Post on 13-Apr-2017
West Herts Cardiology
Heart Failure Update 2003Heart Failure Update 2003
TerminologyPathophysiologyAccurate assessmentEvidence-based treatmentOrganisation / Staffing
Echo services Specialist Nursing Palliative care
West Herts Cardiology
Heart Failure in the NSF for CHD (Ch 6)Heart Failure in the NSF for CHD (Ch 6)
Standard 11Doctors should arrange for people with suspected heart failure to be offered appropriate investigations (eg ECG, Echo) that will confirm or refute the diagnosis.
For those in whom heart failure is confirmed, its its cause should be identified, and treatments most likely to both
relieve their symptoms and reduce their risk of death
should be offered.
West Herts Cardiology
What is Heart Failure?What is Heart Failure? A disease mostly of the elderly
Co-morbidity, Frailty, Drug interactions, Compliance Common
Overall incidence 1 :1,000 pop : year Expensive
Total NHS cost £360m (1% of total budget)GP visits £ 16.6mHosp OPD £ 27.8mInvestigations £ 57.4mHosp admissions £214.2mDrug Rx £ 27.1m
Complex, but manageable!
West Herts Cardiology
Heart failure v Asymptomatic LV Dysfunction
Acute v Chronic / Congestive (CHF, CCF) LVF v Pulmonary oedema Left v Right v Biventricular High output v Low output Backward v Forward
“Mild” !!! THERE IS NO “Mild” HEART FAILURE
What is Heart Failure? : TermsWhat is Heart Failure? : Terms
West Herts Cardiology
Heart FailureHeart Failure
“When the pulse is abundant, tense and full like a chord, then there is dropsical swelling of the legs.The stomach is swelled out, the kidneys pass on the disease to the heart, and the latter causes the troubled breathing.”
The Yellow Emperor's Manual of Internal Medicine (China circa 2500 BC)
West Herts Cardiology
“A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses.”
Prof. Peter Harris 1983
What is Heart Failure?What is Heart Failure?
West Herts Cardiology
What is Heart Failure?What is Heart Failure?Definition (European Society of Cardiology, 2001)
Criteria 1 and 2 should be fulfilled in all cases
1. Symptoms of heart failure (at rest or during exercise)
and2. Objective evidence of cardiac dysfunction (at rest)
and (in cases where the diagnosis is in doubt)
3. Response to treatment directed towards heart failure
European Heart Journal (2001) 22, 1527–1560
West Herts Cardiology
Heart Failure is NOT a DiagnosisHeart Failure is NOT a Diagnosis
Heart Failure is a Clinical Syndrome
CARDIAC abnormality with one or more ofBreathlessnessFatigue, poor perfusionTendency to fluid retention & oedema
MANY possible causesNeed to know CAUSE of Heart Failure
West Herts Cardiology
Causes of Heart Failure : ClinicalCauses of Heart Failure : Clinical LV Myocardial Dysfunction (LV Failure = “LVF”)
“Systolic” : Myocardial Infarction / Ischaemia Dilated Cardiomyopathy Alcohol, Drugs
“Diastolic” : Ischaemia LV Hypertrophy (LVH), Hypertrophic CM Age / Amyloid
Valve disease : Pressure load (AS) Volume load (AR,MR) L RV dysfunction Poor flow (MS)
Arrhythmias: AF, uncontrolled tachy, severe brady (CHB) Pericardial disease Congenital heart disease : ASD, GUCH Drugs: Negative inotropic, NSAIDs, etc Extracardiac causes (Anaemia, Thyroid, ..)
West Herts Cardiology
Heart Failure: ProgressionHeart Failure: ProgressionHigh risk of HF but without heart disease
Hypertension, CHD or risk++, DM, Family History, Cardiotoxins
Structural Heart Disease without symptoms Known – eg Previous MI Unknown – Hypertensive LVH, undetected valve disease,
undetected cardiomyopathySymptomatic Heart Failure
“Mild” “Moderate-Severe”
Refractory Heart Failure
West Herts Cardiology
Heart Failure: Progression of Stages
NORMAL
Asymptomatic LV Dysfunction
“Compensated”CHF
“Decompensated”CHF
No symptomsNormal exerciseNormal LV fxn
No symptomsNormal exerciseAbnormal LV fxn
? No symptoms ExerciseAbnormal LV fxn
Symptoms ExerciseAbnormal LV fxn
“Refractory”CHF
Symptoms not controlled with treatment
American Heart Association
West Herts Cardiology
Class I
Class II
Class III
Class IV
No limitation ofphysical activity
Slight limitationof physical activity
Marked limitationof physical activity
Any physical activitycauses discomfort
No symptoms onordinary activity
Symptoms onordinary activity
Symptoms on lessthan ordinary activity
Symptoms at rest
Heart Failure: NYHA classificationHeart Failure: NYHA classification
West Herts Cardiology
Heart Failure : conceptual problemsHeart Failure : conceptual problemsIn epidemiological studiesLV systolic dysfunction (LVSD)
Not uncommon (1.8–11.3 % prevalence) Difficult to define is often asymptomatic (34-95%)
Clinical Heart Failure LV systolic function often “Normal” (43-71%) ?”Diastolic Heart Failure” by exclusion of LVSD – NO!
