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• 55 year old man with breathlessness on mild exertion. • No cough, fever, chest pain, palpitations. No exertional chest discomfort • Otherwise healthy. • • • Type 2 diabetes, diet controlled 10 pack year cigarette smoking Hypertension, well controlled on perindopril 10mg • • • • • BP 135/90. Resps 26. Afebrile. Sats 95% room air. Normal heart sounds. Lungs normal. JVP not seen. Rest of exam normal. What tests? • • • • • • Normal FBE Normal EUC LFTs Normal TSH HBAIC 6.9% Troponin not raised FEV1 2.9 l, FVC 3.5 l BNP 400 Rapid Measurement of B-Type Natriuretic Peptide in the Emergency Diagnosis of Heart Failure • • • • • • B-type natriuretic peptide is released from the ventricles of the heart in response to hemodynamic stress, and blood levels of B-type natriuretic peptide may be useful in the diagnosis of heart failure In this study, a rapid, bedside immunoassay for B-type natriuretic peptide was used to make or exclude the diagnosis of heart failure in patients with acute dyspnea from various causes The assay was found to have good sensitivity and excellent specificity in the diagnosis of heart failure Measurement of B-type natriuretic peptide levels is not a stand-alone test for heart failure It will be of most value when used in conjunction with clinical observations, especially when the cause of acute dyspnea is unclear The finding of a low level of B-type natriuretic peptide (less than 50 pg per milliliter) is good evidence of the absence of heart failure Box Plots Showing Median Levels of B-Type Natriuretic Peptide Measured in the Emergency Department in Three Groups of Patients Maisel, A. et al. N Engl J Med 2002;347:161-167 Box Plots Showing Median Levels of B-Type Natriuretic Peptide among Patients in Each of the Four New York Heart Association Classifications Maisel, A. et al. N Engl J Med 2002;347:161-167 Multiple Logistic-Regression Analysis of Factors Used for Differentiating between Patients with and Those without Congestive Heart Failure Maisel, A. et al. N Engl J Med 2002;347:161-167 Spot quiz Assessment of left ventricular function Definition? • ‘heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood’ • Cardinal manifestations – Dyspnea and fatigue which may limit exercise tolerance – Fluid retention which may lead to pulmonary congestion and peripheral oedema • Heart failure is preferred to congestive heart failure what are the recommended blood tests for initial diagnosis? • Class 1 – FBE – UA – EUC Ca Mg PO4 – Fasting BSL – Lipids – LFTs – TSH • Class 2a – Iron studies – HIV – Amyloid – Rheumatologic disease – BNP in urgent care setting where diagnosis is uncertain Spot quiz. Long-Term Trends in the Incidence of and Survival with Heart Failure • • • • Congestive heart failure has an extremely poor prognosis This investigation from the Framingham Heart Study tracked trends over a 50-year period in the incidence of heart failure and in survival after its onset During this period, the incidence of heart failure declined among women but not among men, whereas survival improved among both men and women Despite substantial improvement during the study period, overall survival rates among patients with heart failure remained below 50 percent at five years, pointing to the urgent need for better means of preventing this serious health problem N Engl J Med Volume 347;18:1397-1402 October 31, 2002 Temporal Trends in the Age-Adjusted Incidence of Heart Failure Levy, D. et al. N Engl J Med 2002;347:1397-1402 Temporal Trends in AgeAdjusted Survival after the Onset of Heart Failure among Men (Panel A) and Women (Panel B) Levy, D. et al. N Engl J Med 2002;347:13971402 Stages of Heart Failure and Treatment Options for Systolic Heart Failure. NEJM Volume 348:2007-2018 May 15, 2003 Number 20 Mariell Jessup, M.D., and Susan Brozena, M.D. AF and Heart Failure Study Overview • • • In this clinical trial involving patients with atrial fibrillation and congestive heart failure, rhythm control (to maintain sinus rhythm) and rate control (to control the ventricular rate in atrial fibrillation) were compared The two strategies were nearly identical with respect to all