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Optimizing Heart Failure Management 2005 Bridging the CARE GAP

Optimizing Heart Failure Management 2005 Bridging the CARE GAP. Early detection Etiology Prognosis Diagnosis Physical exam Asymptomatic LV dysfunction How to use beta blockers Which beta blocker Better standardization of therapy. Rx titration Diuretics Beta blockers

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Optimizing Heart Failure Management 2005 Bridging the CARE GAP

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  1. Optimizing Heart Failure Management 2005Bridging the CARE GAP

  2. Early detection Etiology Prognosis Diagnosis Physical exam Asymptomatic LV dysfunction How to use beta blockers Which beta blocker Better standardization of therapy Rx titration Diuretics Beta blockers Post hospital interventions Lifestyle Patient education Diet Rx Exercise Rx Compliance Multi-system disease Renal disease CME Needs of Family Physicians re CHF

  3. Measuring the Impact of HF • Currently, there are over 500,000 Canadians with HF • Incidence 50,000 cases/year • One year mortality after diagnosis ranges between 25-40% (ICES Atlas) • 1% of Canadians over age 65 and 4% of Canadians over 70 have CHF • The age-adjusted mortality for CHF is 106/100,000

  4. Measuring the Impact of HF • Median survival currently 1.7 years for males, 3.2 yrs for females • 5-year age adjusted mortality rate of 45% based on the time period 1990-1999 • Commonest diagnosis that brings a patient to hospital for medical admission. • Re-admission rates are 46% within 3 months of discharge and 54% within 6 months.

  5. Heart Failure Epidemiology • Heart failure associated with high morbidity and mortality • Contemporary Canadian data to quantify the burden of CHF is limited • In 2000/01: • Total of 106,130 discharges for 85,679 CHF patients • 32.7% of discharges were readmissions • 19.9% of patients were re-hospitalized once or more during 2000 • Total in-hospital mortality was 15.8%. • CHF is associated with the second highest total number of hospital days and third highest number of patients affected. Can J Cardiol. 2003 Mar 31;19(4):436-8. Contemporary burden of illness of congestive heart failure in Canada.Tsuyuki RT, Shibata MC, Nilsson C, Hervas-Malo M.

  6. Contemporary burden of illness of congestive heart failure in Canada.Tsuyuki RT, Shibata MC, Nilsson C, Hervas-Malo M. “These figures should signal a call to action for researchers, administrators and health care providers regarding the need for more efficacious therapies, better application of already-proven therapies and patient education.” Can J Cardiol. 2003 Mar 31;19(4):436-8.

  7. Heart Failure is the Quintessential Disorder of Cardiovascular Aging • Convergence of • Age related changes in cardiovascular structure and function • Rising prevalence of • Hypertension • Coronary heart disease • Valvular heart disease

  8. Chronic Congestive Heart FailureEvolution of Clinical Stages NORMAL No symptoms Normal exercise Normal LV fxn Asymptomatic LV Dysfunction Compensated CHF No symptoms Normal exercise Abnormal LV fxn Decompensated CHF No symptoms Exercise Abnormal LV fxn Symptoms Exercise Abnormal LV fxn Refractory CHF Symptoms not controlled with treatment

  9. Ventricular Remodeling in CHF Jessup, NEJM 2003

  10. Symptoms of HF • Fatigue • Activity decrease • Cough (especially supine) • Edema • Shortness of breath

  11. Diagnose Etiology Severity (LV dysfunction) Initiate Diuretic/ACE inhibitor -blocker Spirololactone Digoxin Educate Diet Exercise Lifestyle CV Risk Titrate Optimize ACE inhibitor Optimize -blocker DIET Approach to the Patient With Heart Failure

  12. Therapy of CHF • Clinical Approach to CHF: • Consider etiology • Identify triggers • Exclude ischaemia • General measures • Symptomatic therapy • Prognostic therapy • See Guide for HF Management Check-list

  13. Guide for HF Management

  14. Symptoms & Signs of HF: • Fatigue (low cardiac out-put) • SOB •  JVP • Rales • S3 • Edema • Radiologic congestion • Cardiomegaly Obtain CXR to r/o non-cardiac causes e.g. interstitial lung disease & PPH

  15. BNP in the Diagnosis of HF The role of natriuretic peptides • ANP-atrial natriuretic peptide • Produced in atria in response to wall stress • BNP-brain natriuretic peptides • Produced in ventricles in response to volume and pressure overload • CNP-central nervous system and endothelium • Produced in response to endothelial stress • Produced as prohormones and cleaved to active molecule (ANP/BNP)and inactive NT forms

  16. BNP in the Diagnosis of HF ANP/BNP elevated in • Heart failure • Systemic and pulmonary hypertension • Hypertrophic and restrictive cardiomyopathy • Pulmonary embolism • COPD • Cor pulmonale • AMI Cirrhosis • Renal Failure