Petrie M, McMurray J Lancet 2001;358:432-434
West Herts Cardiology
Heart Failure Update 2003Heart Failure Update 2003
TerminologyPathophysiologyAccurate assessmentEvidence-based treatmentOrganisation / Staffing
Echo services Specialist Nursing Palliative care
West Herts Cardiology
Heart Failure: PathophysiologyHeart Failure: Pathophysiology
CHD
Hypertension
Valve disease
Cardiomyopathy
Congenital HD
LVDysfunction
Arrhythmias
Non-Cardiac FactorsNeuroendocrine activationEndothelial dysfunctionCytokines, eg TNFVasoconstrictionSkeletal Muscle abnormalitiesRenal Sodium retention
MostSymptoms
ChronicHeart
Failure
PumpFailure
DEATHLow
EjectionFractionRemodelling
West Herts Cardiology
Heart Failure : AssessmentHeart Failure : Assessment Are the symptoms cardiac ? What is the cause of Heart Failure ? What is the severity / prognosis ? What treatment is appropriate ? Is treatment working ?
History Clinical Examination Investigations
West Herts Cardiology
Heart Failure : AssessmentHeart Failure : Assessment History Clinical Examination (incl. weight, urinalysis) Investigations
ECG, CXR, Routine Bloods (U&E, LFT, Thyroid, FBC) Echocardiogram (? Stress Echo)? BNP (to detect those unlikely to have CHF)
Exercise test (ExECG, VO2, T-wave alternans) Ambulatory ECG Respiratory Function tests
? Nuclear scans (myocardial perfusion)? Cardiac catheterisation & Angiography
West Herts Cardiology
Heart Failure : SymptomsHeart Failure : SymptomsHistory Breathlessness Fatigue, lethargy Poor perfusion, confusion Tendency to fluid retention & oedema
Palpitations, Syncope Loss of appetite “Cardiac cachexia”
West Herts Cardiology
Breathlessness in Primary CareBreathlessness in Primary CareCommon causes of exertional breathlessnessUnfitObesityCOPD / Asthma / SmokerHeart Failure“Angina” – reversible ischaemic LV dysfunction
West Herts Cardiology
Breathlessness in Primary CareBreathlessness in Primary CareBreathless when walking up hill, or worse
855 men born in 1913 in Sweden, assessed by Questionnaire, Exam, ECG, CXR, Gases, SpirometryAge 57 Age 67
Breathless 5.2% 10.3%Probable Cardiac cause 21% 32%Probable Respiratory cause 29% 26%Both 29% 22%Neither 21% 19%
Eriksson H et al Europ Heart J 1987;8:1015-23
West Herts Cardiology
Heart Failure : AssessmentHeart Failure : Assessment
Sens Spec PPV NPVPast history of myocardial infarction 59 86 44 92
Ingesting diuretic 73 41 19 89
Dyspnoea on exertion 100 17 18 100
Orthopnoea 22 74 14 83
Paroxysmal nocturnal dyspnoea 39 80 27 87
Oedema in history 49 47 15 83
Jugular venous pressure distension 17 98 64 86
Crackles 29 77 19 85
Gallop rhythm 24 99 77 87
Oedema on examination 20 86 21 85
Davie AP et al QJM 1997;90:335-9
Predictive value of clinical features
West Herts Cardiology
Signs of LV DysfunctionSigns of LV DysfunctionClinical Examination Systolic LV dysfunction
Sinus tachycardia, Weak arterial pulse Sustained apical impulse Gallop rhythm (S3+S4) Pansystolic murmur of MR
Diastolic LV dysfunction Double apical impulse S4 Eventual PHT : Loud P2, JVP “a” wave +
West Herts Cardiology
Heart Failure : CXRHeart Failure : CXR If CXR is Normal, Systolic LV Dysfunction unlikely
Probable Systolic LV Dysfunction Cardiomegaly Pulmonary congestion (ULBD, Kerley B, Pleural effusion)
Possible Diastolic LV Dysfunction Normal heart size, but with pulmonary congestion (possible LVH, HCM, MS, etc - beware obesity, poor CXR)
Also Assessment of pulmonary pathology
West Herts Cardiology
Heart Failure : ECGHeart Failure : ECG If ECG is Normal, “Heart Failure” is unlikely
Abnormal ECG Sensitivity 94% Specificity 61%+ve Predictive 35% -ve Predictive 98%