clinical outcomes Thus, the simpler approach, rate control, should be considered the treatment of choice in such patients Roy D et al. N Engl J Med 2008;358:2667-2677 Baseline Characteristic s of the Patients Roy D et al. N Engl J Med 2008;358:26672677 Medical Therapy at 12 Months Roy D et al. N Engl J Med 2008;358:2667-2677 Kaplan-Meier Estimates of Death from Cardiovascular Causes (Primary Outcome) Roy D et al. N Engl J Med 2008;358:2667-2677 Kaplan-Meier Estimates of Secondary Outcomes Roy D et al. N Engl J Med 2008;358:2667-2677 Effect of Carvedilol on Survival in Severe Chronic Heart Failure NEJM Volume 344:1651-1658 May 31, 2001 Number 22 Milton Packer, M.D.,et al • • • 2289 patients – heart failure at rest or on minimal exertion – clinically euvolemic – ejection fraction of less than 25 percent In a double-blind fashion – 1133 patients to placebo – 1156 patients to carvedilol – for a mean period of 10.4 months standard therapy for heart failure was continued Kaplan-Meier Analysis of Time to Death in the Placebo Group and the Carvedilol Group Packer M et al. N Engl J Med 2001;344:1651-1658 What is the magnitude of benefit of AICD • EF <31%, previous infarct – Over 20 months • Absolute mortality benefit 5.6% • 31% relative risk reduction • 15% 10% • 20% risk of inappropriate shock • • Reserved for patients with greater than 1 year life expectancy Should not have class 4 symptoms Spot quiz Cardiac Resynchronization in Chronic Heart Failure N Engl J Med Volume 346;24:1845-1853 June 13, 2002 • • • • • • About a third of patients with chronic heart failure have an intraventricular conduction delay, which may lead to dyssynchrony of cardiac contraction and further clinical impairment The patients in this clinical trial were randomly assigned to a group receiving resynchronization therapy with an atrial-biventricular pacemaker or to a control group As compared with the control group, the resynchronization group had improved functional capacity, quality of life, and ejection fraction over a six-month period Resynchronization therapy has considerable promise in patients with heart failure, but there are limitations It is applicable to only about a third of patients, and it requires the insertion of a complex pacing device that may be associated with a variety of technical problems and complications This technique should be reserved for experienced centers Change in the Distance Walked in Six Minutes and the Quality-of-Life Score Abraham, W. et al. N Engl J Med 2002;346:1845-1853 Kaplan-Meier Estimates of the Time to Death or Hospitalization for Worsening Heart Failure in the Control and Resynchronization Groups Abraham, W. et al. N Engl J Med 2002;346:1845-1853 • Don’t forget sprionolactone in class 3 and 4 heart failure • 55 year old female with palpitations. • • • Skipped and extra beats for 3 months No chest pain, shortness of breath No syncope, presyncope • Past history of HT • Currently on atenolol 50 mg daily and candesartan 8mg daily. • • • Pulse irregular 90bpm BP 125/90 Resps 18 Afebrile Sats 97% Heart sounds normal. Chest clear. Rest of examination normal. What tests? • • • • • FBE normal TSH normal BNP, Troponin Normal EUC LFTs Normal Fasting BSL 4.8 Question 1 • Additional diagnostic workup Question 2 • Warfarin or Aspirin Guidelines for Antithrombotic Therapy in Atrial Fibrillation Page R. N Engl J Med 2004;351:24082416 Management Strategies Recommendations CHADS2 Risk Criteria Score Prior stroke or TIA Age >75 years Hypertension Diabetes mellitus Heart failure 2 1 1 1 1 Patients Adjusted Stroke Rate (N=1733) (%/year)* (95% CI) 120 1.9 (1.2-3.0) 463 2.8 (2.0-3.8) 523 4.0 (3.1-5.1) 337 5.9 (4.6-7.3) 220 8.5 (6.3-11.1) 65 12.5 (8.2-17.5) 5 18.2 (10.5-27.4) CHADS2 Score 0 1 2 3 4 5 6 Question 3 • Rate control or rhythm control Pharmacologic Agents to Control Heart Rate and Rhythm Page R. N Engl J Med 2004;351:2408-2416 A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation N Engl J Med Volume 347;23:1825-1833 December 5, 2002 • • • • There are two approaches to the treatment of atrial fibrillation: rate control, allowing atrial fibrillation to persist, and rhythm control, with cardioversion and antiarrhythmic