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
Broken Hearts Acute Heart Failure Dr Andrew Turley Cardiology Consultant South Tees Overview: Acute Heart Failure • New ESC guidelines • Diagnosis – Serum natriuretic peptides • • • • Non-invasive ventilation Inotropes Nesiritide Cardiac Devices Overview: Acute Heart Failure • New ESC guidelines • Diagnosis – serum natriuretic peptides • • • • Non-invasive ventilation Inotropes Nesiritide Cardiac Devices Overview: Acute Heart Failure • Complex syndrome caused by impaired cardiac function • 2 types: • • left ventricular systolic dysfunction (LVSD) • Heart failure with preserved ejection fraction (HFPEF/HFNEF/Diastolic dys.) Commonest cause(s): – IHD, Hypertension, alcohol, cytotoxics • 30–40% of patients die within a year of diagnosis • Around 900,000 people in the UK • Expected to rise in the future • The cardiac dysfunction may be related to – Ischaemia – Arrhythmias – Valvular dysfunction – Pericardial disease – Increased filling pressures – Elevated systemic resistance. Drugs Diagnosis • • • • ECG CXR ABG Laboratory Tests – A small elevation in cardiac troponin may be seen in patients with AHF without ACS. • Echo Diagnosis: Cardiac Biomarkers In patients with symptoms and signs of heart failure: Measure serum natriuretic peptides Refer to have echocardiography and specialist assessment within 2 weeks if –Previous MI •BNP > 400 pg/ml or •NTproBNP > 2000 pg/ml If BNP < 100 pg/ml or NTproBNP < 400 pg/ml, heart failure is unlikely in an untreated patient • Natriuretic peptides – Negative predictive value – There is no consensus regarding BNP or NT-proBNP reference values in AHF. – Important prognostic information. Cardiac Biomarkers Troponin/BNP/CRP New Classification of MI-Type 2? Secondary to spasm, embolism, anaemia, arrhythmia, BP changes Type 1 Type 2 Acute MI Type 3 Type 4 Type 4a Troponinitis Type 5 Type 4b Natriuretic Peptides: Origin and Stimulus of Release Relaxation of smooth muscle cells Vasodilatation of veins and arteries GFR , Na+ reabsorption inhibited diuresis SNS and RAS activity reduced NH 2N- Ser Lys Met Met Asp IIe Cys Gly Gly Leu Arg Gly Ser BNP Val Gin Gly Ser Arg S S Ser Phe Gly Phe Gly Cys Ala Gin Val HOOCAla Arg Ser Ser Leu Gly Ser Ser Arg His Urodilatin Leu Arg Arg Gly Phe Ser Ser Cys Gly Arg Ser Phe Arg Cys Asn Gly H H2NN- Gly Leu Met Asp Arg IIe S S HOOC- Tyr Asp IIe Leu Thr Met Cys Lys Gly Arg Arg Ser Arg Lys S S Tyr NH NH2 Adapted from Burnett JC, J Hypertens 2000;17(Suppl 1):S37-S43 Gly Arg Phe Ser Cys Asn Pro ANP = Atrial Natriuretic Peptide BNP = B-type Natriuretic Peptide CNP = C-type Natriuretic Peptide Gly Ser COOH- H2N- Ser Pro ANP Leu Arg Arg Gly Ala Leu Gin Gly Ser CNP Gly Phe Ser Lys Gly Leu Lys Leu Asp Arg Cys IIe S S HOOC- Cys Gly Gly Ser Leu Gly Ser Met The natriuretic peptides: Biochemistry of NT-proBNP D R M 90 I S K S S R 1 H2N— H P L G S P G S A proBNP 10 S 70 Y 80 T L R A P 76 R S P S C K V M C C G S G Q F C K G L 100 V L 108 R R H —COOH Cleavage D R M I S K H2N— H P L G S P G S A 10 70 S Y t½ 70-120 min BNP S C F 76 T L R A P S R NT-proBNP 1 S R —COOH H2N— S P K M V Q G S C G C t½ 20 min C K L V G L R R H —COOH Clinical Potential of BNP/NT-proBNP • Extensively studied – A “blood test for heart failure” • • • • • Diagnosis-Raised in LVSD/AF/LVH/VHD/ACS Screening for asymptomatic LVSD Risk stratification & Prognosis in established HF Therapy monitoring Treatment of HF Normal BNP makes LVSD very unlikely NEGATIVE PREDICTIVE VALUE Overview: Acute Heart