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Developments in heart failure Developments in heart failure management and clinical practice management and clinical practice
in the UKin the UK
Jamil MayetJamil Mayet
Department of CardiologyDepartment of Cardiology
St Mary’s HospitalSt Mary’s Hospital
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Problems in heart failure Problems in heart failure managementmanagement
• Accurate diagnosisAccurate diagnosis
• Optimising drug therapyOptimising drug therapy
• Identification of patients who will benefit Identification of patients who will benefit from revascularisationfrom revascularisation
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Heart failure therapy - rule of halves
Treatment - no CCF
CCF - inadequatetherapy
CCF -appropriatetherapy
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Cardiac failure - diagnosisCardiac failure - diagnosis
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ElectrocardiogramElectrocardiogram
If ECG normal very unlikely to be systolic dysfunctionIf ECG normal very unlikely to be systolic dysfunction
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EchocardiographyEchocardiography
• Confirms / refutes diagnosis of systolic Confirms / refutes diagnosis of systolic dysfunctiondysfunction
• Can exclude significant valvular diseaseCan exclude significant valvular disease• Can suggest ischaemic aetiology if regional Can suggest ischaemic aetiology if regional
wall motion abnormalitywall motion abnormality• Can assess diastolic dysfunctionCan assess diastolic dysfunction
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Easy access to investigationsEasy access to investigations
• GP educationGP education– Every patient with possible cardiac failure should Every patient with possible cardiac failure should
be considered for echocardiographybe considered for echocardiography
• Open and rapid access to echocardiographyOpen and rapid access to echocardiography
• Clear user-friendly reportsClear user-friendly reports– ““Mild MR; this is not clinically significant”Mild MR; this is not clinically significant”– ““In the absence of clinical contra-indications…”In the absence of clinical contra-indications…”
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Optimising drug therapyOptimising drug therapy
• ACE inhibitorsACE inhibitors– High doses used in clinical trialsHigh doses used in clinical trials– If cough AII antagonistsIf cough AII antagonists– If contra-indications hydralazine/nitratesIf contra-indications hydralazine/nitrates
• Beta blockersBeta blockers
• SpironolactoneSpironolactone
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ACE inhibitor doses used in large ACE inhibitor doses used in large controlled trialscontrolled trials
• CONSENSUSCONSENSUS EnalaprilEnalapril 20mg*20mg*• V-HeFT IIV-HeFT II EnalaprilEnalapril 10mg*10mg*• SOLVDSOLVD EnalaprilEnalapril 10mg*10mg*• SAVESAVE CaptoprilCaptopril 50mg**50mg***twice daily*twice daily **three times a day**three times a day
• ATLAS study showed significant decrease in ATLAS study showed significant decrease in mortality+hospital admissions in high dose mortality+hospital admissions in high dose versus low dose lisinoprilversus low dose lisinopril
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Treatment – AII antagonistsTreatment – AII antagonists• ELITE STUDYELITE STUDY
• 722 patients 722 patients 65 years with:65 years with:– CCF (NYHA class II-IV)CCF (NYHA class II-IV)– LVEF LVEF 40% 40%
• Captopril vs. losartanCaptopril vs. losartan• FU 1 yearFU 1 year• Mortality:Mortality:
– 4.8% losartan 4.8% losartan – 8.7% captopril (p=0.035)8.7% captopril (p=0.035)
• ELITE IIELITE IIEvaluation of Losartan in the Elderly. Lancet 1997;349:747-52Evaluation of Losartan in the Elderly. Lancet 1997;349:747-52
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Treatment – beta Treatment – beta blockersblockers
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Beta-blockers for CCFBeta-blockers for CCF
CIBIS-II: cardiac insufficiency bisoprolol study (II)CIBIS-II: cardiac insufficiency bisoprolol study (II)• >2500 patients>2500 patients
– EF EF 35% ; NYHA III-IV; 50% IHD 35% ; NYHA III-IV; 50% IHD– ~ all on ACE I & diuretics; 50% on digoxin~ all on ACE I & diuretics; 50% on digoxin
