post aha 13: lo mejor en insuficiencia cardiaca
DESCRIPTION
El doctor Domingo Marzal participa en el directo online #PostAHA13 desde la Casa del Corazón (Madrid), explicando las novedades en insuficiencia cardiaca presentadas en el Dallas.TRANSCRIPT
Insuficiencia cardíaca
Domingo Marzal Martín
Complejo Hospitalario de Mérida
Insuficiencia cardíaca
ROSE-AHF
TOPCAT
Insuficiencia cardíaca & Diabetes
Guías ACCF/AHA 2013
ROSE-AHF. Renal Optimization Strategies
Evaluation in Acute Heart Failure
Chen H, et al. online 18 Nov. JAMA 2013
IC aguda + disfunción renal (n=360)
Estrategia Nesiritide (n=177) Estrategia Dopamina (n=183)
MUERTE/IC (60d) MORTALIDAD (180d)
DIURESIS 72h CISTATINA-C 72 h
MUERTE/IC (60d) MORTALIDAD (180d)
DIURESIS 72h CISTATINA-C 72 h
8.3 8.6
0
5
10
15
72-h
ou
r u
rin
e v
olu
me (
L)
Placebo Nesiritide
P=0.25
0.11
0.07
0.00
0.05
0.10
0.15
0.20
Ch
an
ge in
Cysta
tin
C (
mg
/L)
Placebo Nesiritide
P=0.35
TOPCAT. Treatment Of Preserved Cardiac
Function Heart Failure with an Aldosterone
anTagonist
Shah AM, et al. online 18 Nov. Circ Heart Fail 2013
Symptomatic Heart Failure & LVEF ≥ 45% stratified:
• Hospitalization HF < 1 year or
• Elevated natriuretic peptides (BNP ≥100 or NT-proBNP ≥360)
Spironolactone (n=1722) Placebo (n=1723)
3445 patients
34% discontinued study medication
31.4% discontinued study medication
TOPCAT. Treatment Of Preserved Cardiac
Function Heart Failure with an Aldosterone
anTagonist
Shah AM, et al. online 18 Nov. Circ Heart Fail 2013
Variable Spironolactone Placebo
NYHA Class II NYHA Class III
63.3% 33.0%
64.3% 32.2%
LVEF 56% 56%
Stratum Hospitalization for HF Natriuretic Peptide
71.5% 28.5%
71.5% 28.5%
Age (years) 69 69
Atrial Fibrillation 35% 35%
Diabetes Mellitus 33% 32%
ACE-I or ARB Beta-blocker Diuretic Anticoagulant
84% 78% 81% 23%
84% 77% 82% 22%
TOPCAT. Treatment Of Preserved Cardiac
Function Heart Failure with an Aldosterone
anTagonist
Shah AM, et al. online 18 Nov. Circ Heart Fail 2013
Spironolactone
Placebo
HR=0.89 (0.77-1.04)
p=0.138
20.4%
18.6%
End point 1ario
Muerte CV
Hospitalización IC
PCR resucitada
TOPCAT. Treatment Of Preserved Cardiac
Function Heart Failure with an Aldosterone
anTagonist
Shah AM, et al. online 18 Nov. Circ Heart Fail 2013
Spironolactone (n=1722)
Placebo (n=1723)
HR (95% CI)
Primary
Outcome 18.6% 20.4%
0.89 (0.77-1.04)
p=0.138
Hospitalization
Heart Failure 12.0% 14.2%
0.83 (0.69-0.99)
p=0.042
Spironolactone Placebo
Hyperkalemia (≥ 5.5 mmol/L)
18.7% 9.1% p<0.001
TOPCAT. Treatment Of Preserved Cardiac
Function Heart Failure with an Aldosterone
anTagonist
Shah AM, et al. online 18 Nov. Circ Heart Fail 2013
HR=0.82 (0.69-0.98)
HR=1.10 (0.79-1.51)
Interaction
p=0.122
US, Canada, Argentina, Brazil
Russia & Georgia
Placebo
31.8%
Placebo
8.4%
End point 1ario
Muerte CV
Hospitalización IC
PCR resucitada
By region
Insuficiencia cardíaca & Diabetes
≈ 40%
Mortalidad & hospitalización por IC
Individualizar tratamiento
Mecanismos de la miocardiopatía diabética
miocardiopatía lipomatosa
Insuficiencia cardíaca & Diabetes
TZDs en HFrEF
I IIa IIb III
A
2012 ESC
Guideline HF
I IIa IIb III
B
2013 ACCF/AHA
Guideline HF
Inhibidores DPP-4
Metformina
Análogos GLP-1
2013 ACCF/AHA Guideline for the
Management of Heart Failure
Guideline-directed medical therapy - GDMT
HFrEF & HFpEF
heart failure
quality of life
palliative
care
care
coordination
2013 ACCF/AHA Guideline for the
Management of Heart Failure
2013 ACCF/AHA Guideline for the
Management of Heart Failure
Biomarcadores
I IIa IIb III
A Diagnóstico o exclusión de IC
Pronóstico de IC
Péptidos natriuréticos
I IIa IIb III
B Guiar el tratamiento IC
