Presentation on theme: "Heart Failure. Case 1 A 56 year old man with known CAD with NSTEMI x2 and stents in the LAD and LCx presents with 2 months of progressive DOE, LE edema."— Presentation transcript:
Case 1 A 56 year old man with known CAD with NSTEMI x2 and stents in the LAD and LCx presents with 2 months of progressive DOE, LE edema and
Question #1 Which of the following therapies will improve this patient’s mortality? – A. Lasix – B. Carvedilol – C. Spironolactone – E. Digoxin – D. All of the above
Question #2 PVCs are noted in the hospital. An echocardiogram has moderatey-severely decreased systolic function (EF 28%). What should you do next? – Increase the lisinopril and carvedilol dose – Implant and AICD – Start amiodarone – Put the defibrilator patches on him – D/C telemetry
Heart Failure Is a Big Problem Prevalence: >5,000,000 Incidence: >650,000 new cases/year in the US Most common discharge diagnosis Most common cause of readmission < 60 days Cost: > 34.8 billion annualy Rosamond. Circulation, 2008. Braunwald. 2007.
Heart Failure Incidence Has Increased, But No By Much Levy. NEJM, 2002.
Survival has improved, but not dramatically Levy. NEJM, 2002.
What is Heart Failure? Definition: Any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Cardinal manifestations: Dyspnea, fatigue, fluid retention
LV Dysfunction Is Necessary But Not Sufficient For Heart Failure
Acute Compensatory Mechanisms Cause Long Term Damage Activation of renin- angiotensin-aldosterone – Salt and water retention – Myocyte hypertrophy, death and myocardial fibrosis Sympathetic nervous system stimulation – Increase contractility
Cardiac Remodeling Following Injury McMurray. NEJM, 2010.
Activation of the RAS Leads to Remodeling
Etiologies of Heart Failure Depressed LV Function – CAD (2/3 of cases of HF) – Pressure overload: HTN, AS – Volume overload: AI, MR, intra/extra cardiac shunt – NICM: Genetic, infiltrative, toxin/drug, metabolic, viral, Chagas’ – Arrythmias Preserved LV Function – Hypertrophy: HCM, HTN – Aging – Restrictive: Infiltrative (amyloid, sarcoid), storage dz (hemochromatosis) – Fibrosis – Endomyocardial disorders Pulmonary vascular disease High-Output States – Metabolic: Thyrotoxicosis, nutrititional (beriberi) – Excessive flow requirements: AV shunt, anemia
Clinical Classification of Heart Failure Gheorghiade. JACC, 2007.
Initial Evaluation Decreased exercise tolerance Volume overload Asymptomatic or other complaints
Symptoms To Ask About Major Symptoms – Dyspnea – Orthopnea – PND – Ankle edema – Pulmonary edema – Fatigue – Exercise intolerance – Cachexia Minor Symptoms – Weight loss – Cough – Nocturia – Palpitations – Peripheral cyanosis – Depression
Physical Exam Findings To Look For JVP Crackles Pulmonary edema Displaced PMI, S3 and S4,
Measurement of the JVP Clinical Methods. Walker. 1990. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A622 5 cm
How To Measure JVP Clinical Methods. Walker. 1990. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A622
Brain Natriuretic Peptide Natriuretic peptides – ANP- atrium, BNP- ventricles, CNP- endothelial cells – Increased well stress -> pre-proBNP-> pro-BNP-> BNP+NTproBNP (longer t1/2, higher levels,slower fluctuation) – From the heart Induce vasodilation, natriuresis and diuresis – Useful and systolic and diastolic heart failure Daniels. JACC, 2007.
Differential Diagnosis BNP Elevation LV dysfunction Previous CHF Advanced age Renal dysfunction ACS Pulmonary disease PE High output AF Lower then expected – Obesity – Flash pulmonary edema – Heart failure upstream from the LV – Cardiac tamponade – Pericardial constriction
BNP Can Help Differentiate Causes of Dyspnea Maisel. NEJM, 2002.