  17. BNP in the Diagnosis of HF Higher levels of BNP correlate with • higher PCW pressures • in compensated and decompensated patients • larger LV volumes • lower ejection fractions • in symptomatic HF patients • BNP study (Circ 2002;106: 416-422) • BNP sensitivity 90% and specificity 73% for HF

  18. BNP Diagnostic Cut Points for CHFJACC 2001;37(2):379-85. BNP > 400 pg/L – acute CHF present BNP 100 pg/L – 400 pg/L • Diagnostic of CHF with • Sensitivity 90% • Specificity 76% • Predictive accuracy 83% • R/O pulmonary embolism, LV dysfunction without acute CHF or cor pulmonale BNP < 100 pg/L – 98% negative predictive accuracy

  19. Acute-sudden onset Ischaemia Arrhythmia Infection Pulmonary embolism Acute valvular pathology Chronic-gradual onset Anemia Thyrotoxicosis Non-compliance Diet Rx e.g. NSAID’s Identify triggers

  20. Non-Invasive Evaluation of the Heart Failure Patient-Implications of LV Ejection Fraction • To know where you are going you must know where you are coming from • Evaluate LV function • clinical • echo • gated study

  21. Ejection fraction (obtain echo or LV gated study) • LVEF  40% = systolic dysfunction • LVEF 40-55% = mixed systolic and diastolic dysfunction • LVEF  55% = diastolic dysfunction • identify triggers • treat underlying disorder (HPT/ischaemia/pericardial constriction/restrictive CM/infiltrative disorders)

  22. LV function (EF),chamber size,wall motion Segmental dysfunction-coronary disease MS-severity, valve area AS- valve gradient, valve area AR/MR severity TR- RV systolic pressure = PA pressure RV function R/O IHSS, HCM R/O Pericardial Disease R/O rare causes e.g. myxoma, infiltrative disorders- restrictive cardiomyopathy Diastolic function Hyperdynamic states Echocardiographic Evaluation of CHF

  23. Diastolic Dysfunction • 30-50% of elderly HF patients have reserved LV systolic function • Diastolic dysfunction may induce dyspnea on exertion • Frank congestion usually has identifiable precipitant

  24. Calculated EF by echo unreliable in remodeled LV Visual estimate of EF semi-quantitative (CCN LV function scale) Grade I LV EF ≥50% Grade 2 LVEF 35-49% Grade 3 LVEF 20-34% Grade 4 LVEF< 20% LVEF Entry Criteria in ACE inhibitor and -blocker Trials SOLVD treatment an prevention  35% SAVE (post MI)  40% U.S. Carvedilol HF Trials Program LVEF  35% Merit-HF LVEF  40% CIBIS II LVEF  40% Clinical Implications of LV Dysfunction in Heart Failure

  25. Consider etiology • Ischemic- Cardiomyopathy (CM) • HPT-CM • Valvular HD-CM (AS/AR/MR) • Metabolic: • / thyroid/hemochromatosis/ pheochromocytoma • Toxins: • Anthracyclines/Etoh/cocaine/amphetamines • Viral CM • Idiopathic Dilated CM • Other:

  26. General measures: Correct triggers and precipitants of acute and chronic HF Low sodium diet Fluid restriction Regular exercise/ Activity HR Rx Treat ischemia Control hypertension D/C Smoking Treat lipid abnormalities Treat and control diabetes Identify & Rx depression TreatmentGeneral Measures

  27. Is it Heart Failure?Symptoms & Signs Diagnostic Tests:CXR/ECG/±BNP Echo/RNA/MRI:Etiology/Severity Life Style + Patient Education ± HF Clinics F/U HF Management Algorithm YES YES • Additional Tests±Specific Tx • Cath • CABG • Valve Sx Diastolic HF:Rx cause±Referral Systolic HF:Medical±Sx/Device

  28. Primary Targets of Treatments in CHF Jessup, NEJM 2003

  29. Symptoms Prognosis & Symptoms • Assess LV Function (echo, gated RNA) • EF < 40%-systolic dysfunction • EF 40-55%-systolic/diastolic dysfunction • EF >55%-diastolic dysfunction • Assess Volume Status Signs and Symptoms of Fluid Retention No Signs and Symptoms of Fluid Retention Loop Diuretic +/- Thiazide (titrate to euvolemic state) ACE inhibitor/ARB if ACE intolerant Combination Rx if  HF, hospitalization or -blocker intolerant -blocker (NYHA II-IV) Add Digoxin for symptom control Spironolactone (NYHA Class III-IV CHF/EF<35%/Cr<200/K<5)

  30. Heart Failure Therapeutic Goal • Mild-Moderate Heart Failure • Primary goal = Reduce mortality • -blockers + ACE inhibitors • Prevent progression to symptoms • Prevent progressive LV dysfunction

  31. Heart Failure Therapeutic Goal • Moderate-Severe Heart Failure • Primary goal = Reduce symptoms • Improve quality of life (QOL) • Reduce hospitalizations • Prevent sudden death

