N I C H O L A S ( N I C K ) A B B O T T , M D G E N E R A L C A R D I O L O G Y F E L L O W

N A B B O T T @ U C I . E D U

Intro to Heart Failure

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Helpful site for interns!!! • Go here!

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• Well sir/mam you know the xxx guidelines say ***

• Individualization of care still possible and desirable!

General Overview

Methodology (quickly) Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Comorbidities… if I don’t go too slow

Methodology

General Overview

Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Epidemiology (quickly) Initial evaluation Treatment Fun things… if I get the time to show

Definition of HF

“Complex clinical syndrome that results from any structural or functional impairment of ventricular

filling or ejection of blood” Cardinal Manifestations Dyspnea Fatigue limiting exercise Fluid retention – pulmonary, splanchnic, peripheral

Ok but is there anything I can definitively order?

General Overview

Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun things… If I get the time to show

HFrEF: Systolic HF

HFpEF: Diastolic HF

HFpEF: Borderline

HFpEF: Improved

Heart Failure

Basic Ejection Fraction (EF) calculation

End Diastolic Vol – End Systolic Vol ------------------------------------------- x 100 End Diastolic Vol

But wait… what does that mean…

Types of systolic heart failure

Left sided heart failure Clinical syndrome in which the dominant feature is fluid congestion (primarily lung)

Right Sided heart failure Clinical syndrome of tissue congestion: JVP, peripheral edema, ascites, organ engorgement

Remember

Diastolic HF can happen w/o systolic HF

Systolic HF cannot happen w/o diastolic

ICM vs. NICM

Ischemic Cardiomyopathy (ICM)

Clinically apparent that the ischemic coronary disease is responsible for failure

Non-Ischemic cardiomyopathy (NICM) (systolic OR diastolic)

EVERYTHING ELSE: Valvular Heart Disease: Severe AS, MR Toxin mediated: Meth, EtOH, Cancer therapeutics Tachycardia-mediated: AF, AT, AFL… Inflammation: Myocarditis, HIV, Chagas Infiltrative: Iron, Amyloid, Sarcoid Other rare diseses

HFpEF

Clinical signs of heart failure Evidence of preserved/normal ejection fraction EF Evidence of ABNORMAL LV diastolic function 1. Echocardiography 2. Left heart catheterization Diagnosis largely of EXCLUSION 1. Not all that is edema is the heart 2. Look at kidneys… (Urine Pro/Cr) 3. Look at the liver… (US abdomen, LFT/Synthetic) 4. Lymphedema can masquerade

That’s fine and all but WHAT IS HFpEF!

US probe here

Diastole… since evaluating diastolic dysfunction…

Normal

E:A > 1

Abbey something… Abbeynormal..

E:A < 1

If you prefer to think in hemodynamics

LVEDP

SV

Functional Classifications

NYHA – New York Heart Association - Most widely studied evaluation of function - Somewhat limited as has a subjective component AHA/ACC - New classification for at risk of heart failure - Acknowledges you can have SHD w/o symptoms

NYHA – New York Heart Association

I No symptoms No limitation in ordinary physical activities

II Mild shortness of breath &/or angina Slight limitation during normal activity

III Marked Limitation in activity Happens in even less than ordinary activity (20-100m)

Comfortable only at rest

IV Severe Limitation Experiences symptoms even while at rest

Inotropes, VADs, Pre-transplant, Palliative?

ACA/AHA Functional Classification

A At risk for developing heart failure

HTN DM II

Inherited Cardiomyopathy Valvular heart disease

B Asymptomatic heart failure (has SHD w/o symptoms)

Previous MI Asymptomatic VHD

(EF can be < 40 w/o symptoms)

C Symptomatic Heart Failure (SHD with ≥ 1 symptom)

Any heart failure presentation

D Refractory End Stage HF Inotropes VAD

Transplant Palliative/Hospice

General Overview

Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun Things… if I get the chance to show

Compensatory Mechanisms to Low CO

Activation of the RAAS

Don’t Panic…

Remember. You live HERE

It’ll be Ok… I promise

General Overview

Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun things… if I get the chance to show

Historical Findings

Weight Gain Rapid weight gain suggests volume overload

Guideline therapy? Intolerance, adverse event, lapse, or patient compliance

Exacerbating meds NSAIDS, steroid, TZD, CCBS (negative inotrope)

Diet Na restriction diet, Fast food, recent “cheats”

Early satiety GI symptoms common as splanchnic engorgement and can be the primary presentation

