investigators Prognostic value of changes in N‐
terminal pro brain natriuretic peptide in Val‐HeFT (Valsartan Heart Failure Trial)
‐Prognostic value of baseline plasma amino‐terminal pro‐brain natriuretic peptide and its interactions with irbesartan
treatment effects in patients with heart failure and preserved ejection fraction: findings from the I‐PRESERVE trial
Masson S., Latini R., Anand I.S., et al. J Am Coll Cardiol. 2008
Anand I.S., Rector T.S., Cleland J.G., et al. Circ Heart Fail. 2011
Risk Scores to Predict Outcomes in HF
Risk Score
Chronic HF
All patients with chronic HF
Seattle Heart Failure Model
Heart Failure Survival Score
CHARM Risk Score
CORONA Risk Score
Specific to chronic HFpEF
I-PRESERVE Score
Acutely Decompensated HF
ADHERE Classification and Regression Tree
(CART) Model
American Heart Association Get With the
Guidelines Score
EFFECT Risk Score
ESCAPE Risk Model and Discharge Score
OPTIMIZE HF Risk-Prediction Nomogram
Reference/Link
http://SeattleHeartFailureModel.org
http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc-37354.shtml
http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidelinesHFStr
oke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-The-Guidelines-HeartFailure-Home- %20Page_UCM_306087_SubHomePage.jsp
http://www.ccort.ca/Research/CHFRiskModel.aspx
Less Complex Risk Prediction
• Initial heart rate and systolic blood pressure predict outcomes in chronic heart failure
• Heart rate > 100
• SBP < 100
Aranda JM Jr, et al. Clin Cardiol. 2007
McMurray. NEJM 2010
LCZ696?
Back to Our Patient
• 38 year old man presents with 3 week history of abdominal discomfort, postprandial nausea, early satiety. Also reports fatigue, dyspnea and difficulty sleeping – Dyspnea
– Orthopnea and PND
– Early satiety
Physical Examination
Appears tired, pale/ashen. No respiratory distress
HR 122 BP 92/60 mmHg
Jugular venous distension present
Lungs clear
Tachycardic, 2/6 apical holosystolic murmur, third heart sound?
• Abdomen soft, RUQ tenderness
• No edema, cool extremities
•
•
•
•
•
What’s the Next Step in Management ?
A) Referral to General Surgery to evaluate for cholecystectomy
B) Referral to GI for EGD
C) Rx for furosemide, carvedilol and digoxin; check some labs, follow up in 3 weeks
D) Outpatient Cardiology referral for an echocardiogram and stress test
E) Inpatient admission for further evaluation and management
Take Home Points
• Presence of dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea increase likelihood of heart failure • Presence of jugular venous distension and a third heart sound are concerning physical exam findings
• Beware of atypical presentations (GI symptoms)
• Rule out ischemia in patients with risk factors, history of angina • High risk features warrant inpatient evaluation
Thank You
A New PARADIGM in Heart Failure?
• LCZ696
• In this double‐blind trial, we randomly assigned 8442 patients with class II, III, or
• IV heart failure and an ejection fraction of 40% or less to receive either LCZ696 (at
• a dose of 200 mg twice daily) or enalapril (at a dose of 10 mg twice daily), in addition
• to recommended therapy. The primary outcome was a composite of death from
• cardiovascular causes or hospitalization for heart failure, but the trial was designed
• to detect a difference in the rates of death from cardiovascular causes.
McMurray, et al. NEJM 2014
Noninvasive Cardiac Imaging
I IIa IIb III
Patients with suspected or new‐onset HF, or those presenting with acute decompensated HF, should undergo a chest x‐ray to assess heart size and pulmonary congestion, and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patients’ symptoms.
I IIa IIb III
A 2‐dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with HF to assess ventricular function, size, wall thickness, wall motion, and valve function.
I IIa IIb III
Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with HF who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy.
Noninvasive Cardiac Imaging (cont.)
I IIa IIb III
Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with de novo HF who have known CAD and no angina unless the patient is not eligible for revascularization of any kind.
I IIa IIb III
Viability assessment is reasonable in select situations when planning revascularization in HF patients with CAD.
I IIa IIb III
Radionuclide ventriculography or magnetic resonance imaging can be useful to assess LVEF and volume when echocardiography is inadequate.
Recommendations for Invasive Evaluation
Recommendation
COR
LOE
Monitoring with a pulmonary artery catheter should be performed in patients
with respiratory distress or impaired systemic perfusion when clinical
assessment is inadequate
I
C
Invasive hemodynamic monitoring can be useful for carefully selected
patients with acute HF with persistent symptoms and/or when hemodynamics
are uncertain
IIa
C
When coronary ischemia may be contributing to HF, coronary arteriography
is reasonable
IIa
C
Endomyocardial biopsy can be useful in patients with HF when a specific
diagnosis is suspected that would influence therapy
IIa
C
Routine use of invasive hemodynamic monitoring is not recommended in
normotensive patients with acute HF
III: No
Benefit
B
III: Harm
C
Endomyocardial biopsy should not be performed in the routine evaluation of
HF
• Ouwerkerk W., Voors A.A., Zwinderman A.H.; Factors influencing the predictive power of models for predicting mortality and/or heart failure hospitalization in patients with heart failure. J Am Coll Cardiol HF. 2014;2:429‐436.
• Pocock S.J., Ariti C.A., McMurray J.J., et al; Predicting survival in heart failure: a risk score based on 39 372 patients from 30 studies. Eur Heart J. 2013;34:1404‐1413.
• Wang T.J., Gona P., Larson M.G., et al; Multiple biomarkers for the prediction of first major cardiovascular events and death. N Engl J Med. 2006;355:2631‐2639.
• Levy W.C., Mozaffarian D., Linker D.T., et al; The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation. 2006;113:1424‐1433.