Management of Heart Failure: Role of the Heart Failure Clinicyear for heart failure. He is extremely...
Transcript of Management of Heart Failure: Role of the Heart Failure Clinicyear for heart failure. He is extremely...
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Management of Heart Failure: Role of the Heart Failure Clinic
Catherine Marti, MD MScPiedmont Athens Regional Cardiology Group
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Disclosures
• PI: Cardiomems post-approval study (St. Jude)
• Novartis, Abbott, Pfizer, Astra-Zeneca
• Compassionate Care Hospice
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1. Define heart failure, review epidemiologyand outcomes associated with diagnosis
2. Describe the available therapies for heart failure in the outpatient setting
Objectives
3. Identify available therapies for patients with advanced heart failure
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Heart Failure: Definition
• Heart failure is a clinical syndrome caused by various cardiac pathologies
• It is characterized by specific symptoms of impaired cardiac output, venous congestion, and fluid retention
• It results from any structural or functional disorder that impairs the ability of the ventricle to fill with or eject blood
• Can be due to HFrEF, HFpEF, infiltrative cardiomyopathy or other cardiac conditions
4
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Stages of Heart Failure
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Hospital Discharges for Heart Failure
Advanced Data; National Hospital Discharge Survey 1990-2004; Available at: http://www.cdc.gov/nchs/about/major/hdasd/listpubs.htm. Accessed: June 27, 2007.
600,000
700,000
800,000
900,000
1,000,000
1,100,000
1,200,000
Nu
mb
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of
dis
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Year
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Left ventricular modeling post MI
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Role of the Heart Failure Clinic
1. Assist patients with heart failure symptoms to arrive at the correct diagnosis
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All Heart Failure is Not the Same
Dilated Cardiomyopathy Restrictive Cardiomyopathy
Hypertrophic Cardiomyopathy Amyloid Cardiomyopathy
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Role of the Heart Failure Clinic
1. Assist patients with heart failure symptoms to arrive at the correct diagnosis
2. Treat patients with heart failure, titrating evidence based therapies
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Drugs for Long-term Therapy for Heart Failure with Reduced LVEF
Clinical Trial Benefit
✓ACE inhibitors orAngiotensin receptor blockers
✓Beta-blockers✓Aldosterone blockers✓Nitrate/Hydralazine✓Digoxin*
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Life Saving Therapy
35%
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Improvement of Systolic Function is Related to Beta Blocker Dose
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Heart Failure Cocktail: Effect of Adding Therapies
ARNI
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Device Therapy
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New Therapies?
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Drugs for Long-term Therapy for Heart Failure with Reduced LVEF
Clinical Trial Benefit
✓ACE inhibitors orAngiotensin receptor blockers
✓Beta-blockers✓Aldosterone blockers✓Nitrate/Hydralazine✓Digoxin
Sacubitril/Valsartan(ENTRESTO)
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Heart Failure Self Care
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Role of the Heart Failure Clinic
1. Assist patients with heart failure symptoms to arrive at the correct diagnosis
2. Treat patients with heart failure, titrating evidence based therapies
3. Act as an acute care clinic, managing patients with decompensated heart failure to avoid hospitalization
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Heart Failure Hospitalization is Ominous
Setoguchi. Am Heart J. 2007
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High risk patients for readmission
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Diuretic Resistance
• Inadequate dose
• Poor absorption, consider torsemide
• Reinforce salt restriction
• Add thiazide
• Add MRA
• Stop NSAIDS
• Consider low output heart failure
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IV Diuretic in Clinic
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HF Hospitalization Starts WeeksBefore Admission!
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Wireless Pulmonary Hemodynamic Monitoring
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Role of the Heart Failure Clinic1. Assist patients with heart failure symptoms
to arrive at the correct diagnosis
2. Treat patients with heart failure, titrating evidence based therapies
3. Act as an acute care clinic, managing patients with decompensated heart failure to avoid hospitalization
4. Manage patients with end-stage heart failure: advance therapies (transplant or LVAD) or palliative (inotropes)
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Transplant Is Not a Viable Option for Many Patients
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Home Inotropic Therapy
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Improved Outcomes in Stage D with Advanced Therapies for Heart Failure
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Left Ventricular Assist Device
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Improving Outcomes with LVAD
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No. at Risk:HeartMate 3LVADHeartMate II LVAD
Survival at 2 years in the LT cohortKaplan-Meier estimates of all-cause survival
43
43
HeartMate 3™ LVAD survival is comparable to transplant survival at 2
years2*
83%SURVIVAL1
References: 1. Mehra MR, Goldstein DJ, Uriel N, et al. Two-Year Outcomes with a Magnetically Levitated Cardiac Pump in Heart Failure. N Engl J Med. 2018;378(15):1386-1395. 2. Lund LF, Khush KK, Cherikh WS, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirty-fourth Adult Heart Transplantation Report—2017; Focus theme: allograft ischemic time. J Heart Lung Transplant. 2017;36:1037-1046.
43
*82% 2-year survival for heart transplant patients between 2009 and 2015.2
HeartMate II™
LVAD
HeartMate 3™
LVAD
SJM-HM3-1018-0145 | Item approved for U.S. use only.
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STROKE
INFECTION
BLEEDING
RIGHT HEART FAILURE
PUMP THROMBOSIS
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VAD Complications
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Improved Quality of Life
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Palliative Care: Not just for Stage D
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Question #1
A 56 y/o man with ischemic cardiomyopathy comes into clinic. He has been hospitalized four times this year for heart failure. He is extremely fatigued and had to stop twice on the way into clinic. His BP is 82/60 and he is not able to tolerate any medicines for heart failure. You should,
A. Start him on very low dose metoprololB. Increase his diureticsC. Refer him to heart failure clinic for advanced
therapies
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Question #2
You see a 59 y/o man in clinic with new onset heart failure, LVEF 20%. His BP is 97/60 and HR is 72. You are nervous about starting medications because of his low blood pressure but then you remember that if you start him on a beta blocker you could potentially reduce his mortality by:
A. 5%B. 10%C. 35%
49
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Question #3
You see a 74 y/o M in clinic with end stage heart failure. He asks about the “new heart pump”. You tell him that left ventricular assist devices (LVAD) have been shown to:
A. Reduce heart failure mortality
B. Improve quality of life
C. Both
50
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Additional Resources
PAR Heart Failure Clinic!
706-475-1700
• www.hfsa.org/heart-failure-guidelines
• www.hfsa.org/accahahfsa-guideline-management-heart-failure-update/