Probable Systolic LV Dysfunction Q waves / poor R waves : old infarctionPossible Diastolic LV Dysfunction Preserved R waves ST/T repolarisation changes : “LVH” / “strain”Also Rhythm abnormalities Small complexes: ?? pericardial effusion
West Herts Cardiology
Heart Failure : ECGHeart Failure : ECG
Systolic LV Dysfunction: Old Q-wave Anterior MI
West Herts Cardiology
Heart Failure : ECGHeart Failure : ECG
Diastolic LV Dysfunction: LVH
West Herts Cardiology
Heart Failure : ECGHeart Failure : ECG
Arrhythmias
AF
A Flutter
SND
West Herts Cardiology
Differential Diagnosis of BreathlessnessDifferential Diagnosis of BreathlessnessCause Examination ECG
Normal (Unfit) Normal (Unfit)? Hyperventilation
Normal
Asthma ? Atopic, wheezeHyperinflated
Normal
COPD “Blue Bloater”“Pink Puffer”
Small RRA+,RV+,RBBB
PHT, RVF JVP+, RV+, RV S4TR, Oedema
RA+,RV+,RBBB
LV systolic dysfunction
S Tachy, Gallop, MR ?Q, Poor R
LV diastolic dysfunction Double apex, S4 ST/T changes,
LBBB
West Herts Cardiology
Clinical Assessment of LV DysfunctionClinical Assessment of LV DysfunctionClinical assessment often inaccurate,
even with careful examination + CXR + ECG
Sensitivity vs Haemodynamic monitoring 55%
(to assess PAwp and CO) Bayliss J BMJ 1983;287:187-190
vs Echo 46%(to assess LVEF < 40%)Choy A-M et al Brit Heart J 1994;72:16-22
West Herts Cardiology
Heart Failure : AssessmentHeart Failure : Assessment
Sens Spec PPV NPV
Normal ECG to exclude LVSD 94 61 35 98
High BNP for symptomatic HF in Primary care(Cowie M et al Lancet 1997;350:1349-53)
97 84 70 98
High BNP for LVSDin community(McDonagh T et al Lancet 1999;351:9-13)
76 87 16 98
Struthers AD Heart 2000;84:334-8
Predictive value of investigations
West Herts Cardiology
Assessment of LV DysfunctionAssessment of LV Dysfunction Clinical assessment often inaccurate
? Underlying cause? Pathophysiology? Severity of dysfunction
50% of patients with clinical Heart Failure have preserved Systolic LV function (? Diastolic LV Dysfunction)
20% of patients with low EF do not have clinical features of Heart Failure (asymptomatic Systolic LV dysfunction)
Marantz PR et al Circulation 1988;77:607-12
West Herts Cardiology
Heart Failure : need for EchoHeart Failure : need for EchoEchocardiogram often ESSENTIAL
Exclude other structural heart disease Assess LV Systolic Function
Ejection Fraction Regional wall motion abnormalities ?
Assess LVH
? Assess LV “Diastolic Function” specifically? Stress Echo to assess : cardiac reserve
: ischaemia
West Herts Cardiology
Echocardiography in Primary CareEchocardiography in Primary Care 78 patients from a single practice in Dundee Loop diuretics for suspected HF.
Systolic LV Dysfunction 41% (M 63%, F 27%)“Diastolic LV Dysfunction” 91% (of 64 pts)
Concentric LVH 15%Asymmetrical LVH 5%Calcific Aortic Stenosis 2%Aortic Regurgitation 4%Mitral Regurgitation 13%Mitral Stenosis 2%
Wheeldon NM et al Q J Med 1993;86:17-23
West Herts Cardiology
““Open Access” EchocardiographyOpen Access” Echocardiography 119 patients treated by GP with diuretics for Heart Failure 99 as yet untreated patients suspected of Heart Failure 9 asymptomatic patients at risk of LV dysfunction Treated Untreated Asymptomatic
Impaired Systolic function 26% 8% 22%Normal Systolic function 74% 92% 78%Valve disease 4% 6% 11%
ACEI recommended in 14% of patientsDiuretics considered unnecessary in 45% of treated patients
Francis CM et al BMJ 1995;310:634-6
West Herts Cardiology
Access to EchoAccess to Echo “Open access” echo as an investigation
Test performed by technician Specifically to assess LV systolic dysfunction Quick, not too difficult, less wait (?)
