insuficiencia cardiaca ii.pptx

8/10/2019 Insuficiencia Cardiaca II.pptx

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Insuficiencia cardaca

ROSE-AHF

TOPCAT

Insuficiencia cardaca & Diabetes

Guas ACCF/AHA 2013


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ROSE-AHF. Renal Optimization Strategies

Evaluation in Acute Heart Failure

IC aguda + disfuncin renal (n=360)

Estrategia Nesiritide (n=177) Estrategia Dopamina (n=183)

DIURESIS 72h CISTATINA-C 72 h DIURESIS 72h CISTATINA-C 72 h15 0.20

0.1510

0.10

50.05

0 0.00Placebo Nesiritide Placebo Nesiritide

MUERTE/IC (60d) MORTALIDAD (180d) MUERTE/IC (60d) MORTALIDAD (180d)

Chen H, et al. online 18 Nov. JAMA 2013

72-hoururinevolume

(L)

ChangeinCystatin

C(m

g/L)

P=0.35

0.11

0.07

P=0.25

8.3 8.6


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TOPCAT. Treatment Of Preserved Cardiac

Function Heart Failure with an Aldosterone

anTagonist

Symptomatic Heart Failure & LVEF 45% stratified:

Hospitalization HF < 1 year or

Elevated natriuretic peptides (BNP 100 or NT-proBNP 360)

3445patients

Spironolactone (n=1722)34%

discontinued study medication

Placebo (n=1723)31.4%

discontinued study medication

Shah AM, et al. online 18 Nov. Circ Heart Fail 2013


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Function Heart Failure with an Aldosterone

anTagonist


Variable Spironolactone PlaceboNYHA Class II 63.3% 64.3%

NYHA Class III 33.0% 32.2%

LVEF 56% 56%

StratumHospitalization for HF 71.5% 71.5%

Natriuretic Peptide 28.5% 28.5%

Age (years) 69 69

Atrial Fibrillation 35% 35%

Diabetes Mellitus 33% 32%

ACE-I or ARB 84% 84%Beta-blocker 78% 77%

Diuretic 81% 82%

Anticoagulant 23% 22%


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Function Heart

anTagonist

Failure with an Aldosterone

1arioEnd point

Muerte CV

Hospitalizacin IC

PCR resucitada


20.4%

Placebo 18.6%Spironolactone

HR=0.89 (0.77-1.04)

p=0.138


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Function Heart

anTagonist


HR(95%CI)(n=1722) (n=1723)

18.6% 20.4%

12.0% 14.2%

18.7% 9.1% p


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Function Heart

anTagonist


1arioEnd point

Muerte CV

Hospitalizacin IC

PCR resucitada

Byregion


Placebo

US, Canada, Argentina, Brazil

HR=0.82 (0.69-0.98)

Placebo

31.8%Interaction

p=0.122

8.4%

Russia & Georgia

HR=1.10 (0.79-1.51)


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40%

Mortalidad & hospitalizacin

individualizar tratamiento

por IC

Mecanismos de la miocardiopata diabtica

miocardiopata lipomatosa


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Metformina

I IIa IIb III I IIa IIb III

TZDs enHFrEF 2013 ACCF/AHAGuideline HF

2012 ESC

Guideline HF

Inhibidores DPP-4

Anlogos GLP-1

AB


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2013 ACCF/AHA Guideline for the

Management of Heart Failure

Guideline-directed medical therapy -GDMT

HFrEF

& HFpEF


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quality of life

heart failure

care

coordination

palliative

care


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Biomarcadores

Pptidos natriurticos

I IIa IIb IIIDiagnstico o exclusin

Pronstico de ICde IC

I IIa IIb III

Guiar el tratamiento ICB

A


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Estudios no invasivos

I IIa IIb III

Medidas rutinarias de la funcin VIB


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Tratamiento farmacolgico

Antagonistas de los receptores mineralocorticoides

clase funcional II de la NYHA

I IIa IIb III NYHA class II-IV & LVEF 35%

NYHA class II should prior CV hospitalization or

elevated PNP levels

A


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Ivabradina


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Serelaxina & Omecamtiv


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Indications

with CRT

Special CRT

Anticipated to require

frequent ventricular

pacing (>40%)

