Heart Failure Heart Failure Susan Schayes, MD, MPH Program Director Emory Family Medicine Residency...

Heart FailureHeart Failure

Susan Schayes, MD, MPHSusan Schayes, MD, MPHProgram DirectorProgram Director

Emory Family Medicine Residency Emory Family Medicine Residency ProgramProgram

Adapted from Dr. Joel Felner and Dr. Eddie NeedhamAdapted from Dr. Joel Felner and Dr. Eddie Needham

ObjectivesObjectives Define Heart FailureDefine Heart Failure Know the 5 year mortality rate for heart Know the 5 year mortality rate for heart

failurefailure Distinguish between New York Heart Distinguish between New York Heart

Association classes (I – IV) and the new Association classes (I – IV) and the new American College of Cardiology stages (A – American College of Cardiology stages (A – D)D)

Review and become familiar with treatment Review and become familiar with treatment optionsoptions

Know the three beta-blockers demonstrating Know the three beta-blockers demonstrating benefit, and the two that are FDA approvedbenefit, and the two that are FDA approved

ObjectivesObjectives

Know indications for an ICDKnow indications for an ICD Know percent of patients who have Know percent of patients who have

diastolic dysfunctiondiastolic dysfunction

Pre-lecture Needs Pre-lecture Needs AssessmentAssessment

What are the four NYHA classes of What are the four NYHA classes of HF?HF?

What are the four ACC stages of HF?What are the four ACC stages of HF? Which medication classes are Which medication classes are

routinely prescribed in heart failure?routinely prescribed in heart failure? Which three beta-blockers are Which three beta-blockers are

approved to treat HF?approved to treat HF?

DEFINITIONDEFINITION

Clinical syndromeClinical syndrome Inability of the heart to Inability of the heart to

produce sufficient cardiac produce sufficient cardiac output to meet the output to meet the metabolic demands of the metabolic demands of the peripheral tissues peripheral tissues while while operating at normal filling operating at normal filling pressure.pressure.

5

Define Heart FailureDefine Heart Failure ““Heart failure is a complex syndrome that Heart failure is a complex syndrome that

can result from any structural or functional can result from any structural or functional cardiac disorder that impairs the ability of cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.” the ventricle to fill with or eject blood.” 11

The cardinal symptoms are dyspnea and The cardinal symptoms are dyspnea and fatigue, while the predominant clinical sign fatigue, while the predominant clinical sign is fluid retention (rales, elevated jugular is fluid retention (rales, elevated jugular venous pulsations, and pedal edema). Given venous pulsations, and pedal edema). Given that not all patients are volume overloaded at that not all patients are volume overloaded at the time of diagnosis (diastolic dysfunction), the time of diagnosis (diastolic dysfunction), the term “heart failure” is now preferred the term “heart failure” is now preferred over “congestive heart failure.” over “congestive heart failure.”

1Hunt S, et al, ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart

Failure). 2001, ACC web site, accessed November 12, 2004.

CLASSIFICATIONCLASSIFICATION

1. Acute (pulmonary 1. Acute (pulmonary edema)edema)

2. Chronic stable2. Chronic stable a. Systolic / Diastolic a. Systolic / Diastolic

dysfunctiondysfunction

3. Right / Left ventricular 3. Right / Left ventricular failurefailure

4. High output states4. High output states7

ACUTE PULMONARY ACUTE PULMONARY EDEMAEDEMA DefinitionDefinition:: Sudden change: Sudden change:

structure/function(structure/function(LVFP)LVFP) EtiologyEtiology::

Cardiac Cardiac -myocardial (ischemia / -myocardial (ischemia /

infarction)infarction) -mechanical -mechanical (acute regurg; HTN urgency)(acute regurg; HTN urgency) --electrical (tachycardia: AF/VT)electrical (tachycardia: AF/VT)

Non-cardiac Non-cardiac -high altitude -high altitude pulmonary edema (HAPE)pulmonary edema (HAPE) --heroin overdose; chlorine,etcheroin overdose; chlorine,etc

8

Pulmonary edema is caused by

(1) imbalance of the Starling forces in the lung (cardiogenic) (2) disruption in the alveolar capillary membrane (non-cardiogenic).

CARDIOGENIC PULMONARY EDEMA

NON-CARDIOGENIC PULMONARY EDEMA

1. “hydrostatic APE” 1. “hydrostatic APE”

Acute cardiogenic or volume-Acute cardiogenic or volume-overload pulmonary edemaoverload pulmonary edema

-sudden -sudden in in pulmonary venous pressure pulmonary venous pressure pulmonary interstitial and alveolar pulmonary interstitial and alveolar fluid fluid -pulmonary and lymphatic -pulmonary and lymphatic drainage can’t drainage can’t compensate compensate acutely to remove the fluidacutely to remove the fluid

continuedcontinued

Hallmark: rapid increase in hydrostatic pressure in the pulmonary capillaries causing increased transvascular fluid filtration.

IIt is usually due to pulmonary venous pressure from LVEDP/ LAP. As LAP rises above 25 mmHg fluid breaks thru the lung epithelium flooding the alveoli with protein poor fluid.

Non-cardiogenic pulmonary edema

-Lymphatic drainage

cannot compensate for the lung water caused by the disrupted alveolar capillary membrane.

-Caused by vascular permeability of the lung flux of fluid into the interstitium and air spaces

2. “-permeability pulmonary edema” (acute lung injury)

APE with NORMAL HEART APE with NORMAL HEART SIZE*SIZE*

CARDIAC CAUSESCARDIAC CAUSES Acute MR (torn chordae / ruptured PM)Acute MR (torn chordae / ruptured PM) Acute AR (dissection / flail leaflet)Acute AR (dissection / flail leaflet) Mitral stenosisMitral stenosis Ischemic HD: AMI / stunned myocardiumIschemic HD: AMI / stunned myocardium Malignant HTNMalignant HTN Acute rapid AF (WPW)Acute rapid AF (WPW)

*Enlarged heart: Exacerbation of *Enlarged heart: Exacerbation of chronic HF; Myocarditischronic HF; Myocarditis

APE: NON-CARDIAC APE: NON-CARDIAC CAUSESCAUSES

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

Lung injury damages alveolar-Lung injury damages alveolar-capillary membrane capillary membrane “ “capillary capillary leak syndrome” leak syndrome” ie, tie, transudation of ransudation of fluid from pulmonary capillaries to fluid from pulmonary capillaries to alveolialveoli

oncotic pressure oncotic pressure (hypoalbuminemia)(hypoalbuminemia)

Impaired lymphatic drainage Impaired lymphatic drainage

SYSTOLIC SYSTOLIC DYSFUNCTIONDYSFUNCTION

Defect: Defect: -myofibrils cannot shorten -myofibrils cannot shorten against a loadagainst a load

Various clinical presentationsVarious clinical presentations-asymptomatic, w/ -asymptomatic, w/ ejection ejection

fraction fraction -evidence of -evidence of CO: CO: fatigue/confused/fatigue/confused/BUN BUN -evidence of -evidence of congestion: DOE/leg edema congestion: DOE/leg edema --ddilated LV chamber on chest x-rayilated LV chamber on chest x-ray

Annual mortality Annual mortality - -NYHA II-III: 15-20% / NYHA IV: 50%NYHA II-III: 15-20% / NYHA IV: 50%

