Why Care about Heart Failure? -...

Heart Failure Review and Update Through Cases

Ankie Amos, MD, FACC

Alaska Heart Institute

Feb 2017

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 2 Why Care about Heart Failure?

Common Problem:

5 million have HF in the USA

550,000 are diagnosed with HF each year.

Mortality and Morbidity:

4 million hospitalizations per year

60% 5-year Mortality

Costly!

> $32 billion spent on HF in the USA in

2011.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 3 Heart Failure Definition

Clinical syndrome that can

result from any structural or

functional cardiac disorder

that impairs the ability of the

ventricle to fill with or eject

blood.

Dyspnea, edema, fatigue

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Heart Failure: The Tip of the Iceberg?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 5 Heart Failure Staging

At risk for HF-------------------> Heart Failure

Stage A

At High risk for HF

But without structural

Heart disease or

Symptoms of HF.

Stage B

Structural heart

Disease but without

Signs or symptoms.

Stage C

Structural heart disease

With prior or current

Symptoms.

Stage D

Refractory HF

Requiring specialized

Interventions.

Patients with:

-HTN

-CAD

-DM

-Obesity

-Metabolic Syndrome

Patients with:

-Previous MI

-LV remodeling

-LVH

-Low EF

-Valvular disease

Patients with:

-Structural Heart Ds

-SOB/Fatigue

-Reduced Exercise

Tolerance

Patients with:

-Rest Symptoms

-On maximal med

Therapy

-Recurrent hosp.

Structural Hrt Ds Symptoms Refractory Rest Sx

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 6 Define your Heart Failure Patient!

Heart

Failure

L Heart

Failure

R Heart

Failure

HFpEF

EF>50%

AdvancedChronic

Stable

Acute

Failure

New

Onset

HFrEF

EF <40%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Define Your Heart Failure Patient

NYHA Class

I: NO symptoms

II: Symptoms with moderate activity

III: Symptoms with minimal activities of

daily living

IV: Symptoms at rest

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 8 Case of Mr A

Mr. A is a 56yo male who comes in for HF

follow up. No Sx or complaints.

EF 25%, Class II HF (has had CHF dx for 8

years)

Vitals: BP 128/65, P 72

PE: No JVD, minimal LE edema at feet

only, NO crackles. Ext warm

Meds: Coreg 25mg BID, Lisinopril 20mg

BID, Lasix 10mg a day

What Quad is this patient in?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 9 The Quad of HF:

A paradigm to Guide Treatment

Perfusion

V

O

L

U

M

E •BNP elevated

•Crackles in lung

(dyspnea)

•LE edema

•Ascites

•Increased weight

•JVD

•Cr increased

•AMS

•Dyspnea

•Elevated

bilirubin/lfts-Abd pain

•Hypotension

•Feel cold in feet

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Hemodynamics

Perfusion:

CI: Digoxin, Inotropes

SVR: Ace-I, ARBS, Nitrates/Hydralazine

Volume:

PCW (Lung fluid): Diuretics only work if RA

pressure high!

RA (peripheral fluid)=JVD:

Diuretics/ultrafiltration

Normal #’s: PCW 12, RA 5-10, CI >2, CO >4,

SVR 900-1000.

Interrogate Device!! Many have Impedance

Measures (Volume estimations) or Echo.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 11 Hemodynamics in the Quad

Perfusion

V

O

L

U

M

E

•RA/CVP: Normal

•PCW: Normal

•CI/CO: Low

•SVR: High

•RA/CVP: 5-10

•PCW: 10-15

•CI/CO: >2, >4

•SVR: 1000

•RA/CVP: High

•PCW: High•CI/CO: ok

•SVR: ok

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 12 The Quad of HF: Treatments

Perfusion

V

O

L

U

M

E

•Diuretics

•HF Cocktail

HF “Cocktail”

•Ace-I/ARB

•Beta – blocker

•Spironolactone

•Hydralazine/Nitrates

•Digoxin

•Afterload Reduction

•Nitrates/hydralazine

•Ace-I/ARB

•Inotropes

•Dobutamine

•Milrinone

•Same as

these quads

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case of Mr A




years)

Vitals: BP 128/65, P 72

PE: No JVD, 1+ LE edema at feet only, NO

crackles. Ext warm



Would you change anything?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 14 HFrEF Stage C

NYHA Class I – IV

Treatment:

For NYHA class II-IV patients.