Atrial fibrillation, if

ventricular pacing is

required and rate

control will result in

near 100%

ventricular pacing

NYHA class III &

Ambulatory class IV

LVEF 35%

QRS 150ms

LBBB pattern Sinus rhythm

LVEF 35%

QRS 120-149 ms

LBBB pattern Sinus rhythm

LVEF35% QRS 150ms

Non-LBBB pattern

Sinus rhythm

LVEF 35%

QRS 120-149 ms

Non-LBBB pattern Sinus rhythm

NYHA class II

LVEF 35%

QRS 150ms

LBBB pattern

Sinus rhythm

LVEF 35% QRS 120-149 ms

LBBB pattern

Sinus rhythm

LVEF 35%

QRS 150ms

Non-LBBB pattern

Sinus rhythm

QRS 150ms

Non-LBBB pattern

NYHA class I

LVEF 30%

QRS 150ms

LBBB pattern

Ischemic

cardiomyopathy

QRS 150ms

Non-LBBB pattern

Acceptable noncardiac health

Evaluate NYHA clinical status

Evaluate general health statusContinue GDMT without

implanted device

Comorbidities and/or frailty

limit survival with good

functional capacity to 40 d after MI, or

with implantation of pacing or defibrillation device for special indications


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FEVI 35%

CF II-IVambNYHA

Ritmo sinusal

I IIa IIb III I IIa IIb III

BRI

NYHA III-

IVamb

NYHAII

QRS 150 ms

BA


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FEVI 35%

CF II-IVambNYHA

Ritmo sinusal

BR I

I IIa IIb III

QRS 120-149 ms B


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FEVI 35%

Fibrilacin auricular & estimulacin ventricular

I IIa IIb III

Ablacin NAVRV controlada 100% est ventricular

B


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FEVI 35%

I IIa IIb III

Implante de marcapasos

estimacin > 40% estimulacin ventricular

C


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MSC & CSC

Liberacin transcatter

Efectos estructurales

Calidad de vida y la capacidad funcional

MSC. POSEIDON. Hare et al. JAMA 2012

CSC. SCIPIO. Bolli et al. Lancet 2011


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I IIa IIb III

Mechanical Circulatory Support

MCS stage D HFrEF & definitive management or cardiac

recovery is anticipated or planned

Nondurable MCS bridge to recovery or bridge tohemodynamicdecision HFrE

F

with acute, profound

compromise

Durable MCSprolong survival stage D HFrEF

B


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HeartMate II

Supervivencia

Capacidad funcional

Durabilidad


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Stages, PhenotypesAt Risk for Heart Failure

andTreatment ofHeart Failure

HF

e.g., Patients with:

HTN Atherosclerotic disease DM Obesity Metabolic syndrome

orPatients Using cardiotoxins

With family history of

cardiomyopathy

e.g., Patients with: e.g., Patients with:Refractorysymptoms of HFat rest, despiteGDMT

Previous MI LV remodeling including

LVH and low EF

Asymptomatic valvular

disease

Marked HF symptoms atrest

Recurrent hospitalizationsdespite GDMT

Development of

symptoms of HFStructural heartdisease

HFpEF HFrEF

Goals

Improve HRQOL

readmissions

of-life goals

ACEI or ARB Advanced care

Heart transplant

Temporary or permanent

Experimental surgery or

Palliative care and

ICD deactivation

THERAPY

Control symptoms

Reduce hospital

Establishpatientsend-

Options

measures

Chronic inotropes

MCS

drugs

hospice

THERAPYGoals

Control symptoms Improve HRQOL Prevent hospitalization Prevent mortality

Strategies Identification of comorbidities

Treatment

Diuresis to relieve symptoms

of congestion Follow guideline driven

indications for comorbidities,

e.g., HTN, AF, CAD, DM

Revascularization or valvular

surgery as appropriate

THERAPYGoals Control symptoms Patient education Prevent hospitalization Prevent mortality

Drugs for routine use Diuretics for fluid retention

Beta blockers Aldosterone antagonists

Drugs for use in selected patients

Hydralazine/isosorbide dinitrate ACEI and ARB Digoxin

In selected patients CRT ICD Revascularization or valvular

surgery as appropriate

THERAPYGoals

Prevent HF symptoms Prevent further cardiac

remodeling

Drugs ACEI or ARB as

appropriate

Beta blockers asappropriate

In selected patients

ICD Revascularization orvalvular surgery asappropriate

THERAPYGoals

Heart healthy lifestyle

Prevent vascular,

coronary disease

Prevent LV structural

abnormalities

Drugs

ACEI or ARB in

appropriate patients for

vascular disease or DM

Statins as appropriate

e.g., Patients with: Known structural heart disease and

HF signs and symptoms

STAGE DRefractory HF

STAGE C Structuralheart disease with prior

or current symptoms of

HF

STAGE B Structuralheart disease but without

signs or symptoms of

HF

STAGE AAt high risk for HF but

without structural heart

disease or symptoms of HF


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C HFrEFPharmacologicTreatmentHFrEF Stage C

NYHA Class I IV

Treatment:

forStage

Class I , LOE AACEI or ARB AND

Beta Blocker

Provided estimated creatinine

Class I , LOE A

Aldosterone

Antagonist

Class I , LOE CLoop Diuretics

Class I , LOE AHydral-Nitrates

AddAddAdd

For NYHA class II-IV patients.

