congestive heart failure - rsfh.com health/health professionals... · • the incidence and...
TRANSCRIPT
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Congestive Heart Failure: more than just a pump
Patrick M. Looser, MDLowcountry Cardiology Associates
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Disclosures• No disclosures relevant to this talk
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Overview• Review the epidemiology of heart failure in
the US• Brief summary of the nomenclature • Discuss the evidence based pharmacologic
treatments for heart failure with reduced and preserved ejection fraction
• Advanced therapies• Conclusion
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Heart Failure is Common
Braunwald E. JACC Heart Fail. 2013.1:1-20.
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ACC SAP 8, Roger et al. Circ 2011
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Savarese & Lund, Cardiac Failure Review 2017;3(1):7–11.
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Accessed 5 February 2019 https://www.scdhec.gov/sites/default/files/Library/ML-002149.pdf
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Accessed 5 February 2019 https://scdhec.gov/sites/default/files/docs/Health/docs/LCODRegions.pdf
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Accessed 5 February 2019 https://scdhec.gov/sites/default/files/docs/Health/docs/LCODRegions.pdf
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Epidemiology Summary• Heart failure incidence and prevalence is rising• It affects a substantial amount of our older
patients – up to 11% of patients over 80 years of age
• Risk factors are highly prevalent in SC• Heart disease is the second leading cause of
death in the Lowcountry• Associated with a poor prognosis, no matter the
ejection fraction
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HEART FAILURE NOMENCLATURE
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Lorenzini, Primary Care in Practice 2016
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Nomeclature• NYHA Class versus Stage
• NYHA classification refers to functional status of the patient
• Stages refer to symptoms + structural heart disease
• Stratification by EF• Heart failure with preserved EF - > 50%• Heart failure with reduced EF < 35%• Heart failure with mid range EF 35-50%
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MEDICAL THERAPY FOR HEART FAILURE WITH REDUCED EF
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Slide courtesy of Parag Goyal MD
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Kirmani and Squire Curr Rep Heart Fail 2017
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Beta Blockers
Packer M, et al. NEJM. 1996:334:1349.CIBIS-II Investigators. Lancet. 1999;353:9.Packer M, et al. NEJM. 2001;344:1651.MERIT-HF Study Group. Lancet. 1999;353:2001.
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ACE/ARB
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AA
Pitt B, et al. NEJM. 1999;341:709.Pitt B, et al. NEJM. 2003;348:1309.
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Yancy et al JACC 2017
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Cardiac Society of Australia and New Zealand
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Guideline Directed Medical Tx• Beta blockers – carvedilol, bisoprolol, metoprolol succinate• ACE inhibitors/ARB• ARNI – saccubitril/valsartan• Aldosterone receptor antagonists
• Hydralazine/nitrates – in AA populations• Ivabradine – in select patients with elevated HR
• Diuretics for symptoms of congestion
• ICD or BiV ICD in select patient populations
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HEART FAILURE WITH PRESERVED EF
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Reddy et al Circulation 2018
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HFpEF – Differential diagnosis• Non cardiac dyspnea – obesity hypoventilation
syndrome, obstructive sleep apnea, deconditioning, pulmonary causes
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HFpEF – Differential diagnosis• Non cardiac dyspnea – obesity hypoventilation
syndrome, obstructive sleep apnea, deconditioning, pulmonary disease
• Coronary artery disease• Valvular heart disease• Restrictive cardiomyopathy• Pulmonary hypertension with right sided heart
failure• Chronic pericarditis
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Clinical scenario• 48-year-old man, morbid obesity, HTN, DM who was admitted
with SOB, DOE, leg swelling. Exam shows a thick neck, lungs clear, severe LE edema
• BNP 142 pg/ml, Cr 1.2 mg/dl• IV diuresis, negative 3L, by hospital day #3• Echo: normal EF, borderline filling pressures, grade 1 diastolic
dysfunction• Hospital day #4: HCO3 42, Cr 1.6 mg/dL
• RHC/LHC: • RA 18, RV 64/14, PA 62/28 mean , PCWP 28, LVEDP 26
• Diuresed another 10-12 L – doing well
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Slide courtesy of Parag Goyal MD
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TOPCAT
Pfeffer MA, et al. Circulation. 2015;131:34-42.
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HFpEF Recommendations
Yancy et al JACC 2017
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Yancy et al JACC 2017
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DIET AND HEART FAILURE
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Doukkyet al JACC Heart Failure 2016
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Miro et al JACC Heart Failure 2018
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Diet Conclusions• The data on salt intake in CHF is controversial but
professional heart failure societies recommend 2-3g/day in CHF
• Diet is controversial but diets that are lower in processed foods, animal proteins and higher in fruits, vegetables, legumes tend to have fewer heart failure hospitalizations
• The optimal salt intake and dietary profile are still areas of active investigation
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Advanced therapies
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Who to consider for advanced therapies
• Class III-IV HF despite maximal medical therapy• Intolerant of neurohormonal antagaonists• Worsening renal failure• Frequent hospitalizations for heart failure
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IV therapies
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Stulak et al. Ann Thorac Surg 2017
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Courtesy of Thoratec
https://www.thoratec.com/medical-professionals/vad-product-information/heartmate3/HeartMate3_Patient-Education-Brochure.pdf
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https://www.mayoclinic.org/tests-procedures/heart-transplant/about/pac-20384750. Accessed 5 Feb 2019
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Conclusions• The incidence and prevalence of congestive heart failure in the
US is increasing
• Pharmacotherapies include beta blockers, ACE/ARB, ARNI, aldosterone antagonists, hydralazine/nitrates, ivabradine in select populations, diuretics for symptoms of congestion.
• Diet is controversial, but limiting salt to 2-3g per day plus increasing consumption of whole foods and decreasing consumption of added sugars, processed foods, red meat has been show to be beneficial.
• Consider cardiology/advanced heart failure referral when patients become intolerant of medications, have more frequent hospitalizations, develop worsening renal failure etc.
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Questions?