heart disease in kentucky treatment of advanced heart failure ragoplan heart failure.pdf ·...

$: HEART DISEASE IN KENTUCKY TREATMENT OF ADVANCED HEART FAILURE Ragoplan Heart Failure.pdf · Treatment option for systolic heart failure refractory to maximal medical therapy Li it$
1

TREATMENT OF ADVANCED TREATMENT OF ADVANCED HEART FAILUREHEART FAILURE

Navin Rajagopalan, MDNavin Rajagopalan, MDj gj gAssistant Professor of MedicineAssistant Professor of Medicine

University of KentuckyUniversity of KentuckyDirector, Congestive Heart FailureDirector, Congestive Heart Failure

Medical Director of Cardiac TransplantationMedical Director of Cardiac Transplantation

November 1, 2009November 1, 2009

HEART DISEASE IN HEART DISEASE IN KENTUCKYKENTUCKY

TOPICS FOR DISCUSSIONTOPICS FOR DISCUSSION

ACE inhibitors & BetaACE inhibitors & Beta--blockersblockers

DiureticsDiuretics

Cardiac resynchronizationCardiac resynchronization

Cardiac transplantationCardiac transplantation

ACE INHIBITORSACE INHIBITORS

Standard therapy for heart failureStandard therapy for heart failure

Best randomized trial data for captopril, Best randomized trial data for captopril, lisinopril, and enalaprillisinopril, and enalapril

All i d h !All i d h !–– All are now generic and cheap!All are now generic and cheap!

Start low dose and titrate upwards to goalStart low dose and titrate upwards to goal–– Enalapril: 2.5 mg qdEnalapril: 2.5 mg qd--bid to 10bid to 10--20 mg bid20 mg bid

–– Lisinopril: 2.5 mg qd to 20Lisinopril: 2.5 mg qd to 20--40 mg qd40 mg qd

ARB can be used if ACEi intolerantARB can be used if ACEi intolerant

BETA BLOCKERSBETA BLOCKERS

Standard therapy for heart failureStandard therapy for heart failure

Best randomized trial data for metoprolol succinate Best randomized trial data for metoprolol succinate (Toprol XL) and carvedilol (Coreg)(Toprol XL) and carvedilol (Coreg)–– Both are now generic Both are now generic gg–– Start low dose and titrate upwards to goalStart low dose and titrate upwards to goal–– Toprol XL: 25 mg qd to 200 mg qdToprol XL: 25 mg qd to 200 mg qd–– carvedilol: 3.125 mg bid to 25 mg bidcarvedilol: 3.125 mg bid to 25 mg bid

COMET trial suggested better outcomes with carvedilol COMET trial suggested better outcomes with carvedilol than with metoprolol (although metoprolol tartrate was than with metoprolol (although metoprolol tartrate was used)used)

ACE INHIBITORS AND BETAACE INHIBITORS AND BETA--BLOCKERSBLOCKERS

ACE inhibitors are commonly instituted ACE inhibitors are commonly instituted first first –– Beneficial effects of BB were found after use Beneficial effects of BB were found after use

of ACE inhibitors was standardof ACE inhibitors was standard--carecareof ACE inhibitors was standardof ACE inhibitors was standard carecare

–– BB contraindicated if patients are significantly BB contraindicated if patients are significantly volume overloadedvolume overloaded

Is this titration scheme necessary?Is this titration scheme necessary?

2


Sliwa et al. (2004) evaluated initiation of therapy Sliwa et al. (2004) evaluated initiation of therapy with carvedilol either before (n=38) or after with carvedilol either before (n=38) or after (n=40) perindopril therapy in newly diagnosed (n=40) perindopril therapy in newly diagnosed NYHA IINYHA II--III HF patientsIII HF patients

Alternative agent was added at 6 months (target Alternative agent was added at 6 months (target doses: carvedilol 25 mg bid, perindopril 8 mg qd)doses: carvedilol 25 mg bid, perindopril 8 mg qd)

Endpoint: LVEF and functional class at 1 yearEndpoint: LVEF and functional class at 1 year


Carvedilol first group Carvedilol first group @ 12 mo:@ 12 mo:

–– Better improvement Better improvement in NYHA classin NYHA classB tt i tB tt i t–– Better improvement Better improvement in LVEFin LVEF

–– Lower dose of Lower dose of furosemidefurosemide

–– Higher dose of Higher dose of carvedilol (43 carvedilol (43 17 17 mg vs. 33 mg vs. 33 18 mg)18 mg)