Provided estimated creatinine

>30 mL/min and K+ <5.0 mEq/dL

For persistently symptomatic

African Americans,

NYHA class III-IV

Class I, LOE A

ACEI or ARB AND

Beta Blocker

Class I, LOE C

Loop Diuretics

Class I, LOE A

Hydral-Nitrates

Class I, LOE A

Aldosterone

Antagonist

AddAdd Add

For all volume overload,

NYHA class II-IV patients

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 15 Target Doses: Important!

Goal SBP: As low as they can tolerate!

Goal HR 50’s

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

What therapy changes would you recommend?

1. Add digoxin 0.25mg a day

2. Increase Coreg to 50mg BID

3. Add spironolactone 25mg a day

4. Switch Lisinopril to Entresto

5. No changes recommended

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 17 Chronic Heart Failure : ENTRESTO

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 18

Entresto now a class I

recommendation for

NYHA Class 2/3 on

maximized ace/arb and

BB

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 20 Who were the Patients?

<10% were in the USA

5% were African

American

Mostly Class II-III HF with

“sturdy BP”

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 21 Results of Paradigm

Stopped Early due to dramatic benefit

20% reduction of Mortality

Significant differences in 30 days.

More decreased death than all other HF

trials combined and more patients than all

other trials combined.

To prevent one death, need to treat 32

patients.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 23 Practical Entresto Tidbits

Not in Liver Failure

Contraindicated with Ace-I (36hr washout)

Consider switching to ARB for 36 hrs

If following serial BNP’s, they will rise.

Better to follow NT-BNP or pro-bnp

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 24 Switching to Entresto

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Mortality Reduction of Evidence Based Management

ACE Inhibitors/ARB 17-36%

ARB/Neprilysin (Entresto) 16-20%

β-blockers 20-35%

Hydralazine/nitrates 30%

Aldactone 25-30%

Inotropic Drugs 36-50% increase

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 26 The Body’s adaption to the disease becomes as

important than the initial insult itself

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 27

Adapted from Packer M. Prog Cardiovasc Dis. 1998;39(suppl I):39–52.

CNS sympathetic outflow

1-

receptors

Cardiac sympathetic activity

2-

receptors

1-

receptors Activation

of RAS

Vasoconstriction

Sodium retention

Myocyte hypertrophy, dilation,

ischemia, arrhythmias, death

Disease progression

Neurohormonal Hypothesis:

SNS Activation Leads Directly to Impaired Cardiac Fnx

Sympathetic activity to

kidneys + blood vessels

Lasix

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Remodeling

1 week 3 months

EDV 137 mL ESV 80 mL

EF 41%

EDV 189 mL ESV 146 mL

EF 23%

Apical 4 Chamber View

Chamber Enlargement

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 29

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 30 Answer of Mr A Case




years)

Vitals: BP 128/65, P 72

PE: No JVD, 1+ LE edema at feet only, NO

crackles. Ext warm



Switch Lisinopril to Entresto!

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr B

55yo white male who has been

progressively dyspneic for 6 mo. He has

been treated for pneumonia several times.

He has now been bed ridden for a month.

OP Chest CT with PE’s. Given xarelto

Returned next day to ER for evaluation.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 32 Case Mr B

ER Course

PMH: DM, HTN

SH: Married, no tobacco/ETOH. Hasn’t

worked for 3 mo due to illness

PE: 90/56, P 150

• Respiratory distress

• Anasarca (could pit him toes to his nose)

• No JVD seen

Labs: Na 127, Bili 2.8, Hct 27, Cr 2.8, BNP

4000

EKG – Tachy at 150

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 33 What would you do first?

1. Cardiovert

2. Give 80mg IV lasix

3. Start nitro gtt

4. Give Tolvaptan

5. Cath

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

First DEFINE the heart failure

Right and Left Heart failure

Systolic and Diastolic.

