Onn Akbar Ali

MBBS (Adelaide) FRACP

North Adelaide

Ashford Hospital

Consultant CardiologistThe Queen Elizabeth & Lyell Mc Ewin Hospitals

www.OnnAkbarAli.com

Update: Dr. Onn Akbar Ali has moved to Malaysia and now

practicing at

KPJ Kajang Specialist Hospital ( Aug 2013 onwards)

1. Increase confidence in managing chronic heart failure – appropriate use of combination therapy

2. Increase rate of beta blocker use and appropriate dose escalation- decrease reliance on “specialist”

3. Manage symptoms during dose escalation

75 ( Poorly controlled DM, HT & smoker )

3-4 months history of dyspnea & decreased ex. tolerance

10 days orthopnea and PND

BP 130/70 , systolic murmur and gross crepitations , dyspnea from bed to chair. Sleep deprived & lethargic and edematous

• Frusemide ACE Inhibitors

• Nitrates

• Digoxin

Symptomatic

relief (Initial)

• Beta Blocker (dose dependent)

• ACE Inhibitors

• Spironolactone ( Eplerenone)

Prognostic

• AICD – Solely Prognostic

• Bi Ventricular Pacer- Largely symptomatic

• AICD & Bi V

Device

A] Frusemide 80 mg mane, aspirin and digoxin 125 mcg

B] Frusemide 80mg mane, Ramipril 2.5 mg mane Imdur

60mg mane

C] Frusemide 80mg 1400 ,Ramipril 2.5 mane

Imdur 60mg 2100

D] Frusemide 80mg 1400, Ramipril 2.5 mg mane, Imdur 60 mg 2100, Bisoprolol 1.25 mane

A] Frusemide 80 mg mane, aspirin and digoxin 125 mcg

B] Frusemide 80mg mane, Ramipril 2.5 mg mane Imdur

60mg mane

C] Frusemide 80mg 1400 ,Ramipril 2.5 mane

Imdur 60mg 2100

D] Frusemide 80mg 1400, Ramipril 2.5 mg mane, Imdur 60 mg 2100, Bisoprolol 1.25 mane

DrugStarting dose (mg)

Target dose/day

Doses /day

Mean total daily dose achieved in clinical trials

Angiotensin-Converting enzyme inhibitors (ACEI)

Ramipril 1.25 10 daily 1 or 2 8.7 mg

Perindopril 2.5 od 10 daily

Enalapril 2.5 20-40 mg 2 16.6 mg

Angiotensin Receptor 2 blockers

Candersartan 4 32 1 24mg

Beta Blockers

Carvedilol 3.125 bd 50-100 mg 2 37 mg

Bisoprolol 1.25 od 10 1 6.2 mg

Metoprolol CR/XL

12.5 or 25 200 1 159 mg

Aldosterone Blockers

Spironolactone 12.5 mg 50 mg 1 26 mg

Eplerenone 25 50 1 43 g

Provides symptomatic benefit

Vasodilator ( reduce after load)Vasodilatation however induce salt & fluid retention

ACEI facilitate salt and water excretion.

Reduce thirst

Reduce sympathetic drive and catecholamine level

58 2nd opinion & medication review , litigation

lawyer ,HT, Ischemic cardiomyopathy, no angina. Nuclear scan 1 year ago no ischemia, LVEF 33%

COPD ( last cig 2 years), FEV1 1.3 ; 10 % reversibility.

Well, no edema, reduced AE , hyperinflated chest, no creps. BP 120/65 HR 90

Aspirin Seretide 250/25

Perindopril plus mane &Perindopril 5 nocte

Ventolin

Digoxin 125 mcg Atorvastatin 80 mg

Frusemide 80 mg Imdur 60 mg

Aspirin Seretide

Coversyl plus mane & coversyl 5 nocte

Ventolin prn

Digoxin Co Enzyme Q10

Frusemide 80 mg Atorvastatin 80 mg

GTN patch 50 mg on 0800

A] Start Bisoprolol 1.25 mg

B] Cease: Perindopril plus, digoxin,GTN & reduce

Frusemide Start: Bisoprolol 1.25

C] Cease Perindopril , digoxin, GTN

Start: Carvedilol 12.5 mg

D]Referral to Respiratory physician for ? Safety of beta

blocker for heart failure then referral to cardiology

Aspirin Seretide

Coversyl plus mane & coversyl 5 nocte

Ventolin prn

Digoxin Co Enzyme Q10

Frusemide 80 mg Atorvastatin 80 mg

GTN patch 50 mg on 0800

A] Start Bisoprolol 1.25 mg

B] Cease: Perindopril plus, digoxin,GTN & reduce

Frusemide Start: Bisoprolol 1.25

C] Cease Perindopril , digoxin, GTN

Start: Carvedilol 12.5 mg

D]Referral to Respiratory physician for ? Safety of beta

blocker for heart failure then referral to cardiology

Highest prognostic benefit but under utilised

Better tolerated than generally perceived

Few contraindication; severe bradycardia and high degree heart block

( pace maker), severe bronchospasm

Even severe chronic airway disease ( FEV1 < 1.0) could tolerate beta blockers (

preferably selective e.g.. Bisoprolol) with prognostic benefit even with small dose

Start low and go slow

Prepare the patient pharmacologically and mentally

◦ ( reduce other vasoactive if appropriate and motivate patient)

Start ≤10% of the maximum dose and increase every 7-14 days

Aim maximum tolerated dose within 12 weeks or less

Excessive reliance on specialist“Need specialist supervision”

Maximum dose of ACEI before β blocker

Poor patient preparation & motivation.