Sliwa et al. JACC 2004;44:1825-30


CIBIS III study randomized 1010 patients CIBIS III study randomized 1010 patients with class IIwith class II--III systolic HF to monotherapy III systolic HF to monotherapy with bisoprolol (target dose 10 mg qd) or with bisoprolol (target dose 10 mg qd) or enalapril (target dose 10 mg bid) for 6 enalapril (target dose 10 mg bid) for 6 months, followed by their combination for months, followed by their combination for 66--24 months24 months

Primary endPrimary end--point: mortality or point: mortality or hospitalizationhospitalization


Trend towards Trend towards better survival in better survival in bisoprolol first groupbisoprolol first group

Trend towards more Trend towards more HF hospitalization in HF hospitalization in bisoprolol first groupbisoprolol first group

Safe and efficacious Safe and efficacious to initiate CHF to initiate CHF treatment with betatreatment with beta--blockersblockers


Not necessary that ACE inhibitors be used Not necessary that ACE inhibitors be used before betabefore beta--blockersblockers

Titration of both drugs can beTitration of both drugs can beTitration of both drugs can be Titration of both drugs can be accomplished at the same timeaccomplished at the same time

Volume status needs to be managed Volume status needs to be managed before betabefore beta--blockers are aggressively blockers are aggressively titratedtitrated

ACE INHIBITORSACE INHIBITORSIS THE DOSE IMPORTANT?IS THE DOSE IMPORTANT?

ATLAS study randomized 3164 NYHA IIATLAS study randomized 3164 NYHA II--IV systolic HF patients to low dose IV systolic HF patients to low dose lisinopril (2.5 to 5.0 mg qd) or high dose lisinopril (2.5 to 5.0 mg qd) or high dose (32 5 to 35 mg qd)(32 5 to 35 mg qd)(32.5 to 35 mg qd)(32.5 to 35 mg qd)

LVEF < 30%LVEF < 30%

No BB use (trial published in 1999)No BB use (trial published in 1999)

3


HighHigh--dose group dose group had a had a nonsignificant 8% nonsignificant 8% lower risk of death lower risk of death (p = 0.13)(p = 0.13)

Significant 12% Significant 12% lower risk of death lower risk of death or hospitalization or hospitalization for any reason and for any reason and 24% fewer 24% fewer hospitalizations for hospitalizations for HF in high dose HF in high dose groupgroup

Packer et al. Circ 1999;100:2312-2318


Using dose that is similar to that used in clinical Using dose that is similar to that used in clinical trials has meaningful benefit over low dose trials has meaningful benefit over low dose

The differences between intermediateThe differences between intermediate--dose anddose andThe differences between intermediateThe differences between intermediate dose and dose and highhigh--dose lisinopril is likely to be small, if present dose lisinopril is likely to be small, if present at allat all

Is the same thing true of betaIs the same thing true of beta--blockers in heart blockers in heart failure?failure?

BETABETA--BLOCKERSBLOCKERSIS THE DOSE IMPORTANT?IS THE DOSE IMPORTANT?

McAlister et al. (2009) McAlister et al. (2009) performed a metaperformed a meta--analysis analysis on 23 BB trials in systolic on 23 BB trials in systolic HF to determine if the HF to determine if the survival benefits were survival benefits were associated with BB doseassociated with BB doseassociated with BB dose associated with BB dose or the magnitude of heart or the magnitude of heart rate reductionrate reductionMedications: metoprolol Medications: metoprolol (5), carvedilol (9), (5), carvedilol (9), bisoprolol (3), bucindolol bisoprolol (3), bucindolol (3), atenolol (1), and (3), atenolol (1), and nebivolol (2)nebivolol (2)

McAlister et al. Ann Intern Med 2009;150:784-94.

BETABETA--BLOCKERSBLOCKERSIS THE DOSE IMPORTANT?IS THE DOSE IMPORTANT?

For every HR For every HR reduction of 5 reduction of 5 beats/min, a significant beats/min, a significant 18% reduction in the 18% reduction in the risk of death occurredrisk of death occurred

No significant No significant relationship between relationship between allall--cause mortality and cause mortality and BB dosing was BB dosing was observedobserved

McAlister et al. Ann Intern Med 2009;150:784-94.

