CONGESTIVE CARDIAC FAILURE – AN UPDATE ON MANAGEMENT

Dr SYED RAZAConsultant Cardiologist

MD,MRCP(UK),Dip. Card(UK),CCT(UK),FCCP(USA)

OBJECTIVE

• How big is the problem ?• Current Medical Therapy – the

evidence• Device therapy• Treatment in the community – its

benefits

CASE

• 76 years old male, chronic smoker, HPN• Presents to ER with acute SOB of one hour

duration.• BP : 170/100 Chest – few wheeze • ECG- sinus tachycardia• CXR- Normal heart size, hyper inflated lungs• Normal initial lab results

Diagnostic Dilemma

• 1. Acute Heart Failure (LVF)• 2.ACS• 3. Acute PE• 4.Acute exacerbation of COPD LASIX + ASPIRIN +CLEXANE + NEBULISER

FAILING HEART

FURTHER CAREFUL EVALUATION

• Orthopnea• Cold peripheries• S3 Gallop• BNP – markedly elevated• ECHO- LVH , severe diastolic dysfunction

Epidemiology of Heart Failure

• Major public health problem

• 22 million cases world wide

• 550,000 new cases/year in US

• 4.7 million symptomatic patients; estimated 10 million in 2037

*Rich M. J Am Geriatric Soc. 1997;45:968–974.American Heart Association. 2001 Heart and Stroke Statistical Update. 2000.

3.5

4.7

10

0

2

4

6

8

10

12

1991 2000 2037*

Hea

rt F

ailu

re P

atie

nts

in U

S(M

illio

ns)

04/09/23

Facts on Heart Failure

50% readmission rate within 6 months

One of the leading causes of death.

• 35% will die within one year of diagnosis.

Heart Failure Admissions

British Heart Foundation, 2002

0 5 10 15 20 25 30

All diagnoses

All circulatory

Coronary Heart Disease

Angina

Acute MI

Heart failure

Stroke

Diabetes

All cancer

All nervous system

All respiratory system

All digestive system

All GU system

Complications of pregnancy and childbirth

Injuries and poisoning

Average duration of hospital admission (days)

Heart Failure Mortality

Causes of Mortality in Heart Failure

• Pump failure• Arrhythmia• Electrolyte imbalance• Severe Anaemia

Prognostic Value of Haemoglobin Levels at Discharge in Older Patients Admitted With Heart Failure. 2Syed Raza, 1Nicolas Wisniacki, 2Pam Aimson, 2Chris Manning, 1Alejandra Abramovsky, 1Vinod Gowda, 1Michael Lee, 2Jason Pyatt.1Department of Medicine,University of Liverpool & 2Department of Cardiology,Royal Liverpool and Broadgreen University Hospitals. United Kingdom.

How Heart Failure Is Diagnosed

• Medical history • Physical exam • Tests

– Blood tests – Hb , KFT, BNP – Chest X-ray– ECG– Echocardiogram – Cardiac Catheterization

Symptoms

The Donkey Analogy Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…

I GIVE UP . I CAN’T TAKE IT ANY MORE !!

Acute Decompensated Heart Failure /Pulmonary Edema

>Medical Emergency!

But

CHF- Etiology– 1. Impaired cardiac function

• Coronary heart disease• Cardiomyopathies

– 2. Increased cardiac workload• Hypertension• Valvular heart disease• Anemia• Congenital heart defects

– 3.Acute non-cardiac conditions• Volume overload• Thyroid disease

30%30%

70%70%

Diastolic DysfunctionDiastolic DysfunctionSystolic DysfunctionSystolic Dysfunction

(EF < 40%)(EF < 40%)(EF > 40 %)(EF > 40 %)

Left Ventricular Dysfunction• Systolic: Impaired contractility/ejection

– Approximately two-thirds of heart failure patients have systolic dysfunction1

• Diastolic: Impaired filling/relaxation

1 Lilly, L. 1 Lilly, L. Pathophysiology of Heart DiseasePathophysiology of Heart Disease. Second Edition p 200. Second Edition p 200

Systolic vs. Diastolic

• Diastolic dysfunction– EF normal or increased– Hypertension– Due to LVH and chronic replacement by

fibrous tissue - decrease in distensibility• Systolic dysfunction

– EF < 40%– Usually from coronary disease– Due to ischemia-induced decrease in

contractility• Most common is a combination of both

• Mixed systolic and diastolic failure– Seen in disease states such as dilated

cardiomyopathy (DCM)– Poor EFs (<35%)– High pulmonary pressures

• Biventricular failure (both ventricles may be dilated and have poor filling and emptying capacity)

Right Heart Failure• Signs and Symptoms

– fatigue, weakness, lethargy

– wt. gain, inc. abd. girth, anorexia, RUQ pain

– elevated neck veins– Hepatomegaly +HJR– may not see signs of LVF

What is present in this extremity, common to right sided HF?