16

DIASTOLIC DYSFUNCTIONDIASTOLIC DYSFUNCTIONPathophysiology: Pathophysiology: “stiff” ventricle “stiff” ventricle LV: poorly compliant; LV: poorly compliant; filling/relaxation filling/relaxation -systolic function: -systolic function: normal or markedly normal or markedly -evidence of -evidence of HF: 35%HF: 35%

EtiologyEtiology:: ----ischemia/LVH/fibrosis/normal agingischemia/LVH/fibrosis/normal aging

Symptoms:Symptoms: congestive ( congestive (ppul venous ul venous HTN)HTN)

Signs:Signs: apex-normal/ sustained+S apex-normal/ sustained+S44

Hemodynamic abn: Hemodynamic abn: LVEDP / LVEDP / LAPLAPPrognosis:Prognosis: not as bad as systolic dysfn not as bad as systolic dysfn

17

COMPARISON of the TYPES COMPARISON of the TYPES of MYOCARDIAL of MYOCARDIAL DYSFUNCTIONDYSFUNCTION

SYSTOLIC DIASTOLIC

Chamber size /

Ejection fraction

Presence of S3 + -

Presence of S4 + / - +

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LEFT HEART FAILURELEFT HEART FAILURE EtiologyEtiology --

CAD / HTN / Valvular HD / etcCAD / HTN / Valvular HD / etc SymptomsSymptoms -fatigue/-fatigue/

congestion (SOB / DOE)congestion (SOB / DOE) SignsSigns -narrow -narrow

pulse pressurepulse pressure --hypokinetic carotid pulsehypokinetic carotid pulse

-inferolaterally displaced apex-inferolaterally displaced apex-S3/S4 gallops; murmurs -S3/S4 gallops; murmurs

of MR/TR of MR/TR 19

RIGHT HEART RIGHT HEART FAILUREFAILURE

EtiologyEtiology -lung disease: -lung disease: parenchymal / vascular parenchymal / vascular congenital: congenital: ASD / Ebstein’s anomalyASD / Ebstein’s anomaly

SymptomsSymptoms -fatigue / syncope / -fatigue / syncope / girth / edemagirth / edema

SignsSigns -hypotension / -hypotension / parasternal lift parasternal lift distended neck veins / + distended neck veins / + HJ refluxHJ reflux

-right-sided S3 / S4; murmur of TR-right-sided S3 / S4; murmur of TRhepatomegaly / ascites / peripheral hepatomegaly / ascites / peripheral

edemaedema

HIGH OUTPUT FAILUREHIGH OUTPUT FAILURE

Non-cardiac circulatory overloadNon-cardiac circulatory overloadEtiologyEtiology -fistula / anemia / -fistula / anemia / pregnancy / hyperT4 pregnancy / hyperT4

Pathophysiology Pathophysiology --SV: SV: preload (VR) + preload (VR) +

PVR(vasodilate) PVR(vasodilate) --CO at rest: CO at rest: afterload / afterload / preload preload --blood blood volume due to xs Na/Hvolume due to xs Na/H22OO

Symptoms:Symptoms: congestion ( congestion (PCWP)PCWP)Signs:Signs: HR / HR / SBP/SBP/DBP / wide PP / DBP / wide PP / SS33

21

CLINICAL EVALUATION- CLINICAL EVALUATION- HFHF

Risk factors for CAD Risk factors for CAD Symptoms Symptoms -only weakly -only weakly

related to LV dysfunctionrelated to LV dysfunction Fluid status: serum Na / weight Fluid status: serum Na / weight

/ edema/ edema Functional status: NYHA Functional status: NYHA

classificationclassification22

PRECIPITATING PRECIPITATING FACTORSFACTORS

Diet: xs Na / HDiet: xs Na / H22O; alcoholO; alcohol Non-compliance with Non-compliance with

medicationsmedications ArrhythmiaArrhythmia InfectionInfection AnemiaAnemia StressStress Metabolic: Metabolic:

thyroid disease / renal thyroid disease / renal failurefailure 23

LABORATORY LABORATORY EVALUATION EVALUATION 2-D ECHO / 2-D ECHO /

DOPPLERDOPPLERMost useful testMost useful testDetermines primary abnormalityDetermines primary abnormalityDerives Ejection Fraction (EF)Derives Ejection Fraction (EF)-most important single measurement -most important single measurement

-but, poor correlation with -but, poor correlation with symptomssymptoms

Distinguishes systolic / diastolic Distinguishes systolic / diastolic dysfndysfn

Guide to prognosis (EF and ESV)Guide to prognosis (EF and ESV)Assesses disease progression Assesses disease progression (remodels)(remodels) 24

PATHOPHYSIOLOGYPATHOPHYSIOLOGY1.1. Ventricular injury / myocyte Ventricular injury / myocyte

lossloss a. Chronic: CAD / HTN / a. Chronic: CAD / HTN / valvular diseasevalvular disease b. Acute: AMI / b. Acute: AMI / myocarditis / MR / ARmyocarditis / MR / AR

2.2. CompensationCompensation a. a. Ventricular remodelingVentricular remodeling -initially -initially adaptive and benficialadaptive and benficial --eventually maladaptive and harmfuleventually maladaptive and harmful

b. Peripheral remodelingb. Peripheral remodeling

3.3. DecompensationDecompensation25

PATHOPHYSIOLOGY: PATHOPHYSIOLOGY: THEORIESTHEORIES

OLD: OLD: hemodynamic disorder hemodynamic disorder -- ejection (EF) ejection (EF) sx (fatigue / sx (fatigue /

dyspnea)dyspnea) -Rx: -Rx: contractility: contractility: inotropesinotropes unload unload periphery: dilators / diureticsperiphery: dilators / diuretics

CURRENT: CURRENT: uncontrolled LV uncontrolled LV remodeling remodeling -chamber dilates -chamber dilates (spherical); hypertrophy(spherical); hypertrophy --mechanism: mechanism: neurohormonal systemneurohormonal system

-Rx: counteract RAAS / SNS -Rx: counteract RAAS / SNS

FUTURE: FUTURE: genetic abn / xs cytokinesgenetic abn / xs cytokines26

PATHOPHYSIOLOGY: PATHOPHYSIOLOGY: EVENTSEVENTS

Primary response: Primary response: SNS activation SNS activation ((/NE)/NE) -initiates vicious circle: -initiates vicious circle: afterloadafterload

Secondary response: Secondary response: hormone hormone constrictionconstriction --RAAS: RAAS: periph perfusion periph perfusion (Na retained)(Na retained) --Vasopressin: non-Vasopressin: non-osmotic releaseosmotic release

Vascular endothelial dysfunction Vascular endothelial dysfunction ((NO)NO)

Result of neurohormonal Result of neurohormonal compensationcompensation -adaptive / beneficial: -adaptive / beneficial: maintains perfusion maintains perfusion -long term: -long term: maladaptive / deleterious maladaptive / deleterious

27

COMPENSATORY COMPENSATORY MECHANISMSMECHANISMS

COUNTERACTS COUNTERACTS SV and SV and COCO1.1. Starling effectStarling effect: : preload -preload -limited limited rolerole2.2. muscle (muscle (LVH): vs myocyte loss -LVH): vs myocyte loss -keykey3.3. neurohumoral actionneurohumoral action::contractility-contractility-badbad -SNS: -SNS: EPI / NE (EPI / NE (HR / PVR) HR / PVR)

