appn gp hf webinar 2012
TRANSCRIPT
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Heart Failure
A ‘real world’ update for General
Practice
Dr Christine Burdeniuk Southern Adelaide Local Health Network
Learning Objectives
Ø Heart failure signs and symptoms Ø Causes of heart failure Ø Diagnosis and investigation of heart failure Ø NYHA classification of heart failure Ø Treatment
l Pharmacological and non-pharmacological Ø Monitoring clinical signs of heart failure
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What is heart failure?
Ø Chronic Heart Failure (CHF) is l a complex clinical syndrome l characterised by an underlying structural
abnormality or cardiac dysfunction that impairs the ability of the heart to fill with or eject blood
l Manifests with typical symptoms (dyspnoea and fatigue) that occur at rest and on exertion
Left heart failure Ø Involves impairment of the left ventricle
Ø Systolic heart failure (cardiomyopathy) l Inability of the heart to contract and pump blood into
the circulation Ø Diastolic heart failure (HF-preserved EF)
l Inability of the heart to relax and fill properly between each beat
Ø Fluid ‘backs up’ in the lungs (pulmonary oedema)
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Right heart failure
Ø Most commonly occurs as a consequence of left ventricular failure.
Ø Isolated RHF can occur l due to lung disease (cor pulmonale) or
pulmonary embolism Ø Fluid backs up in the peripheral tissues
l Peripheral oedema, ascites
Incidence of Heart Failure Ø 1.5-2% of Australians are living with chronic heart failure. Ø Heart failure is the leading cause of hospitalization of
patients over 65 years in age. Ø Prevalence increases sharply with age.
Ø Rapidly increasing number because of the aging population.
Ø > 15 million new cases of Heart failure estimated each year worldwide.
12/06/12 6
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Prognosis of Heart Failure Ø Despite many new advances in drug therapy and cardiac
assist devices, the prognosis for chronic heart failure remains very poor.
Ø One year mortality figures:
l 50-60% for patients diagnosed with severe failure l 15-30% in mild to moderate failure l 10% in mild or asymptomatic failure
Ø 30–40% of patients die within a year of diagnosis
Causes of heart failure
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Causes of heart failure …1
Ø Loss of myocardium l Infarction (50%) l Myocarditis
• inflammatory, viral l Myopathy
• Genetic/familial • Peri-partum • Alcohol • Chemotherapy-related
l Idiopathic (5-10%)
Causes of heart failure …2
Ø Abnormal myocardium l Haemochromatosis l Sarcoidosis l Amyloidosis l Hypertrophic cardiomyopathy
Ø Tachycardia l Rapid Atrial Fibrillation / Flutter
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Causes of heart failure …3
Ø Pressure load l Hypertension l Aortic stenosis l Obstructive sleep apnoea
Ø Volume load l Mitral / Aortic regurgitation
Causes of HF-preserved EF
Ø Hypertrophy l Hypertension l Infiltration l Fibrosis
Ø Mitral stenosis
Ø Tamponade l Restrictive / constrictive pericarditis
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Heart Failure Signs and Symptoms
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Signs and Symptoms …1
Ø Think FACES….
Ø Fatigue Ø Activities limited Ø Chest congestion Ø Edema or ankle swelling Ø Shortness of breath
Signs and Symptoms …2
Left heart failure Ø Dyspnoea Ø Decreased exercise
tolerance Ø Orthopnoea Ø Paroxysmal nocturnal
dyspnoea Ø Cough
l Pink, frothy sputum
Right heart failure Ø Decreased exercise
tolerance Ø Pitting oedema Ø Hepatomegaly Ø Ascites
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Shortness of breath Ø Blood ‘backs up’ in the
pulmonary veins l Fluid leaks into the lungs
Ø Dyspnoea at rest Ø Dyspnoea on exertion Ø Difficulty lying flat
(orthopnoea) Ø Waking short of breath
(paroxysmal nocturnal dyspnoea)
Progression of signs and symptoms
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Diagnosis of heart failure
Diagnosis …1
Ø In patients with signs and symptoms of heart failure
l Measure serum NT-proBNP
l Refer for echocardiogram
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⇐ normal
cardiomyopathy ⇒
⇐ normal
cardiomyopathy ⇒
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Diagnosis …2
Role of BNP / NT-proBNP Ø Differential diagnosis of dyspnoea to RULE OUT heart failure
l BNP < 100pg/mL BNP Trial NEJM 2002
l NT-proBNP < 300 pg/mL PRIDE Trial JACC 2005
