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Congestion in Heart Failure

Congestion in Heart Failure. Mihai Gheorghiade, MD Professor of Medicine Northwestern University Feinberg School of Medicine Chicago, Illinois. Congestion in HF. Definitions. 2. Congestion in Heart Failure (HF). Clinical congestion: symptoms (dyspnea) and signs (JVD, rales, edema)

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Congestion in Heart Failure

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  1. Congestion in Heart Failure Mihai Gheorghiade, MD Professor of Medicine Northwestern University Feinberg School of MedicineChicago, Illinois

  2. Congestion in HF Definitions 2

  3. Congestion in Heart Failure (HF) Clinical congestion: symptoms (dyspnea) and signs (JVD, rales, edema) Hemodynamic or cardiopulmonary congestion: high LV filling pressures with or without clinical congestion JVD, jugular venous distention; LV, left ventricular. 3

  4. Hemodynamic Congestion Often Does Not Translate into Signs/Symptoms of HF 4

  5. Hemodynamic Congestion Often Does Not Translate in Signs/Symptoms • Among patients with severe heart failure1 • PCWP 33 ± 6 mm Hg, CI 1.8 ± 0.5, LVEF 0.18 ± 0.06 • CXR: 27% no congestion, 41% minimal congestion • Among patients with moderate to severe heart failure2 • PCWP 30 ± 9 mm Hg, CI 2.1 ± 0.8, LVEF 0.18 ± 0.06 • No rales: 84%, no edema: 80%, no JVP 50%,no orthopnea: 22% • Cardiopulmonary congestion may not be recognized clinically (doesn’t translate into symptoms/signs until late) CXR, chest X-ray; LVEF, left ventricular ejection fraction. 1Mahdyoon H, et al. Am J Card. 2003;63:625-627. 2 Stevenson LW, et al. JAMA. 1989;261:884-888. 5

  6. Both Patients Have High PCWP • Radiographic congestion and CTR often does not correlate with PCWP PCWP, pulmonary capillary wedge pressure; CTR, cardiothoracic ratio. Kono T, et al. Jpn Circ J. 1992;56:359-365. 6

  7. S Y M P T O M S Abnormal lung function Respiratory muscle dysfunction Other factors  RV + RA pressure •  Hydrostatic pressure •  Oncotic pressure •  Permeability • Lymphatic drainage capacity • Alveolar-capillary membrane integrity Increase PA pressure Increased PCWP (congestion)  LA and LV diastolic pressure LVDP + impaired volume regulation Mitralregurgitation Abnormal LV function (systolic and/or diastolic) Symptoms and Signs: The Tip of the Congestion Iceberg in HF Systemic congestion(JVD, edema) Dyspnea Alveolar edema Redistribution in pulmonary vascular bed + interstitial edema RV, right ventricular; RA, right atrial; PA, pulmonary artery; LA, left atrial; LVDP, left ventricular diastolic pressure. 7

  8. Absence of Specific Signs, Symptoms and CXR Findings Doesn’t Exclude High PCWP • Ability to predict PCWP >18-20 mm Hg in patients with severe heart failure • Sens. Spec. PPV NPV • Dyspnea on exertion 66 52 45 27 • Orthopnea 66 47 61 37 • Edema 46 73 79 46 • JVD 70 79 85 62 • S3 73 42 66 44 • CXR • Cardiomegaly 97 10 61 --- • Redistribution 60 68 75 52 • Interstitial edema 60 73 78 53 • Pleural effusion 43 79 76 47 PPV, positive predictive value; NPV, negative predictive value. Adapted from Chakko S, et al. Am J Med. 1991;90:353-359. Adapted from Butman SM, et al. J Am Coll Cardiol. 1993;22:968-974. 8

  9. Importance of Recognizing Congestion Early • Identifying hemodynamic congestion early will lead to early treatment, and prevent hospitalizations and possibly progression of heart failure 9

  10. Congestion Is the Main Reason for Heart Failure Hospital Admissions and Readmissions 10

  11. Acute Heart Failure Syndromes (AHFS) Epidemiology (US) • 1 million admissions per year with the primary diagnosis of heart failure (HF) • 3,000,000 admissions per year with primary or secondary diagnosis of HF • Post-discharge event rate (readmissions/death): 35% at 60 days Gheorghiade M, et al. Circulation. 2005;112:3958-3968. 11

