heart failure 2003 - an update

West Herts Cardiology

Heart Failure Update 2003Heart Failure Update 2003

TerminologyPathophysiologyAccurate assessmentEvidence-based treatmentOrganisation / Staffing

Echo services Specialist Nursing Palliative care


Heart Failure in the NSF for CHD (Ch 6)Heart Failure in the NSF for CHD (Ch 6)

Standard 11Doctors should arrange for people with suspected heart failure to be offered appropriate investigations (eg ECG, Echo) that will confirm or refute the diagnosis.

For those in whom heart failure is confirmed, its its cause should be identified, and treatments most likely to both

relieve their symptoms and reduce their risk of death

should be offered.


What is Heart Failure?What is Heart Failure? A disease mostly of the elderly

Co-morbidity, Frailty, Drug interactions, Compliance Common

Overall incidence 1 :1,000 pop : year Expensive

Total NHS cost £360m (1% of total budget)GP visits £ 16.6mHosp OPD £ 27.8mInvestigations £ 57.4mHosp admissions £214.2mDrug Rx £ 27.1m

Complex, but manageable!


Heart failure v Asymptomatic LV Dysfunction

Acute v Chronic / Congestive (CHF, CCF) LVF v Pulmonary oedema Left v Right v Biventricular High output v Low output Backward v Forward

“Mild” !!! THERE IS NO “Mild” HEART FAILURE

What is Heart Failure? : TermsWhat is Heart Failure? : Terms


Heart FailureHeart Failure

“When the pulse is abundant, tense and full like a chord, then there is dropsical swelling of the legs.The stomach is swelled out, the kidneys pass on the disease to the heart, and the latter causes the troubled breathing.”

The Yellow Emperor's Manual of Internal Medicine (China circa 2500 BC)


“A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses.”

Prof. Peter Harris 1983

What is Heart Failure?What is Heart Failure?


What is Heart Failure?What is Heart Failure?Definition (European Society of Cardiology, 2001)

Criteria 1 and 2 should be fulfilled in all cases

1. Symptoms of heart failure (at rest or during exercise)

and2. Objective evidence of cardiac dysfunction (at rest)

and (in cases where the diagnosis is in doubt)

3. Response to treatment directed towards heart failure

European Heart Journal (2001) 22, 1527–1560


Heart Failure is NOT a DiagnosisHeart Failure is NOT a Diagnosis

Heart Failure is a Clinical Syndrome

CARDIAC abnormality with one or more ofBreathlessnessFatigue, poor perfusionTendency to fluid retention & oedema

MANY possible causesNeed to know CAUSE of Heart Failure


Causes of Heart Failure : ClinicalCauses of Heart Failure : Clinical LV Myocardial Dysfunction (LV Failure = “LVF”)

“Systolic” : Myocardial Infarction / Ischaemia Dilated Cardiomyopathy Alcohol, Drugs

“Diastolic” : Ischaemia LV Hypertrophy (LVH), Hypertrophic CM Age / Amyloid

Valve disease : Pressure load (AS) Volume load (AR,MR) L RV dysfunction Poor flow (MS)

Arrhythmias: AF, uncontrolled tachy, severe brady (CHB) Pericardial disease Congenital heart disease : ASD, GUCH Drugs: Negative inotropic, NSAIDs, etc Extracardiac causes (Anaemia, Thyroid, ..)


Heart Failure: ProgressionHeart Failure: ProgressionHigh risk of HF but without heart disease

Hypertension, CHD or risk++, DM, Family History, Cardiotoxins

Structural Heart Disease without symptoms Known – eg Previous MI Unknown – Hypertensive LVH, undetected valve disease,

undetected cardiomyopathySymptomatic Heart Failure

“Mild” “Moderate-Severe”