Ø Both are superior to clinical judgement alone in diagnosing / confirming acute heart failure
Natriuretic peptides
Ø Family of peptides with natriuretic, diuretic and vasorelaxant effects
Ø Role in body’s defence against hypertension and plasma volume expansion
Ø Atrial Natriuretic Peptide (ANP) l Released from atria in response to increased
atrial wall tension Ø Brain / B-type Natriuretic Peptide (BNP)
l Released predominantly from ventricle in response to increased ventricular wall tension
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BNP and NT-proBNP
—COOH
H P L G S P G S A S Y T L R A P R S P K M V Q G
S G C
F C R
K M D R I S
S S S G
L C C
K V
L R
R H
H2N—
1
10 70
76
80
90
100
108
Cleavage
H2N—
—COOH S P K M V Q G
S G C
F C R
K M D R I S
S S S G
L C C
K V
L R
R H
—COOH H2N—
H P L G S P G S A S Y T L R A P R
1 10 70 76
proBNP
BNP NT-proBNP
BLOOD
CARDIOMYOCYTE
-increased collection stability -t½≈2 hours -similar clinical utility, ∝ wall stress Richards et al Br Heart J 93
-biologically active -∝ wall stress -t½≈22 minutes
NT-proBNP
NT-proBNP in CHF
†
controls .1
10
100
1000
10000
II III IV NYHA CHF
NT-p
roBN
P(p
g/m
l)
*
*p<0.001 ‡p=0.02 †p<0.001
‡
De Pasquale et al Circulation04
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Using BNP to guide follow up
Ø Urgent follow up within 2 weeks l BNP > 400 pg/mL l NT-proBNP > 2000 pg/mL
Ø Semi-urgent referral within 6 weeks l BNP 100-400 pg/mL l NT-pro BNP 400-2000 pg/mL
Ø Remember that heart failure excluded if l BNP < 100 pg/mL l NT-proBNP < 300 pg/mL
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NYHA Classification of Heart Failure
New York Heart Association Classification (NYHA)
l Class I • No limitation of ordinary physical activity
l Class II • Slight limitation (fatigue, dyspnoea) of
ordinary physical activity l Class III
• Marked limitation of ordinary physical activity
l Class IV • Unable to carry out any physical activity
without discomfort
asymptomatic LV dysfunction
Severe
CHF Moderate
Mild
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NYHA Classification
Class % of patients
Symptoms
I 35% No symptoms or limitations in ordinary physical activity
II 35% Mild symptoms and slight limitation during ordinary activity
III 25% Marked limitation in activity even during minimal activity. Comfortable only at rest
IV 5% Severe limitation. Experiences symptoms even at rest
Treatment of Heart Failure
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Treatment Goals
Ø Reduce mortality
Ø Reduce morbidity
Ø Prevent further cardiac damage
What Are The Treatments for Heart Failure?
Experts recommend:
• Diuretics - help control symptoms • Digoxin - helps control symptoms • ACE Inhibitors - can slow disease progression • Beta Blockers - can slow disease progression
This combination of medications has been proven to save lives and keep people out of the hospital.
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Non-pharmacological treatment …1
Ø Education, discussion, counselling l Multi-disciplinary management program l Weight control (report 2kg gain in 2 days)
Ø Smoking cessation Ø Caffeine reduction Ø Reduce stress Ø Treat sleep apnoea Ø Vaccination Ø Avoid pregnancy
Non-pharmacological treatment …2
Ø Exercise and rehabilitation l Keep active exercise program for CHF l Improves functional capacity and symptoms
• 20-30min/day • 3-5 days/week • low intensity (60-80% peak HR)
Ø Dietary measures l Salt avoidance (mainly class III/IV) l Fluid restriction ~ 1.5L/day (mainly class III/IV) l Alcohol reduction (1-2/day with alcohol free days)
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Pharmacological treatment …1
Ø Depends on NYHA class Ø Regimen adjusted and adapted depending
on fluid status Ø Cornerstone are ACEi and heart-failure
specific beta blockers
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ACE inhibitors
Ø Reduce symptoms Ø Reduce mortality
• CONSENSUS 1987, AIRE 1993, V-HEFT 1991, SOLVD 1991
Ø Indicated for NYHA I – IV CHF
Angiotensin II Receptor Blockers (ARBs)
Ø Used instead of ACE inhibitors, if intolerant
Ø Reduces symptoms (equal to ACEi) Ø Reduced side effects (compared to ACEi) Ø No mortality benefit over ACEi Ø Reduces CV mortality and morbidity
• CHARM alternative 2003
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Beta Blockers
Ø Improve symptoms l May have initial worsening
• Start when euvolaemic • Start low and up-titration should be slow
Ø Reduces mortality • US Carvedilol Study 1996 • CIBIS II 1999 (Bisoprolol) • MERIT-HF 1999 (Metoprolol XL) • SENIORS 2005 (Nebivolol)