What Quad of Heart Failure is he in?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________



Perfusion

V

O

L

U

M

E •BNP elevated

•Crackles in lung

(dyspnea)

•LE edema

•Ascites

•Increased weight

•JVD

•Cr increased

•AMS

•Dyspnea

•Elevated


•Hypotension


___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 36 Echo clues to Hemodynamics

RA pressure: IVC

Pulmonary pressures: RVSP

Diastology:

Grade I (normal filling pressures=PCW)

Grade IIIV: Fluid overloaded

Our Guy’s Echo: Tachycardic, Grade IV DD,

EF <10%, LV 8 cm, RVSP 70, RA pressure 20

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Hemodynamics in the Quad

Perfusion

V

O

L

U

M

E

•RA/CVP: Normal

•PCW: Normal

•CI/CO: Low

•SVR: High

•RA/CVP: 5-10

•PCW: 10-15

•CI/CO: >2, >4

•SVR: 1000

•RA/CVP: High


•SVR: ok

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Perfusion

V

O

L

U

M

E

•Diuretics

•HF Cocktail

HF “Cocktail”

•Ace-I/ARB

•Beta – blocker

•Spironolactone


•Digoxin



•Ace-I/ARB

•Inotropes

•Dobutamine

•Milrinone

•Same as

these quads

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 39

Case of Acute Heart Failure

Strategy of Vasodilators

(ace/arb, hydralazine/nitrates)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

The Failing Heart is more Afterload sensitive than the

normal LV

Vasodilators

Increase

Stroke Volume

BP stays the

same

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 41 Acute Heart Failure and Vasodilators:

Do not hold meds if SBP >90!!

By afterload reducing with vasodilators

(hydralazine, nitrates, ace-I)

Stroke volume

Blood pressure

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 42 What happened:

Started a nitro gtt and titrated to 100mcg/hr

BP remained at 92/59.

Next day started hydralazine and titrated to

50mg every 8 hours.

Started lasix gtt with I/O neg about 2L

Cr decreased to 2 (from 2.8)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

What else can we do for him?

The patient had a h/o bipolar and off meds had AMS.

Labs: Na 127, Bili 2.8, Hct 27, Cr 2.8

Tolvaptan?

Venofer?

MORE lasix?

RUQ ultrasound?

Consult nephrology?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 44 Tolvaptan

Vasopressin

Antagonism can raise

Na

Can Promote

significant loss of fluid

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 45 Tolvaptan

Very expensive

5,000 pts in many trials for acute

decompensated HF

No mortality benefit

No significant effect on morbidity

Weight loss without clinical benefit

(dyspnea)

It can help with hyponatremia. I added in

our patient and AMS improved and he

diuresed 3L.

Good for RV failure?

Careful with Liver disease.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr B:

Hct 27, Iron sat 8%

Give Iron?

IV iron (IV venofer 100mg QD x 3 doses) NOT

PO iron

3 Randomized (1 large, 2 small) and a

number of observational trials.

Improvements in quality of life, NYHA

class, and decreased hospitalizations.

Benefit not dependent on Hb levels

Still need more data for long term safety

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 47 Case Mr B

The patient continued to have low BP, elevated bili,

diuretic resistance

What is the best next step?

L/RHC

BiV ICD

Dobutamine

LVAD

Transplant

Hospice

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 48 It is important to Define the Cause of

Heart Failure

Nonischemic causes

Valvular disease

Myocardial toxins

Myocarditis

Hypertension

Arrhythmias

Others

Gheorghiade M, Bonow RO. Circulation. 1998;97:282–289.

CAD Causes

History of MI

Hemodynamic CAD

Ischemic

68%

Non-Ischemic

32%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Causes of Heart Failure

Without treating the underlying cause,

progress will be limited.

Examples:

Coronary disease: Revascularization

Valve Disease: Surgery

Chemotherapy: Re-thinking chemo

Lupus: Immunosuppression

Amyloid: BMT

Rhythm: Frequent PVC’s, Afib

Labs: HIV, Ferritin, ESR/ANA, TSH

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 50 MRI is a great tool to define the cause of

New Heart Failure

AmyloidInfarct

Valvular Disease

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 51

ViabilityPerfusionFunction/ValvesAnatomy

Cardiac MRI:

Gives it all, PLUS viability

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr B Data

LHC: normal cors

RHC: RAP 15, PA 54, PCW 14, CI 1.6, SVR

3128, Ao pressure 90

EKG: NSR, QRS 174, RBBB

What is next best step?

