Modern Management of heart Failure

Dr Amanda VarnavaConsultant Cardiologist

Watford & St Mary’s Hospitals

• Background• What is HF?• How to diagnose?• 4 stages of HF and Rx of these stages• Specific therapies• Prognosis• SCD and prevention• HF with normal systolic function• Who manages care?

Background

• Huge health costs $27 billion pa in US• Primarily a disease of the elderly• Incidence of 10/100 in those over 65yrs

What is heart failure?Impaired ventricular filling and / or

contraction

SignsSymptoms

Dyspnoea

Impaired ext tolerance

Fatigue

Fluid overload

3rd Heart sound

Assessment

• ECG• BNP• Echo• Non invasive testing for ischaemia • Angiogram

                                                                                                                 

                                                                           

BNP assessment

3 questions we need addressed with echo

• Is EF preserved?• Is LV structure and wall movement normal?• Are there other structural abnormalities?

– Valvar disease– Atrial dilation– PA hypertension

Stages of Heart Failure

At risk Frank Heart Failure

At risk, but no evidence of structural disease or symptoms

Evidence of structural disease, but no symptoms

Structural disease with symptoms

Refractory symptoms

HT

CAD

Obesity

FH CM

Cardiotoxins

ETOH

1º Prevention

ACEIn/ARB

MI

Valvular disease

LVH

Dyspnoea

Fatigue

Ex Tol

ACEIn

Blockers

Spironolactone

±CRT

NYHA IV despite max Rx

Palliative care

Or

TX

LVADs

Stem cell Tx

Primary prevention

HT• Lifetime risk of HT is 75% • Optimal Rx of HT cuts in 1/2 the risk of HFDM• Females 3 x > likely to develop HF• ACEInCAD• All MI pts should start on ACEIn and • If HF > Add epeleronone

Management of asymptomatic pts

Drugs• ACEIn delay onset of symptoms and improve

mortality• No specific trials with ARBs• No trials with s, but ACC guidance suggests

use esp in CADDevices• MADIT II ICD trial supports use, but no’s huge

thus not current practice

Symptomatic patients

• As with asymptomatic• In addition diuretics for fluid overload• Aldosterone antagonistsAlso• Na restriction• Withdraw NSAIDS, Ca antag• Exercise• Close F/U

Refractory symptoms

• Increased awareness of palliative care

Where appropriate consider• Cardiac TX• LVADs• Stem cell Tx

Heart Failure Therapies

ACEIns

• Inhibit RAS at multiple sites• Start low, go slow• Probably class effect• Side effects related to kinin production

(cough ion 5-10%) and angioedema (1%) > common in Chinese and Blacks

Angiotensin Receptor Blockers

• Developed because of RAS “escape” with ACEIn and side effects

• However, less well studied and some benefits may relate to kinin production

• Thus alternative, not 1st line• Data is equivocal for ACEIn + ARB

Blockers

• Inhibit advrse effects of sympathetic NS• Trials with carvedilol, bisoprolol and LA

metoprolol• Not class effect• Rx as soon as HF diagnosed• If pts on low dose ACEIn greater benefit to

add’n of than ACEIn

Aldosterone antagonists

• Compensate for RAS escape with ACEIn• RALES study provided 30%mortality in

NYHA III/IV• EPESUS study showed 20% mortality post

MI with HF signs (eplerenone)

• Thus in mod-severe HF or HF post MI

Nitrate and Hydralazine

• Less well tolerated• Trials show inferior to ACEIn• Subgroup analysis showed benefit in black

pts when added to standard Rx

Digoxin

• No prognostic benefit• Can improve quality of life• Use in pts with persistent symptoms despite

standard Rx• Caution post MI / ongoing ischaemia

Cardiac resynchronisation therapy (CRT)

• Third of pts in NYHA III/IV have QRS>120ms (+electrical dysynchrony)

• Associated with suboptimal LV filling, prolonged MR and paradoxical septal motion

• Pacing both ventricles improves contractility and reduces MR

CRT cont’d

• When added to optimal drug Rx improves QOL, Ex Tol and hopitalisation

• Recent trials have also shown 20-30% mortality • However, many pts do not benefit thus other

discriminators echo TDI used to select pts

• Thus pts with persitent symptoms, wide QRS and echo dysynchrony

Prognosis

• Likelihood of survival can be reliably predicted for populations, but not individuals (death may be endstage HF or sudden)

• Old prognostic models do not apply due to new drug Rx and devices

• Annual mortality of 7% in those on

Sudden cardiac death

• Proportion with SCD is greater in those with less severe LVSD

• ICD trials show risk reduction 23-30% in pts with EF<35%

However,• Not within 1st 30 days post MI, no benefit

within 1st year and most trials did not inc large no’s of elderly

Heart failure with normal systolic function

Differential causes of signs of HF with normal EFIncorrect diagnosis

Incorrect assessment of LV function

Restrictive Cardiomyopathy

Pericardial constriction

Episodic systolic dysfunction (ischaemia, arrhythmias)

High output failure

Diastolic dysfunction

Management of diastolic dysfunction

• Few trials• Resolve fluid overload• Some data on ACEIn / ARBs• Treat underlying condition

Who should manage care?

Once diagnosed and appropriate investigations completed

Nurse led clinics

GP or specialist run service?1° care manage most ptsIf remain symptomatic or are complex then

refer to specialists