Classics Palpitations, syncope (?VT/SVT), chest pain

Common Precipitators of HF

Physical Findings

Hepato-jugular Reflex (HJR)

One of the most specific findings for congestion

Manual pulse palpation

Throw caution to the wind and… touch the patient

Extra heart sounds • S3 = fluid overload • S4 = stiff ventricle

PMI • Displaced or enlarged portends enlargement • Right ventricular heave portends RV/PA pathos

Peripheral edema • Young patients have less • Older patients can be peripheral causes and not cardiac

Limb temperature Cool lower extremities imply poor cardiac output

How good is the H&P Variable Sensitivity Specificity Accuracy Hx of HF 62 94 80

Dyspnea 56 53 54

Orthopnea 47 88 72

Rales 56 80 70

S3 20 99 66

JVD 39 94 72

Edema 67 68 68

Wang CS, et al, JAMA 2005; 294:1944-1956

Past Hx HF : most sens/spec PND : most specific DOE : most sensitive S3 gallop : most specific not very sensitive JVD : best combination sens/spec Rales : mod spec/sens

Biomarker Testing

Not all that is BNP is the heart you see

Non-invasive imaging testing

Invasive Evaluation / Monitoring

General Overview

Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun Things… if I get the chance to show

Stage A

Treat the underlying disease

Diet and lifestyle

Monitor for progression

Stage B

Stage C

But Why ACE-I?

NYHA Class IV Double Blind Placebo controlled Prospective

Multinational Study

Mortality Benefit!

Great Symptom Improvement

What about ARBs?

Val-HeFT – Subgroup Analysis International Double Blind Prospective Trial

Primary Endpoints • All cause mortality

• Composite all cause mortality and morbidity

Survival Benefits

Endpoints

Beta Blockers?

Multi-center, prospective, double-blind NYHA III-IV LVEF ≤ 25%

Once again… mortality benefit…

Coreg… made of some of the best stuff on earth

Now you’re getting greedy…

Double blind, prospective, randomized LVEF < 35%, NYHA II-IV

What!!! More mortality benefit…

But statins you say?

Patients hospitalized for NSTEMI/STEMI Placed on either Atorvastatin 80 or Pravastatin 40 mg Primary Endpoint – Time until 1st HF hospitalization

N = 4,162

Not mortality but I’d take it

Almost everything improved

So what if I were to compare these…

But when can I add ACE/ARB or MRA?

ACE/ARB

Creatinine ≤ 3 Potassium ≤ 5.5 SBP ≥ 80 mmHg

Minearlocorticoid Antagonist

Creatinine ≤ 2.5 Potassium ≤ 5.0 SBP ≥ 80 mmHg

When are the patients able to go home?

Near optimal volume status achieved or euvolemia No heart failure complaints -declines PND -walk to RN station w/o DOE Near optimal medical therapy achieved /started Transition from IV to oral and appropriate diuresis

for 24 hours in hospital – not squeeze and go HF follow up in 7 days Received bedside education Has a 30, any yes at least 30, day supply of meds

Discharge Criteria-per MOA

1. Resolution of clinical signs of volume overload 2. Decrease of at least one NYHA Classification for heart failure (order changed) 3. Discharge BNP with a minimum reduction of 30% and an optimally reduction of 50%, less than admit BNP 4. Sodium >130 5. No creatinine rise (>0.5 from baseline or for elderly >0.3 from baseline) 6. Comorbid condition controlled & treated, and pain 7. Patient verbalizes understanding of discharge instructions and follow up care with physician/health care providers

In Summary

HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular

filling or ejection of blood

Guideline Directed Medical Therapy Saves Lives

Patients need to be near euvolemic at time of discharge

We have a lot of amazing tings in the pipeline

General Overview

Methodology Definition of heart failure (HF) HF classifications Pathophysiology (quickly) Initial evaluation Treatment Fun Things… if I get the chance to show

ARNI Angiotensin Receptor and Neprolysin Inhibitor

Double Blind, Prospective, Randomized, 1:1 LVEF <40%, NYHA II-IV

Enalapril vs Valsartan + LCZ696

Superiority Achieved!

If your funny you’ll like this one…

Double blind, placebo-controlled, parallel-group LVEF ≤ 35%

IN SINUS RHYTHM Sinus Rate > 70 BPM

Mild decrease in the pulse…

Even this deceased the readmissions!

Trending to significance

VAD

HVAD

SC-ICD

CRT-D