Transcript Slide 1

Broken Hearts
Acute Heart Failure
Dr Andrew Turley
Cardiology Consultant
South Tees
Overview: Acute Heart Failure
• New ESC guidelines
• Diagnosis
– Serum natriuretic peptides
•
•
•
•
Non-invasive ventilation
Inotropes
Nesiritide
Cardiac Devices
Overview: Acute Heart Failure
• New ESC guidelines
• Diagnosis
– serum natriuretic peptides
•
•
•
•
Non-invasive ventilation
Inotropes
Nesiritide
Cardiac Devices
Overview: Acute Heart Failure
• Complex syndrome caused by
impaired cardiac function
• 2 types:
•
•
left ventricular systolic dysfunction
(LVSD)
•
Heart failure with preserved ejection
fraction (HFPEF/HFNEF/Diastolic dys.)
Commonest cause(s):
–
IHD, Hypertension, alcohol,
cytotoxics
• 30–40% of patients die within a
year of diagnosis
• Around 900,000 people in the UK
•
Expected to rise in the future
• The cardiac dysfunction may be
related to
– Ischaemia
– Arrhythmias
– Valvular dysfunction
– Pericardial disease
– Increased filling pressures
– Elevated systemic resistance.
Drugs
Diagnosis
•
•
•
•
ECG
CXR
ABG
Laboratory Tests
– A small elevation in
cardiac troponin may
be seen in patients
with AHF without ACS.
• Echo
Diagnosis: Cardiac Biomarkers
In patients with symptoms and signs of
heart failure:
Measure serum natriuretic peptides
Refer to have echocardiography and
specialist assessment within 2 weeks if
–Previous MI
•BNP > 400 pg/ml or
•NTproBNP > 2000 pg/ml
If BNP < 100 pg/ml or NTproBNP < 400
pg/ml, heart failure is unlikely in an
untreated patient
• Natriuretic peptides
– Negative predictive value
– There is no consensus
regarding BNP or NT-proBNP
reference values in AHF.
– Important prognostic
information.
Cardiac Biomarkers
Troponin/BNP/CRP
New Classification of MI-Type 2?
Secondary to spasm,
embolism, anaemia,
arrhythmia, BP changes
Type 1
Type 2
Acute MI
Type 3
Type 4
Type 4a
Troponinitis
Type 5
Type 4b
Natriuretic Peptides: Origin and Stimulus of
Release
Relaxation of smooth muscle cells
Vasodilatation of veins and arteries
GFR , Na+ reabsorption inhibited  diuresis
SNS and RAS activity reduced
NH 22N- Ser
Arg
Arg
Ser
Lys
Met
Met
Asp
IIe
Cys
Gly
Gly
Leu
Arg
Gly Ser
BNP
Val
Gin
Gly
Ser
Arg
Gly
Phe
Gly Cys
Ala
Gin
Arg Lys
Met
Asp
Arg
IIe
S
S
Val
Ser
Cys
Lys Gly
Ser
Leu
Leu
Arg
Gly Ser
Ser
Arg
HOOC- His
Pro
Ala
Arg Ser
Urodilatin
Leu
Arg
Arg
Gly
Phe
Ser
NH
NH2
Adapted from Burnett JC, J Hypertens 2000;17(Suppl 1):S37-S43
Gly Arg
S
S
Ser
Phe
Thr
ANP = Atrial Natriuretic Peptide
BNP = B-type Natriuretic Peptide
CNP = C-type Natriuretic Peptide
Gly
Phe
Ser Cys
Asn
COOH- Tyr
H2NN- Ser
Pro
ANP
Leu
Ser
Gly Arg
Arg
IIe
S
S
Ser
Phe
Arg
HOOCHOOC-Tyr
H2NN- Gly
Leu
Met
Asp
Cys
Cys
Asn
Gly
Gly
Ala
Leu
Gin
Gly Ser
CNP
Gly
Phe
Ser
Lys
Gly
Leu Lys
Leu
Asp
Arg
Cys
IIe
S
S
HOOC- Cys
Gly
Leu
Gly
Ser
Gly Ser
Met
The natriuretic peptides: Biochemistry
of NT-proBNP
90
I
S
R
1
H2N— H
K
D R
M
P
L G
S
P G
S
A
10
S
70
Y
T
80
L
R
A
P
76
R
S
P
K
Q
V
M
F
G
L
C
100
C
K
V
L
C
G
S
G
S
S
C
proBNP
S
R
108
R
H —COOH
Cleavage
K
NT-proBNP
1
H2N— H
10
P
L G
S
P G
S
A
S
t½ 70-120 min
70
Y
L
R A
P
BNP
R —COOH
H2N— S
P
K
M
V
Q
I
S
S
R
G
S
S
C
F
76
T
D R
M
S
C
G
C
t½ 20 min
C L
K
V
G
L
R
R
H —COOH
Clinical Potential of BNP/NT-proBNP
• Extensively studied
– A “blood test for heart failure”
•
•
•
•
•
Diagnosis-Raised in LVSD/AF/LVH/VHD/ACS
Screening for asymptomatic LVSD
Risk stratification & Prognosis in established HF
Therapy monitoring
Treatment of HF
Normal BNP makes LVSD very unlikely
NEGATIVE PREDICTIVE VALUE
Overview: Acute Heart Failure
• New ESC guidelines
• Diagnosis
– serum natriuretic peptides
•
•
•
•
Non-invasive ventilation
Inotropes
Nesiritide
Cardiac Devices
Acute Cardiogenic Pulmonary Oedema
• Common
– 15-20,000 hospital
admissions per annum in
UK
• Deadly
– 15-20% in-hospital
mortality
• Costly
– 6.5 million hospital days
per annum in USA
Initial Treatment
• The evidence in
favour of morphine
use for AHF is limited.