EMERGENCY MANAGEMENT (Pneumonic)

U Upright Position

N Nitrates

L Lasix

O Oxygen

A Amiodorone > ACEI / ARB

D Digoxin, Dobutamine

M Morphine Sulfate

E Extremities Down

Referral and approach to care NICE (UK) GUIDELINES Refer patients to the specialist multidisciplinary heart failure team in the following situations.– Initial diagnosis of heart failure.– Management of severe heart failure (NYHA class IV), heart failure that does not respond totreatment, heart failure due to valve disease, or heart failure that can no longer be managed at home

– Advice and care of women who are planning a pregnancy or are pregnant. Care of pregnantwomen should be shared between the cardiologist and obstetrician.Patients with previous MI Refer patients with suspected heart failure and previous myocardial infarction (MI) urgently, tohave transthoracic Doppler 2D echocardiography and specialist assessment within 2 weeks

Rational for Medications(Why does my doctor have me on so

many pills??)• Improve Symptoms

– Diuretics (water pills)– digoxin

• Improve Survival– Betablockers– ACE-inhibitors– Angiotensin receptor

blockers (ARB’s)– Aldosterone antagonists

VasoconstrictionVasoconstriction

Oxidative StressOxidative Stress

Cell GrowthCell Growth ProteinuriaProteinuria

LV remodelingLV remodeling

AngiotensinogenAngiotensinogen

Angiotensin IAngiotensin I

Angiotensin IIAngiotensin II

33.AT II receptor.AT II receptor

11.Renin.Renin

22.Angiotensin.AngiotensinConvertingConverting

EnzymeEnzyme

Compensatory Mechanisms: Renin-Angiotensin-Aldosterone

(RAAS)

1.Direct Renin Inhibitor (Aliskiren)

2.ACEI3.A2RB

ACE-I

• SOLVD-Enalapril 20mg/day (41 mo)

• 2569 Patients with and EF <35%– Earlier stages of HF even

asymptomatic– NYHA Class II-III

• All cause mortality dec by 16%

• Morality rate from HF dec by 16%

• CONSENSUS-Enalapril 2.5-40mg (188 days) vs placebo

• Pts were already taking digoxin and diuretics

• 253 Patient with NYHA Class IV

• Dec mortality at:– 6 months -40%– 1 Year – 27%

Angiotensin-Receptor Blockers

– Comparable to ACE inhibitors– Reduce all-cause mortality– Suitable alternative for patient with adverse

events (angioedema and cough) occur with ACEI

ACE + ARB

• CHARM-Added (Lancet 2003)– 2548 NYHA II-IV; LVEF < 40%– Reduced CV death, hospital admission

– Second study found no benefit

• But 23% discontinued due to side effects (increased cr, hypotension, hyperkalemia)

• Currently ACEI + ARB is not recommended

Beta-Blockers

• 34% reduction in all mortality with use of beta-blockers

• Decrease Cardiac Sympathetic Activity

• Use in stable patients (start as early as discharge-IMPACT-HF)

• Titrate slowly• Work irrespective of the etiology

of the heart failure

Beta-Blocker therapy-which to pick?

• Three beta-blockers :

• Bisoprolol (Zebeta) -Trial CIBIS-IIMetoprolol (Toprol XL) –Trial MERIT-HF (sustained release) Carvedilol (Coreg) Trial-COPERNICUS and CAPRICORN

Carvedilol vs. Metoprolol (COMET 2003)– 3029 pts; carvedilol 25mg bid vs. metoprolol 50 mg bid– Patient with NYHA Classes II-IV – Carvedilol –greater reduction in mortality

Initial and Target Doses of beta-blockers for HF

MedicationMedication Starting Starting DoseDose

Target Target DosageDosage

BisoprololBisoprolol 1.25mg daily1.25mg daily 10mg daily10mg daily

CarvedilolCarvedilol 3.125mg bid3.125mg bid 25mg bid25mg bid

Metoprolol Metoprolol CR/XLCR/XL

12.5-25mg 12.5-25mg dailydaily

200mg daily200mg daily

Aldosterone Antagonists

• Spironolactone (Aldactone; RALES 1999)– Pts 1,663 Class III/IV, EF < 35%– Decreased all cause mortality of 30%– Hyperkalemia, gynecomastia

• Eplerenone (Inspra; EPHESUS 2003)– Pts 6,642 asym LV dysfunction, DM, or after MI– Dec CV mortality of 13%, – Newer more selective inhibitor; fewer side effects

Digoxin

• May relieve symptoms, does not reduce mortality . Beneficial in AF

• Reduced hospital admission due to heart failure

• More admissions for suspected digoxin toxicity

• Should not be used in ischaemic cardiomyopathy

Treatment of Special Populations

Class I Level A• African Americans: NYHA functional class III or IV HF

– Combination of a fixed dose of isosorbide dinitrate and hydralazine .