Ø Indicated for NYHA II- IV
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Diuretics (loop)
Ø Reduce symptoms • Wilson et al Am J Med 1981
Ø Requires dose adjustments
Ø Indicated for Class III-IV and often Class II
Digoxin
Ø In CHF with atrial fibrillation l Improves LV function and symptoms
l Khand et al Eur Heart Journal 2000
Ø In CHF with sinus rhythm l Reduces symptoms l Neutral effect on total mortality
l DIG trial 1997
Ø Indicated for NYHA II-IV
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Aldosterone Antagonists
Ø Spironolactone l Reduces symptoms l Reduces mortality
l RALES 1999
l Indicated for NYHA III/IV
Ø Eplerenone l Start 30 days post infarct with LV failure l Reduces mortality and hospitalisations
l EPHESUS 2003
Nitrates
Ø Venous > arterial vasodilatation Ø Reduces symptoms Ø Indicated for
l Pulmonary congestion • APO, orthopnoea, PND
l CHF with ischaemia
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Ivabradine
Ø Selective sinus node inhibitor Ø Lowers resting heart rate Ø Indicated for symptomatic HF with resting
HR > 70bpm despite maximal tolerated beta blocker
Ø Reduces death due to heart failure and hospitalisations
l SHIFT 2010
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NYHA-based recommendations for CHF treatment
NYHA IV
NYHA III
NYHA II
NYHA I
diuretics + digoxin + nitrates tolerated + temporary inotropic support
+ diuretics + ARB + digoxin
+/- diuretic depending on fluid retention +ARB
reduce / stop diuretic
For Symptoms
ACE inhibitor β-blockade spironolactone +/-ARB
ACE inhibitor and β-blockade + ARB + spironolactone
ACE inhibitor and β-blocker
ACE inhibitor, add β-blocker if post MI
For Survival/Morbidity mandatory therapy if Intolerance to ACE inhibition
ARB if ACE inhibitor intolerant
ARB if ACE inhibitor intolerant
ARB if ACE inhibitor intolerant
ARB if ACE inhibitor intolerant
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Monitoring clinical signs of heart failure
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Ø Complex syndrome Ø Complex and varied treatment modalities Ø Disease characterised by fluctuating
relapse/remitting course
CHF: Natural History
Lynn et al JAMA97
Monitoring CHF …1
Ø All patients with CHF require monitoring Ø Clinical assessment
l Functional capacity (NYHA class) • Exercise tolerance, orthopnoea, PND, fatigue
l Cardiac rhythm (pulse +/- ECG) l Cognitive status
• Depression, Delirium (compliance issues)
l Nutritional status l Weight pattern
Ø Examination l JVP, crepitations, peripheral oedema, ascites
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Monitoring CHF …2
Ø Medication review l Changes based on fluid status and possible side effects
Ø Biochemical profile l Routine FBE, ECU, eGFR l LFTs, INR, TFTs, CRP as required
Identifying decompensation
Ø Weight gain > 2kg in 48 hr period l Patient educated to contact HF service for
guidance or implement action plan
Ø Reduced urine output Ø Orthopnoea Ø Paroxysmal nocturnal dyspnoea Ø Increasing peripheral oedema
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Mechanisms of decompensation …1
Ø Cardiac issues l Ischaemia l Arrhythmia l Valvular dysfunction
Ø Patient issues l Non-compliance with drugs or advice
Ø Drug issues l Water and salt retention l Negative inotropes
Mechanism of decompensation …2
Ø Drugs to avoid / use with caution l Antiarrhythmics (except HF beta blockers and
amiodarone) l Calcium antagonists (non-dihydropyridines eg
verapamil and diltiazem) l Tricyclic antidepressants l NSAIDs / COX II inhibitors l Corticosteroids l Thiazolidinediones (rosiglitazone)
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Mechanism of decompensation …3
Ø Co-morbid conditions
l Infection l Renal failure l Anaemia l Thyroid dysfunction
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When to refer to HF specialist clinic
Ø Initial diagnosis of heart failure Ø Management of severe (NYHA IV) heart
failure Ø Management of heart failure that does not
respond to usual treatments Ø Heart failure that can no longer be
managed at home (ie needs admission or specialist HF nursing outreach)
Heart failure clinics
Ø Heart failure nurse l Point of contact for advice, education, drug
titration Ø Heart failure cardiologist
l Increased adherence to treatment guidelines Ø Physiotherapist
l Heart failure exercise program Ø Achieves reduction in risk of death and
hospital readmission l Azevedo et al Eur J Heart Failure 2002
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Thank you