GP “specialist” Echo/Heart Failure assessment
Rapid access Heart Failure Clinic Clinical assessment by cardiologist (longer wait…?) Includes Echo (+ other tests appropriately) More comprehensive assessment of cause of
symptoms, severity and prognosis Involvement of Heart Failure Specialist Nurse
West Herts Cardiology
West Herts Cardiology
Brain Natriuretic Peptide (BNP)Brain Natriuretic Peptide (BNP)
West Herts Cardiology
Brain Natriuretic Peptide (BNP)Brain Natriuretic Peptide (BNP) Indicates raised intracardiac pressure
Something abnormal with cardiac function BUT not helpful for “screening” to identify those who may
have “heart failure” or LV systolic dysfunction Good way to exclude Heart Failure
Normal BNP = No “Heart Failure”, so no need for Echo Good prognostic indicator
Levels correlate with degree of dysfunction Good indicator of therapeutic effect
BNP guided therapy better than clinically guided therapy
Hobbs R BMJ 2000;321:188-9 Cowie MR et al Lancet 1997;350:1347-51 Smith H BMJ 2000;320:906-8
West Herts Cardiology
BNP in detection of LVSDBNP in detection of LVSD
McDonagh TA et al Lancet 1998;351:9-13
1252 randomly selected patients aged 25-74 (50.9)1y care in GlasgowCHD in 23%LVSD in 3% Asymptomatic in half
BNP cut-off 17·9 pg/mL detected LVSD
West Herts Cardiology
BNP in detection of LVSDBNP in detection of LVSD
Group Sensitivity%
Specificity%
PPV%
NPV%
Prevalence of LVSD
%Participants aged 25-74All 76 87 16 97·5 3·2With IHD 84 76 30 97·5 11Participants aged 55All 89 71 18 99·2 5·4With IHD 92 72 32 98·5 12·1
McDonagh TA et al Lancet 1998;351:9-13
Accuracy of BNP (cut-off 17·9 pg/mL) in detection of LVSD
West Herts Cardiology
BNP in detection of LVSD severityBNP in detection of LVSD severity
N=220 Age 35-851-4 days post MI
14months FU
Initial BNPVInitial LVEF
Richards AM et al Heart 1999;81:114-20
West Herts Cardiology
BNP to indicate prognosisBNP to indicate prognosis
Richards AM et al Heart 1999;81:114-20
N=220 Age 35-851-4 days post MI
14months FU
Survival by initial BNP
West Herts Cardiology
BNP guided therapy of CHFBNP guided therapy of CHF
Troughton RW et al Lancet 2000;355:1126-30
N=69 Age 35-85LVSD (EF<40%) + CHFOn ACEI + loop diuretic9.5months follow-up
Rx adjustmentN=33:by BNPN=36:by clinical score
West Herts Cardiology
BNP in Assessment of Heart FailureBNP in Assessment of Heart FailureInitial clinical assessment
ECG, CXR, ?BNP
Abnormal CHF unlikely
HF likelyYes
No
TreatEcho ?BNP
West Herts Cardiology
Improving the assessment of heart failureImproving the assessment of heart failure Recognise Heart Failure / Detect LV dysfunction Determine the Cause(s) Consider the Pathophysiology
Type of LV dysfunction Neuroendocrine compensatory mechanisms
Assess the Severity (& prognosis) Use evidence based treatment (at best doses)
ACEI, Blocker, Spironolactone, ??Digoxin BVpacing (?ICD) Heart Failure Nurse-led continuing care
Monitor effects of therapy & progression of disease Establish Protocols / Standards of care (Audit)
West Herts Cardiology
West Herts Cardiology
Heart Failure Update 2003Heart Failure Update 2003
TerminologyPathophysiologyAccurate assessmentEvidence-based treatmentOrganisation / Staffing
Echo services Specialist Nursing Palliative care
West Herts Cardiology
Heart Failure: Progression of Stages
NORMALAsymptomatic LV Dysfunction
Symptomatic CHFNYHA II
Symptomatic CHFNYHA III
“Refractory”CHF
American Heart Association
ACEI? B
Secondary preventionModification of physical activityReduced Salt intake
ACEI BlockerDiuretics: mild ACEI
BlockerDiuretics: LoopSpironolactone?Nitrates
Specialized therapyTransplant
West Herts Cardiology
Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment
Improved Symptoms
Reduced Morbidity
Reduced Mortality
Digoxin Yes Just NoDiuretics(excl spironolactone)
Yes Probably ?
Vasodilator Nitrates(+Hydralazine) Yes ? Yes
ACE Inhibitors Yes Yes YesAngiotensin II Antagonists ? = to ACEI
(AIIRA+ACEI > ACEI)= to ACEI
(AIIRA+ACEI = ACEI)
Blockers Variable Yes YesSpironolactone(in Severe HF) Yes Yes Yes
Warfarin No ? ?
