heart failure
DESCRIPTION
Heart Failure. Case 1. A 56 year old man with known CAD with NSTEMI x2 and stents in the LAD and LCx presents with 2 months of progressive DOE, LE edema and . Question #1. Which of the following therapies will improve this patient’s mortality? A. Lasix B. Carvedilol C. Spironolactone - PowerPoint PPT PresentationTRANSCRIPT
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Heart Failure
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Case 1
• A 56 year old man with known CAD with NSTEMI x2 and stents in the LAD and LCx presents with 2 months of progressive DOE, LE edema and
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Question #1
• Which of the following therapies will improve this patient’s mortality?– A. Lasix– B. Carvedilol– C. Spironolactone– E. Digoxin– D. All of the above
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Question #2• PVCs are noted in the hospital. An
echocardiogram has moderatey-severely decreased systolic function (EF 28%). What should you do next?– Increase the lisinopril and carvedilol dose– Implant and AICD– Start amiodarone– Put the defibrilator patches on him– D/C telemetry
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Heart Failure Is a Big Problem
• Prevalence: >5,000,000• Incidence: >650,000
new cases/year in the US
• Most common discharge diagnosis
• Most common cause of readmission < 60 days
• Cost: > 34.8 billion annualy
Rosamond. Circulation, 2008.Braunwald. 2007.
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Heart Failure Incidence Has Increased, But No By Much
Levy. NEJM, 2002.
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Survival has improved, but not dramatically
Levy. NEJM, 2002.
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What is Heart Failure?
• Definition: Any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
• Cardinal manifestations: Dyspnea, fatigue, fluid retention
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LV Dysfunction Is Necessary But Not Sufficient For Heart Failure
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Acute Compensatory Mechanisms Cause Long Term Damage
• Activation of renin-angiotensin-aldosterone– Salt and water retention– Myocyte hypertrophy,
death and myocardial fibrosis
• Sympathetic nervous system stimulation– Increase contractility
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Cardiac Remodeling Following Injury
McMurray. NEJM, 2010.
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Activation of the RAS Leads to Remodeling
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Etiologies of Heart Failure• Depressed LV Function
– CAD (2/3 of cases of HF)– Pressure overload: HTN, AS– Volume overload: AI, MR, intra/extra cardiac shunt– NICM: Genetic, infiltrative, toxin/drug, metabolic, viral, Chagas’ – Arrythmias
• Preserved LV Function– Hypertrophy: HCM, HTN– Aging– Restrictive: Infiltrative (amyloid, sarcoid), storage dz (hemochromatosis)– Fibrosis– Endomyocardial disorders
• Pulmonary vascular disease• High-Output States
– Metabolic: Thyrotoxicosis, nutrititional (beriberi)– Excessive flow requirements: AV shunt, anemia
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Clinical Classification of Heart Failure
Gheorghiade. JACC, 2007.
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Initial Evaluation
• Decreased exercise tolerance• Volume overload• Asymptomatic or other complaints
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Symptoms To Ask About
• Major Symptoms– Dyspnea – Orthopnea– PND– Ankle edema– Pulmonary edema– Fatigue– Exercise intolerance– Cachexia
• Minor Symptoms– Weight loss– Cough– Nocturia– Palpitations– Peripheral cyanosis– Depression
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Physical Exam Findings To Look For
• JVP• Crackles• Pulmonary edema• Displaced PMI, S3 and S4,
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Measurement of the JVP
Clinical Methods. Walker. 1990.http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A622
5 cm
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How To Measure JVP
Clinical Methods. Walker. 1990.http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A622
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CXR: Pulmonary Edema
www.yale.edu/imaging/contents.html
CXR findings: heart size, congestion, pleural effusion
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Brain Natriuretic Peptide
• Natriuretic peptides– ANP- atrium, BNP- ventricles, CNP- endothelial
cells– Increased well stress -> pre-proBNP-> pro-BNP->
BNP+NTproBNP (longer t1/2, higher levels,slower fluctuation)
– From the heart• Induce vasodilation, natriuresis and diuresis
– Useful and systolic and diastolic heart failure
Daniels. JACC, 2007.
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Differential Diagnosis BNP Elevation
• LV dysfunction• Previous CHF• Advanced age• Renal dysfunction• ACS• Pulmonary disease• PE• High output• AF
• Lower then expected– Obesity– Flash pulmonary edema– Heart failure upstream
from the LV– Cardiac tamponade– Pericardial constriction
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BNP Can Help Differentiate Causes of Dyspnea
Maisel. NEJM, 2002.
