advanced heart failure: my approach j.l. mehta, md, phd stebbins chair in cardiology
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Feb 4, 2011. Advanced Heart Failure: My Approach J.L. Mehta, MD, PhD Stebbins Chair in Cardiology Professor of Internal Medicine, Physiology and Biophysics University of Arkansas for Medical Sciences Little Rock, AR. Topics to be Discussed. Burden of heart failure - PowerPoint PPT PresentationTRANSCRIPT
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Advanced Heart Failure: My ApproachAdvanced Heart Failure: My Approach
J.L. Mehta, MD, PhDJ.L. Mehta, MD, PhD
Stebbins Chair in CardiologyStebbins Chair in Cardiology
Professor of Internal Medicine, Physiology and BiophysicsProfessor of Internal Medicine, Physiology and Biophysics
University of Arkansas for Medical SciencesUniversity of Arkansas for Medical Sciences
Little Rock, ARLittle Rock, AR
Feb 4, 2011Feb 4, 2011
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Topics to be Discussed
Burden of heart failure
Causes of heart failure, morbidity and mortality
Pathophsiology
Role of RAAS and SNS blockers, and diuretics
When to use defibrillators/biventricular pacing
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CHF affects more than 4.5 million people in the USA
and 0.5 million new cases are diagnosed each year
1.2-2% of the population has CHF, with 75-80% of the
group are above the age of 65 years
Nearly 20 million people have unsuspected disease
and likely to develop CHF in the next 1- 5 years
CHF is responsible for >11 million visits to a
physician's office and result in 3.5 million
hospitalizations per year
Median survival following onset is 1.7 years for men
and 3.2 years for women- worse than lung cancer
Burden of Heart Failure
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Causes of Heart Failure, Morbidity and Mortality
Causes of heart failure- Ischemic heart disease
- Hypertension
- Cardiomyopathies (viral, alcohol)
Causes of Hospitalization
- Non-compliance with drugs
- Excessive salt and alcohol intake
- Infections
- Anemia
- Co-morbidity (e.g. renal dz, Liver dz,
depression)
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Angiotensin - Angiotensin - Angiotensin
Myocardial ischemia and Low Cardiac Output StateMyocardial ischemia and Low Cardiac Output State
InflammationInflammation
Release of MMPs Release of MMPs and collagen and collagen degradationdegradation
Myocyte slippageMyocyte slippage
Wall thinning Wall thinning and regional and regional dilatationdilatation
Wall stress Wall stress
Local Ang II releaseLocal Ang II release
Release of Release of Catecholamines, Catecholamines,
ANP, BNP and ET-1ANP, BNP and ET-1
TGFTGF1, PAI-1, 1, PAI-1, ROS expressionROS expression
Myocyte apoptosis, Myocyte apoptosis, Fibroblast growthFibroblast growth
Collagen Collagen formationformation
Myocyte Myocyte hypertrophyhypertrophy
Cardiac Cardiac enlargement enlargement and fibrosisand fibrosis
Early Stage Intermediate Stage Late Stage
Mehta JL, 2010
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RAS, renin-angiotensin system; SNS, sympathetic nervous system.
Myocardial injury to the heart
Morbidity and mortalityArrhythmiasPump failureRenal dysfn
Peripheral vasoconstrictionHemodynamic alterations
CHF symptoms
Remodeling and progressive
worsening of LV function
Initial fall in LV performance, wall stress
Activation of SNS
Fibrosis, apoptosis,
hypertrophy, cellular,
alterations,myotoxicity
FatigueChest congestionEdemaSOB
Neurohormonal Activation in Heart Failure
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Mortality by Baseline Plasma Norepinephrine Level
Francis G et al. Circulation. 1993;87(suppl VI):VI-40 - VI-48.
100
80
60
40
20
0 6 12 18 24 30 36 42 48 54 60
Months
Cu
mu
lati
ve M
ort
alit
y (%
)
> 900 pg/mL
> 600 and < 900 pg/mL
< 600 pg/mL
OverallP < .0001
0
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When to Use ß-blockers and RAS Inhibitors
It dose not matter which agent is started first, but early ß-blockade reduces the risk of sudden death in the first year
The usual practice of starting the ACE inhibitor first may lead to under-treatment with ß-blockers
Willenheimer, Eur Heart J Suppl 2009;11:A15-A20
The CIBIS III trial
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Treatment of Advanced of Heart Failure Part 1
Hospitalize early Treat first with usual drugs- if patient not
responsive, then change Rx Limit salt intake Treat hypertension Treat infections- usually UTI or pulmonary Treat anemia to hemoglobin to ~10 g/100 ml Treat co-morbidity (e.g. renal dz- may need fluids) Treat abnormal thyroid function If patient has angina, use anti-ischemic therapy If patient has valvular dz, may consider surgery
when patient is stable
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Treatment of Advanced Heart Failure Part 2
ACE inhibitors, ARBs, Hydralazine and Nitrates
Use maximal dose of ACE inhibitors, if not
tolerated then use ARBs May combine the two groups of drugs If patient is already taking ACE inhibitors/ARBs,
switch to hydralazine + nitrates- use adequate
dose, response is quick Dose of hydrazine- 50-100 mg TID and ISD- 40
mg TID
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Diuretics
Excessive diuresis can cause metabolic alkalosis
and poor renal perfusion- if present hold diuretics If no alkalosis, use IV lasix or metalazone If alkalosis present, use K+ and Mg+
supplementation Patient may have acute renal failure from excessive
diuresis, consider gentle fluid administration If patient has hyponatremia, consider half or normal
saline (250 ml per hr until urine output improves or
patient develops rales when diuresis may be begun)
Treatment of Advanced Heart Failure Part 3
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RALES: Probability of Survival
Patients with Class II-IV CHF
30% reduction in risk of death
31% reduction in cardiac death,
P<0.001
Pitt, B. et al. N Engl J Med 1999;341:709-717
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Eplerenone in Mild CHF- EMPHASIS-HF
Zannad F et al. N Engl J Med 2011;364:11-21.
Patients with class I-II CHF
NNT-19
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Other therapies
Digitalis- increases CO and makes patient feel
better Dobutamine / milrinone- use short course only-
no long tem benefit Nasiritide - no role in the therapy of CHF CCBs – no role in the therapy of CHF Ultra-filtration - no better than diuresis
Treatment of Advanced Heart Failure Part 4
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CRT improves functional capacity, quality of life, and reduces hospitalization in patients with advanced symptomatic CHF, and evidence of a ventricular conduction abnormality.
Appropriate method patient selection for CRT is not clear.
Issues about the placement of LV lead remain.
Cardiac Resynchronization Therapy:Treatment of Advanced Heart Failure
Part 5
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Implantable defibrillators reduce the risk of sudden death in patients with CHF, with and without prolonged QRS duration
Patients with Class II-III benefit more than Class IV patients
Issues:
- Who are the best candidates for defibrillators?
- Is the cost of implanting and maintaining these devices worth the benefit?
- How can side effects and risks be minimized?
ICD Therapy:Treatment of Advanced Heart Failure
Part 6
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CRT / ICD and Death or Hospitalization for CHF
Tang AS et al. N Engl J Med 2010;363:2385-2395.
In class II or III CHF patients, with wide QRS complex, and EF <30%, the addition of CRT to ICD reduced rates of death and hospitalization for CHF. This improvement was accompanied by more adverse events in 1 month (pneumothorax, hematoma and infections).
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Thank you