Martin R. Cowie Professor of Cardiology Imperial College ...

Martin R. Cowie

Professor of Cardiology

Imperial College London

(Royal Brompton Hospital)

[email protected]

@ProfMartinCowie

Declaration of interests

• Research grants from ResMed, Boston Scientific, St Jude Medical, Bayer

• Consultancy advice and speaker’s fees from Medtronic, ResMed, Boston Scientific, St Jude Medical, Respicardia, Servier, Pfizer, Novartis, Roche Diagnostics, Sorin, Boehringer-Ingelheim, Vifor, Fire1Foundry, Neurotronik

• Non-Executive Director of National Institute for Health and Care Excellence (NICE): but opinions expressed are my own

Today’s talk

Advanced heart failure

– “Requiring assessment for transplant, MCS or palliative care”,

typically: • Inotrope dependent, and/or

• symptoms at rest, or with minimal exertion, and cannot perform many activities of daily living

• peak MVO2 < 14 mls/kg/min

• 6MWT < 300m

• Failing or intolerant of conventional HF therapy

• Requiring repeated hospitalization for more intensive management

• Estimated 1-year survival by the SHFM of <80%

But, the patient ‘journey’ is complex

Co-morbidity is (almost) universal

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf

$

Hosp

Adm

Readmission within 30 days

The incidence of heart failure The Hillingdon Heart Failure Study

0

2

4

6

8

10

12

14

16

18

25-34 35-44 45-54 55-64 65-74 75-84 85+

Men Women

Incidence

(new cases/1000

population/year)

Age group (years)

Cowie et al, Eur Heart J, 1999; 20: 421-8

Median age at first presentation is 76 years

Coronary artery disease was/is the leading cause of heart failure

Fox et al, Eur. Heart J. 2001; 22: 228-36

Full investigation (including coronary angiography)

in new patients aged <75 in a UK population-based study

Coronary artery

disease (52%)

Hypertension

alone (4%)

Valve disease

(10%)

Alcohol (4%)

AF alone (3%)

Other (5%)

Idiopathic

(no CAD) (13%)

Undetermined

(no angiographic data) (10%)

time (days)

2101801501209060300-30

Cum

ula

tive s

urv

ival

1.1

1.0

.9

.8

.7

.6

.5

.4

Hillingdon/Hastings

2004-5

London studies

1995-7

6%

11% 14%

16% 22% 25%

P < 0.0001

Survival is improving The London Studies

Heart 2009; 95: 1851-6

Sacubitril/Valsartan significantly reduced all-cause mortality vs enalapril1,2

11

1. McMurray et al. N Engl J Med 2014;371:993–1004.

2. McMurray JVV. All-cause and cardiovascular mortality. P1730 Seville 2015.

Hazard ratio 0.84

(95% CI: 0.76, 0.93)

ARR:2.8%

p=0.0005

NNT=35

ARR=absolute risk reduction (at median F/U 27 months).

30

10

0 0 1080 900

Cu

mu

lati

ve p

rop

ort

ion

of

pat

ien

ts

wh

o d

ied

fro

m a

ny

cau

se (

%)

Enalapril n=835

Entresto n= 711

Days after randomisation

20

40

180 360 540 720 1260

835

711

Death from any cause 16% risk reduction

What about the hospital perspective?

Heart failure accounts for 1–3% of European hospital admissions

USA (2007)

2.9%

LOS 5.3d

Sweden (2011)

2.2%

LOS 6.4d

Norway (2008)

1.1% Netherlands (2010)

1.5%

Poland (2010)

1.9%

LOS 8d

Austria (2010)

1.0%

LOS 7.3d

Germany (2007)

2.0%

Switzerland

(2011)

1.1%

Spain

(2011)

1.8%

LOS 7.5d

England

(2011–12)

0.4%

LOS 7d

France

(2008)

1.1%

LOS 9.9d

www.escardio.org/communities/HFA/Pages/global-heart-failure-awareness-programme.aspx

High hospital readmission rates

www.escardio.org/communities/HFA/Pages/global-heart-failure-awareness-programme.aspx

Age-adjusted trends in discharges for a first hospitalization for HF according to sex

Scotland: 1986-2003

Jhund PS et al. Circulation 2009; 119: 515-23

Trends in median survival (excluding deaths within 30 days) according to sex and year of admission.

Scotland: 1986-2003

Jhund PS et al. Circulation 2009; 119: 515-23

The hospital perspective: the national audit 56 915 admissions (>70% of total)

http://www.hqip.org.uk/resources/national-heart-failure-audit-2014-2015/

16% < 65y

Use of life-saving drug therapy


Mortality


Estimating prognosis

When to refer for tx or MCS?

• Not too soon – patient takes unnecessary risk of operation and is exposed to the long-term complications of transplantation (or MCS) therapy

• Not too late e.g. renal failure, liver failure, respiratory failure – risk of an operation increases markedly

Why risk stratify?

Identify risk more accurately

Identify appropriate

interventions (to reduce risk)

Aid decision re appropriate

place of care

Aid shared decision making

Aid advance planning

WHAT? WHERE? WHEN? WHY?

Something we all do subconsciously

BADLY!

Eur Heart J 2012; 33: 1787 – 1847

http://eurheartj.oxfordjournals.org/content/ehj/33/14/1787.full.pdf

How to integrate all these data?

https://www.escardio.org/static_file/Escardio/Guidelines/publications/HFGuidelines-Heart-Failure-Web-Tables.pdf

In the clinic….

NYHA

Hospitalisation history

EF

Peak V02

IV inotropes Eur Heart J 2012; 33: 1787 – 1847


Palliation only….?

Eur Heart J 2012; 33: 1787 – 1847


USA recommended risk model

Levy WC et al. Circulation 2006; 113: 1424 – 33

Seattle HF score

Seattle HF Score For ambulatory patients

Also: HF Survival Score; CHARM score; CORONA score; I-PRESERVE score

Available at:

http://SeattleHeartFailureModel.org

Beware!

AUC for ROC curve for mortality prediction in Seattle HF Score = 0.73 (“moderately good”)

Natriuretic Peptides: even simpler?

Years of thought….

Heart 2003; 89: 587 – 88

Risk stratification relies on communication

Doctors should be more open about

possible courses of action, and

likely results of these actions

No communication = denial of patient

opportunity to make fully informed

choices

Inaccurate estimates of prognosis may

distort a patient’s choice

Predictions do not need to be very

precise: treatment preferences may

change substantially if patient knows

he/she has ≥ 10% chance of dying in 1

year*

Cowie MR. Heart 2003; 89: 587 – 8. *Weeks JC et al. JAMA 1998; 279: 1709 – 14

What would you do differently if you knew you had a 20% chance of being

dead in January 2018?

Martin R. Cowie Professor of Cardiology Imperial College ...

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