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Higher BNP Is Associated With Higher Mortality
Braunwald. 2007.
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New York Heart Association Functional Classification
• Class I: No symptoms with ordinary activity
• Class II: Some symptoms with ordinary activity
• Class III: Symptoms with minimal activity
• ClassIV: Symptoms at rest
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Drugs That May Worsen Heart Failure:Na Retention, Cardiotoxicity, Negative
Inotropy• NSAIDS• Calcium channel blockers- non-dihydropyridine• Metformin• Thiazolidinediones• PDE-3 inhibitors• Antiarrhythmic drugs• Chemotherapy• THF alpha inhibitors• Na Containing drugs• Supplements
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Goals Of Therapy Heart Failure
• Relieve symptoms• Slow or reveres deterioration of myocardial
function• Decrease mortality
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Heart Failure Therapy: A Timeline
1628William Harvey
describes circulation
1950sThiazide Diuretics
1967 First Heart Transplant
1976 Hydralazine
1994Bisoprolol
reduces mortality
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Dietary and Lifestyle Modification: No Randomized Trials
• Sodium Restriction 2-3 gm daily• Weight loss• Smoking cessation• Restriction of alcohol • Daily weight monitoring
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Diuretics
• Used to manage volume status
• Dosing is based on response
• Intravenous versus oral therapy
• Agents can be combined for better efficacy
• No effect on mortality
Libby. Braunwald’s Heart Disease. 2007.
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Digoxin In Heart Failure
• Inhibits the Na-K-ATPase pump-> increased Ca-> inc LV function
• Inhibition of sympathetic outflow
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Digoxin Does Not Improve Mortality
Digitalis Investigation Group. NEJM, 1997.
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Digoxin Improves Heart Failure Symptoms and Reduces Hospitalization
Digitalis Investigation Group. NEJM, 1997.
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Digoxin Level > 1.2 ng/ml Is Associated With Increased Mortality
Adams. JACC, 2005.
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Enalapril Reduces Mortality in NYHA Class IV Heart Failure
Consensus trial study group. NEJM, 1987.
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Meta Analysis: ACE-I Improve Mortality After MI
Flather. Lancet, 2000.
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Candesartan Is An Reasonable Substitute In Patients Who Cannot
Tolerate ACE-I
Granger.Lancet, 2003.
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Mortality Benefit With Hydralazine+ Isordil vs Placebo or Prazosin
Cohn. NEJM, 1986.
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Bidil Improved Survival In Blacks With Heart Failure Taking ACE-I
Taylor. NEJM, 2004.
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Beta Blockers
• Metoprolol: NYHA II-IV, EF <40%, metop succinate 200 daily
• All cause mortality dec by 34% independent of age, sex etiology of CHF or EF
Merit-HF study group. Lancet, 1999.
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Carvedilol Is Superior to Short Acting Metoprolol
Poole-Wilson. L:ancet, 2000.
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Improvement of Systolic Function is Related to Beta Blocker Dose
Bristow. Circulation, 1996.
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Rales Trial: Spironolactone Improves Mortality In Severe Heart Failure
Pitt. NEJM, 1999.
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Ephesus: Epleronone Improves Mortality In Heart Failure Following AMI
Pitt. NEJM, 2003.
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Treat With Proven Dosages
McMurray. NJEM, 2010.
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Oral Milrinone Causes A 28% Increase In Mortality
Packer. NEJM, 1991.
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Take Home Messages About Medical Management of CHF
• Use proven therapies• Treat with proven dosages
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How Do I Start These Drugs?
• Diuretic• ACE Inhibitor or ARB• Beta Blocker• Hydralazine and Nitrates• Spironolactone or eplerenone• Digoxin
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AICD For Primary Prevention Of Sudden Cardiac Death In Patients With
Heart Failure• Ischemic cardiomyopathy
– EF<30%, prior MI
• Non-ischemic cardiomyopathy– EF < 35%, NYHA II or III– EF<35%, NYHA III or IV and QRS>120 AICD with
CRT– Survival of sudden death or with VT
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Mortality Reduction In Patients Post MI: MADIT II
Moss. NEJM, 2002.
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Reduction in Mortality in NICM With ICD: ScD Heft
Bardy. NEJM, 2005.