Modern Management of Heart Failure

1. Modern Management of Heart Failure Dr Amanda Varnava Consultant Cardiologist Watford General Hospital & Imperial College Healthcare Trust

2. Background • Huge health costs $27 billion pa in US • Primarily a disease of the elderly • Incidence of 10/100 in those over 65yrs

4. What is heart failure? • Impaired ventricular filling and / or contraction Symptoms Signs Dyspnoea Impaired ex tolerance Fatigue Fluid overload 3rd Heart sound

6. Assessment of SOB • ECG /CXR or BNP abnormal > • Echo • Additionally • Non invasive testing for ischaemia • Angiogram • MRI

7. Measurement BNP in CHF • Accurately identifies CHF 81-97% of patients • Levels > 100 (sens 90% & spec 76%) • Levels vary according to age and gender

8. BNP assessment

9. 3 questions we need addressed with echo • Is EF preserved? • Is LV structure and wall movement normal? • Are there other structural abnormalities? • Valvar disease • Atrial dilation • PA hypertension

10. Heart Failure Therapies

11. ACEIns • Inhibit RAS at multiple sites • Start low, go slow • Probably class effect • Side effects related to kinin production (cough in 5-10%) and angioedema (1%) > common in Chinese and Blacks • Continue unless > 50% rise in Cr above baseline/ Cr >350 / K> 5.9

12. ACEIn titration

13. Angiotensin Receptor Blockers • Developed because of RAS “escape” with ACEIn and side effects • However, less well studied and some benefits may relate to kinin production • Thus alternative, not 1st line • Data does not support combination of ACEIn + ARB

14.  Blockers • Inhibit adverse effects of sympathetic NS • Trials with carvedilol, bisoprolol and LA metoprolol • Not class effect • Rx as soon as HF diagnosed • If pts on low dose ACEIn greater benefit to add’n of  than  ACEIn

15. β blocker titration

16. Aldosterone antagonists • Compensate for RAS escape with ACEIn • RALES study provided 30%mortality in NYHA III/IV • EPHESUS study showed 20% mortality post MI pts with HF signs (eplerenone) • Thus in mod-severe HF or HF post MI

17. Nitrate and Hydralazine • Less well tolerated • Trials show inferior to ACEIn • Subgroup analysis showed benefit in black pts when added to standard Rx • Use when ACEIn contraindicated (RF)

18. Diuretics • Often first line agent • Treat volume overload • Symptomatic relief, but no clear prognostic benefit

19. Digoxin • No prognostic benefit • Can improve quality of life • Use in pts with persistent symptoms despite standard Rx • Caution post MI / ongoing ischaemia

20. Polyunsatureated fatty acids GISSI study • n-3 polyunsaturated fatty acids (PUFA) vs placebo in > 7000 heart failure pts • Small, but signif reduction in mortality (27% vs 29%, HR 0.9, p= 0.04)

21. Current GP prescribing practices in UK • 163 practices from 2001-06 with 9311 pts • Loop diuretics 79% • ACE In or ARB 71% (35% to target) • β blocker 36% (11% to target)

22. Non pharmacological intervention

23. Implications of myocardial viability (MV) MV - revascularised MV – med Px No MV – med Px No MV - revascularised Senior et al. J Am CollCardiol 1999;33:1848-54

24. Cardiac resynchronisation therapy CRT (biventricular pacing) • As add on Rx it improves QOL, Ex Tol and hospitalisation • Recent trials have also shown 20-30% mortality

25. CRT indications • Third of pts in NYHA III/IV have QRS>120ms (= electrical dysynchrony) • However, 40% pts do not benefit thus need echo evidence of mechanical dysynchrony to further select pts Thus for pts with: • Persistent symptoms, in SR with wide QRS and echo dysynchrony

26. Stages of Heart Failure At risk Frank Heart Failure Evidence of structural disease, but no symptoms At risk, but no evidence of structural disease or symptoms Structural disease with symptoms Refractory symptoms NYHA IV despite max Rx • Dyspnoea • Fatigue •  Ex Tol • HT • CAD • Obesity • FH CM • Cardiotoxins • ETOH • MI • Valvular disease • LVH Palliative care Or TX LVADs Stem cell Tx ACEIn  Blockers Spironolactone ±CRT ACEIn/ARB Blockers 1º Prevention

27. Primary prevention HT • Lifetime risk of HT is 75% • Optimal Rx of HT cuts in 1/2 the risk of HF DM • Females 3 x > likely to develop HF • ACEIn CAD • All MI pts should start on ACEIn and  • If HF > Add epleronone

28. Management of asymptomatic pts Drugs • ACEIn delay onset of symptoms and improve mortality • No specific trials with ARBs • No trials with s, but ACC guidance suggests use esp in CAD Devices • MADIT II ICD trial supports use, but no’s huge thus not current practice

29. Symptomatic patients • As with asymptomatic • In addition diuretics for fluid overload • Aldosterone antagonists Also • Na restriction • Withdraw NSAIDS, Ca antag • Exercise • Close F/U

30. Refractory symptoms • Increased awareness of palliative care Where appropriate consider • Cardiac TX • LVADs • Stem cell Tx

31. Prognosis • Likelihood of survival can be reliably predicted for populations, but not individuals (death may be endstage HF or sudden) • Old prognostic models do not apply due to new drug Rx and devices • Annual mortality of 7% in those on 

32. Sudden cardiac death • Proportion with SCD is greater in those with less severe LVSD • ICD trials show risk reduction 23-30% in pts with EF<35% However, • Not within 1st 30 days post MI, no benefit within 1st year and most trials did not inc large no’s of elderly

33. Lifestyle & rehab • Exercise Aerobic and resistive ideally within rehab programme • Diet Wt reduction, salt and fluid restriction (daily wts) • Stopping smoking • Alcohol • Cessation if causative/ moderate if unrelated • Vaccination Pneumococcal and annual influenza • Air travel Safe in most pts

34. Clinical Review Interval dependent on status but not > 6 monthly • Clinical review • Fluid status • Functional capacity • Cardiac rhythm • Medication review • Bloods

35. Who should manage care? Once diagnosed and appropriate investigations completed • Nurse led clinics GP or specialist run service? • 1° care manage most pts • If remain symptomatic or are complex then refer to specialists

36. NICE guidelines for specialist referral • CCF not related systolic dysfunction • Co-morbidities (COPD, CRF, An, Gout) • Angina • Arrhythmias (inc AF) • Women planning pregnancy • Severe or very symptomatic heart failure

37. Specialist referral • Confirm diagnosis • Invasive assessment to diagnose underlying aetiology and Rx • Addition of beta-blockers and/or spironolactone • Management of difficult / deteriorating cases • Consideration of device therapy

38. Heart failure with normal systolic function

39. Management of diastolic dysfunction • Few trials • Resolve fluid overload • Some data on ACEIn / ARBs • Treat underlying condition

40. Cardiac failure services available at West Herts • Routine outpatients for specialist opinion and invasive investigation • Emergency assessment in A+E with BNP • Specialist heart failure nurse service with consultant supervision (WGH & HH) • Specialist cardiac failure device clinic

41. Thank You