-RAAS: Na/H-RAAS: Na/H22O O retention;retention;K/Mg;K/Mg;GFRGFR -endothelin / -endothelin / vasopressin / prostacyclinvasopressin / prostacyclin

4.4. Brain natriuretic peptide (BNP)Brain natriuretic peptide (BNP)-diagnostic / prognostic-diagnostic / prognostic

5.5. Dilatation / remodelingDilatation / remodeling28

VENTRICULAR VENTRICULAR REMODELINGREMODELING

Definition Definition -altered chamber geometry-altered chamber geometry

-disproportionate -disproportionate cavity to wall cavity to wall thicknessthickness

PathophysiologyPathophysiology -a-altered extracellular matrixltered extracellular matrix myoc myoc

fibrosisfibrosis -up-regulates pro-inflam -up-regulates pro-inflam cytokinescytokines -myocyte -myocyte hypertrophy/apoptosis; hypertrophy/apoptosis; -inotropy-inotropy

-imbalance between -imbalance between production of Oproduction of O- - / NO / NO --rearranges myocardial fibers: rearranges myocardial fibers:

alters length/width ratioalters length/width ratio29

NEUROHORMONAL NEUROHORMONAL RESPONSES TO CHFRESPONSES TO CHF

Initially adaptive Chronically maladaptive

Preload (aldosterone); to counteract low CO

Dyspnea and Na / H2O retention

Vasoconstriction: Angiotensin II; to maintain BP

Hypertrophy / LV cavity, i.e., remodeling; CO

SNS (NEPI / EPI); to maintain forward CO

Down-regulation adrenergic receptors; myocyte toxicity

30

Left Ventricular volume

SYSTOLIC DYSFUNCTION

NORMAL

DIASTOLIC DYSFUNCTION

LV PRESSURE-VOLUME LOOPS:SYSTOLIC DYSFUNCTION: Contractility: ejection

impaired DIASTOLIC DYSFUNCTION: Chamber stiffness: filling impaired

LV Press.

31

LowCO

Normal LV

LV Failure

Congestion

10 15 20

LVEDP

THE RELATIONSHIP BETWEEN SV and LVEDP

StrokeVolume

FRANK-STARLING LV FUNCTION CURVES

Review cardiac physiology to understand these curves

32

MYOCARDIAL DYSFUNCTION / FAILURE

ENDOTHELIALDYSFUNCTION

SYSTOLICDYSFUNCTION

DIASTOLICDYSFUNCTION

CORESERVE

ARTERIALBLOOD VOL

NO ENDO-THELIN

RAAVASO-PRESSIN

SNS(NE)

Periphconstrict

Renalconstrict

Na/H2Oretention

PLASMA VOLUME

ALDO-STERONE

FATIGUE/RENAL DYSFN

PVR

Vascularstiffness

LA cavity

ANF

EDEMA DYSPNEA

CONGESTION

Peripheral Pulmonary

LVEDP

Periphcap press

PCP

33

Epidemiology of Heart Epidemiology of Heart FailureFailure

Approximately 5 million patients in the Approximately 5 million patients in the USA have HF, with a yearly incidence of USA have HF, with a yearly incidence of close to 500,000. close to 500,000.

It is primarily a disease of the elderly, It is primarily a disease of the elderly, with 6-10% patients over 65 years old with 6-10% patients over 65 years old being diagnosed with HF. being diagnosed with HF.

80% of hospitalized patients with HF are 80% of hospitalized patients with HF are > 65yo. > 65yo.

Heart failure is the most common Heart failure is the most common Medicare DRG. Medicare DRG.


“…“…one-year mortality of one-year mortality of approximately 45 percent.” approximately 45 percent.” 22

““Survival ranges from 80% at 2 Survival ranges from 80% at 2 years for patients rendered free of years for patients rendered free of congestion to less than 50% at 6 congestion to less than 50% at 6 months for patients with refractory months for patients with refractory symptoms.” symptoms.” 33

2 Jessup M, Brozena S, Medical Progress: Heart Failure, NEJM, 348(20): 2007-18, 2003.3 Nohria A, et al, Medical Management of Advanced Heart Failure, JAMA, 287(5): 628-40, 2002.


““Heart failure admission rates are rising, Heart failure admission rates are rising, and the prognosis of heart failure has and the prognosis of heart failure has been compared with that of malignancy, been compared with that of malignancy, with a 6-year mortality rate of 84% in with a 6-year mortality rate of 84% in men and 77% in women.” men and 77% in women.” 44

Heart failure kills people much more Heart failure kills people much more surely than most cancers!surely than most cancers!

Coronary artery disease is the cause of Coronary artery disease is the cause of two thirds of left ventricular systolic two thirds of left ventricular systolic dysfunctiondysfunction

4 Mair F, et al, Evaluation of suspected left ventricular systolic dysfunction, JFP, 51(5): 466-71, 2002.

Diagnosing Heart FailureDiagnosing Heart FailureSymptomsSymptoms

Decreased exercise toleranceDecreased exercise tolerance Fluid retentionFluid retention FatigueFatigue Incidentally noted left ventricular Incidentally noted left ventricular

dysfunction in an asymptomatic dysfunction in an asymptomatic patientpatient

Elevated jugular venous pressureElevated jugular venous pressure Pulmonary ralesPulmonary rales SS33

SS33 – volume overload – volume overload

SS44 – pressure overload – pressure overload

Peripheral edemaPeripheral edema

Diagnosing Heart FailureDiagnosing Heart FailureClinical SignsClinical Signs

Diagnosing Diagnosing Heart FailureHeart Failure

Clinical SignsClinical Signs

Auscultatory FindingsAuscultatory Findings

SS33

SS44

http://www.egeneralmedical.com/http://www.egeneralmedical.com/listohearmur.htmllistohearmur.html

RalesRales http://www.wilkes.med.ucla.edu/http://www.wilkes.med.ucla.edu/

intro.htmlintro.html

Common EKG Common EKG FindingsFindings

CXR findings in CXR findings in Heart FailureHeart Failure

Diagnosing Heart FailureDiagnosing Heart Failure

Many different terms:Many different terms: Left vs right-sided failureLeft vs right-sided failure Backward vs forward failureBackward vs forward failure Volume vs pressure overloadVolume vs pressure overload Systolic vs diastolic dysfunction – Systolic vs diastolic dysfunction –

there is a lot of overlap as many there is a lot of overlap as many patients have aspects of both patients have aspects of both entitiesentities

EchocardiographyEchocardiography

A generally accepted definition of A generally accepted definition of depressed systolic function is an depressed systolic function is an ejection fraction < 40%, from the ejection fraction < 40%, from the ACC guideline on the use of ACC guideline on the use of echocardiography.echocardiography.

Note that this is not a useful Note that this is not a useful definition in diastolic dysfunction as definition in diastolic dysfunction as the EF may actually be increased in the EF may actually be increased in diastolic dysfunction.diastolic dysfunction.