Higher BNP Is Associated With Higher Mortality Braunwald. 2007.
New York Heart Association Functional Classification Class I:No symptoms with ordinary activity Class II:Some symptoms with ordinary activity Class III:Symptoms with minimal activity ClassIV:Symptoms at rest
Drugs That May Worsen Heart Failure: Na Retention, Cardiotoxicity, Negative Inotropy NSAIDS Calcium channel blockers- non-dihydropyridine Metformin Thiazolidinediones PDE-3 inhibitors Antiarrhythmic drugs Chemotherapy THF alpha inhibitors Na Containing drugs Supplements
Goals Of Therapy Heart Failure Relieve symptoms Slow or reveres deterioration of myocardial function Decrease mortality
Heart Failure Therapy: A Timeline 1628 William Harvey describes circulation 1785 William Withering describes medical use of digoxin 1950s Thiazide Diuretics 1967 Furosemide 1967 First Heart Transplant 1974 Nitroprusside 1976 Hydralazine 1987 Enalapril reduces mortality 1994 Bisoprolol reduces mortality
Dietary and Lifestyle Modification: No Randomized Trials Sodium Restriction 2-3 gm daily Weight loss Smoking cessation Restriction of alcohol Daily weight monitoring
Diuretics Used to manage volume status Dosing is based on response Intravenous versus oral therapy Agents can be combined for better efficacy No effect on mortality Libby. Braunwald’s Heart Disease. 2007.
Digoxin In Heart Failure Inhibits the Na-K- ATPase pump-> increased Ca-> inc LV function Inhibition of sympathetic outflow
Digoxin Does Not Improve Mortality Digitalis Investigation Group. NEJM, 1997.
Digoxin Level > 1.2 ng/ml Is Associated With Increased Mortality Adams. JACC, 2005.
Enalapril Reduces Mortality in NYHA Class IV Heart Failure Consensus trial study group. NEJM, 1987.
Meta Analysis: ACE-I Improve Mortality After MI Flather. Lancet, 2000.
Candesartan Is An Reasonable Substitute In Patients Who Cannot Tolerate ACE-I Granger.Lancet, 2003.
Mortality Benefit With Hydralazine+ Isordil vs Placebo or Prazosin Cohn. NEJM, 1986.
Bidil Improved Survival In Blacks With Heart Failure Taking ACE-I Taylor. NEJM, 2004.
Beta Blockers Metoprolol: NYHA II-IV, EF <40%, metop succinate 200 daily All cause mortality dec by 34% independent of age, sex etiology of CHF or EF Merit-HF study group. Lancet, 1999.
Carvedilol Is Superior to Short Acting Metoprolol Poole-Wilson. L:ancet, 2000.
Improvement of Systolic Function is Related to Beta Blocker Dose Bristow. Circulation, 1996.
Rales Trial: Spironolactone Improves Mortality In Severe Heart Failure Pitt. NEJM, 1999.
Ephesus: Epleronone Improves Mortality In Heart Failure Following AMI Pitt. NEJM, 2003.
Treat With Proven Dosages McMurray. NJEM, 2010.
Oral Milrinone Causes A 28% Increase In Mortality Packer. NEJM, 1991.
Take Home Messages About Medical Management of CHF Use proven therapies Treat with proven dosages
How Do I Start These Drugs? Diuretic ACE Inhibitor or ARB Beta Blocker Hydralazine and Nitrates Spironolactone or eplerenone Digoxin
AICD For Primary Prevention Of Sudden Cardiac Death In Patients With Heart Failure Ischemic cardiomyopathy – EF<30%, prior MI Non-ischemic cardiomyopathy – EF < 35%, NYHA II or III – EF 120 AICD with CRT – Survival of sudden death or with VT
Mortality Reduction In Patients Post MI: MADIT II Moss. NEJM, 2002.
Reduction in Mortality in NICM With ICD: ScD Heft Bardy. NEJM, 2005.