Refractory Heart Failure


Heart Failure: Progression of Stages

NORMAL

Asymptomatic LV Dysfunction

“Compensated”CHF

“Decompensated”CHF

No symptomsNormal exerciseNormal LV fxn

No symptomsNormal exerciseAbnormal LV fxn

? No symptoms ExerciseAbnormal LV fxn

Symptoms ExerciseAbnormal LV fxn

“Refractory”CHF

Symptoms not controlled with treatment

American Heart Association


Class I

Class II

Class III

Class IV

No limitation ofphysical activity

Slight limitationof physical activity

Marked limitationof physical activity

Any physical activitycauses discomfort

No symptoms onordinary activity

Symptoms onordinary activity

Symptoms on lessthan ordinary activity

Symptoms at rest

Heart Failure: NYHA classificationHeart Failure: NYHA classification


Heart Failure : conceptual problemsHeart Failure : conceptual problemsIn epidemiological studiesLV systolic dysfunction (LVSD)

Not uncommon (1.8–11.3 % prevalence) Difficult to define is often asymptomatic (34-95%)

Clinical Heart Failure LV systolic function often “Normal” (43-71%) ?”Diastolic Heart Failure” by exclusion of LVSD – NO!

Petrie M, McMurray J Lancet 2001;358:432-434


Heart Failure: PathophysiologyHeart Failure: Pathophysiology

CHD

Hypertension

Valve disease

Cardiomyopathy

Congenital HD

LVDysfunction

Arrhythmias

Non-Cardiac FactorsNeuroendocrine activationEndothelial dysfunctionCytokines, eg TNFVasoconstrictionSkeletal Muscle abnormalitiesRenal Sodium retention

MostSymptoms

ChronicHeart

Failure

PumpFailure

DEATHLow

EjectionFractionRemodelling


Heart Failure : AssessmentHeart Failure : Assessment Are the symptoms cardiac ? What is the cause of Heart Failure ? What is the severity / prognosis ? What treatment is appropriate ? Is treatment working ?

History Clinical Examination Investigations


Heart Failure : AssessmentHeart Failure : Assessment History Clinical Examination (incl. weight, urinalysis) Investigations

ECG, CXR, Routine Bloods (U&E, LFT, Thyroid, FBC) Echocardiogram (? Stress Echo)? BNP (to detect those unlikely to have CHF)

Exercise test (ExECG, VO2, T-wave alternans) Ambulatory ECG Respiratory Function tests

? Nuclear scans (myocardial perfusion)? Cardiac catheterisation & Angiography


Heart Failure : SymptomsHeart Failure : SymptomsHistory Breathlessness Fatigue, lethargy Poor perfusion, confusion Tendency to fluid retention & oedema

Palpitations, Syncope Loss of appetite “Cardiac cachexia”


Breathlessness in Primary CareBreathlessness in Primary CareCommon causes of exertional breathlessnessUnfitObesityCOPD / Asthma / SmokerHeart Failure“Angina” – reversible ischaemic LV dysfunction


Breathlessness in Primary CareBreathlessness in Primary CareBreathless when walking up hill, or worse

855 men born in 1913 in Sweden, assessed by Questionnaire, Exam, ECG, CXR, Gases, SpirometryAge 57 Age 67

Breathless 5.2% 10.3%Probable Cardiac cause 21% 32%Probable Respiratory cause 29% 26%Both 29% 22%Neither 21% 19%

Eriksson H et al Europ Heart J 1987;8:1015-23


Heart Failure : AssessmentHeart Failure : Assessment

Sens Spec PPV NPVPast history of myocardial infarction 59 86 44 92

Ingesting diuretic 73 41 19 89

Dyspnoea on exertion 100 17 18 100

Orthopnoea 22 74 14 83

Paroxysmal nocturnal dyspnoea 39 80 27 87

Oedema in history 49 47 15 83

Jugular venous pressure distension 17 98 64 86

Crackles 29 77 19 85

Gallop rhythm 24 99 77 87

Oedema on examination 20 86 21 85

Davie AP et al QJM 1997;90:335-9

Predictive value of clinical features


Signs of LV DysfunctionSigns of LV DysfunctionClinical Examination Systolic LV dysfunction

Sinus tachycardia, Weak arterial pulse Sustained apical impulse Gallop rhythm (S3+S4) Pansystolic murmur of MR

