Download Management of Heart Failure

Management of Heart Failure
Prof. Karen Sliwa
Department of Cardiology
Chris Hani Baragwanath Hospital
Johannesburg, South Africa
Definition:
•Imbalance between volume of blood supplied and the
tissue requirements
•Definition of heart failure: Criteria 1 and 2 should be fulfilled in all cases
1 Symptoms of heart failure (at rest or during exercise)
like breathlessness, ankle swelling and fatigue
2
and
Objective evidence of cardiac dysfunction (at rest)
and
(in cases where the diagnosis is in doubt)
3
Response to treatment directed towards heart failure
Guidelines from European Society of Cardiology Task Force
W.J. Remme and K. Swedberg, European Heart Journal 2001; 22:1528
How big is the Problem?
•2% of the total western population has heart failure
( no data available for SA population)
•Patients over 70 years, the prevalence is > 10 %
•Only 50 % of all patients survive 4 years
•Increasing prevalence due to ageing population and increasing
survivors of MI
Major Causes
•Valvular heart disease
•CAD
•HT
•Cardiomyopathy
–Idiopathic
–Ethanol
–Viral
–Infiltrative
–Metabolic-hypothyroidism/DM
•Pericardial dx
•High output states
•Incessant tachyarrythmias
Evolution of Heart Failure
Stage A:
At risk for HF
But no structural heart disease or
signs /symptoms of HF
e.g HT,CAD, DM,
Cardiotoxins
Stage B:
Structural heart disease
But no symptoms of HF
e.g LVH, prior MI,
asymptomatic valve
disease
Stage C:
Structural ht disease
with prior or current symptoms of
HF
e.g SOB,fatigue due
to LV systolic
dysfunction
Stage D:
Advanced heart disease and severe
symptoms at rest despite max
therapy.
Refractory HF.
unable to safely
discharge without
specialized support
e.g LVAD
Hunt SA et al J Am Coll Cardiol 2001;38:2101
Functional Classification
New York Heart Association (NYHA)
Classes
Description
1 year
Survival Rate
Grade I
Early failure, no symptoms
with regular exercise or restrictions
Grade II
Ordinary activity results in mild symptoms,
but comfortable at rest
80 - 90%
Grade III
Advanced failure, comfortable only at rest;
increased physical restrictions
55 - 65%
Grade IV
Severe failure;
patient has symptoms at rest
 Heart failure is a chronic progressive disease
> 95%
5 - 15%
Assessment of the patient with heart failure
Objectives of initial evaluation of a patient with possible or
definitive heart failure:
•Early diagnosis is important
•In symptomatic patients can be in:
1. Left heart failure
2. Right heart failure
3. Low cardiac output
4. High cardiac output
•Cause of heart failure
•Identification of precipitating factors and reversible causes
•Identify markers of prognosis: left ventricular function
Investigations
Electrocardiogram
•Most pts with CHF due to systolic dysfunction have
a significant abnormality on ECG
•Normal ECG 98% neg. predictive value
•Evidence of
–Ischeamic heart dx
–LVH
–Arrythmias eg atrial fib
–DCMO –
limb leads low voltage/precordial LVH, wide QRS, LBBB
Investigations
CXR
•Diff
HF from lung dx
•CTR>50%
•Upper
lobe diversion
•Kerley-B
•Pleural
effusions
Investigations
Routine blood tests:
• Full blood count-
Anemia
• Blood urea nitrogen and creatinine-
Renal Dysfunction
• Electrolytes-Hyponatraemia,hypokalemia,hyperkalemia
•
Albumin-Hypoalbuminemia
•
Blood glucose-Diabetis mellitus
•
Thyroxine ( in patients with AF or who are >65 years and
the heart failure has no obvious etiology- Hyper
and Hypothyroidism
Investigations
Echocardiography
•Essential in all newly diagnosed
•Detect
•LV size & EF
•Wall thickness / ‘texture’
•RWMA
•Valve dx
•Pericardial dx
•Septal shunts
•RV size, pressures & fn
•LV thrombus
•Expensive/Expertise
LV thrombus postpartum
Naturetic Peptides
Features
Amino acids
Main source
Hormone type
Main function
ANP
BNP
28
cardiac atria cardiac
endocrine endocrine
CNP
32
22 or 53 32 (= ANP + 4)
vascular
ventricle endothelium
autocrine
Cardiac specific
Regulation of homeostasis of salt
and water excretion and blood
pressure (natriuretic, vasodilatory,
renin-and aldosterone inhibitory
properties)
Urodilatin
paracrine
Regulation of
vascular tone
kidney
paracrine
Regulation of
water and sodium
reabsorbtion in
collecting duct
Sensitivity and specificity of clinical signs
in HF
100 patients presenting to casualty with signs or symptoms
of congestive heart failure(eg, dyspnea,edema, wt gain)
Specificity
Sensitivity
Jugular Venous Pressure
92%
34%
Third Heart sound
90%
26%
Rales
81%
57%
BNP (>100pg/ml)
98%
100%
Dao et al, 49th Annual Scientific Session of
the American College of Cardiology
Summary-Assessment of Heart Failure
Heart failure is a composite of clinical symptoms, physical signs,
and abnormalities on the hemodynamic, neurohormonal,
biochemical, anatomic and cellular levels
It’s a large problem both in the developed and developing world
A thorough history is vital in identifying cause and precipitating
factors
Combination of clinical examination and basic investigations will
aid in diagnosis, assessing severity and prognosis
Echocardiography essential in newly diagnosed patients
TREATMENT OF HEART FAILURE
•
Acute heart failure and shock ( not discussed within this lecture):
clinical presentation is regardless of the cause, with hypotension, tachycardia,
tachypnea, oliguria
causes:
-acute MI ( 8% of all cases)
-acute mitral regurgitation, eg. post MI
-acute AR, eg. SBE, Aortic dissection,
-Acute myocarditis
-pericardial tamponade,
-pulmonary embolism
•
Chronic heart failure
GOALS OF THERAPY IN CHRONIC HEART FAILURE
GOAL
Examples
Prevention
Blood pressure control
Symptom reduction
Increased activity tolerance
Prevent progression
(remodeling)
Prolong survival
Diuretics, digoxin, exercise training
ACE-inhibitors, Beta-blockers
ACE-inhibitors, beta-blockers,
spironolactone
Pharmacological Treatment-Diuretics
Diuretics:
•WHO ?