Heart Failure Stages Heart Failure Stages vsvs

NYHA ClassesNYHA Classes ACC-AHA Stage NYHA Functional Classification

A: At high risk for HF but without structural heart disease or symptoms of HF (Eg, patients with HTN or CAD)

None

B: Structural heart disease but without symptoms of HF

I: Asymptomatic

C: Structural heart disease with prior or current symptoms of HF

II: Symptomatic with moderate exertion

III: Symptomatic with minimal exertion

D: Refractory HF requiring specialized interventions

IV: Symptomatic at rest (cardiac cripple)

Stages of Heart FailureStages of Heart Failure

Heart Failure Treatment Heart Failure Treatment OptionsOptions

Angiotensin Converting Enzyme Angiotensin Converting Enzyme Inhibitors (ACEIs)Inhibitors (ACEIs)

Beta-blockersBeta-blockers DiureticsDiuretics DigoxinDigoxin Angiotensin Receptor Blockers Angiotensin Receptor Blockers

(ARBs)(ARBs) Other medicationsOther medications

Site of Site of Action of Action of MedicatioMedicatio

nsns

ACEIs ACEIs

ACEIsACEIs

They are the most studied class with They are the most studied class with years of experience and large years of experience and large patient numbers in RCTs. Proven patient numbers in RCTs. Proven benefit to decrease mortality and benefit to decrease mortality and hospitalization for HF. hospitalization for HF.

ACEIsACEIs

A comparison of enalapril with hydralazine-A comparison of enalapril with hydralazine-isosirbide dinitrate in the treatment of isosirbide dinitrate in the treatment of chronic congestive heart failure.chronic congestive heart failure.

804 men on digoxin and diuretics were 804 men on digoxin and diuretics were randomized to receive enalapril or randomized to receive enalapril or hydralazine and isosorbide dinitrate. The hydralazine and isosorbide dinitrate. The enalapril arm demonstrated an 18% enalapril arm demonstrated an 18% mortality rate at 2 years compared with 25% mortality rate at 2 years compared with 25% for the hydralazine and isosorbide dinitrate for the hydralazine and isosorbide dinitrate arm.arm.

Cohn JN, NEJM, 325(5): 303-10, 1991 Cohn JN, NEJM, 325(5): 303-10, 1991

ACEIs – what dose?ACEIs – what dose?

ATLAS: Patients with NYHA class II to IV with ATLAS: Patients with NYHA class II to IV with and EF< or = 30% were assigned to either and EF< or = 30% were assigned to either low dose (2.5 – 5.0mg) or high dose (32.5 – low dose (2.5 – 5.0mg) or high dose (32.5 – 35mg) of lisinopril for up to five years. 35mg) of lisinopril for up to five years. Patients on the higher dose had a Patients on the higher dose had a nonsignificant decrease in mortality of 8% nonsignificant decrease in mortality of 8% with a significant 12% decrease in death or with a significant 12% decrease in death or hospitalization for any reason, as well as 24% hospitalization for any reason, as well as 24% fewer hospitalizations for heart failure. fewer hospitalizations for heart failure.

Packer M, Circulation, 100(23): 2312-8, 1999 Packer M, Circulation, 100(23): 2312-8, 1999

ACEIs – what dose?ACEIs – what dose?

Outcome of patients with congestive Outcome of patients with congestive heart failure treated with standard heart failure treated with standard versus high doses of enalapril: a versus high doses of enalapril: a multicenter study.multicenter study.

There were no differences in mortality There were no differences in mortality or hospitalizations between patients or hospitalizations between patients treated with up to 20 mg or those treated with up to 20 mg or those treated with up to 60 mg of enalapril.treated with up to 60 mg of enalapril.

Nanas J, JACC, 36: 2090-5, 2000. Nanas J, JACC, 36: 2090-5, 2000.

ACEIsACEIs

HOPE Trial: The use of ramipril in HOPE Trial: The use of ramipril in patients with multiple cardiac risk patients with multiple cardiac risk factors without known CHF or left factors without known CHF or left ventricular dysfunction reduces the risk ventricular dysfunction reduces the risk of death from any cause, MI, stroke, and of death from any cause, MI, stroke, and heart failure.heart failure.

HOPE investigators, NEJM, 342(3): 145-HOPE investigators, NEJM, 342(3): 145-153, 2000153, 2000

Consider in patients with Stage A Heart Consider in patients with Stage A Heart FailureFailure

Beta-blockersBeta-blockers


Beta-1 selective = metoprolol and Beta-1 selective = metoprolol and bisoprololbisoprolol

Alpha-1 and beta-nonselective = Alpha-1 and beta-nonselective = carvedilol. carvedilol.

Beta-blockers reduce the risk of Beta-blockers reduce the risk of death and the hospitalization. All death and the hospitalization. All three have shown benefit. three have shown benefit.


US Carvedilol Heart Failure Study US Carvedilol Heart Failure Study Group: Carvedilol was added to Group: Carvedilol was added to background therapy of ACEI, diuretics, background therapy of ACEI, diuretics, and digoxin. Patients receiving and digoxin. Patients receiving carvedilol experienced a 65% decrease carvedilol experienced a 65% decrease in mortality, a 27% decrease in in mortality, a 27% decrease in hospitalizations, and a 38% decrease in hospitalizations, and a 38% decrease in the combination of the two.the combination of the two.

Packer M, NEJM, 334(21): 1349-55, Packer M, NEJM, 334(21): 1349-55, 1996.1996.


CIBIS-II: Bisoprolol was added to CIBIS-II: Bisoprolol was added to standard therapy (diuretics and standard therapy (diuretics and ACEIs) in patients with NYHA III or ACEIs) in patients with NYHA III or IV with EF < 35%. Study was IV with EF < 35%. Study was stopped early because of the benefit. stopped early because of the benefit. The hazard ratio of death was 0.56 The hazard ratio of death was 0.56 vs placebo.vs placebo.

Anon., Lancet, 353(9146): 9-13, Anon., Lancet, 353(9146): 9-13, 1999.1999.


MERIT-HF: Patients had NYHA class II MERIT-HF: Patients had NYHA class II to IV, an EF<40%, and were stabilized to IV, an EF<40%, and were stabilized with optimum medical therapy. Patients with optimum medical therapy. Patients were randomized to receive the beta-1 were randomized to receive the beta-1 blocker metoprolol CR/XL. Patients in blocker metoprolol CR/XL. Patients in therapy experienced a 19% decrease in therapy experienced a 19% decrease in mortality or all-cause hospitalizations and mortality or all-cause hospitalizations and a 31% decrease in HF hospitalizations.a 31% decrease in HF hospitalizations.

Hjalmarson A, JAMA, 283(10): 1295-1302, Hjalmarson A, JAMA, 283(10): 1295-1302, 2000.2000.


CAPRICORN: Effect of carvedilol on outcome CAPRICORN: Effect of carvedilol on outcome after myocardial infarction in patients with after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN left-ventricular dysfunction: the CAPRICORN randomized trial.randomized trial.

1959 patients post MI with EF<40% were 1959 patients post MI with EF<40% were randomized to carvedilol or placebo. All-randomized to carvedilol or placebo. All-cause (ARR 3%) and cardiovascular cause (ARR 3%) and cardiovascular mortality, as well as non-fatal MI were mortality, as well as non-fatal MI were reduced in patients on carvedilol.reduced in patients on carvedilol.

Dargie H, Lancet, 357(9266): 1385-90, 2001.Dargie H, Lancet, 357(9266): 1385-90, 2001.