Diastolic LV dysfunction Double apical impulse S4 Eventual PHT : Loud P2, JVP “a” wave +


Heart Failure : CXRHeart Failure : CXR If CXR is Normal, Systolic LV Dysfunction unlikely

Probable Systolic LV Dysfunction Cardiomegaly Pulmonary congestion (ULBD, Kerley B, Pleural effusion)

Possible Diastolic LV Dysfunction Normal heart size, but with pulmonary congestion (possible LVH, HCM, MS, etc - beware obesity, poor CXR)

Also Assessment of pulmonary pathology


Heart Failure : ECGHeart Failure : ECG If ECG is Normal, “Heart Failure” is unlikely

Abnormal ECG Sensitivity 94% Specificity 61%+ve Predictive 35% -ve Predictive 98%

Probable Systolic LV Dysfunction Q waves / poor R waves : old infarctionPossible Diastolic LV Dysfunction Preserved R waves ST/T repolarisation changes : “LVH” / “strain”Also Rhythm abnormalities Small complexes: ?? pericardial effusion


Heart Failure : ECGHeart Failure : ECG

Systolic LV Dysfunction: Old Q-wave Anterior MI



Diastolic LV Dysfunction: LVH



Arrhythmias

AF

A Flutter

SND


Differential Diagnosis of BreathlessnessDifferential Diagnosis of BreathlessnessCause Examination ECG

Normal (Unfit) Normal (Unfit)? Hyperventilation

Normal

Asthma ? Atopic, wheezeHyperinflated

Normal

COPD “Blue Bloater”“Pink Puffer”

Small RRA+,RV+,RBBB

PHT, RVF JVP+, RV+, RV S4TR, Oedema

RA+,RV+,RBBB

LV systolic dysfunction

S Tachy, Gallop, MR ?Q, Poor R

LV diastolic dysfunction Double apex, S4 ST/T changes,

LBBB


Clinical Assessment of LV DysfunctionClinical Assessment of LV DysfunctionClinical assessment often inaccurate,

even with careful examination + CXR + ECG

Sensitivity vs Haemodynamic monitoring 55%

(to assess PAwp and CO) Bayliss J BMJ 1983;287:187-190

vs Echo 46%(to assess LVEF < 40%)Choy A-M et al Brit Heart J 1994;72:16-22


Heart Failure : AssessmentHeart Failure : Assessment

Sens Spec PPV NPV

Normal ECG to exclude LVSD 94 61 35 98

High BNP for symptomatic HF in Primary care(Cowie M et al Lancet 1997;350:1349-53)

97 84 70 98

High BNP for LVSDin community(McDonagh T et al Lancet 1999;351:9-13)

76 87 16 98

Struthers AD Heart 2000;84:334-8

Predictive value of investigations


Assessment of LV DysfunctionAssessment of LV Dysfunction Clinical assessment often inaccurate

? Underlying cause? Pathophysiology? Severity of dysfunction

50% of patients with clinical Heart Failure have preserved Systolic LV function (? Diastolic LV Dysfunction)

20% of patients with low EF do not have clinical features of Heart Failure (asymptomatic Systolic LV dysfunction)

Marantz PR et al Circulation 1988;77:607-12


Heart Failure : need for EchoHeart Failure : need for EchoEchocardiogram often ESSENTIAL

Exclude other structural heart disease Assess LV Systolic Function

Ejection Fraction Regional wall motion abnormalities ?

Assess LVH

? Assess LV “Diastolic Function” specifically? Stress Echo to assess : cardiac reserve

: ischaemia


Echocardiography in Primary CareEchocardiography in Primary Care 78 patients from a single practice in Dundee Loop diuretics for suspected HF.