West Herts Cardiology
Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment
Events prevented per 1000 patient years of treatmentHosp Admissions
(any cause)Deaths
Digoxin 40 0ACE Inhibitors 99 13 Blockers 65 38Spironolactone (in Severe HF) 138 57
McMurray J et al Europ J Heart Fail 2001;3:495-502
West Herts Cardiology
Digitalis Investigation Group (DIG)
n=6800 (Digoxin 3397, 3403 Placebo) : FU 47 months Age 63yrs (27% >70yrs, 22% F) 70% Ischaemic LVEF <45%, in SR (only 2% NYHA IV) 94% on ACEI, 44% already on Digoxin
1y Endpoint : Overall Mortality 2y Endpoints: CV Mortality, CHF Mortality, CHF
Hospitalisation, Other Hospitalisation (Dig toxicity)
DIGOXIN in CHF in Sinus RhythmDIGOXIN in CHF in Sinus Rhythm
Digitalis Investigation Group NEJM 1997;336:525-33
West Herts Cardiology
DIG Trial: Overall Mortality
50
40
30
20
10
0
Placebon=3403
DIGOXINn=3397
480 12 24 36
%
Months
p = 0.8
DIGOXIN in CHF in Sinus RhythmDIGOXIN in CHF in Sinus Rhythm
Digitalis Investigation Group NEJM 1997;336:525-33
West Herts Cardiology
Digoxin: Long Term effectsDIGOXIN in CHFDIGOXIN in CHF
Survival similar to placebo Fewer hospital admissions (just) More arrhythmias (AF slightly better controlled) More MIs
West Herts Cardiology
Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment
Improved Symptoms
Reduced Morbidity
Reduced Mortality
Digoxin Yes Just NoDiuretics(excl spironolactone)
Yes Probably ?
Vasodilator Nitrates(+Hydralazine) Yes ? Yes
ACE Inhibitors Yes Yes YesAngiotensin II Antagonists ? = to ACEI
(AIIRA+ACEI > ACEI)= to ACEI
(AIIRA+ACEI = ACEI)
Blockers Variable Yes YesSpironolactone(in Severe HF) Yes Yes Yes
Warfarin No ? ?
West Herts Cardiology
N Engl J Med 1986;314:1547
42
0.6Probof Death
0
Placebo (273)Prazosin (183)Hz + ISDN (186)
Months
0.7
0.5
0.3
0.4
0.2
0.1
0 6 12 18 24 30 36
Nitrates in CHF: Nitrates in CHF: VHefT-1
West Herts Cardiology
Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment
Improved Symptoms
Reduced Morbidity
Reduced Mortality
Digoxin Yes Just NoDiuretics(excl spironolactone)
Yes Probably ?
Vasodilator Nitrates(+Hydralazine) Yes ? Yes
ACE Inhibitors Yes Yes YesAngiotensin II Antagonists ? = to ACEI
(AIIRA+ACEI > ACEI)= to ACEI
(AIIRA+ACEI = ACEI)
Blockers Variable Yes YesSpironolactone(in Severe HF) Yes Yes Yes
Warfarin No ? ?
West Herts Cardiology
N Engl J Med 1987;316:1429
ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVDCONSENSUS
Placebo
Enalapril
12111098765MONTHS
0.1
0.8
0
0.2
0.3
0.7
0.4
0.5
0.6p< 0.001
p< 0.002
43210
Probof Death
West Herts Cardiology
ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVDMeta-analysis of 5 long-term (>3y) trialsAll 5 trials: OR 95%CI
Total mortality 0.80 0.74-0.87Reinfarction 0.79 0.70-0.89Readmission in HF 0.67 0.61-0.74
3 early post-MI trials:Total mortality 0.74 0.66-0.83Reinfarction 0.80 0.69-0.94Readmission ht failure 0.73 0.63-0.85
Lancet 2000; 355: 1575-81
West Herts Cardiology
ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVD
Lancet 2000; 355: 1575-81
West Herts Cardiology
ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVD
Lancet 2000; 355: 1575-81
West Herts Cardiology
Age-adjusted discharge rates for heart failure, Netherlands
ACE inhibitor use, Netherlands(106 Rx-days per yr)
ACE Inhibitors in Heart Failure/LVDACE Inhibitors in Heart Failure/LVD
Heart 2002; 87: 75-76
West Herts Cardiology
Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment
Improved Symptoms
Reduced Morbidity
Reduced Mortality
Digoxin Yes Just NoDiuretics(excl spironolactone)
Yes Probably ?
Vasodilator Nitrates(+Hydralazine) Yes ? Yes
ACE Inhibitors Yes Yes YesAngiotensin II Antagonists ? = to ACEI
(AIIRA+ACEI > ACEI)= to ACEI
(AIIRA+ACEI = ACEI)
Blockers Variable Yes YesSpironolactone(in Severe HF) Yes Yes Yes
Warfarin No ? ?