Beta-blockersBeta-blockers COPERNICUS: Effect of carvedilol on the morbidity of COPERNICUS: Effect of carvedilol on the morbidity of

patients with severe chronic heart failure: results of the patients with severe chronic heart failure: results of the carvedilol prospective randomized cumulative survival carvedilol prospective randomized cumulative survival study.study.

2289 patients with severe heart failure (EF<25%) were 2289 patients with severe heart failure (EF<25%) were randomized to receive carvedilol or placebo for an randomized to receive carvedilol or placebo for an average of ten months. Mortality from cardiovascular average of ten months. Mortality from cardiovascular causes and heart failure mortality or hospitalization causes and heart failure mortality or hospitalization were both decreased by 27% and 31% respectively. In were both decreased by 27% and 31% respectively. In euvolemic patients with symptoms at rest or on minimal euvolemic patients with symptoms at rest or on minimal exertion, the addition of carvedilol to conventional exertion, the addition of carvedilol to conventional therapy ameliorates the severity of heart failure and therapy ameliorates the severity of heart failure and reduces the risk of clinical deterioration, hospitalization, reduces the risk of clinical deterioration, hospitalization, and other serious adverse clinical events.and other serious adverse clinical events.

Packer M, Circulation, 106(17):2194-9, 2002.Packer M, Circulation, 106(17):2194-9, 2002.

Beta-blockersBeta-blockers COMET: Comparison of carvedilol and COMET: Comparison of carvedilol and

metoprolol on clinical outcomes in patients metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or with chronic heart failure in the Carvedilol Or Metoprolol European Trial.Metoprolol European Trial.

1511 patients on standard HF therapy with 1511 patients on standard HF therapy with EF<35% were randomized to receive EF<35% were randomized to receive carvedilol or metoprolol. After 5 years, all carvedilol or metoprolol. After 5 years, all cause mortality was 34% with carvedilol and cause mortality was 34% with carvedilol and 40% with metoprolol. The composite 40% with metoprolol. The composite endpoint of all-cause mortality and endpoint of all-cause mortality and hospitalization was the same in both groups.hospitalization was the same in both groups.

Poole-Wilson P, Lancet, 362(9377):7-13, 2003Poole-Wilson P, Lancet, 362(9377):7-13, 2003

DiureticsDiuretics

DiureticsDiuretics

No dedicated RCTs to evaluate the No dedicated RCTs to evaluate the use of loop diuretics. (Perhaps use of loop diuretics. (Perhaps unethical now that their use is unethical now that their use is standard of care)standard of care)

Diuretics are added when patients Diuretics are added when patients experience symptoms or signs of experience symptoms or signs of volume overload.volume overload.

DiureticsDiuretics

Furosemide (Lasix) usually the first Furosemide (Lasix) usually the first line, although HCTZ could be used.line, although HCTZ could be used.

Only loop diuretics are effective Only loop diuretics are effective when the CrCl drops below when the CrCl drops below 30cc/min.30cc/min.

Diuretics and the Diuretics and the neurohormonal basis of neurohormonal basis of

heart failureheart failure RALES Trial: Spironolactone was added to RALES Trial: Spironolactone was added to

therapy in patients with severe heart failure therapy in patients with severe heart failure and an EF<35% being treated with ACEIs, and an EF<35% being treated with ACEIs, diuretics, and (in most cases) digoxin. The diuretics, and (in most cases) digoxin. The study was stopped early after demonstrating study was stopped early after demonstrating an absolute decrease in mortality of 11% (RR an absolute decrease in mortality of 11% (RR = 0.70) and an relative decrease in = 0.70) and an relative decrease in hospitalization of 35% (RR = 0.65). 10% of hospitalization of 35% (RR = 0.65). 10% of males had gynecomastia or mastalgia. males had gynecomastia or mastalgia. Minimal hyperkalemia was reported.Minimal hyperkalemia was reported.

Pitt B, NEJM, 341(10): 709-17, 1999.Pitt B, NEJM, 341(10): 709-17, 1999.

Diuretics and the Diuretics and the neurohormonal basis of neurohormonal basis of

heart failureheart failure Ephesus trial - The use of eplerenone in Ephesus trial - The use of eplerenone in

patients post-MI who had an EF<40% patients post-MI who had an EF<40% and clinical signs of heart failure showed and clinical signs of heart failure showed benefit. Patients on the medication benefit. Patients on the medication experienced and absolute risk reduction experienced and absolute risk reduction in mortality of 2.3% (RRR = 14%).in mortality of 2.3% (RRR = 14%).

Pitt B, et al. Eplerenone, a selective Pitt B, et al. Eplerenone, a selective aldosterone blocker, in patients with left aldosterone blocker, in patients with left ventricular dysfunction after myocardial ventricular dysfunction after myocardial infarction. N Engl J Med, 348:1309-21, infarction. N Engl J Med, 348:1309-21, 2003. 2003.

DigoxinDigoxin

DigoxinDigoxin

RADIANCE Study: Patients on a stable RADIANCE Study: Patients on a stable regimen of digoxin, ACEI, and diuretic regimen of digoxin, ACEI, and diuretic were randomized to removal of were randomized to removal of digoxin or maintenance of therapy. digoxin or maintenance of therapy. Those patients off digoxin experienced Those patients off digoxin experienced a significant increase in worsening a significant increase in worsening heart failure and decreased measures heart failure and decreased measures of functional capacity.of functional capacity.

Packer M, NEJM, 329(1): 1-7, 1993.Packer M, NEJM, 329(1): 1-7, 1993.

DigoxinDigoxin

Digitalis Intervention Group: Patients Digitalis Intervention Group: Patients on ACEI and diuretics were on ACEI and diuretics were randomized to receive digoxin or randomized to receive digoxin or placebo. Overall mortality was similar placebo. Overall mortality was similar in both groups. However, digoxin did in both groups. However, digoxin did decrease the risk of worsening heart decrease the risk of worsening heart failure and hospitalization.failure and hospitalization.

Rekha G, NEJM, 336(8): 525-33, 1997.Rekha G, NEJM, 336(8): 525-33, 1997.

ARBsARBs

Angiotensin Receptor Angiotensin Receptor Blockers (ARBs)Blockers (ARBs)

The ARBs – studies have shown that The ARBs – studies have shown that they have efficacy close to that of they have efficacy close to that of ACEIs. ACEIs.

ARBs are frequently used in patients ARBs are frequently used in patients who cannot tolerate ACEIs (cough, who cannot tolerate ACEIs (cough, h/o angioedema). h/o angioedema).

They are expensive. They are expensive.

ARBsARBs ELITE: Evaluation of losartan in the elderly. ELITE: Evaluation of losartan in the elderly.

722 patients older than 65 with EF<40% and 722 patients older than 65 with EF<40% and ACEI naïve were randomized to losartan or ACEI naïve were randomized to losartan or captopril, in addition to standard therapies captopril, in addition to standard therapies (ACEIs, diuretics, digoxin, nitrates and (ACEIs, diuretics, digoxin, nitrates and hydralazine). Patients on losartan has less side hydralazine). Patients on losartan has less side effects, a nonsignificant decrease in death effects, a nonsignificant decrease in death and/or hospital admission for heart failure, and and/or hospital admission for heart failure, and a significant decrease in all-cause mortality a significant decrease in all-cause mortality (risk reduction = 46%). Admissions for heart (risk reduction = 46%). Admissions for heart failure were the same in both groups.failure were the same in both groups.