Systolic LV Dysfunction 41% (M 63%, F 27%)“Diastolic LV Dysfunction” 91% (of 64 pts)

Concentric LVH 15%Asymmetrical LVH 5%Calcific Aortic Stenosis 2%Aortic Regurgitation 4%Mitral Regurgitation 13%Mitral Stenosis 2%

Wheeldon NM et al Q J Med 1993;86:17-23


““Open Access” EchocardiographyOpen Access” Echocardiography 119 patients treated by GP with diuretics for Heart Failure 99 as yet untreated patients suspected of Heart Failure 9 asymptomatic patients at risk of LV dysfunction Treated Untreated Asymptomatic

Impaired Systolic function 26% 8% 22%Normal Systolic function 74% 92% 78%Valve disease 4% 6% 11%

ACEI recommended in 14% of patientsDiuretics considered unnecessary in 45% of treated patients

Francis CM et al BMJ 1995;310:634-6


Access to EchoAccess to Echo “Open access” echo as an investigation

Test performed by technician Specifically to assess LV systolic dysfunction Quick, not too difficult, less wait (?)

GP “specialist” Echo/Heart Failure assessment

Rapid access Heart Failure Clinic Clinical assessment by cardiologist (longer wait…?) Includes Echo (+ other tests appropriately) More comprehensive assessment of cause of

symptoms, severity and prognosis Involvement of Heart Failure Specialist Nurse


Brain Natriuretic Peptide (BNP)Brain Natriuretic Peptide (BNP)

http://bmj.com/content/vol320/issue7228/images/large/heart03.f2.jpeg


Brain Natriuretic Peptide (BNP)Brain Natriuretic Peptide (BNP) Indicates raised intracardiac pressure

Something abnormal with cardiac function BUT not helpful for “screening” to identify those who may

have “heart failure” or LV systolic dysfunction Good way to exclude Heart Failure

Normal BNP = No “Heart Failure”, so no need for Echo Good prognostic indicator

Levels correlate with degree of dysfunction Good indicator of therapeutic effect

BNP guided therapy better than clinically guided therapy

Hobbs R BMJ 2000;321:188-9 Cowie MR et al Lancet 1997;350:1347-51 Smith H BMJ 2000;320:906-8


BNP in detection of LVSDBNP in detection of LVSD

McDonagh TA et al Lancet 1998;351:9-13

1252 randomly selected patients aged 25-74 (50.9)1y care in GlasgowCHD in 23%LVSD in 3% Asymptomatic in half

BNP cut-off 17·9 pg/mL detected LVSD


BNP in detection of LVSDBNP in detection of LVSD

Group Sensitivity%

Specificity%

PPV%

NPV%

Prevalence of LVSD

%Participants aged 25-74All 76 87 16 97·5 3·2With IHD 84 76 30 97·5 11Participants aged 55All 89 71 18 99·2 5·4With IHD 92 72 32 98·5 12·1

McDonagh TA et al Lancet 1998;351:9-13

Accuracy of BNP (cut-off 17·9 pg/mL) in detection of LVSD


BNP in detection of LVSD severityBNP in detection of LVSD severity

N=220 Age 35-851-4 days post MI

14months FU

Initial BNPVInitial LVEF

Richards AM et al Heart 1999;81:114-20


BNP to indicate prognosisBNP to indicate prognosis

Richards AM et al Heart 1999;81:114-20

N=220 Age 35-851-4 days post MI

14months FU

Survival by initial BNP


BNP guided therapy of CHFBNP guided therapy of CHF

Troughton RW et al Lancet 2000;355:1126-30

N=69 Age 35-85LVSD (EF<40%) + CHFOn ACEI + loop diuretic9.5months follow-up

Rx adjustmentN=33:by BNPN=36:by clinical score


BNP in Assessment of Heart FailureBNP in Assessment of Heart FailureInitial clinical assessment

ECG, CXR, ?BNP

Abnormal CHF unlikely

HF likelyYes

No

TreatEcho ?BNP


Improving the assessment of heart failureImproving the assessment of heart failure Recognise Heart Failure / Detect LV dysfunction Determine the Cause(s) Consider the Pathophysiology

Type of LV dysfunction Neuroendocrine compensatory mechanisms

Assess the Severity (& prognosis) Use evidence based treatment (at best doses)

ACEI, Blocker, Spironolactone, ??Digoxin BVpacing (?ICD) Heart Failure Nurse-led continuing care