West Herts Cardiology
Angiotensin I
ANGIOTENSIN II
RENIN
AngiotensinogenACE
Other paths
Vasoconstriction Proliferative Action
Vasodilatation Antiproliferative Action
AT1 AT2
AT1 RECEPTOR BLOCKERS
RECEPTORS
Angiotensin Receptor Blockers Angiotensin Receptor Blockers (“sartans”)(“sartans”)
West Herts Cardiology
Angiotensin Receptor Blockers Angiotensin Receptor Blockers (“sartans”)(“sartans”)
Trial n Drugs OutcomeELITE I 722, >65y
II-IVLosartan 50mgCaptopril 150mg
Renal deterioration(Death)
ELITE II 3152, >60yII-IV
Losartan 50mgCaptopril 150mg
= Death= Death+Hosp+safety
ValHeFT 5010 Valsartan 320mg(ACEI, B)Placebo
= DeathMorbidity+Mortality
CHARM(due 2004)
6500, >18II-IV
Candesartan 32mgEF<40% + ACEIEF<40% - ACEIEF≥ 40% - ACEI (Diastolic) Placebo
Comparison to ACE Inhibitors
West Herts Cardiology
Angiotensin Receptor Blockers Angiotensin Receptor Blockers (“sartans”)(“sartans”)
Meta-Analysis of 17 trials in 12,469 patients in HFComparison to Placebo OR 95%CITotal mortality 0.96 0.75-1.23
Readmission in HF 0.86 0.69-1.06Trend in benefit if given in absence of ACEI
Comparison to ACE InhibitorsTotal mortality 1.09 0.92-1.29Readmission in HF 0.95 0.80-1.13
Combination with ACE InhibitorsTotal mortality 1.04 0.91-1.20Readmission in HF 0.74 0.64-0.86
Jong P et al JACC 2002; 39: 463-70
West Herts Cardiology
Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment
Improved Symptoms
Reduced Morbidity
Reduced Mortality
Digoxin Yes Just NoDiuretics(excl spironolactone)
Yes Probably ?
Vasodilator Nitrates(+Hydralazine) Yes ? Yes
ACE Inhibitors Yes Yes YesAngiotensin II Antagonists ? = to ACEI
(AIIRA+ACEI > ACEI)= to ACEI
(AIIRA+ACEI = ACEI)
Blockers Variable Yes YesSpironolactone(in Severe HF) Yes Yes Yes
Warfarin No ? ?
West Herts Cardiology
JACC 1990;16:1327
Mortality50
40
30
20
10
0
LV Ejection Fraction< 30% 30-40% > 40%
%
Blocker Placebo
Beta-Blockers in Heart Failure: Beta-Blockers in Heart Failure: BHAT
West Herts Cardiology
ACEI
ß BLOCKER
Yes
No
n=2231 Yes No
13.3%
19.5%
24.3%
27.7%
Mortality
Circulation 1995;92:3132
Beta-Blockers in Heart Failure: SAVEBeta-Blockers in Heart Failure: SAVE
West Herts Cardiology
Beta-Blockers in Heart FailureBeta-Blockers in Heart Failure
Systematic review of 22 trialsBisoprolol, Carvedilol, Metoprolol-CR/XL
% Control -B ORDeath 12.8 8.0 0.63Adm for heart failure 17.1 11.3 0.63Death or admission 26.9 19.4 0.66
Absolute 5-6% / yr reduction in event rates
Eur J Ht Fail 2001; 3: 351-67
West Herts Cardiology
Carvedilol in heart failureCarvedilol in heart failure
Carvedilol Prospective Randomized Cumulative Survival Study Group (COPERNICUS)
2289 pts severe heart failure LVEF <25% FU 10.4 months
N Engl J Med 2001; 344: 1651-8
West Herts Cardiology
Carvedilol in Heart Failure: Carvedilol in Heart Failure: COPERNICUSCOPERNICUS
35%RR
N Engl J Med 2001; 344: 1651-8
West Herts Cardiology
Carvedilol in Heart Failure: deathCarvedilol in Heart Failure: death
N Engl J Med 2001; 344: 1651-8
West Herts Cardiology
Carvedilol: death or hospitalizationCarvedilol: death or hospitalization
N Engl J Med 2001; 344: 1651-8
West Herts Cardiology
Carvedilol in Heart Failure: withdrawalsCarvedilol in Heart Failure: withdrawals
23%RR
N Engl J Med 2001; 344: 1651-8
West Herts Cardiology
Ideal candidate? Suspected adrenergic activation
Arrhythmias
Hypertension
Angina
Beta-Blockers in Heart FailureBeta-Blockers in Heart Failure
West Herts Cardiology
Hypotension: BP < 100 mmHg Bradycardia: HR < 50 bpm Clinical instability Chronic bronchitis, ASTHMA Severe chronic renal insufficiency
Beta-Blockers in Heart FailureBeta-Blockers in Heart Failure
Contraindications
West Herts Cardiology
Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment
Improved Symptoms
Reduced Morbidity
Reduced Mortality
Digoxin Yes Just NoDiuretics(excl spironolactone)
Yes Probably ?