BiV ICD?

More lasix?

Milrinone?

More vasodilators?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 53 Indications for CRT TherapyPatient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or

with implantation of pacing or defibrillation device for special indications

LVEF <35%

Evaluate general health status

Comorbidities and/or frailty

limit survival with good

functional capacity to <1 y

Continue GDMT without

implanted device

Acceptable noncardiac health

Evaluate NYHA clinical status

NYHA class I

· LVEF ≤30%

· QRS ≥150 ms

· LBBB pattern

· Ischemic

cardiomyopathy

· QRS ≤150 ms

· Non-LBBB pattern

NYHA class II

· LVEF ≤35%

· QRS 120-149 ms

· LBBB pattern

· Sinus rhythm

· QRS ≤150 ms

· Non-LBBB pattern

· LVEF ≤35%

· QRS ≥150 ms

· LBBB pattern

· Sinus rhythm

· LVEF ≤35%

· QRS ≥150 ms

· Non-LBBB pattern

· Sinus rhythm

Colors correspond to the class of recommendations in the ACCF/AHA Table 1.

Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along

with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D

unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and

personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival.

NYHA class III &

Ambulatory class IV

· LVEF ≤35%

· QRS 120-149 ms

· LBBB pattern

· Sinus rhythm

· LVEF ≤35%

· QRS 120-149 ms

· Non-LBBB pattern

· Sinus rhythm

· LVEF ≤35%

· QRS ≥150 ms

· LBBB pattern

· Sinus rhythm

· LVEF≤35%

· QRS ≥150 ms

· Non-LBBB pattern

· Sinus rhythm

· Anticipated to require

frequent ventricular

pacing (>40%)

· Atrial fibrillation, if

ventricular pacing is

required and rate

control will result in

near 100%

ventricular pacing

with CRT

Special CRT

Indications

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 54 Inotropes

Lowers SVR

Increased CI

Lowers PAP

Helps RV

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

HFSA Guidelines

When adjunctive therapy is needed in

patients with ADHF, administration of

vasodilators should be considered instead

of intravenous inotropes (milrinone or

dobutamine). (Strength of Evidence 5 C)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 56 HFSA Guidelines for our patient

12.20 Intravenous inotropes (milrinone or

dobutamine) may be considered to relieve

symptoms and improve end-organ function in

patients with advanced HF characterized by LV

dilation, reduced LVEF, and diminished

peripheral perfusion or end-organ dysfunction

(low output syndrome), particularly if these

patients have marginal systolic blood pressure

(! 90 mm Hg), have symptomatic hypotension

despite adequate filling pressure, or are

unresponsive to, or intolerant of, intravenous

vasodilators. (Strength of Evidence 5 C)

Journal of Cardiac Failure Vol. 16 No. 6 2010

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 57 What We Did:

Continued to titrate up vasodilators

Added milrinone

BiV ICD

(per transplant center prior to transfer)

Patient tuned nicely and has been doing

great as an OP.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr. SW

Mr. SW is a 63yo with a PMH of morbid

obesity (BMI 50), Sleep apnea, and COPD

who presents with SOB and edema.

Over 3 mo he has gained 65lbs

Vitals: BP 98/62, P 90, O2sat 89% on RA

PE: JVD >20cm, CV: irr irr, mildly tachy,

Lungs – mild crackles, abd – ascites, Ext –

anasarca – can pit up to mid chest. Feet

are warm.

Labs: Cr 2, K 4, Hct 50

What kind of heart failure do you suspect?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 59 Case Mr SW: What kind of HF do you suspect?

1) Systolic left heart failure

2) Diastolic left heart failure

3) Right heart failure

4) This is not heart failure

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 60 Pickwickian:

Classic RV

Failure

Afib

Hypotension

Renal failure

Anasarca

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr. SW: What treatments would you suggest?

1) Digoxin or inotropes?

2) Nesiritide

3) Lasix gtt or fluids?

5) Torsemide

6) Spironolactone

7) Isosorbide OR sildenafil

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 62 What is the most common cause of Right Heart

Failure?

