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Modern Management of Heart Failure. Dr Amanda Varnava Consultant Cardiologist Watford General Hospital & Imperial College Healthcare Trust. Background. Huge health costs $27 billion pa in US Primarily a disease of the elderly Incidence of 10/100 in those over 65yrs. - PowerPoint PPT Presentation
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Modern Management of Heart Failure
Dr Amanda VarnavaConsultant Cardiologist
Watford General Hospital&
Imperial College Healthcare Trust
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 ex tolerance
Fatigue
Fluid overload
3rd Heart sound
Assessment of SOB
• ECG /CXR or BNP abnormal >
• Echo
• Additionally– Non invasive testing for ischaemia – Angiogram– MRI
Measurement BNP in CHF
Accurately identifies CHF 81-97% of patients
Levels > 100 (sens 90% & spec 76%)Levels vary according to age and gender
BNP < 100 BNP 100-400 BNP > 400
CHF unlikely
Uncertain diagnosis
CHF very likely
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
Heart Failure Therapies
ACEIns
• Inhibit RAS at multiple sites• Start low, go slow• Probably class effect• Side effects related to kinin production
(cough in 5-10%) and angioedema (1%) > common in Chinese and Blacks
• Continue unless > 50% rise in Cr above baseline/ Cr >350 / K> 5.9
ACEIn titration
Drug Starting dose Target dose
Lisinopril 2.5 or 5mg od 30 or 35mg od
Ramipril 2.5mg od 5mg bd or 10mg od
Perindopril 2mg od 4mg od
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 does not support combination of
ACEIn + ARB
Blockers
• Inhibit adverse 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
β blocker titration
Drug Starting dose Target dose
Carvedilol 3.125mg bd 25mg or 50mg bd
Bisoprolol 1.25mg od 10mg od
Aldosterone antagonists
• Compensate for RAS escape with ACEIn• RALES study provided 30%mortality in
NYHA III/IV• EPHESUS study showed 20% mortality
post MI pts 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• Use when ACEIn contraindicated (RF)
Diuretics
• Often first line agent• Treat volume overload• Symptomatic relief, but no clear prognostic
benefit
Digoxin
• No prognostic benefit• Can improve quality of life• Use in pts with persistent symptoms despite
standard Rx• Caution post MI / ongoing ischaemia
Polyunsatureated fatty acids
GISSI study– n-3 polyunsaturated fatty acids (PUFA)
vs placebo in > 7000 heart failure pts– Small, but signif reduction in mortality
(27% vs 29%, HR 0.9, p= 0.04)
Current GP prescribing practices in UK
• 163 practices from 2001-06 with 9311 pts• Loop diuretics 79%• ACE In or ARB 71% (35% to target)• β blocker 36% (11% to target)
Non pharmacological intervention
MV - revascularised
MV – med PxNo MV – med PxNo MV - revascularised
Implications of myocardial viability (MV)
Senior et al. J Am Coll Cardiol 1999;33:1848-54
Cardiac resynchronisation therapy CRT (biventricular pacing)
• As add on Rx it improves QOL, Ex Tol and hospitalisation
• Recent trials have also shown 20-30% mortality
CRT indications• Third of pts in NYHA III/IV have QRS>120ms (= electrical dysynchrony)
• However, 40% pts do not benefit thus need echo evidence of mechanical dysynchrony to further select pts
Thus for pts with:• Persistent symptoms, in SR with wide QRS and
echo dysynchrony
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
HTCADObesityFH CMCardiotoxinsETOH
1º Prevention
ACEIn/ARB Blockers
MIValvular
diseaseLVH
DyspnoeaFatigue 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 epleronone
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
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
Lifestyle & rehab• Exercise
Aerobic and resistive ideally within rehab programme• Diet
Wt reduction, salt and fluid restriction (daily wts)• Stopping smoking• Alcohol
– Cessation if causative/ moderate if unrelated• Vaccination
Pneumococcal and annual influenza• Air travel
Safe in most pts
Clinical Review
Interval dependent on status but not > 6 monthly• Clinical review
– Fluid status– Functional capacity– Cardiac rhythm
• Medication review• Bloods
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
NICE guidelines for specialist referral
• CCF not related systolic dysfunction• Co-morbidities (COPD, CRF, An, Gout)• Angina • Arrhythmias (inc AF)• Women planning pregnancy• Severe or very symptomatic heart failure
Specialist referral
• Confirm diagnosis• Invasive assessment to diagnose underlying
aetiology and Rx• Addition of beta-blockers and/or
spironolactone• Management of difficult / deteriorating
cases• Consideration of device therapy
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
Cardiac failure services available at West Herts
• Routine outpatients for specialist opinion and invasive investigation
• Emergency assessment in A+E with BNP• Specialist heart failure nurse service with
consultant supervision (WGH & HH)• Specialist cardiac failure device clinic
Thank You
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