• Multiple agents are
used to manage AHF,
but there is a paucity of
clinical trials data and
their use is largely
empiric.
• Most agents improve
haemodynamics but no
agent has been shown
to reduce mortality.
Non-invasive Ventilation In Acute Cardiogenic
Pulmonary Oedema
“When the household vacuum cleaner is employed, the machine should be run for some
minutes first of all to get rid of dust”
Poulton EP, Oxon DM: Left-sided heart failure with pulmonary oedema: Its treatment with
the "pulmonary plus pressure machine." Lancet (1936);231:981-983.
Physiological Improvement with CPAP in Patients
with ACPO
Reduced acidosis, respiratory rate and heart rate
Kelly et al. Eur Heart J 2002;23:1379-1386
Mortality Benefit of CPAP/NIPPV in Patients with
ACPO
Mortality reduced
from 22% to 11%
RR 0.53
(95% CI 0.35-0.81)
(Individual Group
Sizes small)
However, in 3CPO,
a large RCT........
Masip et al. JAMA 2005;294:3124-3130
3CPO
Trial summary
Background
Intervention
Aims
• Randomised (1:1:1)
• Clinical effectiveness of noninvasive ventilation
• Comparative effectiveness of
CPAP and NIPPV
• Safety of non-invasive ventilation
Hypothesis:
• Non-invasive ventilation reduces
mortality
– Standard oxygen therapy (by
facial mask)
– CPAP (5 cmH2O up titrated to
a maximum of 15 cmH2O)
– NIPPV (8/4 cmH2O up titrated
to a maximum of 20/10
cmH2O)
• Inhaled oxygen of 60%
• Attending physicians were
encouraged to use vasodilator
(nitrate) and diuretic therapy
• Opiate therapy was administered
at the discretion of the treating
physician
3CPO
Outcome: Any NIV v Standard
Mortality
Standard
Therapy
NonInvasive
Ventilation
Odds Ratio
95%
Confidence
Intervals
P Value
7-Day
9.8%
9.5%
0.97
0.63 to 1.48
0.869
30-Day
16.7%
15.4%
0.93
0.65 to 1.32
0.685
Active Trial 1069 patients ~ 350 per arm
Baseline Characteristics matched
Baseline Medications matched
Baseline Interventions matched (nitrate, diuretic, opiate, oxygen)
3CPO
Outcome: Hospital stay
Admitted to intensive
Care
Admitted to highdependency Care
Admitted to coronary
Care
Median length of hospital
stay in days ( IQR)
No significant differences (P>0.05)
Standard
CPAP
NIPPV
P-value
8.8%
9.1%
6.6%
0.411
7.7%
10.3%
10.9%
0.301
38.1%
43.7%
40.9%
0.337
8 (5-13)
9 (5-16)
9 (5-16)
0.313
3CPO
CONCLUSIONS
• In patients with acute cardiogenic pulmonary
oedema non-invasive ventilation (1069 patients)
– UK study, RCT:
Produces more rapid resolution of metabolic abnormalities
and respiratory distress
Has no major effect on 7-day or 30-day mortality
Is beneficial irrespective of the mode (CPAP or NIPPV) of delivery
Overview: Acute Heart Failure
• New ESC guidelines
• Diagnosis
– serum natriuretic peptides
•
•
•
•
Non-invasive ventilation
Inotropes
Nesiritide
Cardiac Devices
Inotropes
• Inotropic agents should only
be administered in patients
with low SBP or a low
measured cardiac index in the
presence of signs of
hypoperfusion or congestion.