2013 ACCF/AHA Guideline for the
Management of Heart Failure
Estudios no invasivos
I IIa IIb III
B Medidas rutinarias de la función VI
2013 ACCF/AHA Guideline for the
Management of Heart Failure
Tratamiento farmacológico
Antagonistas de los receptores mineralocorticoides
clase funcional II de la NYHA
NYHA class II-IV & LVEF ≤ 35%
NYHA class II should prior CV hospitalization or
elevated PNP levels
I IIa IIb III
A
2013 ACCF/AHA Guideline for the
Management of Heart Failure
Ivabradina
2013 ACCF/AHA Guideline for the
Management of Heart Failure
Serelaxina & Omecamtiv
Patient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or
with implantation of pacing or defibrillation device for special indications
LVEF <35%
Evaluate general health status
Comorbidities and/or frailty
limit survival with good
functional capacity to <1 y
Continue GDMT without
implanted device
Acceptable noncardiac health
Evaluate NYHA clinical status
NYHA class I
· LVEF ≤30%
· QRS ≥150 ms
· LBBB pattern
· Ischemic
cardiomyopathy
· QRS ≤150 ms
· Non-LBBB pattern
NYHA class II
· LVEF ≤35%
· QRS 120-149 ms
· LBBB pattern
· Sinus rhythm
· QRS ≤150 ms
· Non-LBBB pattern
· LVEF ≤35%
· QRS ≥150 ms
· LBBB pattern
· Sinus rhythm
· LVEF ≤35%
· QRS ≥150 ms
· Non-LBBB pattern
· Sinus rhythm
Colors correspond to the class of recommendations in the ACCF/AHA Table 1.
Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along
with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D
unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and
personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival.
NYHA class III &
Ambulatory class IV
· LVEF ≤35%
· QRS 120-149 ms
· LBBB pattern
· Sinus rhythm
· LVEF ≤35%
· QRS 120-149 ms
· Non-LBBB pattern
· Sinus rhythm
· LVEF ≤35%
· QRS ≥150 ms
· LBBB pattern
· Sinus rhythm
· LVEF≤35%
· QRS ≥150 ms
· Non-LBBB pattern
· Sinus rhythm
· Anticipated to require
frequent ventricular
pacing (>40%)
· Atrial fibrillation, if
ventricular pacing is
required and rate
control will result in
near 100%
ventricular pacing
with CRT
Special CRT
Indications
2013 ACCF/AHA Guideline for the
Management of Heart Failure
2013 ACCF/AHA Guideline for the
Management of Heart Failure
FEVI ≤ 35%
CF II-IVamb NYHA
Ritmo sinusal
BRI
QRS ≥ 150 ms
I IIa IIb III
A
NYHA III-IVamb
I IIa IIb III
B
NYHA II
2013 ACCF/AHA Guideline for the
Management of Heart Failure
FEVI ≤ 35%
CF II-IVamb NYHA
Ritmo sinusal
BRI
QRS 120-149 ms
I IIa IIb III
B
2013 ACCF/AHA Guideline for the
Management of Heart Failure
FEVI ≤ 35%
Fibrilación auricular & estimulación ventricular
• Ablación NAV
• RV controlada ≈ 100% est ventricular
I IIa IIb III
B
2013 ACCF/AHA Guideline for the
Management of Heart Failure
FEVI ≤ 35%
Implante de marcapasos
estimación > 40% estimulación ventricular
I IIa IIb III
C
2013 ACCF/AHA Guideline for the
Management of Heart Failure
MSC & CSC
• Liberación transcatéter
• Efectos estructurales
• Calidad de vida y la capacidad funcional
MSC. POSEIDON. Hare et al. JAMA 2012
CSC. SCIPIO. Bolli et al. Lancet 2011
2013 ACCF/AHA Guideline for the
Management of Heart Failure
I IIa IIb III
B
• MCS stage D HFrEF & definitive management or cardiac
recovery is anticipated or planned
• Nondurable MCS “bridge to recovery” or “bridge to
decision” HFrEF with acute, profound hemodynamic
compromise
• Durable MCS prolong survival stage D HFrEF
Mechanical Circulatory Support
2013 ACCF/AHA Guideline for the
Management of Heart Failure
HeartMate II
Supervivencia
Capacidad funcional
Durabilidad
2013 ACCF/AHA Guideline for the
Management of Heart Failure
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