1. Heart Failure Update

2. Patient #1
33 Y/O man
2 month history of progressive cough and shortness of breath
Rx: Minocycline and oral corticosteroids
Cough persists
CXR: RLL infiltrate
Referred to ED

3. Patient #1 Vital signs Obese man who appeared short of breath
BMI: 33; HR: 101; BP: 127/83; RR: 20; SPO2: 96%
Obese man who appeared short of breath
Lungs: Scattered rales
CV: Regular tachycardia; normal heart sounds; ?S3
Ext: No edema

4. Patient #1 Chest CT: ground glass opacities, heart “unremarkable”
Labs:
BUN-20; creat-1.31; normal electrolytes
BNP-657
Plan:
Ongoing treatment for pneumonia/bronchitis
Repeat BNP
ECHO ordered

5. Patient #1 Echocardiogram

6. DX: Acutely Decompensated Systolic Heart Failure (HFREF)

7. Types of Heart Failure
Heart Failure with Reduced Ejection Fraction (HFREF)
Heart Failure with Preserved Ejection Fraction (HFPEF)
LVEF < 40%
Evidence-based guideline therapy developed for this group
Causes
Ischemic (large untreated STEMI, scar from multiple MI’s)
Non-ischemic
Advanced hypertension
Advanced valvular disease
Primary myocardial disease (dilated cardiomyopathies)
Myocarditis
LVEF > 50%
Little specific evidence-based therapies for this group
Treat the underlying cause
Causes
CAD with ischemia (especially acute)
Hypertension (especially elderly)
Some valvular disease (aortic stenosis)
Other myocardial disease (hypertrophic, restrictive)

8. Heart Failure Symptoms and Findings
Exercise intolerance
Shortness of breath
Orthopnea
PND
“Bendopnea”
Fatigue
Edema/weight gain/abdominal distention
Early satiety
Lightheadedness
Palpitations
Objective weight gain, especially if rapid
Neck vein distention
Low pulse pressure/pulsus alternans S3
Rales/decreased air entry
Enlarged liver and/or spleen
Edema/anasarca

9. Heart Failure – Functional Classification
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea (shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.
Class III (Moderate)
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV (Severe)
Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

10. The Iceberg of Heart Disease Progression
End-stage CHF
Symptomatic CHF
Known structural heart disease
Shortness of breath and fatigue
Reduced exercise tolerance
Asymptomatic Heart Disease
Previous heart attack
Reduced heart muscle function
Asymptomatic valvular disease
High Risk for Developing Heart Disease
Hypertension, Lipid disorder, Obesity, Inactivity, Family History,
Diabetes Mellitus D C B A

11. Stages in the Development of Heart Failure
Recommended Therapy by Stage
Figure 1. Stages in the Development of Heart Failure/Recommended Therapy by Stage. ACEI indicates angiotensin-converting enzyme inhibitors; ARB, angiotensin II receptor blocker; EF, ejection fraction; FHx CM, family history of cardiomyopathy; HF, heart failure; LVH, left ventricular hypertrophy; and MI, myocardial infarction.
Circulation 2009;119:

12. Acute HFREF Characterization of the Patient
Clinical: 2 minute bedside hemodynamic profile
Hemodynamic/laboratory (admission)
Long term risk assessment

13. 2 Minute Clinical Assessment of Patients with Advanced Heart Failure
Four basic Hemodynamic Profiles
Four basic hemodynamic profiles to be determined during 2 min clinical assessment for patients with advanced heart failure. The fundamental questions are: “Is there congestion at rest”, and “Is there physical evidence of low perfusion at rest?” The information is modified from Refs. [30,31].
Stevenson L W. Eur J Heart Fail 2005;7:

14. In-Hospital Mortality by SCr and SBP
Predictors of In-Hospital Mortality in Patients Hospitalized for HF Insights From the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF)
In-Hospital Mortality by SCr and SBP
J Am Coll Cardiol. 2008;52(5):

15. Treatment Basics If wet:
IV diuresis (watch renal function but treat as long as clinical volume overload exists); 2X previous daily oral dose!!!
When adequately diuresed
ACE inhibitor or ARB
Beta blocker
Aldosterone blockade
Be sure patient has “adequate” BP (systolic BP >/= 90 or MAP >/= 70).
Start with low dose of drug and slowly titrate upwards; it can take weeks!

