Download - Which I.V. therapies work in HHF ?
Which I.V. therapies work
in HHF?
Gerasimos Filippatos, MD, FESC, FHFA
President
Heart Failure Association
NONE !!!
Outcome in acute HF is still poor
Death, Rehospitalization or ER visit
DOSE CARRESS-HF
40% at
60 days
All-cause death or hospitalization
Chronic HF: 17.2%
Acute HF: 35.1%
Days from enrollment
A. Maggioni, U Dahltrom, G, Filippatos et al EJHF2011
EURObservational Research Program:
The Heart Failure Pilot Survey
1-year all cause mortality:
acute HF – 16.8% chronic HF – 6.8%
Management of acute heart failure:
why so difficult ?
Clinical Factors:
Underlying causes: multifactorial, precipitating factor often
not identified
Clinical presentation: spectrum of various conditions,
heterogeneous pathophysiology
Cardiovascular and non-cardiovascular comorbidities
Pathophysiological targets: uncertain
End-points selection: not standardized
Courtesy of Piotr Ponikowski
Terminology
• HHF
• AHF
• ADHF
• WHF
• WCHF
• AHFS….
Recommendations for the treatment of acute
heart failure in HFA/ESC 2012 guidelines
Therapies in the Hospitalized HF Patient
Recommendation COR LOE
HF patients hospitalized with fluid overload should be treated with
intravenous diuretics I B
HF patients receiving loop diuretic therapy, should receive an initial
parenteral dose greater than or equal to their chronic oral daily dose, then
should be serially adjusted
I B
HFrEF patients requiring HF hospitalization on GDMT should continue
GDMT unless hemodynamic instability or contraindications I B
Initiation of beta-blocker therapy at a low dose is recommended after
optimization of volume status and discontinuation of intravenous agents I B
Thrombosis/thromboembolism prophylaxis is recommended for patients
hospitalized with HF I B
Serum electrolytes, urea nitrogen, and creatinine should be measured
during the titration of HF medications, including diuretics I C
Goals of Treatment in Acute Heart Failure
Immediate
(ED/ICU/CCU)
Intermediate (in-hospital)
Long-term and pre-
discharge
management
Phases in the
AHF management
• Treat symptoms
• Restore oxygenation
• Improve organ perfusion &
haemodynamics
• Limit cardiac/renal damage
• Prevent thrombo-embolism
• Minimize ICU length of
stay
•Stabilise patient and
optimise treatment strategy
• Initiate and up-titrate
disease-modifying
pharmacological therapy
•Consider device therapy in
appropriate patients
• Identify aetiology and
relevant co-morbidities
• Plan follow-up strategy
• Enrol in disease
management programme,
educate, initiate appropriate
lifestyle adjustments
• Plan to up-titrate/optimize
disease-modifying drugs
• Assess for appropriate
device therapy
• Prevent early readmission
• Improve symptoms, quality
of life and survival
ESC /HFA Guidelines for the Diagnosis and Treatment
of Acute and Chronic Heart Failure 2012
Goals of Treatment in Acute Heart Failure
Immediate
(ED/ICU/CCU)
Intermediate (in-hospital)
Long-term and pre-
discharge
management Phases in the
AHF management
• Treat symptoms
• Restore oxygenation
• Improve organ perfusion &
haemodynamics
• Limit cardiac/renal damage
• Prevent thrombo-embolism
• Minimize ICU length of
stay
•Stabilise patient and
optimise treatment strategy
• Initiate and up-titrate
disease-modifying
pharmacological therapy
•Consider device therapy in
appropriate patients
• Identify aetiology and
relevant co-morbidities
• Plan follow-up strategy
• Enrol in disease
management programme,
educate, initiate appropriate
lifestyle adjustments
• Plan to up-titrate/optimize
disease-modifying drugs
• Assess for appropriate
device therapy
• Prevent early readmission
• Improve symptoms, quality
of life and survival
ESC /HFA Guidelines for the Diagnosis and Treatment
of Acute and Chronic Heart Failure 2012
Recommendations on Prehospital and Early
Hospital Management of AHF:
A consensus paper from the Heart Failure
Association of the ESC, the European Society
of Emergency Medicine and the Society of
Academic Emergency Medicine
EHJ and EJHF 2015: In Press
Important developments
Better use of old drugs
New Drugs
Treatment of co-morbidities
Diuretics in Hospitalized
Patients
ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure
Decompensated chronic HF
• Consider higher dose of diuretics in
renal dysfunction or with chronic
diuretic use.
Diuretic Optimization Strategies
Evaluation in Acute Heart Failure (DOSE)
To evaluate the safety and efficacy of various initial strategies of furosemide
therapy in patients with ADHF
– Route of administration: • Q12 hours bolus
• Continuous infusion
– Dosing • Low intensification (1 x oral dose)
• High intensification (2.5 x oral dose)
Diuretics in Hospitalized Patients
If patients are already receiving loop diuretic therapy, the
initial intravenous dose should equal or exceed their
chronic oral daily dose and should be given as either
intermittent boluses or continuous infusion.
I IIa IIb III
EURObservational Research Programme
Heart Failure PILOT
Acute HF: persisting congestion at discharge and all-cause mortality during the follow-up
Pulmonary and/or
Peripheral congestion
MORTALITY
p<.0001
82.1%
24.0%
At admission At discharge
Determinants and forms of worsening renal function in heart failure.
Filippatos G et al. Eur Heart J 2013;eurheartj.eht515
What to do next ?
1. Increase furosemide dose
2. Ιntravenous infusion rather than bolus therapy
3. Substitution of an ineffective loop diuretic for another one
4. Add metolazone and/ or potasium sparing diuretic
5. Add dopamine at 2-5 mcg/k/m
6. Withdraw b-blocker and/ or ACE inhibitor
7. Add vasodilator
8. Add dobutamine
9. Add levosimendan
10. Add vasopressin antagonist ?
11. Start ultrafiltration
12. Start dialysis
13. Insert IABP
14. Insert another device
Maisel A, Filippatos G, Heart Failure. Jaypoor. Publishers, 2014
If symptomatic hypotension is absent, intravenous
nitroglycerin, nitroprusside or nesiritide may be considered
an adjuvant to diuretic therapy for relief of dyspnea in
patients admitted with acutely decompensated HF.
I IIa IIb III
ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012
Hasenfuss G and Teerlink J, EHJ 2011
Inotropic Therapies
Inotropic Support
Short-term, continuous intravenous inotropic support may
be reasonable in those hospitalized patients presenting
with documented severe systolic dysfunction who present
with low blood pressure and significantly depressed
cardiac output to maintain systemic perfusion and
preserve end-organ performance.
I IIa IIb III
MECHANISMS OF DISEASE PROGRESSION
Cardiac and Renal Injury Cell death by necrosis and apoptosis
Tn Release
Fibrosis
Progression
of Heart and
Kidney Failure
Neurohormonal
Activation
Hemodynamic
Deterioration
Modified from Filippatos G et al. Am J Physiol 1999
Acute Timeline
29
Conclusions
The IV drug therapy in acute HF has not changed
much in the last few decades
• only one drug in the USA and one drug in Europe have
been approved in the last 15 years
There is a need to identify treatment strategies
and regimens that reduce mortality and the
incidence of HF rehospitalization