drugs This North American study found that, contrary to prevailing practice, rhythm control offered no survival advantage and was associated with higher rates of adverse drug effects than rate control Atrial fibrillation is associated with substantial morbidity and mortality As compared with rhythm control, rate control has advantages that have previously been underappreciated Cumulative Mortality from Any Cause in the Rhythm-Control Group and the Rate-Control Group The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators, . N Engl J Med 2002;347:1825-1833 Base-Line Characteristic s of the Patients The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators, . N Engl J Med 2002;347:18251833 Drugs Used in the RateControl Group and the RhythmControl Group The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators, . N Engl J Med 2002;347:18251833 Adverse Events The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators, . N Engl J Med 2002;347:18251833 Spot quiz. • 60 year old female • • • Mother AMI age 70 Glucose intolerance Obese • • • Candesartan for HT BP at home average 125 systolic Osteoathritis • • 2 episodes of prolonged chest pain, last one 5 days ago. Dull retrosternal lasted 15 minutes • Examination normal • • • • • Cholesterol 6.5, LDL 3.5 BSL 6.4 HBAIC 6.4% Normal FBE EUC LFTs Troponin not raised Stress test showed equivocal ST depression with non limiting chest pain at 5 minutes on Bruce Protocol. EST in determining prognosis • Asymptomatic population – EST is positive in 5 –10% of middle age men – If abnormal, risk is 9 times higher – Over 5 years only 25% have cardiac event, commonly angina • Symptomatic patients – If exercise tolerance >10 mets prognosis is excellent regardless the severity of coronary angiography – Provides an estimate of the functional significancd of CAD – If Bruce < 1 AND >1mm ST depression - mortality 5%/year (12% of those undergoing EST) – If Bruce > 3 AND no ST depression – mortality <1%/yr over next four years (35% of those undergoing EST) Duke treadmill score • Duke Treadmill Score: Calculation (Time in minutes on Bruce protocol) (eg 1 if exercises for 1 minute, 12 if exercise for 12 minutes) then subtract (5 x amount of ST depression (in mm)) (eg: if 1 mm of ST depression subtract 5, if 2 mm of ST depression subtract 10) then subtract (0 if no angina on test, 4 if non-limiting angina, 8 if limiting angina) Total score = Score Risk Group Annual Mortality • IF treadmill score is >=5 THEN annual mortality is LOW (0.25%/yr) • IF treadmill score is –10 to +4 THEN annual mortality is INTERMEDIATE (1.25%/year) • IF treadmill score is <=-11 THEN annual mortality is HIGH (5.25%/yr) • • • Coronary angiography showed 50% LAD stenosis. Left ventricular function normal. Recommended for medical management. HOPE study – study population Effects of an Angiotensin-Converting-Enzyme Inhibitor, Ramipril, on Cardiovascular Events in HighRisk Patients NEJM Volume 342(3) 20 January 2000 • • > 55 years old history of – coronary artery disease – stroke – peripheral vascular disease – diabetes (& at least 1 other cardiovascular risk factor) • hypertension • elevated total chol., LDL chol. • cigarette smoking • Microalbuminuria Composite Outcome of Myocardial Infarction, Stroke, or Death from Cardiovascular Causes Spot quiz CARE – inclusion criteria The Effect of Pravastatin on Coronary Events after Myocardial Infarction in Patients with Average Cholesterol Levels NEJM 335(14) 3 October 1996 • • • • • • Inclusion criteria – total cholesterol < 6.2 mmol/l and – LDL cholesterol 3.0 to 4.5 mmol/l AMI 3 and 20 months before randomization 21 to 75 years of age Fasting triglyceride levels < 4.0 mmol/l BSL < 12.2 mmol/l EF > 25% (no symptomatic CCF) Effect of Beta-Blockade on Mortality among High-Risk and Low-Risk Patients after Myocardial Infarction NEJM 339(8) • 20 August 1998 Several large trials show long-term administration of beta blockers to patients after myocardial infarction improves survival – physicians prescribe for < 35% – cardiologists prescribe for < 50%, especially in.. • older age • impaired left ventricular function • transient heart failure • patients on diuretic drugs. Spot Quiz