Failure • New ESC guidelines • Diagnosis – serum natriuretic peptides • • • • Non-invasive ventilation Inotropes Nesiritide Cardiac Devices Acute Cardiogenic Pulmonary Oedema • Common – 15-20,000 hospital admissions per annum in UK • Deadly – 15-20% in-hospital mortality • Costly – 6.5 million hospital days per annum in USA Initial Treatment • The evidence in favour of morphine use for AHF is limited. • Multiple agents are used to manage AHF, but there is a paucity of clinical trials data and their use is largely empiric. • Most agents improve haemodynamics but no agent has been shown to reduce mortality. Non-invasive Ventilation In Acute Cardiogenic Pulmonary Oedema “When the household vacuum cleaner is employed, the machine should be run for some minutes first of all to get rid of dust” Poulton EP, Oxon DM: Left-sided heart failure with pulmonary oedema: Its treatment with the "pulmonary plus pressure machine." Lancet (1936);231:981-983. Physiological Improvement with CPAP in Patients with ACPO Reduced acidosis, respiratory rate and heart rate Kelly et al. Eur Heart J 2002;23:1379-1386 Mortality Benefit of CPAP/NIPPV in Patients with ACPO Mortality reduced from 22% to 11% RR 0.53 (95% CI 0.35-0.81) (Individual Group Sizes small) However, in 3CPO, a large RCT........ Masip et al. JAMA 2005;294:3124-3130 3CPO Trial summary Background Intervention Aims • Randomised (1:1:1) • Clinical effectiveness of noninvasive ventilation • Comparative effectiveness of CPAP and NIPPV • Safety of non-invasive ventilation Hypothesis: • Non-invasive ventilation reduces mortality – Standard oxygen therapy (by facial mask) – CPAP (5 cmH2O up titrated to a maximum of 15 cmH2O) – NIPPV (8/4 cmH2O up titrated to a maximum of 20/10 cmH2O) • Inhaled oxygen of 60% • Attending physicians were encouraged to use vasodilator (nitrate) and diuretic therapy • Opiate therapy was administered at the discretion of the treating physician 3CPO Outcome: Any NIV v Standard Mortality Standard Therapy NonInvasive Ventilation Odds Ratio 95% Confidence Intervals P Value 7-Day 9.8% 9.5% 0.97 0.63 to 1.48 0.869 30-Day 16.7% 15.4% 0.93 0.65 to 1.32 0.685 Active Trial 1069 patients ~ 350 per arm Baseline Characteristics matched Baseline Medications matched Baseline Interventions matched (nitrate, diuretic, opiate, oxygen) 3CPO Outcome: Hospital stay Admitted to intensive Care Admitted to highdependency Care Admitted to coronary Care Median length of hospital stay in days ( IQR) No significant differences (P>0.05) Standard CPAP NIPPV P-value 8.8% 9.1% 6.6% 0.411 7.7% 10.3% 10.9% 0.301 38.1% 43.7% 40.9% 0.337 8 (5-13) 9 (5-16) 9 (5-16) 0.313 3CPO CONCLUSIONS • In patients with acute cardiogenic pulmonary oedema non-invasive ventilation (1069 patients) – UK study, RCT: Produces more rapid resolution of metabolic abnormalities and respiratory distress Has no major effect on 7-day or 30-day mortality Is beneficial irrespective of the mode (CPAP or NIPPV) of delivery Overview: Acute Heart Failure • New ESC guidelines • Diagnosis – serum natriuretic peptides • • • • Non-invasive ventilation Inotropes Nesiritide Cardiac Devices Inotropes • Inotropic agents should only be administered in patients with low SBP or a low measured cardiac index in the presence of signs of hypoperfusion or congestion. • Dobutamine – Positive inotropic agent acting through stimulation β1-receptors to produce dosedependent positive inotropic and chronotropic effects. – The infusion rate may be progressively modified according to