Transcript Managing the High Risk Patient

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55 year old man with breathlessness on mild exertion.
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No cough, fever, chest pain, palpitations. No exertional chest discomfort
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Otherwise healthy.
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Type 2 diabetes, diet controlled
10 pack year cigarette smoking
Hypertension, well controlled on perindopril 10mg
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BP 135/90. Resps 26. Afebrile. Sats 95% room air.
Normal heart sounds.
Lungs normal.
JVP not seen.
Rest of exam normal.
What tests?
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Normal FBE
Normal EUC LFTs
Normal TSH
HBAIC 6.9%
Troponin not raised
FEV1 2.9 l, FVC 3.5 l
BNP 400
Rapid Measurement of B-Type Natriuretic Peptide in the Emergency
Diagnosis of Heart Failure
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B-type natriuretic peptide is released from the ventricles of the heart in
response to hemodynamic stress, and blood levels of B-type natriuretic
peptide may be useful in the diagnosis of heart failure
In this study, a rapid, bedside immunoassay for B-type natriuretic peptide
was used to make or exclude the diagnosis of heart failure in patients
with acute dyspnea from various causes
The assay was found to have good sensitivity and excellent specificity in
the diagnosis of heart failure
Measurement of B-type natriuretic peptide levels is not a stand-alone
test for heart failure
It will be of most value when used in conjunction with clinical
observations, especially when the cause of acute dyspnea is unclear
The finding of a low level of B-type natriuretic peptide (less than 50 pg
per milliliter) is good evidence of the absence of heart failure
Box Plots Showing Median Levels of B-Type Natriuretic Peptide Measured in the Emergency
Department in Three Groups of Patients
Maisel, A. et al. N Engl J Med 2002;347:161-167
Box Plots Showing Median Levels of B-Type Natriuretic Peptide among Patients in Each of
the Four New York Heart Association Classifications
Maisel, A. et al. N Engl J Med 2002;347:161-167
Multiple Logistic-Regression Analysis of Factors Used for Differentiating between Patients
with and Those without Congestive Heart Failure
Maisel, A. et al. N Engl J Med 2002;347:161-167
Spot quiz
Assessment of left ventricular function
Definition?
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‘heart failure is a complex clinical syndrome that can result from any
structural or functional cardiac disorder that impairs the ability of the
ventricle to fill with or eject blood’
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Cardinal manifestations
– Dyspnea and fatigue which may limit exercise tolerance
– Fluid retention which may lead to pulmonary congestion and peripheral
oedema
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Heart failure is preferred to congestive heart failure
what are the recommended blood tests for initial diagnosis?
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Class 1
– FBE
– UA
– EUC Ca Mg PO4
– Fasting BSL
– Lipids
– LFTs
– TSH
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Class 2a
– Iron studies
– HIV
– Amyloid
– Rheumatologic disease
– BNP in urgent care setting where diagnosis is uncertain
Spot quiz.
Long-Term Trends in the Incidence of and Survival with Heart Failure
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Congestive heart failure has an extremely poor prognosis
This investigation from the Framingham Heart Study tracked trends over
a 50-year period in the incidence of heart failure and in survival after its
onset
During this period, the incidence of heart failure declined among women
but not among men, whereas survival improved among both men and
women
Despite substantial improvement during the study period, overall survival
rates among patients with heart failure remained below 50 percent at five
years, pointing to the urgent need for better means of preventing this
serious health problem
N Engl J Med
Volume 347;18:1397-1402
October 31, 2002
Temporal Trends in the Age-Adjusted Incidence of Heart Failure
Levy, D. et al. N Engl J Med 2002;347:1397-1402
Temporal
Trends in
AgeAdjusted
Survival
after the
Onset of
Heart Failure
among Men
(Panel A)
and Women
(Panel B)
Levy, D. et al. N
Engl J Med
2002;347:13971402
Stages of Heart Failure and Treatment Options for Systolic Heart
Failure.
NEJM Volume 348:2007-2018 May 15, 2003 Number 20 Mariell Jessup, M.D., and Susan Brozena,
M.D.
