Transcript
Page 1: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

CONGESTIVE HEART FAILUREMarcy W. Long, MMS, PA-CBaylor Scott and White HealthRound Rock Cardiology

Page 2: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

DISCLOSURES

•No Relevant disclosures

Page 3: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

OBJECTIVES

•Discuss epidemiology of heart failure•Define the different types of heart failure• Explain the different heart failure classifications• Review heart failure pathophysiology•Discuss strategies for heart failure treatment with

focus on HFrEF

• Keep the Audience awake and interested in heart failure after lunch

Page 4: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

DEFINITIONS• Heart failure, sometimes known as congestive heart failure,

occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to fill and pump efficiently. • The Mayo Clinic

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DEFINITIONS• As blood flow out of the heart slows, blood returning to the heart

through the veins backs up, causing congestion in the body's tissues. Often swelling (edema) results. Most often there's swelling in the legs and ankles, but it can happen in other parts of the body, too.• Sometimes fluid collects in the lungs and interferes with breathing,

causing shortness of breath, especially when a person is lying down. This is called pulmonary edema and if left untreated can cause respiratory distress.• Heart failure also affects the kidneys' ability to dispose of sodium and

water. This retained water also increases swelling in the body's tissues (edema).

• The American Heart Association

Page 6: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

TYPES OF HEART FAILURE

Page 7: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

CHARACTERISTICS

Page 8: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

WHEN THE LEFT HAS LOST…..

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DEFINITIONS OF HEART FAILURE• Classification EF (%) Description• HFrEF• ≤ 40 Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with

HFrEF, and it is only in these patients that efficacious therapies have been demonstrated to date

• a. HFpEF Borderline• 41 to 49 These patients fall into a borderline or intermediate group. Their characteristics,

treatment patterns, and outcomes appear similar to those of patients with HFpEF

• b. HFpEF Improved• > 40 It has been recognized that a subset of patients with HFpEF previously had HFrEF. These

patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients

Page 10: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

DEFINITIONS OF HEART FAILURE

• HFpEF

• ≥ 50 Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified

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EPIDEMIOLOGY

• 5.7 Million adults have heart failure in the United States• About half of people who develop heart failure die within 5 years of

diagnosis• Heart disease is the leading cause of death for African American and white

women in the United States• Heart failure is the only major cardiovascular disorder on the rise. An

estimated 400,000 to 700,000 new cases of heart failure are diagnosed each year and the number of deaths in in the United States from this condition has more than doubled since 1979, averaging 250,000 annually

Page 12: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

EPIDEMIOLOGY

• Annually, >1 Million patients are hospitalized with the primary diagnosis of heart failure in the United States

• Heart failure is the leading cause of hospitalization among adults >65 years of age in the United States

• The total cost of heart failure care in the US exceeded $30 billion annually in 2012• Health care costs, medications, lost of productivity

• Estimated that total heart failure costs in the US will exceed $70 billion by 2030

• CDC, AHA

Page 13: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HEART FAILURE PATHOPHYSIOLOGYWhat is happening to my heart?

Page 14: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

Activation NeurohormonalCascade

Sympathetic nervous system (SNS) Renin-angiotensin-aldosterone system (RAAS) Arginine-vasopressin (AVP) and endothelin (ET) axis

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NEUROHORMONAL ACTIVATIONSympathetic Nervous System

• Epinephrine, Norepinephrine• Tachycardia, éContractility, éSystemic Vascular Resistance

RAAS• Angiotensin II, Aldosterone (Salt

retention, vasoconstriction, LV remodeling)

Arginine Vasopressin• Water Retention

Endothelial Hormones• Endothelin (potent vasoconstrictor)• Prostacyclin, Prostaglandin E, Nitrous

Oxide (potent vasodilators)

Natriuretic Peptides• ANP and BNP

Page 16: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

SOME CONSEQUENCES OF PATHWAY ACTIVATION

Tachycardia and Increased Contractility• Acutely: Improves cardiac output and blood pressure• Chronically: Increases myocardial oxygen consumption, myocardial ischemia, atrial