16. Diuretics in HF Not all loop diuretics are the same!
Torsemide and Bumetanide may offer more predictable diuresis (increased bioavailability and pleotropic effects)
Increased half life of torsemide may be advantageous in HF
Small scale studies suggest advantage of torsemide vs. furosemide
Decreased neurohormonal activation, LV fibrosis, and adverse LV remodeling
Decreased hospitalization and mortality
Improved symptoms
DOSE trial – no benefits of continuous infusion of loop diuretics

17. Treatment Basics If cool: Are they in shock?
Consider ICU and invasive hemodynamic monitoring, especially if considering inotropes and/or IV vasodilators
Consider inotropes/vasopressors
Background therapy may have to take a “back seat”

18. Escalating Therapy for HF as Symptoms Progress
Escalating therapy for heart failure as symptomatic status progresses. Bars extending from the right across accepted therapies indicate that these therapies may no longer be tolerated in some patients with advanced disease. Information is adopted from Refs. [2,30].
Stevenson L W. Eur J Heart Fail 2005;7:

19. Use of Hemodynamic Profiles to Conceptualize Therapy for AHF Patients
Suggestions for how the hemodynamic profiles may be used to conceptualize initial therapy for patients with advanced heart failure. Patients who are wet and warm (Profile B) generally can be “dried out” without complex intervention. Patients who are “cold and wet” (Profile C) often require addition of other therapy to “warm up” before they can “dry out”. Concepts are further discussed in text and in Ref. [30].
Stevenson L W Eur J Heart Fail 2005;7:

20. Interventions Made in AHF Program During the first 3 Months after
HF Hospitalization
Pie and bar graphs of interventions made in Advanced Heart Failure Program for 32 patients during the first 3 months after heart failure hospitalization. Patients had advanced disease, as indicated by low median left ventricular ejection fraction (LVEF) and systolic blood pressure (SBP). The majority of interventions related to diuretic dose (diur). Fewer modifications were made in potassium dose (KCl), angiotensin converting enzyme or ARB doses (ACEI), and beta blockers (Bblocker).
Stevenson L W. Eur J Heart Fail 2005;7:

21. Long Term Risk Prediction The Seattle HF Model
Initial model developed in the PRAISE study cohort
Model validated in 5 other cohorts: ELITE2, Val-Heft, UW Clinic, RENAISSANCE, Italian HF Registry
Provided accurate estimates of 1, 2, and 3 year survival in each cohort tested
Available as smartphone app

22. Seattle HF Model

23. Seattle HF Model Impact of Evidence Based Therapy

24. The Dilemmas of Disease Progression in HF

25. Patient #2 Age 37: MI; quits smoking Age 43: MI Age 47: MI; CABG
Age 59: MI; coronary stent
Age 60
Angina: angioplasty
Ventricular arrhythmias; ICD
Age 64-69: Recurrent HF

26. Courtesy, LaTora Scott, R.N.
Transitions of Care
Courtesy, LaTora Scott, R.N.
BUMC Dallas

27. When Should a Patient be Referred for Advanced Therapies?
A. Hospitalized for decompensation
B. Rest symptoms
C. At initial diagnosis
D. EF <30%
E. Any of the above

28. When Should a Patient be Referred for Advanced Therapies?
A. Hospitalized for decompensation
B. Rest symptoms
C. At initial diagnosis
D. EF <30%
E. Any of the above

29. Guide to Early Referral to Advanced Heart Failure Center
A clinical algorithm to guide early referral to advanced heart failure centers specializing in mechanical circulatory support. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; BUN, blood urea nitrogen; CRT, cardiac resynchronization therapy; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; NSR, normal sinus rhythm; and RV, right ventricular. Reproduced from Mehra and Griffith16 with permission from the publisher. Copyright © 2011 Elsevier Saunders.
Mehra M R , Domanski M J Circulation 2012;126:

30. Stage D Heart Failure Management Pathways
CM indicates cardiomyopathy; HF, heart failure; HFNEF, heart failure with normal ejection fraction; HFREF, heart failure with reduced ejection fraction; LVAD, left ventricular assist device; and LVEF, left ventricular ejection fraction. *All patients who are stage D can be considered appropriate for hospice/palliative care as an alternative to transplantation or ventricular assist device.
Owens A T , Jessup M Circulation 2012;126:

31. Refractory or End Stage HF
1- to 2-year mortality of ~50% despite advanced medical therapy
Before patient considered to have refractory HF, caregivers should:
Confirm accuracy of the diagnosis
Identify any contributing conditions
Ensure that all conventional medical strategies have been optimally employed

32. Reasons for Preventable Hospitalization
Patients may not understand diagnosis
Patients may be confused about their meds and proper usage (time, dose, restrictions)
Hospital staff may not communicate important information to primary care providers
Patients may not schedule needed follow-up appointments (primary care or specialists)
Hospital staff may not forward test results that could affect care
Family members may not know how to provide care at home
The Dartmouth Atlas of Health Care, 2011

33. Having “The Talk”
Timing: Discharge or first office visit within two weeks afterwards.
HF is a chronic “waxing and waning” condition, with progression culminating in death
Is this a patient with serial readmissions?