BETA BLOCKERSBETA BLOCKERSIS THE DOSE IMPORTANT?IS THE DOSE IMPORTANT?

Other investigators have observed that HF patients with Other investigators have observed that HF patients with higher baseline HR exhibit the greatest improvements in higher baseline HR exhibit the greatest improvements in LVEF with BB therapy and that greater reductions in HR LVEF with BB therapy and that greater reductions in HR are associated with greater improvements in LVEFare associated with greater improvements in LVEF

Optimal HR is unknownOptimal HR is unknown

If substantial HR reduction is achieved with lowIf substantial HR reduction is achieved with low--dose BB, dose BB, should you keep titrating?should you keep titrating?

Is there any benefit to using dosing higher than trial Is there any benefit to using dosing higher than trial doses if HR reduction is suboptimal?doses if HR reduction is suboptimal?

MY OPINIONMY OPINION

If limited by BP, it is better to get a patient on If limited by BP, it is better to get a patient on small doses of both classes of medications, as small doses of both classes of medications, as opposed to a moderate dose of oneopposed to a moderate dose of one

A hi i i l d f BB i lik lA hi i i l d f BB i lik lAchieving maximal dose of BB is likely more Achieving maximal dose of BB is likely more important than achieving maximal dose of ACE important than achieving maximal dose of ACE inhibitorinhibitor

If tolerated, discharge patients with both If tolerated, discharge patients with both medications, even if low dosemedications, even if low dose

4

DIURETICSDIURETICS

Aldosterone antagonist (spironolactone)Aldosterone antagonist (spironolactone)

Loop diureticsLoop diuretics

SPIRONOLACTONESPIRONOLACTONE

RALES randomized RALES randomized 1663 systolic heart 1663 systolic heart failure patients (LVEF < failure patients (LVEF < 35%; NYHA class III/IV) 35%; NYHA class III/IV) to spironolactone or to spironolactone or l bl bplaceboplacebo

Serum Cr < 2.5, K < 5.0Serum Cr < 2.5, K < 5.0

Initial dose 25 mg qd, Initial dose 25 mg qd, increased to 50 mg qd if increased to 50 mg qd if no benefit, no side no benefit, no side effectseffects

94 % on ACEi; 10% on 94 % on ACEi; 10% on BBBB

SPIRONOLACTONE IN THE “REAL SPIRONOLACTONE IN THE “REAL WORLD”WORLD”

Retrospective studies Retrospective studies have identified have identified inappropriate use of inappropriate use of spironolactone in patients spironolactone in patients with renal insufficiency as with renal insufficiency as yywell as less than ideal well as less than ideal followfollow--upup

Bozkurt et al. in a Bozkurt et al. in a retrospective review of retrospective review of 104 pts reported 10% 104 pts reported 10% rate of serious rate of serious hyperkalemia (K+ > 6)hyperkalemia (K+ > 6)

Bozkurt et al. JACC 2003; 41: 211-4.

LOOP DIURETICSLOOP DIURETICS

Loop diuretics (IV) are a mainstay of therapy for AHFSLoop diuretics (IV) are a mainstay of therapy for AHFS–– 7575--80% in ADHERE received IV diuretics80% in ADHERE received IV diuretics

Reduce left ventricular filling pressuresReduce left ventricular filling pressures

Reduce central venous pressureReduce central venous pressure

40 mg furosemide = 20 mg torsemide = 1 mg 40 mg furosemide = 20 mg torsemide = 1 mg bumetanidebumetanide

PROBLEMS WITH DIURETICSPROBLEMS WITH DIURETICS

Adverse neurohormonal activationAdverse neurohormonal activation–– Increased plasma renin, aldosterone, norepinephrineIncreased plasma renin, aldosterone, norepinephrine

In SOLVD trial, use of longIn SOLVD trial, use of long--term diuretics was term diuretics was associated with a 1 33 fold increase in risk of arrhythmicassociated with a 1 33 fold increase in risk of arrhythmicassociated with a 1.33 fold increase in risk of arrhythmic associated with a 1.33 fold increase in risk of arrhythmic death after correcting for other mortality risk factorsdeath after correcting for other mortality risk factors

Postdiuretic sodium rebound as a result of poor dietary Postdiuretic sodium rebound as a result of poor dietary compliancecompliance–– Given short halfGiven short half--life of diuretics, there is a significant amount of life of diuretics, there is a significant amount of

time where the tubular concentration of the diuretic is time where the tubular concentration of the diuretic is subtherapeutic.subtherapeutic.