& ventricular arrhythmias

Salt and Water Retention• Acutely: Supports blood pressure (BP) & cardiac output (CO)• Chronically: Vascular congestion, peripheral & pulmonary edema, SOB, orthopnea

Peripheral Vasoconstriction• Acutely: Supports blood pressure (BP) & cardiac output (CO) • Chronically: Decreases cardiac output & organ perfusion

Page 17: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

CLASSIFICATION OF HEART FAILURE

• NYHA Functional Classification

• Class I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.• Class II Slight limitation of physical activity. Comfortable at rest, but

ordinary physical activity results in symptoms of HF.• Class III Marked limitation of physical activity. Comfortable at rest, but

less than ordinary activity causes symptoms of HF.• Class IV Unable to carry on any physical activity without symptoms of

HF, or symptoms of HF at rest.

Page 18: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

STAGES OF HEART FAILURE

• Stage A: High risk for developing HF, but without structural heart disease • Stage B: Structural Heart Disease (low EF, LVH, prior MI, Valve

disease), but never experienced CHF symptoms • Stage C: Structural Heart Disease w/ current or prior

symptoms • Stage D: Refractory Heart Failure despite guideline directed

medical therapy.

Page 19: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

ACCF/AHA Stages of HF NYHA Functional Classification

A At high risk for HF but without structural heart disease or symptoms of HF

None

B Structural heart disease but without signs or symptoms of HF I No limitation of physical activity. Ordinary physical

activity does not cause symptoms of HF.

C Structural heart disease with prior or current symptoms of HF I No limitation of physical activity. Ordinary physical

activity does not cause symptoms of HF.

II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.

III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.

IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

Yancy C et al. Circulation 2013;128:e240-e327

D Refractory HF requiring specialized interventions

Page 20: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

WHAT IS BEHIND THE TREATMENT• Beta Blockers

• ACEi

• ARB

• Aldosterone antagonist

• Hydralazine/Isosorbide dinitrate

• ARNI

• Ivabradine

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BETA BLOCKERS

¯ 23%1959 pts/ 1.3yCarvedilol

MI 3-21d, EF < 40%, on ACEI

CAPRICORNLancet 2001

¯ 32%2647 pts/ 1.3yBisoprolol

NYHA III-IV and EF < 35%

CIBIS-IILancet 1999

¯ 48% in death/hosp/incr meds

1094 pts/ 6-12mCarvedilol

NYHA II-III and EF < 35%

US Carvedilol HF Study GroupCirculation 1996

¯ 17% in carvedilol3029 pts/ 4.8yCarved vsmetop

NYHA II-IV and EF < 35%

COMETLancet 2003

¯ 35%2289 pts/ 10.4mCarvedilol

NYHA IV and EF < 25%

COPERNICUSNEJM 2001

¯ 19%3991 pts/ 1yMetoprolol XL

NYHA II-III and EF < 40%

MERIT-HFJAMA 2000

Mortality# pts/ dur/ drugEntry CriteriaTrial

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ACE INHIBITORS

¯ 28% vs isordil/hydral

804 pts/ 6m-5yEnalapril v I/H

EF <45% and NYHA II-III

V-HeFT IINEJM 1991

¯ 27%1986 pts/ 30mRamipril

MI w/in 2-9d and evidence of CHF

AIRELancet 1993

¯ 16%2569 pts/ 41mEnalapril

EF <35% and acute CHF (II-III)