Monitor effects of therapy & progression of disease Establish Protocols / Standards of care (Audit)


Heart Failure: Progression of Stages

NORMALAsymptomatic LV Dysfunction

Symptomatic CHFNYHA II

Symptomatic CHFNYHA III

“Refractory”CHF

American Heart Association

ACEI? B

Secondary preventionModification of physical activityReduced Salt intake

ACEI BlockerDiuretics: mild ACEI

BlockerDiuretics: LoopSpironolactone?Nitrates

Specialized therapyTransplant


Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment

Improved Symptoms

Reduced Morbidity

Reduced Mortality

Digoxin Yes Just NoDiuretics(excl spironolactone)

Yes Probably ?

Vasodilator Nitrates(+Hydralazine) Yes ? Yes

ACE Inhibitors Yes Yes YesAngiotensin II Antagonists ? = to ACEI

(AIIRA+ACEI > ACEI)= to ACEI

(AIIRA+ACEI = ACEI)

Blockers Variable Yes YesSpironolactone(in Severe HF) Yes Yes Yes

Warfarin No ? ?



Events prevented per 1000 patient years of treatmentHosp Admissions

(any cause)Deaths

Digoxin 40 0ACE Inhibitors 99 13 Blockers 65 38Spironolactone (in Severe HF) 138 57

McMurray J et al Europ J Heart Fail 2001;3:495-502


Digitalis Investigation Group (DIG)

n=6800 (Digoxin 3397, 3403 Placebo) : FU 47 months Age 63yrs (27% >70yrs, 22% F) 70% Ischaemic LVEF <45%, in SR (only 2% NYHA IV) 94% on ACEI, 44% already on Digoxin

1y Endpoint : Overall Mortality 2y Endpoints: CV Mortality, CHF Mortality, CHF

Hospitalisation, Other Hospitalisation (Dig toxicity)

DIGOXIN in CHF in Sinus RhythmDIGOXIN in CHF in Sinus Rhythm

Digitalis Investigation Group NEJM 1997;336:525-33


DIG Trial: Overall Mortality

50

40

30

20

10

0

Placebon=3403

DIGOXINn=3397

480 12 24 36

%

Months

p = 0.8

DIGOXIN in CHF in Sinus RhythmDIGOXIN in CHF in Sinus Rhythm

Digitalis Investigation Group NEJM 1997;336:525-33


Digoxin: Long Term effectsDIGOXIN in CHFDIGOXIN in CHF

Survival similar to placebo Fewer hospital admissions (just) More arrhythmias (AF slightly better controlled) More MIs



Improved Symptoms

Reduced Morbidity

Reduced Mortality


Yes Probably ?




(AIIRA+ACEI = ACEI)


Warfarin No ? ?


N Engl J Med 1986;314:1547

42

0.6Probof Death

0

Placebo (273)Prazosin (183)Hz + ISDN (186)

Months

0.7

0.5

0.3

0.4

0.2

0.1

0 6 12 18 24 30 36

Nitrates in CHF: Nitrates in CHF: VHefT-1



Improved Symptoms

Reduced Morbidity

Reduced Mortality


Yes Probably ?




(AIIRA+ACEI = ACEI)


Warfarin No ? ?


N Engl J Med 1987;316:1429

ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVDCONSENSUS

Placebo

Enalapril

12111098765MONTHS

0.1

0.8

0

0.2

0.3

0.7

0.4

0.5

0.6p< 0.001

p< 0.002

43210

Probof Death


ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVDMeta-analysis of 5 long-term (>3y) trialsAll 5 trials: OR 95%CI

Total mortality 0.80 0.74-0.87Reinfarction 0.79 0.70-0.89Readmission in HF 0.67 0.61-0.74

3 early post-MI trials:Total mortality 0.74 0.66-0.83Reinfarction 0.80 0.69-0.94Readmission ht failure 0.73 0.63-0.85

Lancet 2000; 355: 1575-81


ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVD

Lancet 2000; 355: 1575-81


Age-adjusted discharge rates for heart failure, Netherlands

ACE inhibitor use, Netherlands(106 Rx-days per yr)

ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVD

Heart 2002; 87: 75-76



Improved Symptoms

Reduced Morbidity

Reduced Mortality


Yes Probably ?