• Dobutamine
– Positive inotropic agent
acting through
stimulation β1-receptors
to produce dosedependent positive
inotropic and
chronotropic effects.
– The infusion rate may be
progressively modified
according to symptoms,
diuretic response.
•
•
The elimination of the drug is rapid
after cessation of infusion.
Care should be exercised in weaning
patients from dobutamine infusion.
Treatment related to BP
Respiratory support, Furosemide (infusion)
IV Dobutamine plus low dose IV GTN
± IABP
Other treatment options
• Vasopressin antagonists
– Unproven
• Levosimendan is a calcium
sensitiser that improves
cardiac contractility
• Levosimendan infusion
increases cardiac output
and stroke volume and
reduces pulmonary wedge
pressure, systemic vascular
resistance, and pulmonary
vascular resistance.
• Exerts significant
vasodilatation mediated
through ATP-sensitive
potassium channels
• Vasopressors
(norepinephrine) are not
recommended as first-line
agents
Overview: Acute Heart Failure
• New ESC guidelines
• Diagnosis
– serum natriuretic peptides
•
•
•
•
Non-invasive ventilation
Inotropes
Nesiritide
Cardiac Devices
Vasodilators
• Vasodilators relieve pulmonary congestion usually
without compromising stroke volume or increasing
myocardial oxygen demand in acute HF.
• Often combined with diuretic ± inotrope
• Nitrates: Predominantly venodilator effect.
Nesiritide
• Intravenous
• Recombinant form of
human B-type
natriuretic peptide,
• Venous and arterial
vasodilator with a
combined modest
diuretic and natriuretic
effect.
• Approved by FDA in 2001
– Reduce PCWP (@ 3 hrs!)
• Non-invasive BP
measurements are
usually adequate.
• Combination with
other i.v. vasodilators
is not recommended.
• 2005
– 2 meta-analysis
? Renal safety
Nesiritide is not available in most European countries.
Ascend HF*: AHA 14th Nov 2010
• 7141 patients
• 1:1
– Placebo vs Nesiritide
Safe
No mortality benefit
Minimal symptomatic improvement
*Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure Trial
Overview: Acute Heart Failure
• New ESC guidelines
• Diagnosis
– serum natriuretic peptides
•
•
•
•
Non-invasive ventilation
Inotropes
Nesiritide
Cardiac Devices
What is the rhythm?
Causes of death in heart failure
NYHA II
NYHA IV
NYHA III
12%
26%
24%
64%
33%
56%
59%
15%
11%
Pump failure
Other
Sudden death
I
II
III
IV
No Limitation
SOB on severe exertion
SOB on mild exertion
House bound (SOB at rest)
Pre-implant counselling
How do you want to die?
Heart failure death
Sudden death
Device X Rays
ICD Lead
BiV LV Lead position
ICD Myths
• Myths
– ICDs prevent syncope
– Contacts can be electrocuted
by ICD discharge
– Not safe to use mobile phone,
mircowave, playstation etc.
– Will stop you dying from VF
• “Diathermy kills patients &
devices”
– PPM – may inhibit (pulse
oximetry)
– ICD – will detect as VF
(reprogram)
Consequences of tachycardia therapy
VT Storm
Inappropriate shocks
End of life issues: NECVN
Ventricular arrhythmias and/or poor LV function → is an ICD indicated ?
Temporarily disabled with a ring magnet
The Future?
Intrathoracic Impedance: Concept
The Reality
Drier lungs
means the
intrathoracic
impedance is
higher
Less
Fluid
Wetter lungs
means the
intrathoracic
impedance is
lower
More
Fluid
Summary
• Normal BNP makes LVSD very unlikely
– NEGATIVE PREDICTIVE VALUE
• Non invasive ventilation
– Produces more rapid resolution of metabolic abnormalities and
respiratory distress
– Has no major effect on 7-day or 30-day mortality
– Is beneficial irrespective of the mode (CPAP/NIPPV)
• Respiratory support, Furosemide (infusion), IV Dobutamine
plus low dose IV GTN, (± IABP)
• Nesiritide
– Safe, No mortality benefit, Minimal symptomatic improvement
• ICD: Temporarily disabled with a ring magnet
• End of life issues: NECVN