SOLVD-rxNEJM 1991

¯ 24%1749 pts/ 24mTrandolapril

MI w/in 2-6d and EF <35%

TRACENEJM 1995

¯ 19% 2231pts/ 4yCaptopril

MI w/in 3-16d and EF <40%

SAVENEJM 1992

¯ 8% NS¯ 29% death/HF

4228 pts/ 37mEnalapril

EF <35% andNYHA I

SOLVD-prevNEJM 1992

¯ 31%253 pts/ 6mEnalapril

NYHA IVCONSENSUSNEJM 1987

MortalityNumber pts/ duration/ drug

Entry criteriaTrial

Page 23: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

ANGIOTENSIN RECEPTOR BLOCKERS

• ARB + ACEI ¯ 16%• No incr death in ACEI/ARB/beta

2548 pts/ 2yCandesartan vs placebo

NYHA II-IVEF <40% On an ACEI

CHARM-addedLancet 2003

• NS: ACEI better5477 pts/ 2.7yValsartan v Captopril

Acute MI and CHFOPTIMAALLancet 2002

• V vs C: equivalent• V + C: the most adverse events

14703 pts/ 2yValsartan vs Captopril vs both

MI w/in 12h-10d + EF < 40% or CHF

VALIANTNEJM 2003

• ARB ¯ 20%-2028 pts/ 2yCandesartan vs plac

NYHA II-IV; EF <40% +ACEI intolerant

CHARM-alternLancet 2003

•Similar mortality•CHF hosp: ¯ 27%•­ death if ACEI/ARB/B

5010 pts/ 2yValsartan vs placebo

NYHA II-IV, EF < 40%90% on ACEI

Val-HeFTNEJM 2001

No superiority of one agent over another

3152 pts/ 1.5yLosartan v Captopril

>60y, EF < 40%,NYHA II-IV

ELITE-IILancet 2000

Mortality# Patients,Duration, Drug

Entry criteriaTrial

Page 24: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

ALDOSTERONE ANTAGONIST• The effect of Spironolactone on morbidity and mortality in patients with severe

heart failure. Randomized ALdactone Evaluation Study (RALES)

• Randomized, double blind, placebo controlled trial • To evaluate the effect of Spironolactone on survival of patients with history of

NYHA Class IV symptoms due to reduced LV systolic function on optimal medical therapy including ACEi

• Baseline Therapy: ACEi 95%, Beta-blockers 11%, Digoxin 74%, Loop diuretics 100% • Primary Outcome: All cause mortality (35% vs 46% p<0.001) • Secondary Outcome(s): Death from CV causes (27% vs 37% p<0.001);

Hospitalization for cardiac causes (32% vs 40% p<0.001) • Pitt B, et al. NEJM 1999 Sep 2;341(10):709-17

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HYDRALAZINE/ISOSORBIDE DINITRATE

• V-HEFT I, V-HEFT II, A-HEFT (vasodilator studies vs. placebo, vasodilators vs. ACEi, African American Heart failure trial ACEi/ARBs,BB, diuretics with addition of vasodilators)

• Showed improved mortality benefits

• showed improved left ventricular function

• Trials published in NEJM 1986, 314:1547-52, NEJM 1991; 325:301-10, NEJM 2004;351:2049-2057

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Angiotensin-Neprilysin Inhibition VS Enalapril in HF (PARADIGM-HF)

8442 patients

NYHA Class II-IV, EF < 40%, pro BNP ≥ 600

Randomized to LCZ696 VS Enalapril

1° Endpoint – CV Death, HF hospitalization

Secondary – Time to death, KCCQ, Time to new A fib, Renal function

NEJM 2014; 371: 993-1004.

Page 27: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

PARADIGM-HF• Showed decrease in CV death• Showed decrease in over all Heart failure hospitalization• Showed decrease in overall mortality (death from any cause)

• But……..• Some side effects noted with both arms

• Hypotension ARNI > Enalapril• Elevated serum creatinine ARNI < Enalapril• Elevated potassium ARNI = Enalapril• Cough ARNI < Enalapril• Angioedema à with or without airway compromise ARNI > Enalapril

• NEJM 2014; 371: 993-1004.