Vasodilator Nitrates(+Hydralazine) Yes ? Yes
ACE Inhibitors Yes Yes YesAngiotensin II Antagonists ? = to ACEI
(AIIRA+ACEI > ACEI)= to ACEI
(AIIRA+ACEI = ACEI)
Blockers Variable Yes YesSpironolactone(in Severe HF) Yes Yes Yes
Warfarin No ? ?
West Herts Cardiology
Spironolactone in severe Heart FailureSpironolactone in severe Heart Failure
RALES Study:(Randomized ALdactone Evaluation Study)
1663 pts severe heart failure LVEF ≤35% On ACEI & diuretic 24 month follow-up 10% men gynaecomastia
N Engl J Med 1999; 341: 709-17
West Herts Cardiology
30%RR
N Engl J Med 1999; 341: 709-17
Spironolactone in severe Heart FailureSpironolactone in severe Heart Failure
West Herts Cardiology
Spironolactone in severe Heart FailureSpironolactone in severe Heart Failure
N Engl J Med 1999; 341: 709-17
West Herts CardiologyN Engl J Med 1999; 341: 709-17
Spironolactone in severe Heart FailureSpironolactone in severe Heart Failure
West Herts Cardiology
Chronic Heart Failure: Medical TreatmentChronic Heart Failure: Medical TreatmentEvidence based Treatment
Improved Symptoms
Reduced Morbidity
Reduced Mortality
Digoxin Yes Just NoDiuretics(excl spironolactone)
Yes Probably ?
Vasodilator Nitrates(+Hydralazine) Yes ? Yes
ACE Inhibitors Yes Yes YesAngiotensin II Antagonists ? = to ACEI
(AIIRA+ACEI > ACEI)= to ACEI
(AIIRA+ACEI = ACEI)
Blockers Variable Yes YesSpironolactone(in Severe HF) Yes Yes Yes
Warfarin No ? ?
West Herts Cardiology
Chronic Heart Failure: Chronic Heart Failure: Other Medical TreatmentOther Medical Treatment
Evidence based Treatment
Improved Symptoms
Reduced Morbidity
Reduced Mortality
Ca++ antagonists No/?Yes No No (?)Class 1 anti-arrhythmicsAmiodarone
NoNo
No ()No
No ()?Yes
ICDDDD pacingBiventricular pacing
NoYesYes
NoYesYes
Yes??
Neuropeptidase inhibitors Yes Yes ?
Endothelin antagonists ? ? ?
West Herts Cardiology
Cardiac Resynchronisation TherapyCardiac Resynchronisation Therapy
Abraham WT et al NEJM 2002;346:1845-53
Multicenter Insync RAndomized CLinical Evaluation(MIRACLE)
RCT n=453 Mod-Severe HF, EF≤35%, QRS≥130msResynchronising Biventricular pacing for 6m or not
Improvements in 6min walk distance, treadmill time, NYHA class, QoL score, EF Hospitalisation for HF
Complications in 6.8% Serious in 1.2%, lead repositioning in 6%
West Herts Cardiology
Multicenter Automatic Defibrillator Implantation Trial II(MADIT II)
RCT n=1232 mean age 64, 35-39% NYHA IPrevious MI, EF≤30%, No EPICD or not 20 month follow up
Lead complications requiring resurgery in 2.5%
Implantable Cardioverter DefibrillatorsImplantable Cardioverter Defibrillators
Moss AJ et al NEJM 2002;346:877-83
“Usual care”(72% ACEI, 70% BB, 10% Amio)
ICD(68% ACEI, 70% BB, 13% Amio)
Death 19.8% 14.2%
Worsening CHF 14.9% 19.9%
West Herts Cardiology
Chronic Heart Failure: Surgical TreatmentChronic Heart Failure: Surgical Treatment
Coronary Revascularisation if ischaemia ++ ? Minimally invasive approach
Valve Replacement / Repair Cardiac Transplantation
?? xenotransplantation
Cardiomyoplasty LV volume reduction New implantable ventricular support devices
eg Jarvik 2000 axial flow pump
West Herts CardiologyWest Herts Cardiology
Heart Failure: New technologyHeart Failure: New technology
Peter Houghton underwent the operation in June
The Englishman who received the world's first permanent artificial heart pump says he has been given a new lease of life.
Peter Houghton, 61, was given just weeks to live before he underwent pioneering surgery to have a thumb-sized pump implanted into his heart.