Left heart failure

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 63 Case Mr SW: Right Heart Failure

The cause is usually pulmonary.

Pulmonary HTN work up:

PFT

V/Q scan for chronic PE’s

LE U/s to rule out DVT

Non-contrasted Chest CT

Sleep study

RHC with nitric oxide

Echo with bubble

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr. SW

Isolated RV failure

TV issue? Carcinoid

RV issue? Cardiac MRI

• ARVD

• Can consider RVAD

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 65 RV Failure Treatment Strategies: No Data

Reduce RV Afterload

Reduce RV Pressure

Increase RV

contractility

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 66 RV failure Treatment Strategies: No Data

Reduce RV afterload

O2 for hypoxia/CPAP

Treat underlying causes for pulmonary

hypertension

Sildenafil

Isosorbide

Reduce RV Pressure

Diuretics: Lasix gtt, high dose spiro

Ultrafiltration

*Careful as they are preload dependent

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

RV failure Treatment Strategies:

No Data

Increase RV contractility

Digoxin

Milrinone, dobutamine, NE, Dopamine

?Raise BP to help kidneys?

Midodrine?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 68 Case Mr. SW: What we did (no data)

Digoxin

Lasix gtt and got off 55lbs of fluid

Dopamine at 5mcg/kg/min continuous

Spironolactone 50mg BID

Work up: Ruled out PE, PFT’s with

obesity/hypoventilation sx, Bipap at night

and chronic o2 during day.

Cr decreased to 0.8, then increased back to

2.

Patient felt A LOT better.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 69 Case Mr. S

Mr S is a 43yo with a PMH of tobacco use

who presents to the ER with chest pain,

shortness of breath at rest, orthopnea, and

PND. No syncope, no dizziness.

It has been gradually getting worse over 2

years, but exponentially so the last 2 mo to

the point that he now has resting sx

PMH: tobacco use, heart murmur (never

had echo)

FH: no CAD, no SCD, NO CVA. Parents

still alive.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr. S

PE: SEM at RUSB, JVD 10-15cm, Lungs –

crackles at bases, Abd obese, Ext – trace

edema

EKG:

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 71 EKG – Case Mr S

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 72 Cardiac MRI:

Case Mr S

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

What would you do?

1) Add NTG gtt

2) Add Toprol

3) Give Lasix

4) Refer to surgery

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 74 Hypertrophic Cardiomyopathy

Not Rare: 1 in 500 people

Treatments:

Decrease Contraction: betablockers,

verapamil

Increase Resistance: avoid ace-I, nitrates

Increase volume: Careful with diuretics

Surgical Myectomy

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 75 Hypertrophic Cardiomyopathy

If 2+ RF recommend ICD

When to refer for ICD?

Severe LVH (>3cm)

VT/syncope always gets

Scar

Hypotention with exercise

FH of SCD

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr. ABC

65yo with a PMH of an ICM with a stable EF

of 30%, NYHA class II HF, CKD (Cr 1.8)

presenting for routine follow up.

Meds: Coreg 50mg BID, Cozaar 50 BID,

Spironolactone 25mg QD, Lasix 20mg QD

Vitals: HR 95, BP 128/78 PE: Euvolemic

Do these vitals make sense?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 77 Case Mr. ABC: Compliance?

CHF Medication non-adhearance is common

After a hospital DC, 80% are still on their Ace-I

at 1 mo, only 60% at 1 year.

1 year after initiation of CHF meds, 10% are

still on the full regimen at the end of 1 year Moname M et al; Arch Int Med 1994; 154: 433-437. Vanderwal et al. Int J Cardiol 2008; 125: 203-208

Think about remembering 6-10 meds 3 times a

day plus a regimen fluid/salt restriction

(possibly also low sugar?).

Takes high IQ, organization, Literacy

Consider neurocognitive testing, mini-mental

status testing.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 78 Super Bowl Sunday:

Mean Heart Failure Admissions During HolidaysHoliday 4 Immediate

post-holiday

Days

The month – 4

immediate post

holiday days

Holiday itself

Independence Day 5.6 5 3.8

Thanksgiving 5.7 5.6 4.2

Christmas 6.5 5.5 3.6

New Year’s 6.5 6.3 5.1

Superbowl Sunday 7 6.2 5.5

Shah, et al. HFSA poster 2014. Study of 12,727 CHF admits in Philadelphia.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr. ABC

Assuming compliance, what med can be

added to lower CV death and

hospitalization?