Page 28: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

IVABRADINE

• Works by selective inhibition of the If current channel at the SA node• Slows heart rate by blocking this channel. Has no negative inotropic effect

and no effect on ventricular repolarization• Major Trial was Shift Lancet. 2010 376(10):875-885

• Showed 5% absolute reduction in heart failure hospitalization as well as a 2% reduction in heart failure mortality

Page 29: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,
Page 30: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,
Page 31: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

2017 ACC/AHA/HFSA FOCUSED UPDATE OF THE 2013 ACCF/AHAGUIDELINE FOR THE MANAGEMENT OF HEART FAILURE

Page 32: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HEART FAILURE PRESERVED EF TREATMENT

• In patients with increased risk, control blood pressure to <130/80• In these patients it is appropriate to use BB, ACEi, ARBS• Diuretics for salt and water retention• Control/treat comorbidities

• anemia• HTN• Atrial Fibrillation• Sleep apnea

Page 33: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HEART FAILURE WITH REDUCED EF TREATMENT STAGE A• Weight Loss, Healthy diet, Exercise

• Avoid Smoking, ETOH abuse, Illicit drug use

• Periodic evaluation for signs and symptoms of HF

• Evaluation of LV function in those with a strong family history of cardiomyopathy or received cardiotoxic drugs

• NEW HTN Recommendations• Optimal BP should be < 130/80 (Class I, LOE B-R)

• NEW BNP Recommendations• BNP-based screening followed by team-based care, including a cardiovascular specialist

optimizing GDMT, can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset HF (Class II, LOE B-R)

Page 34: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,
Page 35: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HFREF STAGE B TREATMENT

• Aggressive risk factor modification• Medical therapy• ACEI (or ARB) & Beta Blockers• No role for digoxin or aldosterone antagonists

• ICD in selected patients• Coronary revascularization if evidence of ischemia and

viable myocardium• Valve replacement or repair in selected patients

Page 36: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HFREF STAGE C TREATMENT

MEDICATIONS• ACE-I/ARB’s or ARNI• Beta-Blockers• Aldosterone Antagonist• Possibly ISDN/Hydralazine• Possibly Ivabridine• Possibly Digoxin• Diuretics if needed

ADDITIONAL TXS• ICD VS CRT-D• Cardiac Rehab/Exercise Training• Consider Referral to Heart Failure

Specialist• New Systolic BP Target < 130 mmHg

(Class I, LOE C-EO)• Consider referral to advanced heart

failure specialist

Page 37: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,
Page 38: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,
Page 39: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HFREF STAGE C GUIDELINESRenin - Angiotensin System Inhibition• ACE-I (Class I, LOE A) or• ARBs (Class I, LOE A) or• ARNI (Class I, LOE B-R)

AND

HF Evidence-Based Beta Blockers• Metoprolol Succinate (Toprol XL)• Carvedilol• Bisoprolol

AND

Aldosterone Antagonism• Spironolactone• Epleronone

Recommended for patients with chronic HFrEF to reduce Morbidity and Mortality

Page 40: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HFREF STAGE C GUIDELINES

ACE-I is beneficial for patients with prior or current symptoms of chronic HFrEF to reduce morbidity and mortality (I, A)

ARB’s to reduce morbidity and mortality is recommended in patients with prior or current symptoms of chronic HFrEF who are intolerant to ACE-I because of cough or angioedema (I, A)

Page 41: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HFREF STAGE C GUIDELINESIn patients with chronic symptomatic HFrEF NYHA class II or III who

tolerate an ACE-I or ARB, replacement by an ARNI is Recommended to further reduce morbidity and mortality (I, B-R)

ARNI should NOT be administered concomitantly with ACE-I or within 36 hrs of the last dose of an ACE-I (III, B-R)

ANRI should NOT be administered to patients with a history of Angioedema (III, C-EO)

Page 42: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HFREF STAGE C GUIDELINES

IVABRADINE (IIa, B)

- To reduce HF Hospitalization in NYHA Class II – III, Stable Chronic HFrEF(LVEF < 35%), receiving guideline-directed evaluation and management including

- A Beta-Blocker at Maximum Tolerated Dose- Sinus Rhythm- A HR > 70 bpm at Rest

- Guideline Emphasizes to make sure patient is on Maximal B-blocker prior to initiating Ivabradine

Page 43: CONGESTIVE HEART FAILURE - TAPA · •Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions,

HFREF STAGE D TREATMENTS

• Palliative Care

• Left Ventricular Assist Devices

• Orthotopic Heart Transplantation• Recipient heart replaced with donor heart

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THANK YOU!


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