HEART FAILURE SYMPOSIUM 23rd of January 2013

GULF HOTEL

Sponsor : SERVIER Laboratories

Programme

5-5.30 pm Registration

5.30 – 5.45 pm Welcome and Introduction SESSION I

Chaired by Dr Fuad Saeed, BDF Hospital Dr Taysir Garadah, AGU/Dr Sulaiman Al Habib

5.45 – 6.15 pm Heart Failure in the 21st century – An Overview Speaker -Dr Syed Raza, Awali Hospital

6.15 – 6.45 pm Management of Acute Heart Failure Dr Haitham Amin, BDF Hospital

6.45 – 7.15 pm Evidence based management of Chronic Heart Failure Speaker: Dr Hussam Noor, BDF Hospital

7.15 – 7.25 pm Panel discussion

7.25- 7.40 pm Coffee break

SESSION II Chaired by Dr Rashed Al Bannay, Salmaniya Hospital Dr Sadananda Shivappa, BDF Hospital 7.40 – 8.10 pm Diastolic Heart Failure Speaker : Dr Said Al Said, Salmaniya Hospital

8.10 – 8.40 pm Device Therapy in Heart Failure Speaker: Dr Adel Khalifa, BDF Hospital

8.40 – 9.10 pm Cardio-renal Syndrome – Definition and Management. Speaker: Dr Jafar Al- Said, Consultant Nephrology &Internal Med. Bahrain Specialist Hospital9.10 – 9.40 pm Integrated and End of Life Care in Heart Failure Speaker: Dr Syed Raza, Awali Hospital

9.40 -9.50 pm Panel Discussion

9.50 pm Vote of thanks followed by dinner

Heart Failure in the 21st Century-An Overview

SYED RAZA

OBJECTIVES

• Size of the problem• Assessment and making the

diagnosis• Therapy – Drug and Device• Novel Therapy in heart failure

Case • 76 years old male, chronic smoker, HPN,

Previous MI• Presents to ER with acute SOB and chest

tightness of one hour duration.• BP : 170/100 Chest -few wheeze CVS- no

murmur• ECG- sinus tachycardia, Q waves in anterior

leads.• CXR- ?Cardiomegaly, hyper inflated lungs,

increased broncho- vascular markings.• Normal initial lab results

Diagnostic Dilemma

• 1.ACS• 2.Acute exacerbation of COPD• 3. Acute PE 4. Acute Heart Failure (LVF)

Aspirin + Bronchodilator + Clexane + Diuretic ( ‘ABCD’ treatment)

FAILING HEART

Further Careful Evaluation

• Orthopnoea, PND• Cold peripheries, leg swelling, fine inspiratory

crackles at lung bases , JVP rise• S3 Gallop• BNP – markedly elevated• ECHO- Dilated LV , severe LV systolic

dysfunction- EF 20%

• “The very essence of cardiovascular practice is the early detection of heart failure”

Sir Thomas Lewis, 1933

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)

04/08/23

Facts on Heart Failure

One of the leading causes of death.

• 35% will die within one year of diagnosis.

50% of HF patients will die 5 years after the diagnosis.

• Less than 50% of patients with HF have typical physical signs

• Less than 50% of patients being correctly identified during the initial consultation.

• 50% readmission rate within 6 months• It is estimated that in Europe total cost of HF

exceeds 50 billion Euro every year.

Heart Failure Mortality

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 IS A CLINICAL DIAGNOSIS

Galectin-3

• New bio-marker for heart failure• Galectin – 3 produced by macrophages sec. to

injury. • High levels signify Increase fibrosis and

stiffening of heart muscle.• Not specific for heart

BNP & NT-pro BNP

• Levels in pg/ml • • No HF Further evaluation HF BNP < 100 100-400 > 400

NT-pro BNP <400 400-2000 >2000

ECHOCARDIOGRAM

• EF is the most important parameter most physicians are interested in.

• Tells about the type of heart failure• Etiology of heart failure• Cost effective if well utilized

CHF- Etiology– 1. Impaired cardiac function

• Coronary heart disease• Cardiomyopathies• Arrhythmia

– 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

Advanced Imaging in Heart Failure

• Real Time and contrast enhanced 3-Dimenstional Echocardiography

Nuclear Imaging : SESTAMIBI SPECT – Myocardial Perfusion scan.