34. Components of “The Talk”
What are appropriate levels of symptom relief, support?
ICD or pacemaker?
Advanced therapy (MCS, cardiac transplantation)?
End of life preferences; palliative care?
It takes a multidisciplinary team to evaluate, educate, and treat heart failure patients

35. Indications for Heart Transplant
Cardiogenic shock with reversible organ
dysfunction
Low cardiac output state or refractory HF requiring
inotropes
Class III-IV HF with poor exercise tolerance:
Peak VO2 < 10 ml/kg/min or
Peak VO ml/kg/min with HF worsening
Refractory ventricular arrhythmia
Refractory angina
Hypertrophic or restrictive cardiomyopathy Class 4

36. Contraindications for Heart Transplant
Severe systemic disease with poor survival
Severe peripheral vascular disease
Severe COPD, emphysema or pulmonary disease
CVA with severe cognitive impairment
Uncontrolled diabetes with proteinuria, renal disease, vasculopathy, and/or neuropathy
Active infection, malignancy or bleeding
Ongoing substance abuse, smoking or other psychosocial serious problems
Lack of family support or adequate financial resources
Severe obesity (BMI > 40, IBW >140%)

37. Adult and Pediatric Heart Transplants Number of Transplants by Year and Location Courtesy - ISHLT
NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide.

38. Adult and Pediatric Heart Transplants Kaplan-Meier Survival (Transplants: January 1982 – June 2011)
N at risk at 26 years = 117
Survival was calculated using the Kaplan-Meier method, which incorporates information from all transplants for whom any follow-up has been provided. Since many patients are still alive and some patients have been lost to follow-up, the survival rates are estimates rather than exact rates because the time of death is not known for all patients. Therefore, 95% confidence limits are provided about the survival rate estimate; the survival rate shown is the best estimate but the true rate will most likely fall within these limits.
The median survival is the estimated time point at which 50% of all of the recipients have died. The conditional median survival is the estimated time point at which 50% of the recipients who survive to at least 1 year have died. Because the decline in survival is greatest during the first year following transplantation, the conditional survival provides a more realistic expectation of survival time for recipients who survive the early post-transplant period.

39. Advanced HF Emergence of a New Therapy
Birks EJ. Tex Heart Inst J. 2011; 38(5): 552–554.

40. Miller L et al. N Engl J Med 2007;357:885-896
Components of the Continuous-Flow Left Ventricular Assist Device (LVAD)
Figure 1. Components of the Continuous-Flow Left Ventricular Assist Device (LVAD). The inflow cannula is inserted into the apex of the left ventricle, and the outflow cannula is anastomosed to the ascending aorta. Blood exits through the left ventricular apex and into the left ventricular assist device, which pumps throughout cardiac diastole and systole into the ascending aorta, with the rotor being the only moving part. The left ventricular assist device pump is placed within the abdominal wall or peritoneal cavity. A percutaneous lead carries the electrical cable to an electronic controller and battery packs, which are worn on a belt and shoulder holster, respectively.
Miller L et al. N Engl J Med 2007;357:

41. Advanced HF Emergence of a New Therapy
Birks EJ. Tex Heart Inst J. 2011; 38(5): 552–554.

42. Indications for Left Ventricular Assist (LVAS)
Bridge to transplant – established transplant centers
Acute cardiogenic shock (bridge to recovery or to alternative therapy)
Myocarditis
Acute ischemic syndrome
High risk intervention (e.g., unprotected LMCA intervention in patient with LV systolic dysfunction and/or hemodynamic instability)
Failure to wean from cardiopulmonary bypass (LVAD, RVAD, or BiVAD)
Established transplant centers
Hospitals that are part of a referral network for VAD referral
Destination therapy for patients who are not candidates for cardiac transplantation

43. Kaplan-Meier Survival Analysis Long Term VAD
Pagani, F. D. et al. J Am Coll Cardiol 2009; 54:

44. Typical LVAD Patient
Courtesy: Thoratec

45. Patient Number 2 Headline #1

46. Patient #2 Headline #2

47. Success with Heart Failure
It takes a village!
Fundamentals – time with the patient at all stages
Patient (and family) education and inspiration – we have the playbook but they have to perform!
Recognize and respond to transitions
Leverage technical expertise when needed

48. Thank You!
Questions?