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Anticoagulation and Atrial
Fibrillation 2011
2012
New oral anti-coagulants
Big reduction in
stroke rates
Better understanding of stroke risk scores in
2011
Big reduction in stroke rates
- one stroke risk factor now makes an AF patient eligible for
anticoagulation
- moving away from just trying to identify the high-risk AF
patients and putting them on warfarin toward identifying the low-risk
patients without any other risk factors who don't need
anticoagulation and putting everyone else on an anticoagulant.
ASA of little to no benefit
Optimizing Treatment for
Heart Failure
January 12, 2012
Mario L Maiese DO FACC FACOI
Associate Professor UMDNJSOM
South Jersey Heart Group
www.sjhg.org
Email @ [email protected]
Optimizing Treatment for HF
Warfarin Versus Aspirin in Reduced
Cardiac Ejection Fraction
(WARCEF) Trial
Top HF Studies 2011
 CABG vs. Medical Therapy in Patients with
Ischemic Left Ventricular Systolic Dysfunction
(STICH Trial)
 Velazquez EJ et al. for the STICH Investigators. Coronary-artery bypass surgery in patients with left
ventricular dysfunction. N Engl J Med 2011 Apr 4; [e-pub ahead of print].
(http://dx.doi.org/10.1056/NEJMoa1100356)
 Bonow RO et al. for the STICH Trial Investigators. Myocardial viability and survival in ischemic left
ventricular dysfunction. N Engl J Med 2011 Apr 4; [e-pub ahead of print].
(http://dx.doi.org/10.1056/NEJMoa1100358)
 Diuretic Therapy for Acute Decompensated
Heart Failure: Putting Practice to the Test
(DOSE Trial)
 Felker GM et al for the NHLBI Heart Failure Clinical Research Network. Diuretic strategies in patients with
acute decompensated heart failure. N Engl J Med 2011 Mar 3; 364:797.
 Fonarow GC. Comparative effectiveness of diuretic regimens. N Engl J Med 2011 Mar 3; 364:877.
Top HF Studies 2011
 ASCEND-HF: Nesiritide Does Not Benefit
Patients with Acute Heart Failure
 O'Connor CM et al. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J
Med 2011 Jul 7; 365:32.
 Substudies of EMPHASIS-HF [eplerenone in
patients with mild systolic heart failure] fills in the
gap between RALES [NYHA class 3-4 heart
failure] and EPHESUS [post-MI LV dysfunctionNYHA class 1]
 McMurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. Zannad
F, N Engl J Med January 6 2011; 364:11-21.
Home Hemodynamic Monitoring of Chronic HF
Bui, A. L. et al. J Am Coll Cardiol 2012;59:97-104
Copyright ©2012 American College of Cardiology Foundation. Restrictions may apply.
Optimizing Treatment for HF
At Risk for Heart Failure:
_
STAGE A
High risk for developing HF
–
STAGE B
Asymptomatic LV dysfunction
–
Heart Failure:
–
STAGE C
HF
Past or current symptoms of
–
STAGE D
End-stage HF
Optimizing Treatment for HF
Optimizing Treatment for HF
HF Treatment Results: On SNS &
Renin-Angiotensin-Aldosterone (RAAS)
Angiotensinogen
β-Blockers
Renin
SNS
Angiotensin I
Angiotensin
Converting
Enzyme
ACEIs
Angiotensin II
Aldosterone Antag
AT I receptor
Vasoconstriction
LV remodeling
ARBs
Vascular remodeling
Optimizing Treatment for HF
Optimizing Treatment for HF
ACE Inhibitors:
 compounds characterized by
a non-linear dose-response
curve.
 A low-dose of an ACE
inhibitor has the same
potency as a high-dose but a
shorter duration of action.
Taddei S et al. The Correct Administration of
Antihypertensive Drugs According to the
Principles of Clinical Pharmacology.
Am J Cardiovasc Drugs. 2011; 11(1): 13.
Take home points:
 Low dose not good for BPcauses more variability
associated with poorer
outcomes.
 Less effects on the RAAS;
higher doses associated with
more benefit in LVEF
patients.
Optimizing Treatment for HF
Optimizing Treatment for HF
Beta blockers first:
• In a scientifically humble, yet piercing report,
β-blockers beat ACEIs as initial HF therapy
Sliwa K, et al. J Am Coll Cardiol November 2 2004; 44: 1825-1830.
 β-blockade blunts the hyperactivation and effects of the major neuroendocrine forces in HF
(SNS & RAAS).
 β-blockade reduces heart rate with a fall in myocardial oxygen consumption and increased
coronary perfusion.
 β-blockade alone impedes the direct toxic effects of elevated circulating catecholamines on
the myocardium in HF.
Optimizing Treatment for HF
Digoxin
•
Enhances inotropy of cardiac muscle
•
Reduces activation of SNS and
RAAS
•
Controlled trials have shown longterm digoxin therapy:
– Reduces symptoms
– Increases exercise tolerance
– Improves hemodynamics
– Decreases risk of HF progression
– Reduces hospitalization rates for
decompensated HF
– Does not improve survival
–
The Digitalis Investigation Group. The
effect of digoxin on mortality and morbidity
in patients with heart failure. N Engl J
Med. 1997;336:525–33.
Expert Opinion:
Digoxin in low doses also
decreases mortality
(levels < 0.9)
Rathore SS, Curtis JP, Wang Y, Bristow MR,
Krumholz HM. Association of serum digoxin
concentration and outcomes in patients with
heart failure. JAMA. 2003;289:871–8.
Adams KF Jr, Gheorghiade M, Uretsky BF,
Patterson JH, Schwartz TA,
Young JB. Clinical benefits of low serum
digoxin concentrations in heart failure.
J Am Coll Cardiol. 2002;39:946–53.
Optimizing Treatment for HF
“OMT includes TLC”
 OMT: Diet and Exercise
O’Connor CM et al. Efficacy and safety of exercise training in patients with chronic
heart failure: HF-ACTION randomized controlled trial.
JAMA Apr 8 2009; 301:1439.
The Problem:
“Will power only lasts 3 weeks and in
addition it is alcohol soluble.”
….Don’t have a pill for diet & exercise.
Cure all Med
Optimizing Treatment for HF
Optimizing Treatment for HF
Fonarow GC, et al. Potential impact of optimal implementation of evidence-based
heart failure therapies on mortality. Am Heart J June 2011;161:1024-1030.
Optimizing Treatment for HF
Fonarow GC, et al. Am Heart J June 2011; 161: 1024-1030.
Potential Survival Gains From Full
Implementation of Evidence-Based,
Guideline Recommended HF Therapies.
Recommended
HF Therapy
Eligible but
untreated, % of
current HF
population
Preventable deaths/yr with
optimal implementation (n)
Lives saved /yr, % of
current HF
population
Aldosterone
Antagonists
63.9
21,407
31.5
Beta Blockers
14.4
12,922
19.0
ICD
50.6
12,179
17.9
CRT
61.2
8,317
12.2
Hydralzaline/
ISDN
92.7
6,655
9.8
ACE inhibitors
or ARBs
20.4
6,516
9.6
Optimizing Treatment for HF
Spironolactone for all except:
 GFR: < 30mL/min.
 Potassium > 5.5 meq
Events of 2011 may have...
Disturbed You,
Troubled You,
Pestered You,
Irritated You,
Bugged You,
Or got on your Nerves!!
So today, I just wanted to tell
you:
Suck it up,
Cupcake!!
Cause there
AIN'T NO CHANGES
Planned for 2012
Happy New Year!