• Bisoprolol vs. placeboBisoprolol vs. placebo– Starting dose 1.25mg, gradually Starting dose 1.25mg, gradually to 10mg od over 4/52 to 10mg od over 4/52
• Study ended prematurely after 1.3 years:Study ended prematurely after 1.3 years:– Annual mortality:Annual mortality:
• 8.8% bisoprolol; 13.2% placebo; Hazards Ratio 0.668.8% bisoprolol; 13.2% placebo; Hazards Ratio 0.66• Risk reduction greatest in patients with IHDRisk reduction greatest in patients with IHD
Lancet 1999 Jan 02; 353:9-13Lancet 1999 Jan 02; 353:9-13
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Treatment – beta blockersTreatment – beta blockers
Patients were largely in NYHA class II-IIIPatients were largely in NYHA class II-III
Benefits are additive to those conferred by ACEI Benefits are additive to those conferred by ACEI
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Treatment – beta blockersTreatment – beta blockers
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Treatment – spironolactoneTreatment – spironolactone• 1663 patients with:1663 patients with:
– Stable CCF NYHA III-IVStable CCF NYHA III-IV
– LVEF LVEF 35%35%
– On ACE I and diureticsOn ACE I and diuretics
– Some also on digoxinSome also on digoxin
• SpironolactoneSpironolactone (25-50mg od) vs. (25-50mg od) vs. placeboplacebo• Primary endpoint:Primary endpoint: death from any cause death from any cause• Study stopped prematurely:Study stopped prematurely:
– 30% 30% mortality in spironolactone group mortality in spironolactone group
• Significant improvement in functional classSignificant improvement in functional class
Randomized Aldactone Evaluation Study. NEJM 1999;341:709-717Randomized Aldactone Evaluation Study. NEJM 1999;341:709-717
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Diagnosing ischaemic heart Diagnosing ischaemic heart diseasedisease
• 75% of white males in SOLVD were related 75% of white males in SOLVD were related to ischaemic heart diseaseto ischaemic heart disease
• 50% of patients in Framingham had an 50% of patients in Framingham had an ischaemic aetiology to their heart failureischaemic aetiology to their heart failure
• Identification of patients who will benefit Identification of patients who will benefit from revascularisationfrom revascularisation
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Hibernating myocardiumHibernating myocardium
• Chronic LV dysfunction does not Chronic LV dysfunction does not necessarily imply dead myocardiumnecessarily imply dead myocardium
• ““Hibernating myocardium” termed by Hibernating myocardium” termed by Rahimtoola in 1989Rahimtoola in 1989
• LV systolic function improved following LV systolic function improved following coronary revascularisationcoronary revascularisation
Rahimtoola. Am Heart J 1989;117:211-Rahimtoola. Am Heart J 1989;117:211-2121
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Hibernating myocardiumHibernating myocardium
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Prediction of functional recovery Prediction of functional recovery following revascularisationfollowing revascularisation
TechniqueTechnique SensitivitySensitivity SpecificitySpecificity Number ofNumber of
PatientsPatients
Number ofNumber of
StudiesStudies
Tc 99m MIBITc 99m MIBI
ScanningScanning
83%83% 69%69% 207207 1010
DobutamineDobutamine
Stress EchoStress Echo
84%84% 81%81% 448448 1616
Th 201 StressTh 201 Stress
RedistributionRedistribution
86%86% 47%47% 209209 77
1818F PETF PET 88%88% 73%73% 327327 1212
Th 201 RestTh 201 Rest
RedistributionRedistribution
90%90% 54%54% 145145 88
Wijns et al. N Engl J Med 1998;339:173-81Wijns et al. N Engl J Med 1998;339:173-81
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Implications of viable Implications of viable myocardiummyocardium
• 87 patients with ischaemic CHF, LVEF<0.3587 patients with ischaemic CHF, LVEF<0.35
• Low dose stress echoLow dose stress echo
• 40+/-17 months follow up40+/-17 months follow up
• 37 patients received revascularisation37 patients received revascularisation
• 22 cardiac related deaths22 cardiac related deaths
Senior et al. J Am Coll Cardiol 1999;33:1848-54Senior et al. J Am Coll Cardiol 1999;33:1848-54
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MV - revascularisedMV - revascularised