Pitt B, Lancet, 349(9054): 747-52, 1997 Pitt B, Lancet, 349(9054): 747-52, 1997

ARBsARBs

ELITE-II: Effect of losartan compared with ELITE-II: Effect of losartan compared with captoril on mortality in patients with captoril on mortality in patients with symptomatic heart failure: a randomized symptomatic heart failure: a randomized trial – the Losartan Heart Failure Survival trial – the Losartan Heart Failure Survival Study. 3152 patients 60 years or older with Study. 3152 patients 60 years or older with NYHA class II to IV heart failure and NYHA class II to IV heart failure and EF<40% were randomized to losartan or EF<40% were randomized to losartan or captopril. The mortality and rates of captopril. The mortality and rates of sudden death or resuscitated arrests were sudden death or resuscitated arrests were the same in both groups.the same in both groups.

Pitt B, Lancet, 355(9215): 1582-7, 2000Pitt B, Lancet, 355(9215): 1582-7, 2000

ARBsARBs

LIFE trial: Hypertensive patients were LIFE trial: Hypertensive patients were treated with either losartan or atenolol. treated with either losartan or atenolol. Patients were followed for at least four Patients were followed for at least four years. 508 patients on losartan years. 508 patients on losartan experienced the composite endpoint of experienced the composite endpoint of death, MI, or stroke, compared with 588 death, MI, or stroke, compared with 588 patients on atenolol (RR = 0.87).patients on atenolol (RR = 0.87).

Dahlof B, Lancet, 359(9311): 995-1003, Dahlof B, Lancet, 359(9311): 995-1003, 2002.2002.

ARBsARBs Val-HeFT: A randomized trial of the Val-HeFT: A randomized trial of the

angiotensin-receptor blocker valsartan in angiotensin-receptor blocker valsartan in chronic heart failure. 5010 patients with chronic heart failure. 5010 patients with NYHA class II to IV HF were randomized to NYHA class II to IV HF were randomized to receive valsartan or placebo in addition to receive valsartan or placebo in addition to standard therapy. Overall mortality was the standard therapy. Overall mortality was the same. Hospitalizations were 4.4% less. same. Hospitalizations were 4.4% less. Treatment with valsartan improved NYHA Treatment with valsartan improved NYHA class, EF, signs and symptoms of HF, and class, EF, signs and symptoms of HF, and quality of life. Post hoc analysis showed the quality of life. Post hoc analysis showed the valsartan had a favorable outlook in patients valsartan had a favorable outlook in patients receiving ACEI or beta-blockade but an receiving ACEI or beta-blockade but an adverse effect in patients receiving both.adverse effect in patients receiving both.

Cohn J, et al, NEJM, 345(23): 1667-75, 2001Cohn J, et al, NEJM, 345(23): 1667-75, 2001

ARBsARBs

CHARM-Alternative Trial CHARM-Alternative Trial (Candesartan substituted for ACEI in (Candesartan substituted for ACEI in ACEI intolerant patients).ACEI intolerant patients).

2028 patients with symptomatic heart 2028 patients with symptomatic heart failure and EF<40% were randomized failure and EF<40% were randomized to candesartan or placebo, in addition to candesartan or placebo, in addition to standard therapy. After 3 years, to standard therapy. After 3 years, cardiovascular mortality and hospital cardiovascular mortality and hospital admissions for CHF were both less admissions for CHF were both less (3% and 8% absolute risk reduction).(3% and 8% absolute risk reduction).

ARBsARBs

CHARM-Added TrialCHARM-Added Trial In this trial, 2548 patients taking In this trial, 2548 patients taking

ACEIs with a decreased EF<40% were ACEIs with a decreased EF<40% were randomized to receive candesartan or randomized to receive candesartan or placebo in addition to the ACEI.placebo in addition to the ACEI.

Cardiovascular and noncardiovascular Cardiovascular and noncardiovascular mortality were reduced significantly in mortality were reduced significantly in the candesartan group (ARR = 4%, the candesartan group (ARR = 4%, RRR = 10%), as were hospitalizations.RRR = 10%), as were hospitalizations.

ARBsARBs

CHARM-Preserved Trial: Candasartan in CHARM-Preserved Trial: Candasartan in Heart failure Assessment of Reduction in Heart failure Assessment of Reduction in Mortality and morbidity study. (A trio of Mortality and morbidity study. (A trio of trials.)trials.)

In this trial, 3023 patients with a preserved In this trial, 3023 patients with a preserved EF>40% were randomized to receive EF>40% were randomized to receive candesartan or placebo. Cardiovascular and candesartan or placebo. Cardiovascular and noncardiovascular mortality were the same in noncardiovascular mortality were the same in both groups, while hospitalizations were both groups, while hospitalizations were modestly decreased.modestly decreased.

Yusuf S, Lancet, 362: 777-81, 2003.Yusuf S, Lancet, 362: 777-81, 2003.

ARBsARBs

VALIANT trial – valsartan is as effective VALIANT trial – valsartan is as effective as captopril post-MI in patients with as captopril post-MI in patients with decreased EF.decreased EF. Pfeffer MA et al, NEJM, 349: 1893-906, 2003 Pfeffer MA et al, NEJM, 349: 1893-906, 2003

RESOLVD trial – candesartan with RESOLVD trial – candesartan with enalapril and ER metoprolol enalapril and ER metoprolol demonstrated the most improvement in demonstrated the most improvement in EF from baseline. No clinical outcomes.EF from baseline. No clinical outcomes. McKelvie RS et al, Eur Heart J, 24: 1727-34, McKelvie RS et al, Eur Heart J, 24: 1727-34,

20032003

Number Needed to Treat* for Different Number Needed to Treat* for Different Drugs in CHF Drugs in CHF

ACE inhibitors14 6 One death over one year in patients with NYHA class III and IV failure

100

One death over one year in patients with NYHA class I or II failure

Beta blockers15 23 One death over one year

13 One hospitalization over one year

Spironolactone2 9 One death over two years in patients with NYHA class IV failure

Hydralazine and isosorbide dinitrate13

14 One death over one year

Digoxin16 9 Emergency department visits or hospitalizations

*--Number needed to treat (NNT) is the number of patients who need to be treated to prevent one outcome from occurring. NNT=100/absolute risk reduction.

Now, let’s have Now, let’s have some shocking some shocking

news…news…

Yes, we’re talking Yes, we’re talking about ICDsabout ICDs

Implantable cardioverter-Implantable cardioverter-defibrillatordefibrillator

SCD-HeFT trialSCD-HeFT trialSudden Cardiac Death in Sudden Cardiac Death in

Heart Failure Trial Heart Failure Trial InvestigatorsInvestigators

2521 pts with NYHA class II or III 2521 pts with NYHA class II or III were randomized to placebo, were randomized to placebo, amiodarone, or ICD.amiodarone, or ICD.