Meds: Coreg 50mg BID, Cozaar 50 BID,

Spironolactone 25mg QD, Lasix 20mg QD

Vitals: HR 95, BP 128/78

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 80 SHIFT Trial: Corlanor/Ivabradine

>6500 patients with Class II-IV CHF and EF

<35%.

Corlanor/ivabradine adjusted to achieve a

HR 50-60

Selective inhibitor of Na/K channel in SA

node.

Approved for Chronic, stable HF with HR

>70 maximized on a BB.

18% decrease in CV death/hospitalization

(Criticism: not all patients on target BB

therapy)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 81 Case Mr. Z

59yo with an ICM who has been in the hospital 9

times over a year for heart failure – he presents

with SOB.

Last cath 2 years ago – Prior stents in LAD and

RCA patent. LCX non-dominant.

Echo: 6 mo ago: EF 30% (down from 45% 1 yr

ago)

Meds: Coreg 20, Lisinopril 10 BID, Lasix 80 qd,

Kcl 40 qd

Vitals: BP 95/62, P 100, RR 29, O2sat 95% RA.

JVD 8cm, Lungs – decreased BS at bases, CV –

tachy, RR, pmi displaced, SEM at LLSB 3/6, Ext –

cool,trace edema

Labs: Na 128, K 5, Cr 1.9 (baseline 0.9), Hct 29,

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr Z:

What would you do first?

1) Increase lisinopril by 2.5mg a day

2) Re-echo

3) Cath or stress MRI

4) Give Lasix 80mg IV in clinic

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 83 It is important to Define the Cause of

Worsening Left Heart Failure

Nonischemic causes

Valvular disease

Myocardial toxins

Myocarditis

Hypertension

Other

Gheorghiade M, Bonow RO. Circulation. 1998;97:282–289.

CAD Causes

History of MI

Hemodynamic CAD

Ischemic

68%

Non-Ischemic

32%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 84 Back to Case Mr. Z

I would cath him or do a stress MRI: He

already has a history of CAD.

What “quad” is this patient in?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

The Quad of HF: Patient Physical Exam

Lasix would not help

symptoms, may worsen.

Increasing lisinopril with a

high K and Cr and low BP

would probably worsen

things.

Perfusion

V

O

L

U

M

E

•Cold hands/feet

•Confusion, fatigue

•Abdominal pain

•Labs: Elevated Bili, LFt’s, Cr

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 86 Case Mr. Z:

MRI without ischemia. Moderate MR. What

would you do medically?

1) Increase lisinopril by 2.5mg a day

2) Add Digoxin

3) Give up and call hospice

4) Give Lasix 80mg IV in clinic

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 87 Definition of Heart Failure: Staging

At risk for HF-------------------> Heart Failure

Stage A

At High risk for HF

But without structural

Heart disease or

Symptoms of HF.

Stage B

Structural heart

Disease but without

Signs or symptoms.

Stage C

Structural heart disease

With prior or current

Symptoms.

Stage D

Refractory HF

Requiring specialized

Interventions.

Patients with:

-HTN

-CAD

-DM

-Obesity

-Metabolic Syndrome

Patients with:

-Previous MI

-LV remodeling

-LVH

-Low EF

-Valvular disease

Patients with:

-Structural Heart Ds

-SOB/Fatigue

-Reduced Exercise

Tolerance

Patients with:

-Rest Symptoms

-On maximal med

Therapy

-Recurrent hosp.

