Diagnosis and management of heart failure due to valvular heart disease

Jim Newton

Consultant cardiologist

Oxford University Hospitals

JIM.NEWTON@OUH.NHS.UK

Outline

• Background

• Clinical cases

• Summary of guidelines

• Areas for development

BACKGROUND

How many people >75 have moderate or severe valve disease?

1. 2%

2. 13%

3. 20%

4. 30%

5. 50%

Prevalence of moderate or severe valvular heart disease(%)

How many people 75-84 will there be in 2018?

1. 0.5 million

2. 2 million

3. 4 million

4. 8 million

5. 10 million

Potential scale of the problem

• 4 million aged 75 – 84

• Overall rate of significant valve disease = 13%

• Total number of patients ~ 520,000

How many patients admitted with heart failure have valve disease

1. 29%

2. 39%

3. 49%

4. 59%

Aetiology of heart failure

Aetiology %

Ischaemic heart disease 68

Moderate or severe valve disease 29

Dilated cardiomyopathy 3

How many patients with moderate or severe valve disease are dead at 5 years?

1. 7%

2. 17%

3. 21%

4. 25%

5. 30%

Mortality of valve disease

Do we know how to manage them?

Why do we need guidelines?

Why do we need guidelines?

Why do we need guidelines?

• Up to 49% of patients with symptomatic valvular heart disease do not receive surgical therapy

• Elderly patients with comorbidities

• Complex decision making

Background

• 13% >75 years have moderate or severe valve disease

• 29% of heart failure is due to valve disease

• 5 year survival with valve disease is poor

• Large proportion denied surgery

CLINICAL CASE 1

Making the diagnosis

• 75 year old male

• Hypertensive ex-smoker

• Progressive dyspnoea for 6 weeks

• Now significantly limited

• Examination reveals a systolic murmur

• ECG demonstrates left ventricular hypertrophy

How many patients referred for an echo for a murmur have valve disease?

1. 100%

2. 80%

3. 60%

4. 40%

5. 20%

Echocardiography

Echocardiography

Diagnosis made

• Severe aortic stenosis

• Good left ventricular systolic function

• No other valvular heart disease

What is best evidence based therapy?

1. Loop diuretic

2. Beta blocker

3. ACE inhibitor

4. Spironolactone

5. Statins

6. Other

Medical therapy in aortic stenosis

• No medical therapy is able to improve outcome

• Early intervention is required

• No role for statin treatment

Lessons

• Symptoms = intervention

• Heart failure therapy can reduce symptoms

• Even if improve on treatment still refer

• If any possibility of symptoms then refer

CLINICAL CASE 2

Chain of communication

• 72 year old female

• No comorbidities or past medical history

• Significant dyspnoea over 48 hours

• Awakes in night very breathless

• Seen by GP next morning

• In heart failure – referred to admissions unit

Examination

• In established heart failure

• Breathless at rest

• Sinus tachycardia

• Congestion on CXR

• Loud ejection systolic murmur

• Slow rising pulse

Investigations

• Small Troponin rise

• Widespread static ST changes on ECG

• Borderline elevation in creatinine

Management

• Intravenous diuretics

• Coronary angiography

• Echocardiography

Echocardiography

Echocardiography

Echocardiography

48 hours later

• Significant improvement in symptoms

• Normal coronary arteries

• Discharged home on oral diuretics

• GP asked to review and refer to cardiology OPD

Was that appropriate management?

1. Yes

2. No

2 weeks later

• Seen by GP

• Mildly breathless

• Referred to cardiology urgently

4 weeks later

• Due to be seen next week

• Sudden onset acute dyspnoea

• Readmitted in established heart failure

Currently

• Ongoing intravenous diuretic therapy

• Renal impairment

• Secondary respiratory infection

• Inpatient surgery when optimised

Lessons

• Patients presenting acutely need urgent treatment

• Medical therapy can mask severity

• Critical aortic stenosis is potentially lethal

• Early surgery preferable

CLINICAL CASE 3

History

• 85 year old male

• Prior coronary artery bypass grafting

• Renal impairment

• Probable COPD – on inhaler therapy

• Recent attendances with increasing dyspnoea

• Progressive peripheral oedema

• Cardiomegaly on chest X-ray

How accurate is cardiomegaly on a CXR?

1. 95%

2. 85%

3. 75%

4. 65%

5. 55%

Management

• Diuretic introduced with improvement

• No murmur heard

• Relapses few weeks later

Where would you refer?

