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The Treatment of Advanced Heart Failure Shiva Roy FRACP POWH Nov 2000.

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Presentation on theme: "The Treatment of Advanced Heart Failure Shiva Roy FRACP POWH Nov 2000."— Presentation transcript:

1 The Treatment of Advanced Heart Failure Shiva Roy FRACP POWH Nov 2000

2 Heart Failure: where are we now? P P CCF is a major health problem » »400,000 new cases / yr in USA » »300,000 Australians affected P P Care is expensive » »70% of costs relate to hospitalisation » »$1.1 billion/year inpatient costs in Australia » »commonest hospital DRG in USA in pts > 65 yrs P P High mortality & readmission rates » »> 40% readmissions / year after index admission

3 Heart Failure Definition “The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return” E. Braunwald

4 Normal Chronic CCF: Evolution of stages NYHA Class Asymptomatic LV dysfunction 1 Symptoms on exercise 2 Symptoms with minor exertion 3 LV dysfunction = CCF Symptoms may not be proportional to extent of LV dysfunction 4 Symptoms at rest

5 Assessment of Heart Failure P Diagnosis »symptoms often more useful than signs »CXR, ECG helpful »echocardiography is essential P Exclusion of treatable causes »ischaemia »valvular lesions »uncontrolled HT »thyrotoxicosis »arrhythmias »anaemia

6 Determinants of Cardiac Output STROKE VOLUME CONTRACTILITY PRELOAD HEART RATE CARDIAC OUTPUT AFTERLOAD Synergy of LV contractionSynergy of LV contraction Valvular competenceValvular competence

7 Pharmacological Therapy Drug Class NYHAMortalitySymptoms ACE-I 1 - 4 Diuretics 2 - 4 Digoxin 2 - 4 ß-blockers 2 - 3 ( ) Spironolactone 3 - 4 Amlodipine 2 - 4 A2 receptor blockers 2 - 4 ? ? (if ACE-Inhibitor cough) (if ACE-Inhibitor cough)

8 ACE Inhibitors P Alters balance between vasoconstrictive, salt retaining, hypertrophic properties of angiotensin II and, the vasodilatory and natriuretic properties of bradykinin. P Morbidity and mortality data from large trials in spectrum of LVF make ACE inhibitors mandatory (SAVE, SOLVD, CONCENSUS, AIRE…) P ? High dose – ATLAS study P HOPE – reduced Cardiac death, CVA, & non fatal MI in ramipril treated pts with documented vascular disease but no heart failure

9 Aldosterone antagonists P Aldosterone causes Na retention, K/Mg loss, myocardial fibrosis, baroreceptor dysfunction, catechol augmentation and ventricular arrhythmogenicity. P RALES demonstrated 30% reduction in all cause mortality, and in hospitalisation in spironolactone (md 26mg) treated pts with NYHA III & IV heart failure P Well tolerated with conventional therapy.

10 Angiotensin receptor antagonists P High levels of Angiotensin II predict poor outcome, and ACE inhibition of bradykinin metabolism may induce cough. P Unexpected benefit of Losartan in ELITE, not confirmed in ELITE II P Adverse outcome with Candesartan v Enalapril in RESOLVD P Val- HeFT (class II and III)standard triple Rx v combination Rx, and VALIANT – valsartan v Captopril V combination post MI P Current role of AII R blockers is in ACE I intolerant pts and as adjunct to conventional therapy.

11 Sympathetic activation in CCF P B Blockers ? Contraindicated P Down regulation of B1 AR’s due to high catechol levels with failing myocardium. P US Carvedilol heart failure study 65% decrease mortality, ANZHF 24% NS reduction in mortality. P COPERNICUS – favourable carvedilol effect in severe HF. P B1 selective blockers Metoprolol (CR) – MERIT-HF 3991 pts, FC II-IV, 34% decrease in CV mortality, 41% decrease in SCD with similar results for Bisoprolol – CIBIS II. P COMET – Carvedilol or Metoprolol European Trial…

12 Therapy of Heart Failure » »pharmacological management » »treatment of arrhythmias: esp AF » »lifestyle: Na+ & fluid restriction, weight loss, cessation of smoking, alcohol » »exercise » »management of co-morbidities: depression, sleep apnoea » »vaccination against respiratory pathogens Comprehensive care is essential

13 Diastolic Heart Failure P Stiffening of the ventricle »Poor filling, need for higher than normal filling pressures »Small fluid shifts often poorly tolerated »Difficult balance between pulmonary congestion and systemic hypotension P Often accompanies systolic heart failure P Isolated diastolic failure: Common causesUncommon causes Hypertension Hypertrophic cardiomyopathy Ischaemia Infiltration

14 Management is difficult! Isolated Diastolic Heart Failure P P treat the underlying cause P P lower the HR, improve relaxation: ß-blocker or verapamil P P atrial fibrillation: attempt restoration of sinus rhythm P P ACE-inhibitors, spironolactone: may cause regression of hypertrophy P P cautious use of diuretics P P digoxin unhelpful

15 Biventricular Pacing P DCM with IVCD is associated with significant interventricular dyssynchrony P BV pacing may promote a coordinated ventricular pattern of contraction. P Symptomatic benefit demonstrated to date.

16 Surgery for Heart Failure Conventional Conventionalrevascularisation valve replacement or repair transplantation mechanical ‘bridge’ to transplant cardiomyoplasty LV reduction surgery permanent mechanical heart xenotransplantationInvestigational

17 Heart Transplantation Indications End stage heart failure, NYHA class 3-4, no further therapeutic options Poor LV function alone is not an indication in the absence of significant symptoms Contraindications Severe systemic disease limiting survival Active infection Irreversible pulmonary hypertension Adverse psycho-social factors

18 Heart Transplantation 1982 - 1999 Years post Heart Transplant Actuarial Survival ISHLTx Reg 2000

19 Heart Transplantation Disadvantages: P Donor shortage P Long waiting times P 10-20% mortality on waiting list P Risks of immuno- suppression P Risk of rejection: acute & chronic Number Australian Transplants Year

20 Thoratec in Intensive Care Evolution in VAD Support Novacor out of hospital Thoratec on the ward

21 Case 1 P 40 yr old female lawyer, N Coast P 30 cigarettes daily, Hypertension P Severe chest pain, nausea, diaphoresis P Refused thrombolysis P Medical therapy





26 Case 2 P 77 yr old female P Independent with medical therapy for ischemic cardiomyopathy and hypertension P Known moderate LV impairment (EF ~40%) P Sudden onset of increasing breathlessness P No chest pain




30 Case 3 P 19 yr old indigenous Australian P 22 wks pregnant P Intermittent palpitations P Increasing dyspnoea and peripheral oedema


32 Case 4 P 70 yr old surgeon P Sudden dyspnoea after driving off 1 st tee P Previously well with no CV history P Loud apical PSM on auscultation with pulmonary oedema



35 Case 5 P 24 yr old Chinese basketballer P ?Deteriorating physical fitness




39 Case 6 P 43 yr old radio presenter P ESRF secondary to wegeners granulomatosus, x3/wk HD P Hypertensive P Inceasingly dyspnoeic




43 Heart Failure 2000: Therapeutic Options High risk conventional surgery Transplantation LVADs Total artificial heart? Xenografts? Tolerance? Bi-ventricular pacing? Myoplasty? Left Ventricular reduction surgery? Exercise ß-blockers ACE-Inhibitors Angio-II blockers digoxin diuretics Spironolactone CPAP Medical Therapy Surgical Therapy

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