Structural Hrt Ds Symptoms Refractory Rest Sx

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Clinical Events and Findings Useful for

Identifying Patients With Advanced HFRepeated (≥2) hospitalizations or ED visits for HF in the past year

Progressive deterioration in renal function (e.g., rise in BUN and creatinine)

Weight loss without other cause (e.g., cardiac cachexia)

Intolerance to ACE inhibitors due to hypotension and/or worsening renal function

Intolerance to beta blockers due to worsening HF or hypotension

Frequent systolic blood pressure <90 mm Hg

Persistent dyspnea with dressing or bathing requiring rest

Inability to walk 1 block on the level ground due to dyspnea or fatigue

Recent need to escalate diuretics to maintain volume status, often reaching daily

furosemide equivalent dose >160 mg/d and/or use of supplemental metolazone

therapy

Progressive decline in serum sodium, usually to <133 mEq/L

Frequent ICD shocks

Adapted from Russell et al. Congest Heart Fail. 2008;14:316-21.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 89 Highest Risk Indicators

Drug Intolerance

Lasix > 1.5mg/kg/day

BUN > 40

Adapted from Russell SD, et al. in press.

64% 1-year

Mortality

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 90 Recognize Stage D Heart Failure:

Options

Options:

1. Hospice

2. Inotropes

3. Mechanical support

4. Transplant

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

DT Trial CAP: Background

1 Slaughter MS, Rogers JG, Milano CA et al: Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J

Med. 2009 Dec 3;361(23):2241-51.2 Fang JC: Rise of Machines – Left Ventricular Assist Devices as Permanent Therapy for Advanced Heart Failure N Engl J Med. 2009

Dec 3;361(23):2282-84.Source: Park SJ, AHA 2010

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 92 HeartMate III Trial

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 93 Worldwide HeartMate II Clinical Experience

More than 20,000+ patients worldwide have now been implanted with the HeartMate II®

LVAS.

Over 6,000 patients on ongoing support

Patients supported ≥ 1 year: 1,634

Patients supported ≥ 2 years: 963

Patients supported ≥ 5 years: 143

8 Years is the longest

As of April 2016

*Based on clinical trial and device tracking data

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Mechanical Circulatory Support

Today

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 95 Heartmate

Patients

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 96 HeartMate II VAD

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Jarvick

Mastoid Bone Exit or Abdominal

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 98 Heartware Device

Centrifugal pump

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 99 HeartMate III Trial

Smaller

Pulse Technology

-Lower GI bleeding?

Magnetically levitated centrifugal pump

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Ms M

A 80yo female presents with SOB, LE

edema.

EKG with LBBB (QRS duration 145)

EF 25%, Cath with nl cors

Meds: Ramipril 2.5 mg BID, Toprol XL 100


BP 125/80, P 58, BMI 18

Labs: Cr 1.2, K 5.1

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 101 Case Ms M

After diuresis, what can be offered to avoid

decompensation again?

1) Add Digoxin 0.25mcg Po daily

2) Increase Ramipril by 2.5mg a day

3) Add spironolactone 12.5mg a day

4) Refer for CRT

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 102 Dosing of Digoxin- level should be <1ng/ml

Adams, et al. JACC 2002; 39: 946

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Cardiac Resynchronization Therapy (CRT)

MADIT-CRT: NYHA I and II, EF <30%, QRS>130

JACC 2011; 57: 813-20.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 104 Significance of MADIT-CRT Study for Women

Women CRT-D had a 72% reduction in risk of

HF or Death

Greater reductions in mortality with patients

with QRS> 150 ms or LBBB (82% & 78%,

respectively)

Benefits showed consistent evidence of

greater reverse cardiac remodeling in

women than men via echo

Bottom Line: Screen all women with low EF

for LBBB.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 105 Case Mr. T

Mr. T is a 47yo without insurance or money who

comes in with sob, le edema, and increased abd

girth. Weight up 35lbs over month.

He cannot afford and refuses imaging

He cannot afford and refuses hospitalization.

PE: BP 159/95, P 100, O2sat 90%

JVD 20cm, Lungs- crackles, abd – ascites, ext 2+

edema – warm

Meds: none – he will take meds

Labs: (1 mo prior for health fair) nl Cr and K

What will you put him on?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mr. T

1) Toprol XL 50mg a day

2) Lisionpril 10mg a day

3) Spironolactone 50mg BID

4) Lasix 80mg a day

5) Torsemide 80mg a day

6) Metolazone 5mg a day

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 107 Diuretics

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 108 Diuretics

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Switch to Torsemide if Failing Lasix

Murray MD et al. Am J Med. 2001; 111: 513-520

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 110 Diuretic Resistance Challenges

Restrict Na/H2O intake.