symptoms, diuretic response. • • The elimination of the drug is rapid after cessation of infusion. Care should be exercised in weaning patients from dobutamine infusion. Treatment related to BP Respiratory support, Furosemide (infusion) IV Dobutamine plus low dose IV GTN ± IABP Other treatment options • Vasopressin antagonists – Unproven • Levosimendan is a calcium sensitiser that improves cardiac contractility • Levosimendan infusion increases cardiac output and stroke volume and reduces pulmonary wedge pressure, systemic vascular resistance, and pulmonary vascular resistance. • Exerts significant vasodilatation mediated through ATP-sensitive potassium channels • Vasopressors (norepinephrine) are not recommended as first-line agents Overview: Acute Heart Failure • New ESC guidelines • Diagnosis – serum natriuretic peptides • • • • Non-invasive ventilation Inotropes Nesiritide Cardiac Devices Vasodilators • Vasodilators relieve pulmonary congestion usually without compromising stroke volume or increasing myocardial oxygen demand in acute HF. • Often combined with diuretic ± inotrope • Nitrates: Predominantly venodilator effect. Nesiritide • Intravenous • Recombinant form of human B-type natriuretic peptide, • Venous and arterial vasodilator with a combined modest diuretic and natriuretic effect. • Approved by FDA in 2001 – Reduce PCWP (@ 3 hrs!) • Non-invasive BP measurements are usually adequate. • Combination with other i.v. vasodilators is not recommended. • 2005 – 2 meta-analysis ? Renal safety Nesiritide is not available in most European countries. Ascend HF*: AHA 14th Nov 2010 • 7141 patients • 1:1 – Placebo vs Nesiritide Safe No mortality benefit Minimal symptomatic improvement *Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure Trial Overview: Acute Heart Failure • New ESC guidelines • Diagnosis – serum natriuretic peptides • • • • Non-invasive ventilation Inotropes Nesiritide Cardiac Devices What is the rhythm? Causes of death in heart failure NYHA II NYHA IV NYHA III 12% 26% 24% 64% 33% 56% 59% 15% 11% Pump failure Other Sudden death I II III IV No Limitation SOB on severe exertion SOB on mild exertion House bound (SOB at rest) Pre-implant counselling How do you want to die? Heart failure death Sudden death Device X Rays ICD Lead BiV LV Lead position ICD Myths • Myths – ICDs prevent syncope – Contacts can be electrocuted by ICD discharge – Not safe to use mobile phone, mircowave, playstation etc. – Will stop you dying from VF • “Diathermy kills patients & devices” – PPM – may inhibit (pulse oximetry) – ICD – will detect as VF (reprogram) Consequences of tachycardia therapy VT Storm Inappropriate shocks End of life issues: NECVN Ventricular arrhythmias and/or poor LV function → is an ICD indicated ? Temporarily disabled with a ring magnet The Future? Intrathoracic Impedance: Concept The Reality Drier lungs means the intrathoracic impedance is higher Less Fluid Wetter lungs means the intrathoracic impedance is lower More Fluid Summary • Normal BNP makes LVSD very unlikely – NEGATIVE PREDICTIVE VALUE • Non invasive ventilation – Produces more rapid resolution of metabolic abnormalities and respiratory distress – Has no major effect on 7-day or 30-day mortality – Is beneficial irrespective of the mode (CPAP/NIPPV) • Respiratory support, Furosemide (infusion), IV Dobutamine plus low dose IV GTN, (± IABP) • Nesiritide – Safe, No mortality benefit, Minimal symptomatic improvement • ICD: Temporarily disabled with a ring magnet • End of life issues: NECVN