(AIIRA+ACEI = ACEI)


Warfarin No ? ?


Angiotensin I

ANGIOTENSIN II

RENIN

AngiotensinogenACE

Other paths

Vasoconstriction Proliferative Action

Vasodilatation Antiproliferative Action

AT1 AT2

AT1 RECEPTOR BLOCKERS

RECEPTORS

Angiotensin Receptor Blockers Angiotensin Receptor Blockers (“sartans”)(“sartans”)



Trial n Drugs OutcomeELITE I 722, >65y

II-IVLosartan 50mgCaptopril 150mg

Renal deterioration(Death)

ELITE II 3152, >60yII-IV

Losartan 50mgCaptopril 150mg

= Death= Death+Hosp+safety

ValHeFT 5010 Valsartan 320mg(ACEI, B)Placebo

= DeathMorbidity+Mortality

CHARM(due 2004)

6500, >18II-IV

Candesartan 32mgEF<40% + ACEIEF<40% - ACEIEF≥ 40% - ACEI (Diastolic) Placebo

Comparison to ACE Inhibitors



Meta-Analysis of 17 trials in 12,469 patients in HFComparison to Placebo OR 95%CITotal mortality 0.96 0.75-1.23

Readmission in HF 0.86 0.69-1.06Trend in benefit if given in absence of ACEI

Comparison to ACE InhibitorsTotal mortality 1.09 0.92-1.29Readmission in HF 0.95 0.80-1.13

Combination with ACE InhibitorsTotal mortality 1.04 0.91-1.20Readmission in HF 0.74 0.64-0.86

Jong P et al JACC 2002; 39: 463-70



Improved Symptoms

Reduced Morbidity

Reduced Mortality


Yes Probably ?




(AIIRA+ACEI = ACEI)


Warfarin No ? ?


JACC 1990;16:1327

Mortality50

40

30

20

10

0

LV Ejection Fraction< 30% 30-40% > 40%

%

Blocker Placebo

Beta-Blockers in Heart Failure: Beta-Blockers in Heart Failure: BHAT


ACEI

ß BLOCKER

Yes

No

n=2231 Yes No

13.3%

19.5%

24.3%

27.7%

Mortality

Circulation 1995;92:3132

Beta-Blockers in Heart Failure: SAVEBeta-Blockers in Heart Failure: SAVE


Beta-Blockers in Heart FailureBeta-Blockers in Heart Failure

Systematic review of 22 trialsBisoprolol, Carvedilol, Metoprolol-CR/XL

% Control -B ORDeath 12.8 8.0 0.63Adm for heart failure 17.1 11.3 0.63Death or admission 26.9 19.4 0.66

Absolute 5-6% / yr reduction in event rates

Eur J Ht Fail 2001; 3: 351-67


Carvedilol in heart failureCarvedilol in heart failure

Carvedilol Prospective Randomized Cumulative Survival Study Group (COPERNICUS)

2289 pts severe heart failure LVEF <25% FU 10.4 months

N Engl J Med 2001; 344: 1651-8


Carvedilol in Heart Failure: Carvedilol in Heart Failure: COPERNICUSCOPERNICUS

35%RR

N Engl J Med 2001; 344: 1651-8


Carvedilol in Heart Failure: deathCarvedilol in Heart Failure: death

N Engl J Med 2001; 344: 1651-8


Carvedilol: death or hospitalizationCarvedilol: death or hospitalization

N Engl J Med 2001; 344: 1651-8


Carvedilol in Heart Failure: withdrawalsCarvedilol in Heart Failure: withdrawals

23%RR

N Engl J Med 2001; 344: 1651-8


Ideal candidate? Suspected adrenergic activation

Arrhythmias

Hypertension

Angina



Hypotension: BP < 100 mmHg Bradycardia: HR < 50 bpm Clinical instability Chronic bronchitis, ASTHMA Severe chronic renal insufficiency


Contraindications



Improved Symptoms

Reduced Morbidity

Reduced Mortality


Yes Probably ?