>30 mL/min and K+


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Results: Mortality Reduction Based on Number ofGuideline-Recommended Therapies at Baseline

24 Month MortalityAdjusted Odds Ratios (95% CI Displayed)

Number of Therapies(vs 0 or 1 therapy)

Odds Ratio(95% confidence interval)

2 therapies 0.63 (0.47-0.85)(p=0.0026)

3 therapies 0.38 (0.29-0.51)(p


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Systolic DysfunctionClinical/HemodynamicGuide for Management

New Medical and Interventional TherapeuticChallenges

Summary: Two Patients/Two ChallengesA. The elderly patient with HF

B. The hospitalized patient with HF


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Patient A80 year old man with a remote history of prior myocardial

infarction; now with NYHA class IV HF; residual LVEF 0.10. Twohospitalizations in the prior10 months.

Rx: carvedilol, lisinopril, furosemide, digoxin, spironolactone;

ICD in place

c/o profound weakness, unable to walk the dog, decliningfunctional capacity

EXAM: Weight- 130 lb. (- 15 lb over 12 mos); elevated JVP; +

S3, cool extremitiesCreat 1.8 mg/dL; BNP 2,113 pg/ml


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The elderly patient withHF

Prevalence of HF increases with age80% of patients with HF are > 65

Prevalence doubles for eachdecadeolderthan65Reaches 10% in thoseWho is elderly?

>80

> 6570-80

> 85: very elderly


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Comparison of short-term vs.lifetime cumulative risksofCHFformenandwomenatselectedindexages

ONE IN FIVEINDIVIDUALS

WILL DEVELOP HF

FRAMINGHAM Donald M. Lloyd -Jones et al Circulat ion2002;106:3068

S ggested pathoph siological mechanisms predisposing to the de elopment of diastolic


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Suggested pathophysiological mechanisms predisposing to the development of diastolicdysfunction and heart failure in otherwise healthy ageing hearts.

Lazzarini V et al. Eur J Heart Fail 2013;15:717-723

Published on behalf of the European Society of Cardiology. All rights reserved. The Author2013. For permissions please email: [email protected].
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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Heart Failure Trials and the Elderly


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FrailtyDistinct biological syndrome Characterized

by profound weight loss, sarcopenia,

physical exhaustion, weakness,

decline in walking speed and reduced

functional capacity; Friedor Lachs criteriaPrevalence: 3% @ 65-70; 23% @ >90

Attributable to inflammation and associatedwith elevated C-reactive protein, factor VIII

and reduced vit D

Murad K, Kitzman, D. Heart Failure Reviews. 31 May 2011


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Cli i l P l i h f h


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Clinical Pearls in the treatment of theElderly with HF

Evidence-based medical and device therapy work though the risk profile

may be higherExercise prudence in dose titration of vasoactive drugs; avoid falls

Consider all co-morbidities

65% of all Medicare recipients have multiple co-morbid conditionsIn elderly HF patients, 70% > 3, & 40% > 5 co-morbidities

Those with > 5 co-morbidities are responsible for 80% of all in-patient

hospital days for all HF patients

Encourage shared-decision makingPrompt discussions RE: advanced directives where appropriate


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The hospitalized patient with HF

Still > 1,000,000 hospitalizations with HF asthe primary diagnosis; > 3 million with HFany mention; 3,434,000 ambulatory carevisitsMean cost /HF hospitalization: $23,077

(higher if HF was a secondary diagnosis)

as

83% are hospitalized at least once amd 43%are hospitalized at least 4 times

Th l hi f HF / HF h i li i


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The natural historyof HFs/pHF hospitalization

Hospital Readmissions Mortality

100100

7575

50% 50%50 50 33%

20%25 25 12%

0 030

days

6

months

30

days

12

months

5

years

Annual mortality rateNYHA class III HF: 12% [COPERNICUS DATA]

NYHA class II HF: 7% [SCD-HeFT DATA]

Jong P et al.Arch Intern Med. 2002;162:1689

Median hospital LOS: 6 days


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From: National Trends in Heart Failure Hospital Stay Rates, 2001 to 2009

J Am Coll Cardiol. 2013;61(10):1078-1088. doi:10.1016/j.jacc.2012.11.057

Figure Legend:Heart Failure Hospital Stay Rate by Age Category/100,000 Persons

Heart failure hospital stay rate/100,000 over time from 2001 to 2009, stratified by age categories.

Date of download:3/10/2013 Copyright The American College of Cardiology.All rights reserved.


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From: National Trends in Heart Failure Hospital Stay Rates, 2001 to 2009

J Am Coll Cardiol. 2013;61(10):1078-1088. doi:10.1016/j.jacc.2012.11.057

Figure Legend:In-Hospital Survival for Heart Failure Hospital Stay, by Hospital Day

Proportion of hospitalized heart failure patients who remain alive by hospital day, stratified by time periods 2001 to 2003, 2004 to 2006, and 2007 to

2009.

