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