(AIIRA+ACEI = ACEI)


Warfarin No ? ?


Spironolactone in severe Heart FailureSpironolactone in severe Heart Failure

RALES Study:(Randomized ALdactone Evaluation Study)

1663 pts severe heart failure LVEF ≤35% On ACEI & diuretic 24 month follow-up 10% men gynaecomastia

N Engl J Med 1999; 341: 709-17


30%RR

N Engl J Med 1999; 341: 709-17




N Engl J Med 1999; 341: 709-17

West Herts CardiologyN Engl J Med 1999; 341: 709-17




Improved Symptoms

Reduced Morbidity

Reduced Mortality


Yes Probably ?




(AIIRA+ACEI = ACEI)


Warfarin No ? ?


Chronic Heart Failure: Chronic Heart Failure: Other Medical TreatmentOther Medical Treatment

Evidence based Treatment

Improved Symptoms

Reduced Morbidity

Reduced Mortality

Ca++ antagonists No/?Yes No No (?)Class 1 anti-arrhythmicsAmiodarone

NoNo

No ()No

No ()?Yes

ICDDDD pacingBiventricular pacing

NoYesYes

NoYesYes

Yes??

Neuropeptidase inhibitors Yes Yes ?

Endothelin antagonists ? ? ?


Cardiac Resynchronisation TherapyCardiac Resynchronisation Therapy

Abraham WT et al NEJM 2002;346:1845-53

Multicenter Insync RAndomized CLinical Evaluation(MIRACLE)

RCT n=453 Mod-Severe HF, EF≤35%, QRS≥130msResynchronising Biventricular pacing for 6m or not

Improvements in 6min walk distance, treadmill time, NYHA class, QoL score, EF Hospitalisation for HF

Complications in 6.8% Serious in 1.2%, lead repositioning in 6%


Multicenter Automatic Defibrillator Implantation Trial II(MADIT II)

RCT n=1232 mean age 64, 35-39% NYHA IPrevious MI, EF≤30%, No EPICD or not 20 month follow up

Lead complications requiring resurgery in 2.5%

Implantable Cardioverter DefibrillatorsImplantable Cardioverter Defibrillators

Moss AJ et al NEJM 2002;346:877-83

“Usual care”(72% ACEI, 70% BB, 10% Amio)

ICD(68% ACEI, 70% BB, 13% Amio)

Death 19.8% 14.2%

Worsening CHF 14.9% 19.9%


Chronic Heart Failure: Surgical TreatmentChronic Heart Failure: Surgical Treatment

Coronary Revascularisation if ischaemia ++ ? Minimally invasive approach

Valve Replacement / Repair Cardiac Transplantation

?? xenotransplantation

Cardiomyoplasty LV volume reduction New implantable ventricular support devices

eg Jarvik 2000 axial flow pump

West Herts CardiologyWest Herts Cardiology

Heart Failure: New technologyHeart Failure: New technology

Peter Houghton underwent the operation in June

The Englishman who received the world's first permanent artificial heart pump says he has been given a new lease of life.

Peter Houghton, 61, was given just weeks to live before he underwent pioneering surgery to have a thumb-sized pump implanted into his heart.


Management of Systolic LV DysfunctionManagement of Systolic LV Dysfunction? Cause

Ischaemic Consider Revascularisation (PTCA, CABG) Valve Consider Valve Replacement Dilated CM Minimise Alcohol, Consider Transplant

ACE Inhibitor (?A2RA if cough) Maximise dose Blocker Increase gently Diuretic Clear / Prevent oedema Spironolactone in Severe CHF Digoxin Essential to control AF Warfarin If AF or LV dilated Control / Prevent Arrhythmia Amiodarone? (ICD ??) ?BiVentricular pacing If EF≤35% + QRS≥130ms