Increase dose, frequency, iv

Combine loop diuretic with thiazide

/spironolactone

Try inotrope or dopamine to increase CO

Ultrafiltrate

Consider Stage D Treatments

Motwani et al Circulation 1992;86:439

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 111 Thiazides, Loop Diuretics: Adverse Effects

Lowers K+, Mg+ (15 - 60%)

(sudden death ???)

Lowers Na+

Stimulation of the neurohormonal activity

Hyperuricemia (15 - 40%)

Hypotension. Ototoxicity. Gastrointestinal.

Alkalosis.

Sharpe N. Heart failure. Martin Dunitz 2000;43

Kubo SH , et al. Am J Cardiol 1987;60:1322

MRFIT, JAMA 1982;248:1465

Pool Wilson. Heart failure. Churchill Livinston 1997;635

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Mrs. DN

33yo dx 3 mo ago with a PPCM EF 10% and

recent h/o meth use who presents to the

ER with abd pain. Cardiology consulted

pre-op choly.

Vitals: BP 90/66, P 110

Exam: +JVD, +crackles, no LE edema,

abd bloating per report, warm ext

Labs: WBC nl, Hct 33, Cr 1.9, Bilirubin 2

Abd ultrasound unremarkable except for

ascites

Dx?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 113 Case Ms. DN

What is best first step?

Clear for Choly

Dobutamine

Digoxin

Hydralazine/nitrates

Nipride

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________



Perfusion

V

O

L

U

M

E •BNP elevated

•Crackles in lung

(dyspnea)

•LE edema

•Ascites

•Increased weight

•JVD

•Cr increased

•AMS

•Dyspnea

•Elevated


•Hypotension


___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Hemodynamics in the Quad

Perfusion

V

O

L

U

M

E

•RA/CVP: Normal

•PCW: Normal

•CI/CO: Low

•SVR: High

•RA/CVP: 5-10

•PCW: 10-15

•CI/CO: >2, >4

•SVR: 1000

•RA/CVP: High


•SVR: ok

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Perfusion

V

O

L

U

M

E

•Diuretics

•HF Cocktail

HF “Cocktail”

•Ace-I/ARB

•Beta – blocker

•Spironolactone


•Digoxin



•Ace-I/ARB

•Inotropes

•Dobutamine

•Milrinone

•Same as

these quads

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 117 Case Ms DN: RHC on patient

RHC: CI 1.3, RA 5, PCW 30, SVR 2010

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Case Ms DN: Answer?

What is best first step?

Dobutamine

Digoxin

Cholyctectomy

Hydralazine/nitrates

Nipride

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 119 HFSA Guidelines for our patient

12.20 Intravenous inotropes (milrinone or

dobutamine) may be considered to relieve

symptoms and improve end-organ function in

patients with advanced HF characterized by LV

dilation, reduced LVEF, and diminished

peripheral perfusion or end-organ dysfunction

(low output syndrome), particularly if these

patients have marginal systolic blood pressure

(! 90 mm Hg), have symptomatic hypotension

despite adequate filling pressure, or are

unresponsive to, or intolerant of, intravenous

vasodilators. (Strength of Evidence 5 C)

Journal of Cardiac Failure Vol. 16 No. 6 2010

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 120 HFSA Guidelines

When adjunctive therapy is needed in

patients with ADHF, administration of

vasodilators should be considered instead

of intravenous inotropes (milrinone or

dobutamine). (Strength of Evidence 5 C)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

What we did: Patient Cold and wet

Afterload reduction (Target SVR) with

hydralazine/isosorbide/captopril

Lasix gtt at 5mg/hr

Bp stayed the same/then increased. HR

decreased.

Bilirubin normalized, Cr normalized

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 122 EF is not Enough:

Echocardiography STRAIN Imaging

Strain Imaging

A measure of muscle stretch and

deformation

Can catch muscle abnormalities from many

disease BEFORE the EF drops

Valve disease, Chemotherapy, Coronary

disease, Stage A heart failure (Risk factors)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 123 Normal vs Abnormal

Strain Examples

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Strain Examples

Normal Abnormal

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Why Care about Heart Failure? -...

Documents

Transcript of Why Care about Heart Failure? -...