Pts were already receiving standard Pts were already receiving standard medical therapymedical therapy

DeathsDeaths Placebo group = 244 (29%)Placebo group = 244 (29%) Amiodarone = 240 (28%) Amiodarone = 240 (28%) ICD = 182 (22%)ICD = 182 (22%)Bardy, G, et al, SCD-HeFT, NEJM, January 20, 2005; 352: 3, pp 225-237

SCD-HeFT trialSCD-HeFT trialSudden Cardiac Death in Sudden Cardiac Death in

Heart Failure Trial Heart Failure Trial InvestigatorsInvestigators

The ICD group had a 23% relative risk The ICD group had a 23% relative risk reduction, or an absolute risk reduction reduction, or an absolute risk reduction of 7.2%.of 7.2%.

NNT for benefit = ?NNT for benefit = ? So, who should get an ICD?So, who should get an ICD?

Current Indications for Current Indications for ICDICD

Patients at high risk for ventricular Patients at high risk for ventricular arrhythmiasarrhythmias

Patients with EF < 35% and NYHA class Patients with EF < 35% and NYHA class II or III heart failureII or III heart failure

Patients with a history of MI and EF < Patients with a history of MI and EF < 30%30%

Goldberger, Z, Implantable Cardioverter-Defibrillators, JAMA, February 15, 2006; 295:7, pp 809 - 818

Summary PointsSummary Points

Heart failure has a prognosis similar to that Heart failure has a prognosis similar to that of cancer. As such, treat it aggressively.of cancer. As such, treat it aggressively.

There is a new staging system to classify There is a new staging system to classify heart failure:heart failure: Stage A – at risk but no structural heart disease Stage A – at risk but no structural heart disease

(HD)(HD) Stage BStage B – no symptoms but structural HD – no symptoms but structural HD

presentpresent Stage C – patient with symptomatic HFStage C – patient with symptomatic HF Stage D – refractory heart failureStage D – refractory heart failure


Standard medication classes for HF Standard medication classes for HF include:include: ACEIsACEIs Beta blockersBeta blockers Diuretics if volume overloadedDiuretics if volume overloaded Consider digoxin, spironolactoneConsider digoxin, spironolactone Consider ARBs, especially in ACEI intolerant Consider ARBs, especially in ACEI intolerant

patientpatient Beta-blockers continue to look good for Beta-blockers continue to look good for

HFHF


Preserved EF is about as common as Preserved EF is about as common as depressed EF in heart failure.depressed EF in heart failure.

Many patients have diastolic Many patients have diastolic dysfunction.dysfunction.

Remember to also care for the patient Remember to also care for the patient as a person, not just a disease.as a person, not just a disease.

A gentle touch and a kind smile might A gentle touch and a kind smile might feel better than a lasix-induced feel better than a lasix-induced diuresis diuresis

Thank you for Thank you for your timeyour time

The EndThe End

101

Additional Additional materialmaterial

BNPBNP

The Breathing Not Properly study The Breathing Not Properly study Maisel A, et al, Rapid Measurement of B-Maisel A, et al, Rapid Measurement of B-

Type Natriuretic Peptide in the Emergency Type Natriuretic Peptide in the Emergency Diagnosis of Heart Failure, NEJM, 347(3): Diagnosis of Heart Failure, NEJM, 347(3): 161-7, 2002.161-7, 2002.

A number > 100 is suggestive of heart A number > 100 is suggestive of heart failure. failure.

Some thought to using this Some thought to using this prospectively to screen for heart prospectively to screen for heart failure, stage B. No RCTs to date. failure, stage B. No RCTs to date.

ACEIsACEIs CONSENSUS: Enalapril added to CONSENSUS: Enalapril added to

vasodilator therapy decreased vasodilator therapy decreased mortality by 27% in patients with mortality by 27% in patients with severe (NYHA IV) heart failure.severe (NYHA IV) heart failure.

Anon., NEJM, 316(23): 1429-35, Anon., NEJM, 316(23): 1429-35, 1987.1987.

ACEIsACEIs SAVE Trial: Effect of captopril on mortality and SAVE Trial: Effect of captopril on mortality and

morbidity in patients with left ventricular morbidity in patients with left ventricular dysfunction after myocardial infaction. Results dysfunction after myocardial infaction. Results of the Survival And Ventricular Enlargement of the Survival And Ventricular Enlargement trial.trial.

2231 patients with an EF<40% who survived an 2231 patients with an EF<40% who survived an MI were randomized to receive captopril and MI were randomized to receive captopril and followed for 42 months. Risks for mortality (5% followed for 42 months. Risks for mortality (5% absolute risk reduction), fatal and nonfatal absolute risk reduction), fatal and nonfatal major cardiovascular events, development of major cardiovascular events, development of severe heart failure, and recurrent MI were all severe heart failure, and recurrent MI were all reduced.reduced.

Pfeffer MA, NEJM, 327(10): 669-77, 1992Pfeffer MA, NEJM, 327(10): 669-77, 1992

ACEIsACEIs

SOLVD Trial: Enalapril therapy in SOLVD Trial: Enalapril therapy in patients with an EF< 35% not being patients with an EF< 35% not being treated for CHF demonstrated a treated for CHF demonstrated a statistically significant decrease in the statistically significant decrease in the combined endpoint of development of combined endpoint of development of clinical CHF and death. Of note, when clinical CHF and death. Of note, when studying the end point of mortality, studying the end point of mortality, there was no statistical difference there was no statistical difference between enalapril and placebo.between enalapril and placebo.

Anon., NEJM, 327(10): 685-91, 1992.Anon., NEJM, 327(10): 685-91, 1992.

Beta-blockersBeta-blockers Differential effects of beta-blockers in Differential effects of beta-blockers in

patients with heart failure: A prospective, patients with heart failure: A prospective, randomized double-blind comparison of the randomized double-blind comparison of the long-term effects of metoprolol versus long-term effects of metoprolol versus carvedilol.carvedilol.

150 patients with EF <35% were randomized 150 patients with EF <35% were randomized to metoprolol or carvedilol. After 2 years, to metoprolol or carvedilol. After 2 years, patients in the carvedilol showed a 3.7% patients in the carvedilol showed a 3.7% increase in EF, greater stroke volume and increase in EF, greater stroke volume and decreased PCWP compared with metoprolol. decreased PCWP compared with metoprolol. Conversely, metoprolol showed a greater Conversely, metoprolol showed a greater increase in exercise capacity. Mortality was increase in exercise capacity. Mortality was similar (small study).similar (small study).

Metra M, Circulation, 102(5): 546-51, 2000.Metra M, Circulation, 102(5): 546-51, 2000.

Trends in Prevalence and Trends in Prevalence and Outcome of Heart Failure with Outcome of Heart Failure with

Preserved Ejection FractionPreserved Ejection Fraction 4596 patients admitted to Mayo Clinic 4596 patients admitted to Mayo Clinic

Hospitals from 1987 to 2001.Hospitals from 1987 to 2001. 53% had reduced ejection fraction53% had reduced ejection fraction 47% had preserved ejection fraction47% had preserved ejection fraction Survival was slightly better among Survival was slightly better among

those with preserved EF – adjusted those with preserved EF – adjusted hazard ration for death = 0.96, p = hazard ration for death = 0.96, p = 0.01.0.01.

Owan, TE, et al, Trends in Prevalence and Outcome of Heart Failure with Trends in Prevalence and Outcome of Heart Failure with Preserved Ejection Fraction, NEJM, 355:3, July 20, 2006, pp 251-259Preserved Ejection Fraction, NEJM, 355:3, July 20, 2006, pp 251-259

Take home pointsTake home points

Starting with an ACEI is still Starting with an ACEI is still standard of care.standard of care.

