Congestive Heart Failure: more than just a pump

Patrick M. Looser, MDLowcountry Cardiology Associates

Disclosures• No disclosures relevant to this talk

Overview• Review the epidemiology of heart failure in

the US• Brief summary of the nomenclature • Discuss the evidence based pharmacologic

treatments for heart failure with reduced and preserved ejection fraction

• Advanced therapies• Conclusion

Heart Failure is Common

Braunwald E. JACC Heart Fail. 2013.1:1-20.

ACC SAP 8, Roger et al. Circ 2011

Savarese & Lund, Cardiac Failure Review 2017;3(1):7–11.

Accessed 5 February 2019 https://www.scdhec.gov/sites/default/files/Library/ML-002149.pdf

Accessed 5 February 2019 https://scdhec.gov/sites/default/files/docs/Health/docs/LCODRegions.pdf

Accessed 5 February 2019 https://scdhec.gov/sites/default/files/docs/Health/docs/LCODRegions.pdf

Epidemiology Summary• Heart failure incidence and prevalence is rising• It affects a substantial amount of our older

patients – up to 11% of patients over 80 years of age

• Risk factors are highly prevalent in SC• Heart disease is the second leading cause of

death in the Lowcountry• Associated with a poor prognosis, no matter the

ejection fraction

HEART FAILURE NOMENCLATURE

Lorenzini, Primary Care in Practice 2016

Nomeclature• NYHA Class versus Stage

• NYHA classification refers to functional status of the patient

• Stages refer to symptoms + structural heart disease

• Stratification by EF• Heart failure with preserved EF - > 50%• Heart failure with reduced EF < 35%• Heart failure with mid range EF 35-50%

MEDICAL THERAPY FOR HEART FAILURE WITH REDUCED EF

Slide courtesy of Parag Goyal MD

Kirmani and Squire Curr Rep Heart Fail 2017

Beta Blockers

Packer M, et al. NEJM. 1996:334:1349.CIBIS-II Investigators. Lancet. 1999;353:9.Packer M, et al. NEJM. 2001;344:1651.MERIT-HF Study Group. Lancet. 1999;353:2001.

ACE/ARB

AA

Pitt B, et al. NEJM. 1999;341:709.Pitt B, et al. NEJM. 2003;348:1309.

Yancy et al JACC 2017

Cardiac Society of Australia and New Zealand

Guideline Directed Medical Tx• Beta blockers – carvedilol, bisoprolol, metoprolol succinate• ACE inhibitors/ARB• ARNI – saccubitril/valsartan• Aldosterone receptor antagonists

• Hydralazine/nitrates – in AA populations• Ivabradine – in select patients with elevated HR

• Diuretics for symptoms of congestion

• ICD or BiV ICD in select patient populations

HEART FAILURE WITH PRESERVED EF

Reddy et al Circulation 2018

HFpEF – Differential diagnosis• Non cardiac dyspnea – obesity hypoventilation

syndrome, obstructive sleep apnea, deconditioning, pulmonary causes

HFpEF – Differential diagnosis• Non cardiac dyspnea – obesity hypoventilation

syndrome, obstructive sleep apnea, deconditioning, pulmonary disease

• Coronary artery disease• Valvular heart disease• Restrictive cardiomyopathy• Pulmonary hypertension with right sided heart

failure• Chronic pericarditis

Clinical scenario• 48-year-old man, morbid obesity, HTN, DM who was admitted

with SOB, DOE, leg swelling. Exam shows a thick neck, lungs clear, severe LE edema

• BNP 142 pg/ml, Cr 1.2 mg/dl• IV diuresis, negative 3L, by hospital day #3• Echo: normal EF, borderline filling pressures, grade 1 diastolic

dysfunction• Hospital day #4: HCO3 42, Cr 1.6 mg/dL

• RHC/LHC: • RA 18, RV 64/14, PA 62/28 mean , PCWP 28, LVEDP 26

• Diuresed another 10-12 L – doing well

Slide courtesy of Parag Goyal MD

TOPCAT

Pfeffer MA, et al. Circulation. 2015;131:34-42.

HFpEF Recommendations

Yancy et al JACC 2017

Yancy et al JACC 2017

DIET AND HEART FAILURE

Doukkyet al JACC Heart Failure 2016

Miro et al JACC Heart Failure 2018

Diet Conclusions• The data on salt intake in CHF is controversial but

professional heart failure societies recommend 2-3g/day in CHF

• Diet is controversial but diets that are lower in processed foods, animal proteins and higher in fruits, vegetables, legumes tend to have fewer heart failure hospitalizations

• The optimal salt intake and dietary profile are still areas of active investigation

Advanced therapies

Who to consider for advanced therapies

• Class III-IV HF despite maximal medical therapy• Intolerant of neurohormonal antagaonists• Worsening renal failure• Frequent hospitalizations for heart failure

IV therapies

Stulak et al. Ann Thorac Surg 2017

Courtesy of Thoratec

https://www.thoratec.com/medical-professionals/vad-product-information/heartmate3/HeartMate3_Patient-Education-Brochure.pdf

https://www.mayoclinic.org/tests-procedures/heart-transplant/about/pac-20384750. Accessed 5 Feb 2019

Conclusions• The incidence and prevalence of congestive heart failure in the

US is increasing

• Pharmacotherapies include beta blockers, ACE/ARB, ARNI, aldosterone antagonists, hydralazine/nitrates, ivabradine in select populations, diuretics for symptoms of congestion.

• Diet is controversial, but limiting salt to 2-3g per day plus increasing consumption of whole foods and decreasing consumption of added sugars, processed foods, red meat has been show to be beneficial.

• Consider cardiology/advanced heart failure referral when patients become intolerant of medications, have more frequent hospitalizations, develop worsening renal failure etc.

Questions?