– 29% Reduction in mortality.

– Headache, flushing

Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

Nesiritide (Natrecor)

• Recombinant form of human BNP • Causes venous and arterial vasodilation

– has been shown to improve dyspnea – Shown to reduce 30 day mortality

Some Practical Tips• Diuretics : Intravenous for 48-72 hours in acute decompensation, then change to oral

Beta blocker to be initiated when lungs are ‘Dry’(“Start low and go slow” )

First dose of ACEI /ARB (small dose) usually at night

Calcium channel blocker esp. Diltiazem useful for Diastolic heart failure

Do not forget prophylactic clexane to prevent VTE

ENHANCED EXTERNAL COUNTERPULSATION (EECP)

Ultrafiltration

DEVICE THERAPY

• Unacceptably high morbidity and mortality despite medical therapy.

• Device therapy in heart failure has shown to improve symptoms as well as reduce mortality and sudden death.

• Must be used in patients with good indications

• Needs skills and resources

Overview of Device Therapy 44

Biventricular Pacing(CARDIAC RESYNCHRONISATION THEARPY)

• Abnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction

Cardiac Resynchronization TherapyKey Points

• Indications– Moderate to severe CHF who have failed optimal medical

therapy– EF<30%– Evidence of electrical conduction delay ( QRS > 120 ms) or

Dysynchrony demonstrated on ECHO.

Heart Failure and Sudden Cardiac Death

Sudden Cardiac Death (SCD)

– Usually caused by serious ventricular arrhythmia i.e. VT and VF

– SCD is one of the leading causes of death in the U.S. – approximately 450,000 deaths a year

– Patients with heart failure are 6-9 times as likely to develop sudden cardiac death as the general population

IMPLANTABLE CARDIAC DEFIBRILLATOR

Device Shown:

Combination Pacemaker & Defibrillator

Who should receive an ICD?• New York Heart Association (NYHA) Class II and

III heart failure• Left ventricular ejection fraction (LVEF) < 35%

• Usually combined with BiVentricular pacemaker (CRT-D)

Implantable Cardiac Defribrillators

EBM Therapies Relative RiskReduction

Mortality2 year

ACE-I 23% 27%

Β-Blockers 35% 12%

Aldosterone Antagonists

30% 19%

ICD 31% 8.5%

Other Therapies?

• Left Ventricular Assist Device• Artificial hearts• Heart Transplant

Left ventricular assist device

Newer Generation Artificial Hearts

ARTIFICIAL HEART

Heart Transplantation

• A good solution to the failing heart– get a new heart

• Demand is high , limited donor hearts• Approximately 2200 transplants are

performed yearly in the US

Worldwide Heart Transplants

04/09/23

Trends in Hospitalization for Heart Failure by Age Group 1979-2004(CDC, 2006)

04/09/23

MULTI DISCIPLINARY APPROACH (INTEGRATED CARE)

Purpose: To improve the care delivered to heart failure patients across the continuum

04/09/23

Outcomes of the Heart Failure Team

• Interdisciplinary approach• Physician Support• Patient Education• Comprehensive discharge

instructions• Regular follow up in the

community • Telehealth program

• Increase in patient self-management skills

• Increase in patient satisfaction

• Decrease variation in care delivered

• Decrease LOS • Decrease readmissions • Decrease mortality

04/09/23

Telehealth Program

• Remote home monitoring will include vital signs, oxygen level assessment and body weight

• Screening for eligibility is performed while the patient is hospitalized

• Patient education provided by nurses

One of the Best Devices for Monitoring Heart Failure

• OptiVol (Medtronic)• Measures body fluid status by measuring intra thoracic impedance.

 

                                                                

                                                      

 

                                                                

                                                      

Recent Developments and Future Challenges of Integrated Care in Heart Failure in Europe and Northern America The International Network of Integrated Care, The Julius Center of the University Medical Center Utrecht and the University of Southern Denmark 11th International Conference on Integrated Care:

4.7. Paper session: IC for heart failure patientsPilot Study of Integrated home Care for Patients of Congestive Cardiac Failure: BritishDistrict Hospital Experience – Dr Syed S.M. Raza et al., Dept. of Cardiology & AcuteMedicine, Huddersfield and Calderdale Royal Hospitals NHS Trust, UK March 30 - April 1, 2011 in Odense, Denmark 

REHABLITATION PROGRAMME

In Summary….

• Heart failure is common and has high mortality

• Drug therapy improves survival• Newer device therapies are showing promise

for symptom relief and improved survival• Transplants remain rare, but technology for

mechanical assist devices continues to improve- stay tuned!