  12. AHFS: Hospitalizations • Worsening chronic HF (80%) • Acute de novo heart failure (diagnosed for the first time) (15%) • Advanced/end-stage/refractory HF (5%) Gheorghiade M, et al. Circulation. 2005;112:3958-3968. 12

  13. Clinical Presentation of Patients Hospitalized with Heart Failure(200,000 patients) Any dyspnea (%) 89 Dyspnea at rest (%) 34 Fatigue (%) 32 Rales (%) 68 Peripheral edema (%) 66 Initial CXR assessed (%) 91 Chest X-ray congestion (%) 75 Fonarow GC. Rev Cardiovasc Med. 2003;4(Suppl 7):S21-S30. Cleland JG, et al. Eur Heart J. 2003;24:442-463. 13

  14. SBP >140 mm Hg1 50% SBP 90-140 mm Hg1 48% SBP <90 mm Hg1 2% Mean heart rate (bpm)2 90 PCWP (mm Hg)2 25-30 Cardiac index2 usually preserved Congestion, Not Low Cardiac Output: Main Finding in Hospitalized Patients 1 Fonarow GC. Rev Cardiovasc Med. 2003;4(Suppl 7):S21-S30. 2The VMAC Investigators. JAMA. 2002;287:1531-1540. 14

  15. Outcomes Adams KF, et al. Am Heart J. 2005;149:209-216. Cleland JGF, et al. Eur Heart J. 2003;24:442-463. Fonarow GC, et al. J Am Coll Cardiol. 2005; oral presentation 844-4. 15

  16. More Than 50% of Patients Have Little or No Weight Loss During Hospitalization 33% 35 30 24% 25 20 Patients (%) 13% 15 15% 7% 10 6% 3% 2% 5 0 (<-20) (-20 to -15) (-15 to -10) (-10 to -5) (-5 to 0) (0 to 5) (5 to 10) (>10) Change in Weight (lbs) Fonarow GC. Rev Cardiovasc Med. 2003;4(Suppl 7):S21-S30. 16

  17. Change in Heart Failure Signs and Symptoms (Admission to Discharge) PND, paroxysmal nocturnal dyspnea. Gattis WA, et al. J Am Coll Cardiol. 2004;43:1534-1541. 17

  18. Hospitalizations for Heart Failure • Clinical congestion is the primary reason for HF admissions • Low cardiac output and associated signs/symptoms are uncommon • Suboptimal weight reduction during hospitalization • Although appearing improved clinically, many patients are discharged with signs and symptoms (related to hemodynamic congestion that is not being identified clinically) 18

  19. Congestion and Prognosis in Heart Failure 19

  20. JVD & S3* Predict Hospitalization/Death No JVP No S3 Event-free survival 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 P<0.001 Event-free survival P<0.001 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 JVP S3 0 250 500 750 1000 1250 1500 0 250 500 750 1000 1250 1500 Days Days *Difficult to assess clinically. Drazner MH, et al. N Engl J Med. 2001;345:574-581. 20

  21. High PCWP at Hospital Discharge Is Associated with Higher Long-Term Mortality 60 60 Mortality (%) Mortality (%) 50 50 PCWP >16 mmHg 40 40 N=199 CI >2.6 L/min/m2 N=236 P=0.001 30 30 P=NS CI ≤2.6 L/min/m2 20 20 PCWP ≤16 mmHg N=220 N=257 10 10 0 0 0 6 12 18 24 0 6 12 18 24 Time (months) Time (months) 21 Fonarow GC, et al. Circulation. 1994;90:I-488.

  22. Post-discharge Freedom from Congestion Is Associated with Better Prognosis 100 No congestion (N=80) 80 1-2 congestion (N=40) 60 P<0.001 Survival (%) 3-5 congestion (N=26) 40 20 Reassess at 4-6 weeks 0 0 6 12 18 24 Months after reassess Criteria for congestion: Orthopnea, JVD, weight gain ≥2 lb in a week, need (0-5) to increase diuretic dose, leg edema Lucas C, et al. Am Heart J. 2000;140:840-847. 22