CARDIOCARDIO--RENAL SYNDROMERENAL SYNDROME

Low cardiac output is not necessary and many patients have preserved LVEF (diastolic HF) and/or elevated BP

Gheorghiade et al. JACC 2009; 53: 557-73.

Registry of 1004 patients admitted with CHF found worsening renal function during hospitalization (Cr rise > 0.3 mg/dl) in 27% which was statistically associated with hospital deaths and LOS > 10 days

5


Animal studies have demonstrated that temporary Animal studies have demonstrated that temporary elevation of CVP can lead to worsened renal function via elevation of CVP can lead to worsened renal function via congestion of the renal veinscongestion of the renal veins

Mullens et al (JACC 2009) recently showed in 145Mullens et al (JACC 2009) recently showed in 145Mullens et al. (JACC 2009) recently showed in 145 Mullens et al. (JACC 2009) recently showed in 145 patients with AHFS that patients who developed patients with AHFS that patients who developed worsening renal function had greater CVP upon worsening renal function had greater CVP upon admission as well as greater CVP following medical admission as well as greater CVP following medical therapytherapy–– Renal function did not correlate with other hemodynamic Renal function did not correlate with other hemodynamic

variables variables


Mullens et al. JACC 2009;53:589-96.

COMBATING DIURETIC COMBATING DIURETIC RESISTANCERESISTANCE

Addition of thiazide diuretic to a loop diuretic results in greater di i d t i thdiuresis and naturesis than increasing dose of loop diuretic alone

Stewart JH et al. BMJ 1965; 5473: 1277-81

COMBATING DIURETIC COMBATING DIURETIC RESISTANCERESISTANCE

Dormans et al. (JACC 1996) randomized 20 CHF patient Dormans et al. (JACC 1996) randomized 20 CHF patient on high doses of oral lasix (> 250 mg/day) to intravenous on high doses of oral lasix (> 250 mg/day) to intravenous bolus therapy versus the same dose given as a bolus therapy versus the same dose given as a continuous infusion for 1 daycontinuous infusion for 1 day

Urinary volume and urinary excretion of sodium were Urinary volume and urinary excretion of sodium were both significantly greater at 8 hours and 24 hours in the both significantly greater at 8 hours and 24 hours in the continuous infusion group (mean daily dose of 690 mg)continuous infusion group (mean daily dose of 690 mg)

Less peak concentration with continuous infusion may Less peak concentration with continuous infusion may lessen risk of ototoxicitylessen risk of ototoxicity

DOES THE CHOICE OF DIURETIC DOES THE CHOICE OF DIURETIC MATTER?MATTER?

Oral torsemide may be better and more reliably Oral torsemide may be better and more reliably absorbed than either furosemide or bumetanide, with absorbed than either furosemide or bumetanide, with more consistent bioavailabilitymore consistent bioavailabilitymore consistent bioavailabilitymore consistent bioavailability

Furosemide in particular has variable absorption Furosemide in particular has variable absorption

Response to intravenous doses likely to be similarResponse to intravenous doses likely to be similar

DIURETICSDIURETICS

Use lowest dose possible to achieve effective diuresisUse lowest dose possible to achieve effective diuresis

Loop + thiazide combination and consideration of Loop + thiazide combination and consideration of continuous infusion are options for those difficult to continuous infusion are options for those difficult to diuresediuresediuresediurese

Worsening renal function is a not a contraindication to Worsening renal function is a not a contraindication to diuretic therapydiuretic therapy

6

CARDIAC RESYNCHRONIZATION CARDIAC RESYNCHRONIZATION THERAPY (CRT)THERAPY (CRT)

Biventricular Biventricular pacemaker / ICDpacemaker / ICDLeft ventricular Left ventricular dyssynchronydyssynchrony

Right AtrialLead

dyssynchrony dyssynchrony prevalent in systolic prevalent in systolic HFHFIndicated in:Indicated in:–– Chronic systolic HF Chronic systolic HF

on optimal medical Rxon optimal medical Rx–– NYHA class III/IVNYHA class III/IV–– QRS duration > 120 QRS duration > 120

secondsseconds

Right VentricularLead

Left VentricularLead

CARDIAC RESYNCHRONIZATION CARDIAC RESYNCHRONIZATION THERAPY (CRT)THERAPY (CRT)

CRT alone (without CRT alone (without ICD) improved ICD) improved survival in chronic survival in chronic class III/IV HF class III/IV HF

ti t ith QRS >ti t ith QRS >patients with QRS > patients with QRS > 120 ms over OMT120 ms over OMT

Benefit greater in pts Benefit greater in pts with QRS duration > with QRS duration > 160 msec160 msec

Cleland J et al. NEJM 2005; 352:1539-49

CRTCRT

Can CRT be utilized in patients with less severe Can CRT be utilized in patients with less severe heart failure?heart failure?