-Those with signs of Na and water retention
I.e. peripheral or pulmonary oedema,↑JVP
Pharmacological Treatment-Diuretics
Spironolactone:
•RALES TRIAL reduction in all cause mortality by
27% in NYHA III-IV heart failure on conventional
treatment, 17% reduction in hospitalisations
•WHO ?
-NYHA III-IV on diuretics/ACE/digoxin
Pharmacological Treatment-Digoxin
Digoxin:
•- DIG TRIAL: no net effect on mortality in CHF, does
improve symptoms and reduce hospitalisations
•- WHO ?
-Those with CHF in AF who need rate control
-Those with moderate or severe symptoms
despite optimal treatment
Pharmacological Treatment-Neurohormonal
antagonists
Angiotensin Converting Enzyme Inhibitors:
•Several randomised controlled clinical trials as
CONSENSUS I, SOLVD, VHeFT II have shown that in
patients with CHF they reduce-mortality
-hospitalisation
-improve symptoms and signs
-slow progression from mild to congestive cardiac
failure
Pharmacological Treatment-Neurohormonal
antagonists
Angiotensin II Type I receptor antagonists:
• WHO?
- Those intolerant to ACE-inhibitors ( especially because of
cough)
Pharmacological Treatment-Beta-blockers
Beta-blockers:
• Over 13,000 patients evaluated in placebocontrolled clinical trials
• Consistent improvement in cardiac function,
symptoms and clinical status
• Decrease in all-cause mortality by 30–35%
(p<0.0001)
• Decrease in combined risk of death and
hospitalisation by 25–30% (p<0.0001)
US Carvedilol Study
 blockers in
heart failure all-cause mortality
Survival
1.0
Carvedilol
(n=696)
0.9
Placebo
(n=398)
0.8
Risk reduction = 65%
0.7
p<0.001
0.6
0.5
0 50 100 150 200 250 300 350 400
Days
Mortality %
20
Survival
CIBIS-II
1.0
Packer et al (1996)
MERIT-HF
Placebo
Bisoprolol
15
0.8
Metoprolol CR/XL
10
Risk reduction = 34%
Placebo
Risk reduction = 34%
5
0.6
p=0.0062
p<0.0001
0
0
0
200
400
Time after inclusion (days)
600
800
Lancet (1999)
0
3
6
9
12 15
Months of follow-up
18
21
The MERIT-HF Study Group (1999)
 blockers in heart failure
Consensus recommendations
All patients with stable class II or III heart failure
due to left ventricular systolic dysfunction should
receive a beta-blocker (in addition to an ACE
inhibitor) unless they have a contraindication to its
use or cannot tolerate treatment with the drug
Implications for public health
Lives saved by treating
1000 patients for 1 year
HOPE (ramipril)
SOLVD Prevention (enalapril)
<1
7
SOLVD Treatment (enalapril)
MERIT-HF (metoprolol)
CIBIS-II (bisoprolol)
RALES (spironolactone)
COPERNICUS (carvedilol)
17
38
42
52
70
Packer, AHA 2000
Management of acute exacerbation of chronic
heart failure
Investigation and treatment of precipitating
factors: infections, thiamine deficiency ( alcohol
abuse), anaemia
Intermittent use of positive inotropic drugs:
• WHO?
- patients admitted to hospital with severely decompensated
heart failure, particular those with ‘ cardiorenal syndrome’ in
which sufficient diuresis cannot be obtained without progressive
deterioration of renal function
New concepts in the treatment of heart
failure
-Anti-inflammatory/cytokine therapy
-Modification of cardiac matrix
-Myocyte/Myoblast implant
-Biventricular pacing
-Anti-remodeling strategies
-Cardiac transplantation
Summary-Treatment of CHF
Heart failure is a composite of clinical symptoms, physical signs,
and abnormalities on the hemodynamic, neurohormonal,
biochemical, anatomic and cellular levels
Therapy should aim:
-To
improve symptoms
-Prevent
progression of disease
Early diagnosis is important!
All patients should be on a beta-antagonists ( preferentially
carvedilol