  23. High PCWP: Important Independent Predictor for Survival • In the ESCAPE trial, PCWP and not cardiac output was a significant predictor of subsequent survival • Other independent predictors of survival: • Systolic blood pressure <120 mm Hg • Distance walked in 6 minutes • Blood urea nitrogen ESCAPE Investigators. Presented at the 77th American Heart Association Scientific Sessions. Late Breaking Clinical Trials Session. New Orleans, LA. 11/10/2004. 23

  24. Pathophysiology of Congestion Way congestion develops? What are the consequences? 24

  25. Why Do Patients With HF Develop Congestion? Heart • Cardiac pump function/loading conditions (diastolic failure) Kidney • Sodium and water handling (retention/edema) Neurohormonal abnormalities • Modulates cardiac and renal function • eg, excess vasopressin ≥ hyponatremia, water retention All 3 need to be abnormal in order to have significant congestion 25

  26. The Cardiorenal Syndrome in Heart Failure Decreased cardiac output Decreased cardiac performance Neurohormonal activation Increased venous pressure Increased water & Na+ retention (Congestion) Diminished blood flow Impaired renal function Decreased renal perfusion Modified from Abraham WT. 26

  27. Effect of Increasing Central Venous Pressure (CVP) on GFR inIntact Dogs with Constant BP High CVP significantly impairs GFR 1.4 Raised venous pressure: A direct cause of renal sodium retention P<.05 1.1 GFR (ml/min) P<.05 0.8 0.5 Central Venous Pressure 0 6.25 12 18.75 25 0 0 2 4 6 8 mm Hg GFR, glomerular filtration rate; BP, blood pressure. Firth JD et al. Lancet. 1988;1(8593):1033-1035. 27

  28. Congestion May Contribute to the Progression of Heart Failurein Patients Admitted With HF 28

  29. Progression of Heart Failure Coronary artery disease Arrhythmia Left ventricularinjury Low ejectionfraction PathologicRemodeling Death Hypertension Cardiomyopathy Pump failure Valvular disease Symptoms:DyspneaFatigueEdema Chronicheartfailure • Neurohormonal stimulation • Endothelialdysfunction • Vasoconstriction • Renal sodium retention Cohn J. N Engl J Med. 1996;335:490-498. 29

  30. Severe Congestion (PCWP/LVDP) in Heart Failure* – Potential Deleterious Effects • Subendocardial ischemia/cell death by necrosis/apoptosis1 • Changes in extracellular matrix structure and function1 • Changes in LV shape: • Increased afterload • Leads to mitral regurgitation • Impaired cardiac venous drainage from coronary veins (diastolic dysfunction) • Lower threshold for arrhythmias • Progression of LV dysfunction/remodeling *The number of patients with congestion will probably increase due to a decrease in the rate of sudden death (beta-blockers, ICD). 1Gheorghiade M, et al. Circulation. 2005;112:3958-3968. 30

  31. Myocardial Injury in AHFS Hemodynamic deterioration(eg, fluid overload)  Myocardial injury (Tn release)  Progression of heart failure Tn, serum troponin. Gheorghiade M, et al. Circulation. 2005;112:3958-3968. 31

  32. Pilot Randomized Study of Nesiritide vs Dobutamine in Heart Failure (PRESERVD-HF) Patients with CAD • At the time of admission for HF, elevations of TnT and TnI are present in 43% and 74% of patients • During hospitalizations, among those without elevated Tn at baseline, 42% of patients will release TnI and 8% of patients will release TnT • TnT/I correlated with short term outcomes TnT, troponin T; TnI, troponin I. Gheorghiade M, et al. Am J Cardiol. 2005;96(6A). 32

  33. AHFS: Prognostic Value of Tn T 1 0.9 TnT <0.1 ng/mL (N=46) 0.8 0.7 0.6 Survival TnT >0.1 ng/mL (N=32) 0.5 0.4 0.3 0.2 0.1 0 3 6 9 12 15 18 21 24 27 30 33 36 Months Perna ER, et al. Am Heart J. 2002;143:814-820. 33

  34. Acute Exacerbations May Contribute to the Progression of Heart Failure With each event, myocardial injury may contribute to progressive LV dysfunction Acute event Cardiac Function • Death Time Gheorghiade M, et al. Am J Cardiol. 2005;96(6A-11A). 34