Previous studies have suggested that CRT can Previous studies have suggested that CRT can lead to positive remodeling includinglead to positive remodeling includinglead to positive remodeling including lead to positive remodeling including improvement in left ventricular endimprovement in left ventricular end--systolic systolic volumesvolumes

MADITMADIT--CRT was designed to determine if CRT CRT was designed to determine if CRT could improve outcomes in NYHA Icould improve outcomes in NYHA I--II HF II HF patients with QRS duration > 130 mspatients with QRS duration > 130 ms

CRT IN NYHA I/II HEART FAILURECRT IN NYHA I/II HEART FAILURE

Moss AJ et al. NEJM 2009; 361

Benefit of CRT driven by significant 41% reduction in HF events over 2.4 years (no difference in mortality)

Benefit confined to those with QRS duration > 150 msec

CRTCRT

Future guidelines may incorporate the Future guidelines may incorporate the latest data suggesting benefit of CRT in latest data suggesting benefit of CRT in class I/II HF, particularly those with QRS class I/II HF, particularly those with QRS duration > 150 msecduration > 150 msec

Procedure does have increased risk Procedure does have increased risk compared to ICD alonecompared to ICD alone

Cost effectiveness?Cost effectiveness?

CARDIAC TRANSPLANTATIONCARDIAC TRANSPLANTATION

Treatment option for systolic heart failure Treatment option for systolic heart failure refractory to maximal medical therapyrefractory to maximal medical therapy

Li it d b l f dLi it d b l f dLimited by supply of donor organsLimited by supply of donor organs–– 30003000--4000 heart transplants / year in US4000 heart transplants / year in US

Extensive patient evaluation requiredExtensive patient evaluation required–– Medical, psychosocial, insurance, etc. Medical, psychosocial, insurance, etc.

7

TRANSPLANT EVALUATIONTRANSPLANT EVALUATION

Mehra MR et al. Listing Criteria for Heart Transplantation. J Heart Lung Transplant 2006;25:1024-42.

WHEN TO REFERWHEN TO REFER

Symptoms limiting quality of lifeSymptoms limiting quality of life

Recurrent heart failure admissions despite maximal Recurrent heart failure admissions despite maximal therapytherapy

W i dW i d f ti ( l h ti )f ti ( l h ti )Worsening endWorsening end--organ function (renal, hepatic)organ function (renal, hepatic)–– Before they become irreversibleBefore they become irreversible

Refractory ventricular arrhythmias Refractory ventricular arrhythmias

For younger patients, may be useful to be “plugged” into For younger patients, may be useful to be “plugged” into the systemthe system

ADULT HEART TRANSPLANTATIONADULT HEART TRANSPLANTATIONKaplanKaplan--Meier Survival by Era Meier Survival by Era (Transplants: 1/1982 (Transplants: 1/1982 –– 6/2006)6/2006)

60

80

100

1982-1991 (N=18 854)

All comparisons significant at p < 0.0001

viva

l (%

)

0

20

40

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

1982-1991 (N=18,854)

1992-2001 (N=35,146)

2002-6/2006 (N=12,369)

HALF-LIFE 1982-1991: 8.8 years; 1992-2001: 10.5 years; 2002-6/2006: NA

Su

rv

ISHLT 2008

J Heart Lung Transplant 2008;27: 937-983

ADULT HEART RECIPIENTSADULT HEART RECIPIENTSFunctional Status of Surviving RecipientsFunctional Status of Surviving Recipients

(Follow(Follow--ups: 1995 ups: 1995 -- June 2006)June 2006)

60%

80%

100%

0%

20%

40%

1 Year (N = 15,388) 3 Years (N = 13,600) 5 Years (N = 11,698) 7 Years (N = 9,306)

No Activity Limitations Performs with Some Assistance Requires Total Assistance

ISHLT 2008

Last updated based on data as of December 2006J Heart Lung Transplant 2008;27: 937-983