MV – med PxMV – med PxNo MV – med PxNo MV – med PxNo MV - revascularisedNo MV - revascularised
Implications of viable myocardiumImplications of viable myocardium
Senior et al. J Am Coll Cardiol 1999;33:1848-54Senior et al. J Am Coll Cardiol 1999;33:1848-54
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Cardiac failure – services Cardiac failure – services available at St Mary’savailable at St Mary’s
• Open access ECG / CXR / echocardiographyOpen access ECG / CXR / echocardiography
• Routine outpatients for specialist opinion and Routine outpatients for specialist opinion and invasive investigationinvasive investigation
• Emergency assessment in A+EEmergency assessment in A+E
• Specialist cardiac failure follow up clinicSpecialist cardiac failure follow up clinic
• Specialist heart failure nurseSpecialist heart failure nurse
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Specialist referralSpecialist referral
• Confirm diagnosisConfirm diagnosis
• Invasive assessment to diagnose underlying Invasive assessment to diagnose underlying ischaemic aetiologyischaemic aetiology
• Addition of beta-blockers and/or Addition of beta-blockers and/or spironolactonespironolactone
• Management of difficult / deteriorating Management of difficult / deteriorating casescases
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Heart failure specialist nurseHeart failure specialist nurse
• Monitoring weight and blood testsMonitoring weight and blood tests
• Educating patient and familyEducating patient and family– Daily weighingDaily weighing– Self management of diureticsSelf management of diuretics– Regular exerciseRegular exercise
• Promoting long term compliancePromoting long term compliance
• Implementing treatment protocolsImplementing treatment protocols
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Diastolic heart failureDiastolic heart failure
• Up to a third of patients have clinical heart Up to a third of patients have clinical heart failure with normal LV systolic functionfailure with normal LV systolic function
• Underlying pathophysiology relates to Underlying pathophysiology relates to diastolic dysfunctiondiastolic dysfunction
• Commonest underlying pathologies Commonest underlying pathologies – Normal ageingNormal ageing– HypertensionHypertension– Myocardial ischaemiaMyocardial ischaemia
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Mechanisms of diastolic Mechanisms of diastolic dysfunctiondysfunction
• Impaired ventricular relaxationImpaired ventricular relaxation– Energy dependent processEnergy dependent process– Susceptible to myocardial ischaemiaSusceptible to myocardial ischaemia
• Decreased myocardial complianceDecreased myocardial compliance– Altered compliance mediated by collagenAltered compliance mediated by collagen– Fibrosis related to activation of RAASFibrosis related to activation of RAAS
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Doppler patterns of diastolic dysfunction
• Impaired relaxation– Reduced E/A ratio
– Increased EDT
– Increased IVRT
• Restriction– LA pressure increases due to myocardial stiffness
– High peak E wave velocity
– Short EDT
– Very short IVRT
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Treatment of diastolic heart Treatment of diastolic heart failurefailure
• Treat underlying cause eg ischaemiaTreat underlying cause eg ischaemia
• Impaired relaxationImpaired relaxation– Theoretically rate-limiting agents effectiveTheoretically rate-limiting agents effective
• Beta-blockers, verapamilBeta-blockers, verapamil
• Reduce HR and prolong diastoleReduce HR and prolong diastole
• Reduce myocardial oxygen demandReduce myocardial oxygen demand
• Lower BP and reduce LVHLower BP and reduce LVH
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Treatment of diastolic heart Treatment of diastolic heart failurefailure
• RestrictionRestriction– Drugs which reduce fibrosis and lower LA Drugs which reduce fibrosis and lower LA
pressure theoretically should be effectivepressure theoretically should be effective• ACEIACEI• AII blockersAII blockers• DiureticsDiuretics
– If LA pressure lowered too much cardiac output If LA pressure lowered too much cardiac output significantly worsenedsignificantly worsened
• Can cause significant morbidityCan cause significant morbidity