Management of Diastolic LV DysfunctionManagement of Diastolic LV Dysfunction Control Heart Rate Blocker (?? or Verapamil)

Digoxin essential to control AF

Control LVH (BP) ACEI carefully, Blocker (? else Verapamil)

Diuretic Carefully, low dose Control / Prevent Arrhythmia Amiodarone Consider Warfarin Especially if AF

Be very careful with Nitrates, and with Diuretics in high dose


Management of “Resistant” oedema in CHF Management of “Resistant” oedema in CHF Pharmacological methods

Withdraw NSAI, Ca++ antagonists, Class I antiarrhythmics Control heart rate if in AF : Digoxin ± Amiodarone Aldosterone effect : Spironolactone (if K+ <5.0) diuretic effect : Bumetanide ± Thiazide : Frusemide iv bolus, ivi Glomerular Filtration : Consider dose of ACEI

Non-pharmacological methods Salt & water restriction Elevate legs (Compression stockings with care) Warm bath / lower body immersion (Sitzbad) Haemofiltration


Heart Failure: common errorsHeart Failure: common errors Failure of recognition Failure to diagnose (and treat) the cause Failure in assessing severity and prognosis Failure to consider long term goals of Rx Failure to use ACE Inhibitors (or too little) Failure to use Blockers when possible Failure to use Spironolactone when possible Using wrong dose of diuretics

Using potentially harmful drugs Failure to communicate with patient


NICE guideline on heart failure (8/03)NICE guideline on heart failure (8/03)

The diagnosis and management of chronic heart failure in primary and secondary care

Best practice advice on the care of adult patients

Interface between primary and secondary care Circumstances for referral or admission to

secondary care. Not screening or diagnosis of asymptomatic

people Not management of cor pulmonale


NICE guideline on heart failure (8/03)NICE guideline on heart failure (8/03)

DiagnosisSystolic & diastolic dysfunction, valve disease, other

Diagnostic techniquesECG, CXR, biochem (BNP), imaging (echo/MRI).

Pharmacological treatmentsDiuretic, dig, ACEI, ßB, AT2B, spirono, NO3, dilators

Dose, initiation, freq, monitoring, combin, seqNon-pharmacological treatment

Exercise, diet, physical activity, weight, smokingInvasive procedures, including

Pacing, implantable cardiac defibrillators, CABG, angioplasty, valve surgery and transplantation


Heart Failure:Heart Failure: Recommended References Recommended ReferencesStruthers AD The Diagnosis of Heart Failure

Heart 2000;84:334-8

Hobbs R Can heart failure be diagnosed in primary careBMJ 2000;321:188-189

Drug & Therapeutics bulletin Heart Failure drugs: What’s new?Drugs &Therapeutics Bulletin 2000;38:25-27

ACC/AHA Guidelines for the Evaluation and Managementof Chronic Heart Failure in the Adult: Executive Summary

JACC 2001;38:2101-13

McMurray J Practical recommendations for the use of ACEI, blockers and Spironolactone in Heart Failure: putting guidelines into practiceEurop J Heart Fail 2001;3:495-502


Heart Failure : Exercise testingHeart Failure : Exercise testingDetect myocardial ischaemia / arrhythmiasConfirm & categorise severity of disabilityPredict prognosisAssess effects of treatmentProblems

Motivation (Patient, Doctor) Exercise type & Protocol Access


Myocardial perfusion (Thallium) imagingMyocardial perfusion (Thallium) imaging

Stress

InferiorIschaemia

Recovery

Vertical Long Axis Short AxisHorizontal Long Axis

Ant

Inf

Ant

Septum

InfLatApex

Apex

Lat


Heart Failure : Assessment of prognosisHeart Failure : Assessment of prognosisHistory & Examination

Age Underlying Diagnosis of CHD Functional Impairment (eg NYHA class) S3

Investigations LV Ejection Fraction : < 40% Aerobic exercise capacity (VO2) : < 12ml/Kg/min Serum Na+ : < 137 mmol/l? Plasma Noradrenaline, Natriuretic peptides, Endothelin-1

heart failure 2003 - an update

Documents