However, future studies with FDA However, future studies with FDA approved drugs for heart failure in approved drugs for heart failure in the USA may confirm that beta-the USA may confirm that beta-blockers are equally efficacious blockers are equally efficacious (noninferior) to ACEIs for the initial (noninferior) to ACEIs for the initial treatment of HF.treatment of HF.

Outcome of Heart Failure Outcome of Heart Failure with Preserved Ejection with Preserved Ejection

Fraction in a Population-Fraction in a Population-Based StudyBased Study

2802 patients admitted to 103 2802 patients admitted to 103 Canadian hospitals from April 1999 to Canadian hospitals from April 1999 to March 2001 with a discharge March 2001 with a discharge diagnosis of heart failure.diagnosis of heart failure.

31% had ejection fraction (EF) > 50%31% had ejection fraction (EF) > 50% More likely to be older, female, history More likely to be older, female, history

of HTN, history of atrial fibrillationof HTN, history of atrial fibrillationBhatia, RS, et al, Outcome of Heart Failure with Preserved Ejection Fraction in a Outcome of Heart Failure with Preserved Ejection Fraction in a Population-Based Study, NEJM, 355:3, July 20, 2006, pg 260-269Population-Based Study, NEJM, 355:3, July 20, 2006, pg 260-269

Outcome of Heart Failure Outcome of Heart Failure with Preserved Ejection with Preserved Ejection

Fraction in a Population-Fraction in a Population-Based StudyBased Study

Mortality rate of preserved EF (>50%) Mortality rate of preserved EF (>50%) vs reduced EF (<40%) at 30 daysvs reduced EF (<40%) at 30 days 5% vs 7% respectively5% vs 7% respectively

At one year, the rates were 22% vs 26%, At one year, the rates were 22% vs 26%, p=0.07, not significantly different.p=0.07, not significantly different.

Patients with preserved EF have similar Patients with preserved EF have similar rates for mortality and readmission for rates for mortality and readmission for heart failureheart failure

Bhatia, RS, et al, Outcome of Heart Failure with Preserved Ejection Fraction in a Outcome of Heart Failure with Preserved Ejection Fraction in a Population-Based Study, NEJM, 355:3, July 20, 2006, pg 260-269Population-Based Study, NEJM, 355:3, July 20, 2006, pg 260-269

Systolic blood pressure on Systolic blood pressure on admission and patient admission and patient

outcomesoutcomes 41,267 patients admitted for heart 41,267 patients admitted for heart

failure to 259 hospitals between failure to 259 hospitals between March 2003 – December 2004.March 2003 – December 2004. Good numbers!Good numbers!

21,149 (51%) had preserved systolic 21,149 (51%) had preserved systolic functionfunction Meaning, half the patients had diastolic Meaning, half the patients had diastolic

dysfunctiondysfunctionGheorghiade, M, et al, Systolic Blood Pressure at Admission, Clinical Characteristics, and Outcomes in Patients Hospitalized With Acute Heart Failure, JAMA, Nov. 8, 2006, Vol. 296, No. 18, pp 2217-26

Straw poll…Straw poll…Sys 120 = Sys 120 = outcome?outcome?

vs Sys 150 = vs Sys 150 = outcome?outcome?

Who does better?Who does better?

Systolic blood pressure on Systolic blood pressure on admission and patient admission and patient

outcomesoutcomes

0

1

2

3

4

5

6

7

8

<120 120-139 140-161 >161

Systolic blood pressure at admission in mmHg

Percentmortalityat discharge

7.2%

3.6%

2.5%1.7%

Interesting outcomesInteresting outcomes Lower systolic at admission directly Lower systolic at admission directly

correlated with increased mortalitycorrelated with increased mortality Concept of the “J” curve in treatment of Concept of the “J” curve in treatment of

hypertensionhypertension So, what systolic blood pressure do we So, what systolic blood pressure do we

shoot for in patients with stable heart shoot for in patients with stable heart failure in the clinic?failure in the clinic?

Still use national guidelines but stay tunedStill use national guidelines but stay tuned

Systolic and Diastolic Heart Systolic and Diastolic Heart Failure in the CommunityFailure in the Community

Inpatients and outpatients diagnosed with heart Inpatients and outpatients diagnosed with heart failure underwent echocardiographic testing failure underwent echocardiographic testing between September 10, 2003 and October 27, between September 10, 2003 and October 27, 2005.2005.

556 study participants556 study participants Preserved EF > 50 % present in 308 (55%) of Preserved EF > 50 % present in 308 (55%) of

patientspatients Associated with older age, female sex, no h/o MI Associated with older age, female sex, no h/o MI Isolated diastolic dysfunction present in 242 of patients of Isolated diastolic dysfunction present in 242 of patients of

these patients – 44% of total number (556) and 78% of these patients – 44% of total number (556) and 78% of patients with preserved EFpatients with preserved EF

EF < 50% in 248 patients (45%)EF < 50% in 248 patients (45%) Diastolic dysfunction present in 204 (83%) of these Diastolic dysfunction present in 204 (83%) of these

patientspatientsBursi, F, Systolic and Diastolic Heart Failure in the Community, JAMA, Nov. 8, 2006, Systolic and Diastolic Heart Failure in the Community, JAMA, Nov. 8, 2006, 296:18, pp 2209-2216296:18, pp 2209-2216

Systolic and Diastolic Heart Systolic and Diastolic Heart Failure in the CommunityFailure in the Community

Needham’s take on this data…Needham’s take on this data… A little more than half (55%) of patients A little more than half (55%) of patients

had preserved EF at the time of diagnosis had preserved EF at the time of diagnosis of heart failure.of heart failure.

Almost 80% of all patients with heart Almost 80% of all patients with heart failure have diastolic dysfunction, whether failure have diastolic dysfunction, whether they have depressed or preserved EF.they have depressed or preserved EF.

Many patients will have a mix of systolic Many patients will have a mix of systolic dysfunction (depressed EF) and diastolic dysfunction (depressed EF) and diastolic dysfunction.dysfunction.

Bursi, F, Systolic and Diastolic Heart Failure in the Community, JAMA, Nov. 8, 2006, Systolic and Diastolic Heart Failure in the Community, JAMA, Nov. 8, 2006, 296:18, pp 2209-2216296:18, pp 2209-2216

Patient PresentationPatient Presentation Mr. Smith is a 67 yo male with a history of Mr. Smith is a 67 yo male with a history of

hypertension and diabetes who now hypertension and diabetes who now presents to your clinic with mild dyspnea presents to your clinic with mild dyspnea at the end of his 1 mile walk. No chest at the end of his 1 mile walk. No chest pain. He has occasional pedal edema. pain. He has occasional pedal edema.

VS – stableVS – stable Lungs – CTA, normal work of breathingLungs – CTA, normal work of breathing CV – RRR, nl S1 S2, no MRG heardCV – RRR, nl S1 S2, no MRG heard Extremities - 1-2+ pitting edema. Extremities - 1-2+ pitting edema.

Where do you go from here?Where do you go from here?

Heart Failure Heart Failure Susan Schayes, MD, MPH Program Director Emory Family Medicine Residency...

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