Medication error.

Permanent Treatment Withdrawal or dose reduction before other measures

Adverse effects, disease progression or just myth?

Bradycardia & conduction abnormalities

Worsening Heart failure

Dizziness ,Hypotension : Lethargy & malaise

Worsens airways disease ( COPD)

COMET ( Carvedilol vsmetoprolol trial) In Carvedilol versus

placebo trial , Carvedilol significantly reduced HR

12.6±12.8 bpm vs.

1.4±12.2, P<0.001)

The Effect of Carvedilol on Morbidity and Mortality in

Patients with Chronic Heart Failure; 1996

1. Consider Holter monitor

2. Reduce or stop digoxin & amiodarone ,ensure

Verapamil or diltiazem are discontinued

3. Consider PPM (particularly biventricular device if QRS

greater than 120 and advanced conduction disease

4. β Blocker at night

Adverse effects, disease progression or just myth?

√Bradycardia & conduction abnormalities

Worsening Heart failure

Dizziness and Hypotension

Worsens airways disease ( COPD)

Lethargy & malaise

COMET( Carvedilol versus Metoprolol)

At 4 months, mean decrease of systolic BP from baseline was 3–8 mm Hg (SD 17·4) in the carvedilol group and 2–0 mm Hg

The Carvedilol &Mortality in CHF1996

Adverse reaction leading to discontinuation of Carvedilol or placebo

Placebo Carvedilol

no (%)

Heart failure 9 (2.3) 11 (1.6)

Fatigue 3 ( 0.8) 5 (0.7)

Dizziness 0 3 (0.4)

Hypotension 1 (0.3) 2 (0.3)

No significant change in BP in either

group from baseline

2003

1. Give β blocker 2 hours before/after other vasoactive agents

2. Beta blocker at bedtime & ACEI/ARB in the a.m

3. Reduce diuretics or nitrates & even ACE Iprazosin (prostate)

4. Reduce beta-blocker dose only as last resortMotivate and wait as symptoms are often self-limiting

39 %

COPD

NO

COPD

Chronic Heart FailureAHJ 2006

Majority of COPD dies from CV

disease & lung cancer related cause.

Despite clear benefit , beta blocker

under prescribed

Cardio selective β blockers, as a single

dose or chronic:

1. Produced no change in FEV1 or,

2. Respiratory symptoms

3. Do not affect the FEV1 treatment

response to beta2-agonists.

Even in subgroup participants with

severe COPD or for those with a

reversible obstructive component.

Salpeter et al; 2009

Withdrawal or reduction of beta blocker dose

Avoid dual renin angiotensin system (RAS) blockade, improve albuminuria but increased creatinine & dialysis without mortality benefit (Ontarget).

Long term , loosely supervised diuretics combination (loop, thiazide, spironolactone ).

JACC 2008

Days since Discharge

Mort

ality

rate

(%

)

Permanent withdrawal of treatment increased mortality

In CIBIS II trial 81% of withdrawal in active and placebo arms were not due to medical reason (patient and physician “personal decision” )

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Reduced versus

stopped

Reduced or stopped

versus maintained

(unadjusted)

Reduced or stopped

versus maintained

(adjusted)

COMET: Mortality after hospitalization by whether beta-

blocker dose was stopped, reduced, or maintained

Rela

tive r

isk P=0.43

P=0.03P<0.001

Effects of beta blocker dose

reduction

Metra M. American Heart Association Scientific Sessions 2004. Nov 7-10, 2004; New Orleans, LA.

Motivate your patient !! This medication will,

make you breath better, make your heart stronger, keep you out off hospital ,

LIVE LONGER

Motivate your patient !!

It may make you feel a bit tired and very occasionally dizzy but most of the time will improve if you continue and persist

22.4% of patients in the placebo arms develop symptoms of fatigue, and 33.5% developed

worsening dyspnea

Appropriate use of combinations therapy

Lower threshold for commencing beta blocker in heart failure

Managing side effects

Majority of COPD dies from CV disease & lung cancer related

cause.

Despite clear benefit , beta blocker under prescribed

20 RCTs have shown that use of cardio selective Beta

blockers do not lead to worsening symptoms or decrease in

FEV1 even with Severe COPD or reversibility

Tolerated dose in CIBIS II

patients may have been

influenced to some extent

to the physician's tolerability

Comparison Relative

risk 95% CI p

Reduced vs

stopped 1.2 0.76-1.92 0.43

Reduced or stopped vsmaintained

(unadjusted)

1.59 1.28-1.97 <0.001

Reduced or stopped vsmaintained

(adjusted)

1.30 1.02-1.65 0.03

Metra M. American Heart Association Scientific Sessions 2004. Nov 7-10, 2004; New Orleans, LA.

COMET: Mortality after hospitalization by whether

beta-blocker dose was stopped, reduced, or

maintained

Onn Akbar Ali

MBBS (Adelaide) FRACP

North Adelaide

Ashford Hospital

Consultant CardiologistThe Queen Elizabeth & Lyell Mc Ewin Hospitals

www.OnnAkbarAli.com

Update: Dr. Onn Akbar Ali has moved to Malaysia and now practicing at

KPJ Kajang Specialist Hospital ( Aug 2013 onwards)