1. Heart failure clinic

2. General cardiology clinic

3. Echocardiography

4. Respiratory

5. Do not refer

Echocardiography

Echocardiography

Echocardiography

Echocardiography

Management

• Severe aortic stenosis

• Severe LV dysfunction

• Moderate mitral regurgitation

• Prior bypass surgery and poor lungs

What options would you discuss?

1. Heroic re-do surgery

2. Palliative care

3. Referral to heart team

Seen by heart team

• Myocardium remains viable

• Anatomical suitability for transcatheter aortic valve implantation

• Mitral regurgitation secondary to LV dilation

• Pulmonary function reasonable

TAVI

Outcome

• Successful TAVI procedure

• Improvement to NYHA II within 6 weeks

• Follow up imminent

Lessons

• High risk patients should still be referred

• Transcatheter treatments evolving

• 1 year survival post TAVI of 90%

CLINICAL CASE 4

Reluctant customer

• 78 year old female

• Independent at home

• Doesn’t like to bother GP

• Not been attending social meetings recently

• Reluctantly admits to effort dyspnoea for over a year

• Also palpitations on effort

Clinical findings

• In atrial fibrillation

• Mild peripheral oedema

• Loud systolic murmur and dynamic pulse

• Clear lung fields

What are you suspecting?

1. Aortic stenosis

2. Mitral regurgitation

3. Aortic regurgitation

4. Left ventricular dysfunction

Initial management

• Rate control – beta blocker

• Thromboprophylaxis – Warfarin

• Symptom relief - diuretic

Would you refer now?

1. Yes

2. No – see how she gets on

Echocardiography

Echocardiography

Echocardiography

Attends cardiology OPD

• Does not feel symptoms are intrusive

• Reluctant to take medication

• Extremely reluctant to consider intervention

• Doesn’t know what all the fuss is about

Challenging management

• Phone call to GP to discuss strategy

• Information provided

• Regular follow up arranged

• Involvement of friends and family

Over the next year

• Progressive decline in activity levels

• One episode of acute dyspnoea

• Persuade to revisit options

• Referred to nicest surgeon

6 month later

• Successful mitral valve repair

• Rapid return to prior activities

• Now extremely grateful and actively fundraising for department

Lessons

• Severe MR can be tolerated for a long time

• Symptoms often very insidious and patients down play them

• Perseverance and team approach important

CLINICAL CASE 5

A real challenge

• 42 year old male

• Learning difficulties

• Long standing Crohn’s disease

• Admitted with severe PR bleeding

Progress

• Multiple endoscopies

• Intermittent bleeding

• Acute deterioration and major haemorrhage overnight

• Rapid transfusion and volume replacement

Subsequent developments

• Acute pulmonary oedema

• Required non-invasive ventilation and intravenous therapy for 24 hours

• Echocardiography on coronary care

Echocardiography

Echocardiography

Echocardiography

Does this man need surgery?

1. Yes

2. No

3. Probably – but not yet

Options

• Acute surgery difficult option

• No prior symptoms

• Careful liaison with all involved needed

Progress

• Bowel resection with cardiology support uneventful

• Recovered and discharged home

• Referred back early by GP as symptomatic

Referred for surgery

• Referred for mitral valve repair

• Prosthetic valve not an option

• Extensive counselling and discussion required

• Patient very dependent on GP opinion and advice

Surgery performed

• Mitral repair undertaken

• Complex bileaflet disease

• Difficult but successful

And then

• Readmitted 8 weeks post discharge

• Severely jaundiced and anaemic

• Not breathless

• Loud murmur

Unfortunately

• Small high velocity residual mitral regurgitation

• Severe haemolysis

• Requiring transfusion

Ultimately

• No progress with haematological input

• Jaundice intolerable

• Re-do surgery locally with single suture to close defect

• Symptom and jaundice free 3 months later

Lessons

• Valvular heart disease can be very complex

• Multidisciplinary approach key

• Be prepared to deal with complications

SUMMARY OF GUIDELINES

Summary of guidelines

• Comprehensive evaluation of cardiac and extra-cardiac conditions required

• Ensure consistency between clinical findings and investigations

• Decision making in high risk patients is difficult

Summary of guidelines

• Intervention is indicated in patients with severe valve disease and symptoms

• Transcatheter options are rapidly evolving

Area of contention

• Surgery should be considered in asymptomatic patients if:

– Low operative risk

– Rapid disease progression

– Progressive ventricular enlargement or LVH

– Likelihood of durable outcome

AREAS FOR DEVELOPMENT

Areas for development

• Major lack of evidence in valve disease

• Management of asymptomatic patients

• Novel medical therapy options

• Transcatheter treatment options

Conclusion

• Valve disease is common

• Valve disease causing heart failure is common

• Surgery best option if feasible

• Frequently complex and challenging patients