CONTRAINDICATIONSCONTRAINDICATIONS

Active substance abuseActive substance abuse

Lack of social supportLack of social support

Severe peripheral vascular diseaseSevere peripheral vascular disease

Severe lung diseaseSevere lung disease

Active viral hepatitis / HIVActive viral hepatitis / HIV

Recent malignancy Recent malignancy

VADVAD

Option for patients with Option for patients with endend--stage HF and who are stage HF and who are not candidates for not candidates for transplantation, or who transplantation, or who cannot wait for transplantcannot wait for transplantcannot wait for transplantcannot wait for transplant

Requires major Requires major cardiothoracic surgery with cardiothoracic surgery with similar contraindications as similar contraindications as transplanttransplant

Devices are getting smaller Devices are getting smaller and saferand safer

Rose EA et al. NEJM 2001;345:1435-43

8

REMATCH (2001)REMATCH (2001)DESTINATION LDESTINATION L--VADVAD

129 patients with end129 patients with end--stage stage CHF, 80% requiring IV CHF, 80% requiring IV inotropic therapy, inotropic therapy, randomized to medicalrandomized to medicalrandomized to medical randomized to medical therapy versus HeartMate I therapy versus HeartMate I LVAD (pulsatile device)LVAD (pulsatile device)

Patients were not transplant Patients were not transplant candidatescandidates

Cause of death in LVAD Cause of death in LVAD group was predominantly group was predominantly sepsis, LVAD failure, and sepsis, LVAD failure, and CVACVARose EA et al. NEJM 2001;345:1435-43

HEARTMATE IIHEARTMATE II

Continuous flow rotary Continuous flow rotary pumppumpExternal drive line still External drive line still needed needed Smaller size allows forSmaller size allows forSmaller size allows for Smaller size allows for use in smaller patients, use in smaller patients, femalesfemalesRecent studies have Recent studies have shown lower adverse shown lower adverse events (stroke, bleeding, events (stroke, bleeding, infection) compared to infection) compared to older, larger devicesolder, larger devices

Pagani FD et al. JACC 2009;54:312-21

HEARTMATE IIHEARTMATE II

HM II device appears to be safe for bridge to HM II device appears to be safe for bridge to transplant and an improvement over older transplant and an improvement over older pulsatile devicespulsatile devices

No randomized study versus transplantNo randomized study versus transplantNo randomized study versus transplantNo randomized study versus transplant

Learning curve is presentLearning curve is present

Outcomes not assessed after transplant Outcomes not assessed after transplant ––does VAD prior to transplant constitute a risk does VAD prior to transplant constitute a risk factor for poor outcome?factor for poor outcome?

WHAT ABOUT THE COST?WHAT ABOUT THE COST?

Hernandez et al. (JAMA, 2008) examined Medicare Hernandez et al. (JAMA, 2008) examined Medicare data for patients who underwent VAD implant data for patients who underwent VAD implant between 2/2000 and 6/2006between 2/2000 and 6/2006–– Primary device group (n = 1476)Primary device group (n = 1476)–– Post cardiotomy (n =1467)Post cardiotomy (n =1467)

1 year survival was 51.6% in the primary device 1 year survival was 51.6% in the primary device group and 30.8% in postgroup and 30.8% in post--cardiotomy groupcardiotomy group

Mean 1Mean 1--year Medicare payments for inpatient care year Medicare payments for inpatient care was $178714 in the primary device group and was $178714 in the primary device group and $111769 in the post$111769 in the post--cardiotomy groupcardiotomy group

CONCLUSIONCONCLUSION

Advanced heart failure is a severe, Advanced heart failure is a severe, debilitating illness that requires a debilitating illness that requires a multidisciplinary approachmultidisciplinary approach

Evidence based therapy is still underutilized Evidence based therapy is still underutilized

Referral for transplantation should be Referral for transplantation should be considered in acceptable candidatesconsidered in acceptable candidates

QUESTIONS?QUESTIONS?

Navin RajagopalanNavin RajagopalanEmail: Email: [email protected]@uky.eduPhone: 800Phone: 800--888888--5533 (UK MD)5533 (UK MD)Cell: 859Cell: 859--317317--07750775

9

For each of the following For each of the following medications used in chronic HF, medications used in chronic HF, specify if they improve mortality, specify if they improve mortality, worsen mortality, or are neutral worsen mortality, or are neutral

A.A. EnalaprilEnalaprilB.B. DigoxinDigoxinC.C. AmlodipineAmlodipineD.D. DobutamineDobutamineE.E. NesiritideNesiritide

IMPROVEIMPROVENEUTRALNEUTRALNEUTRALNEUTRALWORSENWORSEN????????????????