• Cardiac Magnetic Resonance (CMR) Imaging

Cardiac MRI in Heart Failure

Ability to assess in a single setting• Cardiac morphology,• Function, flow, perfusion,• Acute tissue injury, and fibrosis in a single

setting.• Risk stratification

Referral and approach to care NICE (UK) GUIDELINES

Refer patients to the specialist multidisciplinary heart failure team in the following situation:

1. Initial diagnosis of heart failure. 2. Management of severe heart failure (NYHA class IV), heart failure that does not respond to treatment, 3. Patients with previous MI 4.heart failure due to valve disease. 5.Patient who is pregnant or planning a pregnancy

Heart Failure Diagnosis – Not A Death Sentence !

ADVERSE PROGNOSTIC MARKERS IN CHRONIC HEART FAILURE

• Old Age, • Severity of heart failure (NYHA class)• Left ventricular dysfunction, • Diabetes Mellitus, • Raised creatinine, • Hyponatremia , Hypoalbuminaemia,Anaemia• Presence of arrhythmia : AF / VT

Causes of Mortality in Heart Failure

• Pump failure• Arrhythmia• Severe Anaemia • Associated serious co-morbidities i.e. Renal

failure

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.

Southey’s Tubes

In the 19th and early 20th centuries, heart failure associated with fluid retention was treated with Southey's tubes, which were inserted into edematous peripheries, allowing some drainage of fluid.

Heart Failure Management: The Time Line

• 1920 Organo-mercurial diuretics• 1970s and before- Bed rest and fluid

restriction• 1980s- Diuretics and Digoxin• 1990s- Nitrate, ACEI and ARB• 2000s (early)- Aldosterone antagonist• 2000s (late) – Device therapy ,Artificial heart• 2010s- Gene and Stem Cell therapy.

Acute Heart Failure

>Medical Emergency !

EMERGENCY MANAGEMENT (Mnemonic)

U Upright Position

N Nitrates

L Lasix

O Oxygen

A ACEI / ARB

D Digoxin, Dobutamine

M Morphine Sulfate

E Extremities Down

Use of CPAP /BiPAP

• Ample evidence• CHF and Sleep Apnea/COPD often co-exist• Bi PAP useful at later stage of acute heart

failure when patient starts to fatigue.

Acute Heart Failure

• In the setting of acute heart failure, new inotropes such as cardiac myosin activators and new vasodilators such as relaxin have been developed

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

Annual Mortality Reduction With Successful Therapies

11.25%-beta blocker Carvedilol [COPERNICUS] 16% ACEI Enalapril [SOLVD] 13% - ARB : Valsartan [Val-HeFT] • 17.5%- Aldactone -[RALES] • 24% CRT [COMPANION]• 36% CRT+D [COMPANION]

Newer Drugs

• 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

• Nesiritide (Natrecor) Recombinant form of human BNP

• Causes venous and arterial vasodilation– has been shown to improve dyspnea – Shown to reduce 30 day mortality

Newer Drugs- contd.

• Ivabradine - Ifc current inhibitor in SA node• SH IFc T study (6505 pts, 37 countries)• Reduce hospitalization, mortality and improve

exercise tolerance. • Add on therapy- chronic symptomatic systolic

heart failure (NYHA functional class II–IV) and a heart rate ≥70 bpm.-ESC guideline May 2012

Drugs for systolic heart failure

• Direct Renin Inhibitors• Neprilysin inhibitor• Ryanodine receptor stabilizers, SERCA activators

Diastolic Heart Failure

• no therapy has been demonstrated to improve symptoms or outcomes

• Dicarbonyl-breaking compounds reverse advanced glycation-induced cross-linking of collagen reduce stiffness and improve the compliance of aged and/or diabetic myocardium

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. Combination not recommended.

Calcium channel blocker - Limited evidence for Amlodipine (PRAISE )

Do not forget prophylactic clexane to prevent VTE

ENHANCED EXTERNAL COUNTERPULSATION (EECP)

Ultrafiltration

ULTRAFILTRATION

• Removal of isotonic fluid through an extra-corporeal filter.

• Controlled and predictable even if urine output is low i.e. Renal Failure

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 50

Biventricular Pacing(CARDIAC RESYNCHRONISATION THEARPY)

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

Heart Failure and Sudden Cardiac Death

– 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

Other Therapies?

• Left Ventricular Assist Device• Artificial hearts• Heart Transplant• Gene and Stem Cell Therapy

Worldwide Heart Transplants

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

Beyond Drug and Device Therapy!

• Cardiac rehabilitation programme• Discharge planning• Patient monitoring and follow up.• Patient and family education

04/08/23

MULTI DISCIPLINARY APPROACH (INTEGRATED CARE)

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

In Summary….

• Heart failure is common and has high mortality

• Timely and accurate assessment is the key to management

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

for symptom relief and improve survival• Transplants remain rare.• Think beyond drug and device therapy.