West Herts Cardiology
West Herts Cardiology
Management of Systolic LV DysfunctionManagement of Systolic LV Dysfunction? Cause
Ischaemic Consider Revascularisation (PTCA, CABG) Valve Consider Valve Replacement Dilated CM Minimise Alcohol, Consider Transplant
ACE Inhibitor (?A2RA if cough) Maximise dose Blocker Increase gently Diuretic Clear / Prevent oedema Spironolactone in Severe CHF Digoxin Essential to control AF Warfarin If AF or LV dilated Control / Prevent Arrhythmia Amiodarone? (ICD ??) ?BiVentricular pacing If EF≤35% + QRS≥130ms
West Herts Cardiology
Management of Diastolic LV DysfunctionManagement of Diastolic LV Dysfunction Control Heart Rate Blocker (?? or Verapamil)
Digoxin essential to control AF
Control LVH (BP) ACEI carefully, Blocker (? else Verapamil)
Diuretic Carefully, low dose Control / Prevent Arrhythmia Amiodarone Consider Warfarin Especially if AF
Be very careful with Nitrates, and with Diuretics in high dose
West Herts Cardiology
Management of “Resistant” oedema in CHF Management of “Resistant” oedema in CHF Pharmacological methods
Withdraw NSAI, Ca++ antagonists, Class I antiarrhythmics Control heart rate if in AF : Digoxin ± Amiodarone Aldosterone effect : Spironolactone (if K+ <5.0) diuretic effect : Bumetanide ± Thiazide : Frusemide iv bolus, ivi Glomerular Filtration : Consider dose of ACEI
Non-pharmacological methods Salt & water restriction Elevate legs (Compression stockings with care) Warm bath / lower body immersion (Sitzbad) Haemofiltration
West Herts Cardiology
Heart Failure: common errorsHeart Failure: common errors Failure of recognition Failure to diagnose (and treat) the cause Failure in assessing severity and prognosis Failure to consider long term goals of Rx Failure to use ACE Inhibitors (or too little) Failure to use Blockers when possible Failure to use Spironolactone when possible Using wrong dose of diuretics
Using potentially harmful drugs Failure to communicate with patient
West Herts Cardiology
West Herts Cardiology
NICE guideline on heart failure (8/03)NICE guideline on heart failure (8/03)
The diagnosis and management of chronic heart failure in primary and secondary care
Best practice advice on the care of adult patients
Interface between primary and secondary care Circumstances for referral or admission to
secondary care. Not screening or diagnosis of asymptomatic
people Not management of cor pulmonale
West Herts Cardiology
NICE guideline on heart failure (8/03)NICE guideline on heart failure (8/03)
DiagnosisSystolic & diastolic dysfunction, valve disease, other
Diagnostic techniquesECG, CXR, biochem (BNP), imaging (echo/MRI).
Pharmacological treatmentsDiuretic, dig, ACEI, ßB, AT2B, spirono, NO3, dilators
Dose, initiation, freq, monitoring, combin, seqNon-pharmacological treatment
Exercise, diet, physical activity, weight, smokingInvasive procedures, including
Pacing, implantable cardiac defibrillators, CABG, angioplasty, valve surgery and transplantation
West Herts Cardiology
Heart Failure:Heart Failure: Recommended References Recommended ReferencesStruthers AD The Diagnosis of Heart Failure
Heart 2000;84:334-8
Hobbs R Can heart failure be diagnosed in primary careBMJ 2000;321:188-189
Drug & Therapeutics bulletin Heart Failure drugs: What’s new?Drugs &Therapeutics Bulletin 2000;38:25-27
ACC/AHA Guidelines for the Evaluation and Managementof Chronic Heart Failure in the Adult: Executive Summary
JACC 2001;38:2101-13
McMurray J Practical recommendations for the use of ACEI, blockers and Spironolactone in Heart Failure: putting guidelines into practiceEurop J Heart Fail 2001;3:495-502
West Herts Cardiology
West Herts Cardiology
Heart Failure : Exercise testingHeart Failure : Exercise testingDetect myocardial ischaemia / arrhythmiasConfirm & categorise severity of disabilityPredict prognosisAssess effects of treatmentProblems
Motivation (Patient, Doctor) Exercise type & Protocol Access
West Herts Cardiology
Myocardial perfusion (Thallium) imagingMyocardial perfusion (Thallium) imaging
Stress
InferiorIschaemia
Recovery
Vertical Long Axis Short AxisHorizontal Long Axis
Ant
Inf
Ant
Septum
InfLatApex
Apex
Lat
West Herts Cardiology
Heart Failure : Assessment of prognosisHeart Failure : Assessment of prognosisHistory & Examination
Age Underlying Diagnosis of CHD Functional Impairment (eg NYHA class) S3
Investigations LV Ejection Fraction : < 40% Aerobic exercise capacity (VO2) : < 12ml/Kg/min Serum Na+ : < 137 mmol/l? Plasma Noradrenaline, Natriuretic peptides, Endothelin-1