Which of the following statements is true about management of chronic Which of the following statements is true about management of chronic HF?HF?

A.A. ACE inhibitors should be started before beta blockersACE inhibitors should be started before beta blockersB.B. Carvedilol is the only FDA approved betaCarvedilol is the only FDA approved beta--blocker for blocker for

heart failureheart failureC.C. ACE inhibitors are contraindicated in HF patients with ACE inhibitors are contraindicated in HF patients with

serum creatinine > 2.0serum creatinine > 2.0D.D. Despite benefits seen with hydralazine / nitrates in Despite benefits seen with hydralazine / nitrates in

African Americans, African Americans with HF should African Americans, African Americans with HF should still be started on ACE inhibitors firststill be started on ACE inhibitors first

E.E. If a HF patient develops cough from ACE inhibitor, it is If a HF patient develops cough from ACE inhibitor, it is advisable not to switch to an angiotensin receptor advisable not to switch to an angiotensin receptor blocker (ARB) given the lack of data using ARBs in blocker (ARB) given the lack of data using ARBs in heart failureheart failure

DIURETICS IN HEART FAILUREDIURETICS IN HEART FAILURE

Which of the following has proven mortality benefit Which of the following has proven mortality benefit in patients with systolic heart failure?in patients with systolic heart failure?

A.A. FurosemideFurosemideA.A. FurosemideFurosemide

B.B. SpironolactoneSpironolactone

C.C. TorsemideTorsemide

D.D. ChlortalidoneChlortalidone

E.E. None of the aboveNone of the above

DEVICE THERAPYDEVICE THERAPY

48 year old female presents with progressive SOB 48 year old female presents with progressive SOB following mild viral illnessfollowing mild viral illnessSubsequent echo shows dilated LV (LVEDD 6.8 cm) and Subsequent echo shows dilated LV (LVEDD 6.8 cm) and EF 20%EF 20%ECG shows LBBB which is old (patient has known of ECG shows LBBB which is old (patient has known of (p(pLBBB since age 25). QRS duration 150 msecLBBB since age 25). QRS duration 150 msecLHC showed no CADLHC showed no CADStarted on carvedilol and lisinopril and medications are Started on carvedilol and lisinopril and medications are titrated upwardstitrated upwardsSymptoms improve and patient is back to baseline, Symptoms improve and patient is back to baseline, exercising, in NYHA class Iexercising, in NYHA class IRepeat echo in 3 months shows LVEF 25%Repeat echo in 3 months shows LVEF 25%

DEVICE THERAPYDEVICE THERAPY

Patient is referred to Electrophysiology. Patient is referred to Electrophysiology. What device is recommended by the What device is recommended by the current heart failure guidelines?current heart failure guidelines?

A.A. No deviceNo device

B.B. Dual chamber pacemakerDual chamber pacemaker

C.C. Biventricular pacemaker / ICD (i.e CRT)Biventricular pacemaker / ICD (i.e CRT)

D.D. Dual chamber ICDDual chamber ICD

CARDIAC TRANSPLANTATIONCARDIAC TRANSPLANTATION

All of the following statements are true, except:All of the following statements are true, except:

A.A. Following cardiac transplantation, 5 year survival is 75% and 10 Following cardiac transplantation, 5 year survival is 75% and 10 year survival is 50%year survival is 50%

BB History of drug abuse including smoking is a contraindication forHistory of drug abuse including smoking is a contraindication forB.B. History of drug abuse including smoking is a contraindication for History of drug abuse including smoking is a contraindication for cardiac transplantationcardiac transplantation

C.C. For patients who unable to receive a heart transplant in time, left For patients who unable to receive a heart transplant in time, left ventricular assist devices (VAD) can be utilized as a “bridge” to ventricular assist devices (VAD) can be utilized as a “bridge” to transplantationtransplantation

D.D. Referral for heart transplantation should be considered if a patient Referral for heart transplantation should be considered if a patient remains significantly limited despite optimal medical therapyremains significantly limited despite optimal medical therapy

heart disease in kentucky treatment of advanced heart failure ragoplan heart failure.pdf ·...

Documents