  35. ESCAPE Trial Design: ESCAPE was a randomized study of pulmonary artery catheter (PAC) guided therapy (n=215) vs clinical assessment alone (n=218) among patients hospitalized with recurrent heart failure but without an established need for a PAC. Primary endpoint was days neither dead nor hospitalized through 6 months. Results • Study population had severe illness (mean LVEF 20% and mean SBP 105.6 mm Hg) • Trial discontinued early by DSMB due to lack of efficacy • No difference between groups in primary endpoint of days neither dead nor hospitalized through 6 months (HR 1.00; 95% CI 0.83-1.21 • Also no difference in frequency of rehospitalization or death (Figure) • Both groups had improvements in exercise and quality of life endpoints, with non-significant trend for larger improvement in PAC group Conclusions • Among patients hospitalized with recurrent heart failure but without an established need for a PAC, use of PAC to guide therapy was not associated with a reduction in days neither dead nor hospitalized compared with clinical assessment alone • Data cannot be extrapolated to patients that do have indication for PAC guided therapy Rehospitalization by 6 months P=NS Death by 6 months P=NS 25 3 20 2 15 % 10 1 5 0 0 PAC Control SBP, systolic blood pressure. Presented at AHA Scientific Sessions 2004.www.cardiosource.com 35

  36. Mortality at 6 Months in Patients Admitted with HF in the ESCAPE Trial 35 Mortality 30 25 20 % 15 10 5 0 mEq/dL NA: 121-134 135-136 137-139 140-147 CI PCWP RAP 1.8 2.3 1.9  2.1 1.9  1.2 2.1  2.1 27  19 22  18 25  15 22  17 15  9 12  8 9  8 12  8 CI, cardiac index; RAP, right atrial pressure. Gheorghiade M, et al. Presented at ACC, 2005. 36

  37. Rapid and Substantial vs Gradual and Modest Hemodynamic Improvement • In patients hospitalized for HF, normalization of markedly abnormal hemodynamics with high doses of diuretics, vasodilators and/or inotropes was associated with an increase in post-discharge mortality and hospitalizations (ESCAPE) • In outpatients with HF, hemodynamic improvement appears to prevent hospitalizations in class III but not IV patients (COMPASS) 37

  38. Hospitalizations for Heart Failure:Congestion Precedes Hospitalization Pressure Change Hospitalization 40 RV Systolic Pressure 30 Estimated PA Diastolic Pressure Heart Rate 20 Percent Change 10 0 -10 Baseline -7 -6 -5 -4 -3 -2 -1 Recovery Days Relative to the Event Adamson PB, et al. J Am Coll Cardiol. 2003;41:565-571. 38

  39. Congestion in HF: Conclusions • Congestion is an important predictor of mortality and morbidity • Congestion is the primary cause of HF hospital admissions and predicts readmissions • Hemodynamic congestion is often difficult to recognize, delaying appropriate interventions • Clinical congestion often lags behind hemodynamic congestion • Congestion may contribute to the progression of HF 39

  40. Hemodynamic Congestion • Hemodynamic or cardiopulmonary congestion (elevated PCWP) starts days or weeks prior to hospitalization • May occur in the absence of signs (rales, JVD, edema) or symptoms of clinical congestion • Early treatment of hemodynamic congestion may prevent hospitalization and progression of heart failure • Improved methods of monitoring hemodynamic congestion may improve clinical managementand outcomes 40

  41. Why Prevent Hospitalizations*? • Prevent possible myocardial injury(progression of HF) • Once the patient is hospitalized, we're forced to use interventions (eg, inotropic agents) that may cause myocardial injury • High post-discharge mortality and hospitalizations • Cost *The most important predictor of prognosis.Gheorghiade M, et al. Circulation. 2005;112:3958-3968. 41

  42. ACC/AHA HF Performance Measures: Outpatient • Initial laboratory tests • Left ventricular systolic function assessment • Weight measurement • Blood pressure measurement • Assessment of clinical symptoms of congestion • Assessment of clinical signs of congestion • Assessment of activity level • Patient education • Beta-blocker therapy in patients with HF and LVSD • ACEI or ARB in patients with HF and LVSD • Warfarin therapy in patients with atrial fibrillation ACC/AHA, American College of Cardiology/American Heart Association;ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker. Bonow RO, et al. J Amer Coll Cardiol. 2005;46:1144-1178. 42

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