  32. Inotropes, mitral repair, VAD, Tx Tailored Rx Digoxin Diuretics (Spironolactone) Carvedilol/ -Blockers Angiotensin Converting Enzyme Inhibitors General Rx Strategies in HF Asymptomatic Mild/Mod Severe Refractory Correct Cause:ArrhythmiasIschemia Pressure Load No Added Salt 2 gm Na Activity as Tolerated Customized Ex Training Modified from Warner-Stevenson, ACC HF Summit

  33. Symptomatic therapy Diuretics (see How to Adjust Your Diuretic) • Titrate to euvolemic state • Maintain Ideal Body Weight • (dry weight = JVP normal / trace pedal edema) • Furosemide 20 mg. – 80 mg OD-BID • HCT/Zaroxolyn for refractory congestion Digoxin • For persisting symptoms in NSR (systolic dysfunction) • or symptoms and rate control in Afib. • Dose:0.125 mg – 0.25 mg • (Lower dose in elderly: 0.0625 mg)

  34. The Effect of Digoxin on Mortality and Morbidity in Patients with Heart Failure NEJM Volume 336:525-533 February 20, 1997 Number 8

  35. DIG Trial

  36. DIG Trial

  37. ACE Inhibitors are the Cornerstone of Rx in CHF CCS 2003 Consensus HF Update (draft) • ACE I Rx ASAP post MI • Continue indefinitely if EF < 40% or clinical HF • Rx for all asymptomatic patients with LVEF  35% • Rx for all symptomatic patients with LVEF  35% • Target dose use in clinical trials or max tolerated dose

  38. ACE Inhibitors in CHF

  39. ACE Inhibitors Post MI

  40. Overview of Long Term ACE Inhibitor Trials Showing Mortality Benefit

  41. What’s New in Ace inhibition in HFLong Term Follow-up

  42. SOLVD

  43. X-SOLVD

  44. General Guideline: Start low and titrate to the target dose used in the clinical trials or the MAXIMUM TOLERATED DOSE (ATLAS trial) Captopril 6.25-12.5 mg 50 mg BID-TID (SAVE) Enalapril 2.5 mg BID 20 mg BID (SOLVD/X) Ramipril 2.5 mg BID  5 mg BID (AIRE/EX) Lisinopril 10 mg OD  30-40 mg OD (GISSI 3) Trandolapril 1mg  4 mg (TRACE) Optimal Dosing of ACE Inhibitors

  45. Summary – ARBs in CHF

  46. Combined Morbidity/Mortality in Subgroups: Val-HeFT Favors valsartan Favors placebo • No. patients • All 5010 • Demographics • < 65 2660 • 65 2350 Male 4007 Female 1003 Etiology/Co-morbidity IHD (yes) 2865 IHD (no) 2145 Diabetes (yes) 1276 Diabetes (no) 3734 Disease Severity NYHA II 3095 NYHA III/IV 1910 EF  27 2623 EF < 27 2385 LVIDD < 3.57 2505 LVIDD  3.57 2505 0.4 0.6 0.8 1.0 1.2 1.4 Cohn JN, et al: Val-HeFT NEJM December 2001

  47. SAVE TRACE AIRE Combined VALIANT (imputed placebo) Pfeffer M et al. N Engl J Med 2003;349:1893-906 Mortality in SAVE,TRACE, AIRE, and VALIANT Hazard Ratio for Mortality Valsartan preserves 99.6% of mortality benefit of captopril, representing a 25% RR 0.5 1 2 FavorsActive Drug FavorsPlacebo

  48. CHARM Programme Mortality and morbidity CV Death or CHF Hospitalisation All Cause Mortality 0.77 Alternative p=0.0004 0.85 Added p=0.011 0.89 Preserved p=0.118 0.91 0.84 Overall p=0.055 p<0.0001 0.7 0.8 0.9 1.0 1.1 1.2 0.6 0.7 0.8 0.9 1.0 1.1 1.2 Hazard ratio Hazard ratio p heterogeneity=0.37 p heterogeneity=0.43

  49. Evidence for Various ARBs Diovan Avapro Cozaar Atacand Micardis Teveten (valsartan) (irbesartan) (losartan) (candesartan (telmisartan) (eprosartan) cilexetil) Reduction in -45% -6% -35% -30% N/a N/a microalbumin-uria withstarting dose Heart failure -27.5% N/a -8.1% -17% N/a N/a hospitaliza- (ValHeFT) (ELITE II) (CHARM) tions CV outcome in -13.3% N/a +7% -15% N/a N/a CHF-treated (ValHeFT) (ELITE II) (CHARM) patients Positive CV Yes N/a No Yes N/a N/a outcomes inCHF Equivalent Yes N/a No N/a N/a N/a Efficacy to ACEipost MI

  50. b-Blocker Saves Lives in Heart Failure? b–blocker is the most important progress in Heart Failure Rx in the last 5 years

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