acute and advanced heart failure
TRANSCRIPT
The European Heart Journal’s / European Journal of Heart Failure’s year in cardiology
Piotr Ponikowski, MD, PhD, FESC Medical University, Centre for Heart Disease
Clinical Military HospitalWroclaw, Poland
Acute and Advanced Heart Failure
Disclosure
Consultancy fees and speaker’s honoraria from:
Vifor Pharma Ltd, Amgen, Servier, Novartis, Bayer, Pfizer, Johnson&Johnson, Abbott Vascular, Coridea, Respicardia
Research grant: Vifor Pharma Ltd, Respicardia
Heart Failure: treatable and preventable disease (?)
Landscape at the end of 20th century: HF more malignant than cancer Framingham study
Median survival:Men – 1.7 yrs, women – 3.2 yrs
Ho KKL et al., Circulation 1993;88:107-15
Hospitalizations due to HF worsening often complicate patient’s journey
Severity ofsymptoms
Death
Time
Sudden death
HospitalizationHospitalization
Hospitalization
Mild HF
Moderate-severe HF
End-stage HF
Repeated Hospitalizations
161.131 pts; mean age: 78 yrs (M:77 vs F:82); 20% ≥ 2 HHF; LOS: 10 daysIn-hospital mortality: 7.8%
Average annual change in mortality for HF (2000-12) Trends in age-standardized rates of HHF pts and proportion of readmissions (2002-12)
Year 2012
Patient characteristics by geographic region
Conclusion for designing future HHF clinical trials: region of enrolment for clinical trial as independent and strong
predictor of death
Relative risk of clinical outcomes by geographic region relative to North America
Greene SJ et al. Eur J Heart Fail 2015 (in press)
CardShock Study: 219 pts, ACS – 81%, in-hospital mortality – 37%
CardShock risk Score for risk prediction of in-hospital mortality in cardiogenic shock
Distribution of the population (red) and in-hospital mortality (blue) according to cumulative points
low risk
intermediaterisk
high risk
Simple index of diuretic response: ∆weight (kg) / 40 mg furosemide Day 4 response: differentiation in responsiveness and diuretics adjustment to clinical responsePredictors of poor diuretic response: low SBP, high BUN, diabetes, atherosclerotic disease
“This is the first guidance to insist that acute heart failure (AHF) is like acute coronary syndrome
(ACS) in that it needs urgent diagnosis and appropriate treatment. In ACS when the coronary is occluded we say ‘time is muscle’ which means that the quicker the
vessel is dilated, the more heart muscle is saved. The same principle is true for AHF.
By introducing the time to therapy concept together with new medications for AHF we hope to
achieve the reductions in mortality and morbidity seen with ACS.”
ESC WEBPAGE
„Time is muscle in acute heart failure”
Urgent treatment emphasised for the first time
in recommendations from across specialties
and continents
Alexandre Mebazaa
Mebazaa A et al. Eur J Heart Fail 2015 (in press)
Bedside assessment to identify hemodynamic profilesPatient with acute heart failure
signs/symptoms: •orthopnea, PND, breathlessness, bi-basal rales, an abnormal BP response to the Valsalva maneuver (left-sided); •symptoms of gut congestion, elevated jugular venous distention, hepato-jugular reflux, hepatomegaly, ascites, and peripheral edema (right-sided);
Presence of congestion
YES (95% of all AHF patients)
„Wet” patient
NO (5% of all AHF patients)
„Dry” patient Adequate peripheral perfusion
YES„Wet and Warm” patient
(typically elevated/normal systolic blood pressure)
NO
„Wet and Cold” patient(typically low systolic blood pressure)
•inotropes: dobutamine, levosimendan, milrinone
•vasodilators (if peripheral vasoconstriction): nitroprusside, nitrates
•diuretics
Vascular type (fluid redistribution):
•Vasodilators•diuretics (small dose)
Cardiac type (fluid accumulation):
•diuretics •ultrafiltration
(if diuretic resistance)
Ponikowski P et al. submitted
Treatment of iron deficiency: Attractive therapeutic target in heart failure ?
• Iron deficiency (ID) – frequent co-morbidity in stable CHF
• CHF complicated with ID – associated with impaired functional capacity, poor quality of life and increased mortality
• Deleterious consequences of ID in CHF are irrespective of anaemia
• Correction of ID itself as an attractive therapeutic target in CHF – hypothesis recently being tested in clinical studies
• What about iron status in Acute Heart Failure ?
Iron deficiency (new definition): •depleted body iron stores (low serum hepcidin)
•insufficient iron amount in metabolizing cells (high serum sTfR)
20%
40%
60%
80%
% of AHF pts
Preserved iron status
Isolated high sTfR
Isolated low hepcidin
Iron deficiency(↓hepcidin & ↑sTfR)
75% of AHF - impaired iron status
Iron deficiency is common and predicts poor outcomein patients hospitalized for AHF
Cumulative survival
Follow-up (months)
χ2=29.45, p<0.001
100% 93% (81-100%)85% (75-95%)
59% (47-71%)
Iron deficiency (both low hepcidin and high sTfR) (1)Isolated high sTfR (2)Isolated low hepcidin (3)Preserved iron status (4)
Jankowska EA et al. Eur Heart J 2014
Sleep disordered breathing in heart failureProblems with nomenclature and perception
Sleep Physician• obstructive sleep apnoea
• central sleep apnoeaNomenclature accepted
Prevalent and relevant for M&M and QoL
Target for intervention
Prevalent in obese & HTN pts
Snoring problem
Affecting QoL
Cardiologist
Sleep disordered breathing in heart failureProblems with nomenclature and perception
Sleep Physician• obstructive sleep apnoea
• central sleep apnoeaNomenclature accepted
Prevalent and relevant for M&M and QoL
Target for intervention
Heart Failure Specialist
Breathing abnormality
•Cheyne-Stokes respiration
•During sleep (also at rest)
Nomenclature accepted ?
Prevalent and relevant for M&M and QoL
Target for intervention ?
Prevalent in obese & HTN pts
Snoring problem
Affecting QoL
Cardiologist
Prevalence of sleep apnoea in patients with chronic HFrEF
Krawczyk M et al. Cardiol J 2013
Ominous pathophysiological and clinical consequences(progression of the disease, increased M&M)
Largest prospective evaluation of SDB in AHF: 1117 pts with HFrEFExcluded: unstable, hypoxic, unable to sleep flat; 97 % with chronic decompensated HFPrevalence: 31% central sleep apnoea, 47% obstructive sleep apnoea, 22% with nmSDB
CSA and OSA – independent risk factors for post-discharge mortality
Modification of the mortality effect with SDB treatment
Khayat R et al. Eur Heart J 2015 (in press)
The great thing in this world is not so much where we stand, as in what direction we are moving
Oliver Wendell Holmes 1841-1935