Date of download:3/10/2013 Copyright The American College of Cardiology.All rights reserved.


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Frequency distribution of rehospitalizations for fee-for-service Medicare beneficiaries dischargedafter ~ 1,500,000 heart failure hospitalizations from >4,000US hospitals, 20042006.

Ross J S et al. Circ Heart Fail 2010;3:97-103

Copyright American Heart Association


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Medicare ProvisionsinPPACAReadmissions

Source: US House of Representatives, Amendment in the Nature of a Substitute to H.R. 4872, as Reported,March 18, 2010; US Senate, The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act,December 24, 2009; Health Care Advisory Board interviews and analysis.

Hospitals will have1. Readmission rates

made publicallyavailable

2. Hospitals with highrisk adjustedreadmissions withno steps to reducereadmission will berequired to reporton process.


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Medicare Assessment and Penalty-2013

HospitalsHeart Failure 30 day readmission benchmarkdata is measured from July 1, 2003-June 30, 2011In 2013, a 1% penalty on all DRGs will be withheld from

those hospitals with 30 day excessive readmissions

By 2015 up to a 3% penalty on all DRGs can be withheldthose hospitals with 30 day excessive readmissions

Planned readmissions such as heart transplant and

implantation of a VAD for Destination Therapy or planned

hospital transfer are included in excessive readmissions

CMS Readmission Penalties; 2200


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; hospitals;$280million

Courtesy of Kaiser Health News, August 13, 2012


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Comparison of Risk-Adjusted Hospital Readmission Rates and Mortality Rates 30 Days after an Index Admission


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Comparison of Risk-Adjusted Hospital Readmission Rates and Mortality Rates 30 Days after an Index Admissionfor Heart Failure.

Gorodeski EZ et al. N Engl J Med 2010;363:297-298.


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From: Characteristics of Hospitals Receiving Penalties Under the Hospital Readmissions Reduction Program

JAMA. 2013;309(4):342-343. doi:10.1001/jama.2012.94856

Copyright 2012 American MedicalAssociation. All rights reserved.Date of download: 2/11/2013


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From: Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia

JAMA. 2013;309(4):355-363. doi:10.1001/jama.2012.216476

Figure Legend:

The denominators used to calculate the percentage of 30-day readmissions on each day after hospitalization were 329 308 30-day

readmissions following heart failure hospitalization, 108 992 30-day readmissions following acute myocardial infarction

hospitalization, and 214 239 30-day readmissions following pneumonia hospitalization.

Copyright 2012 American MedicalAssociation. All rights reserved.Date of download: 2/11/2013


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Unadjusted30-day all-cause and HF-relatedreadmission

ratesand95%CIbypayer.

N.B., very lowrate of HFrelatedreadmissions

Allen L A et al. Circ Heart Fail 2012;5:672-679

Copyright American Heart Association


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Thirty Day ReadmissionsTruth orConsequences, NEJM 2012; 336:1366-1369

The emphasis on 30-day readmissions ismisguidedThe metric is problematic

Primary driver of readmissions? PATIENT POPULATION

and the Community served by the hospital, i.e., thebuilt environment

Update on HRRP FY 14


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Update on HRRPFY 14

Proportion of Hospitals Facing No Readmissions Penalty (Panel A) and Median Amount of Penalty (Panel B),


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p p g y ( ) y ( ),According to the Proportion of Hospital's Patients Who Receive Supplemental Security Income.

Joynt KE, Jha AK. N Engl J Med 2013. DOI:10.1056/NEJMp1300122


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What can you do today?

Hospital Discharge


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p g

Recommendation or Indication COR LOE

Performance improvement systems in the hospital and early postdischarge outpatient setting

to identify HF for GDMTI B

Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits,

the following should be addressed:

a) initiation of GDMT if not done or contraindicated;

b) causes of HF, barriers to care, and limitations in support;

c) assessment of volume status and blood pressure with adjustment of HF therapy;

d) optimization of chronic oral HF therapy;

e) renal function and electrolytes;f) management of comorbid conditions;

g) HF education, self-care, emergency plans, and adherence; and

h) palliative or hospice care.

I B

Multidisciplinary HF disease-management programs for patients at high risk for hospital

readmission are recommendedI B

A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospital

discharge is reasonableIIa B

Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is

reasonableIIa B

R l i


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Resolution Patient A

Referral to Palliative CareInitiation of continuous home dobutamine

Traveling to NYC, 12/16 to spend quality time withfamily81stand celebrate birthday

Amenable to Hospice Patient B

Referred to HF Disease Management ProgramWife educated RE: diet & medical therapy

NYHA class II symptoms

No further admissions

insuficiencia cardiaca ii.pptx

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