AF and Heart Failure Study Overview
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In this clinical trial involving patients with atrial fibrillation and congestive
heart failure, rhythm control (to maintain sinus rhythm) and rate control
(to control the ventricular rate in atrial fibrillation) were compared
The two strategies were nearly identical with respect to all clinical
outcomes
Thus, the simpler approach, rate control, should be considered the
treatment of choice in such patients
Roy D et al. N Engl J Med 2008;358:2667-2677
Baseline
Characteristic
s of the
Patients
Roy D et al. N
Engl J Med
2008;358:26672677
Medical
Therapy at 12
Months
Roy D et al. N Engl J Med
2008;358:2667-2677
Kaplan-Meier Estimates of Death from Cardiovascular Causes (Primary Outcome)
Roy D et al. N Engl J Med 2008;358:2667-2677
Kaplan-Meier
Estimates of
Secondary
Outcomes
Roy D et al. N Engl J Med
2008;358:2667-2677
Effect of Carvedilol on Survival in Severe Chronic Heart Failure
NEJM Volume 344:1651-1658 May 31, 2001 Number 22
Milton Packer, M.D.,et al
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2289 patients
– heart failure at rest or on minimal exertion
– clinically euvolemic
– ejection fraction of less than 25 percent
In a double-blind fashion
– 1133 patients to placebo
– 1156 patients to carvedilol
– for a mean period of 10.4 months
standard therapy for heart failure was continued
Kaplan-Meier Analysis of Time to Death in the Placebo Group and the Carvedilol Group
Packer M et al. N Engl J Med 2001;344:1651-1658
What is the magnitude of benefit of AICD
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EF <31%, previous infarct
– Over 20 months
• Absolute mortality benefit 5.6%
• 31% relative risk reduction
• 15%  10%
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20% risk of inappropriate shock
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Reserved for patients with greater than 1 year life expectancy
Should not have class 4 symptoms
Spot quiz
Cardiac Resynchronization in Chronic Heart Failure
N Engl J Med Volume 346;24:1845-1853 June 13, 2002
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About a third of patients with chronic heart failure have an
intraventricular conduction delay, which may lead to dyssynchrony of
cardiac contraction and further clinical impairment
The patients in this clinical trial were randomly assigned to a group
receiving resynchronization therapy with an atrial-biventricular
pacemaker or to a control group
As compared with the control group, the resynchronization group had
improved functional capacity, quality of life, and ejection fraction over a
six-month period
Resynchronization therapy has considerable promise in patients with
heart failure, but there are limitations
It is applicable to only about a third of patients, and it requires the
insertion of a complex pacing device that may be associated with a
variety of technical problems and complications
This technique should be reserved for experienced centers
Change in the Distance Walked in Six Minutes and the Quality-of-Life Score
Abraham, W. et al. N Engl J Med 2002;346:1845-1853
Kaplan-Meier Estimates of the Time to Death or Hospitalization for Worsening Heart Failure in
the Control and Resynchronization Groups
Abraham, W. et al. N Engl J Med 2002;346:1845-1853
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Don’t forget sprionolactone in class 3 and 4 heart failure
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55 year old female with palpitations.
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Skipped and extra beats for 3 months
No chest pain, shortness of breath
No syncope, presyncope
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Past history of HT
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Currently on atenolol 50 mg daily and candesartan 8mg daily.
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Pulse irregular 90bpm BP 125/90 Resps 18 Afebrile Sats 97%
Heart sounds normal. Chest clear.
Rest of examination normal.
What tests?
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FBE normal
TSH normal
BNP, Troponin Normal
EUC LFTs Normal
Fasting BSL 4.8
Question 1
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Additional diagnostic workup
Question 2
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Warfarin or Aspirin
Guidelines for
Antithrombotic
Therapy in Atrial
Fibrillation
Page R. N Engl J
Med 2004;351:24082416
Management Strategies Recommendations
CHADS2 Risk Criteria Score
Prior stroke or TIA
Age >75 years
Hypertension
Diabetes mellitus
Heart failure
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1
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1
Patients Adjusted Stroke Rate
(N=1733)
(%/year)* (95% CI)
120
1.9 (1.2-3.0)
463
2.8 (2.0-3.8)
523
4.0 (3.1-5.1)
337
5.9 (4.6-7.3)
220
8.5 (6.3-11.1)
65
12.5 (8.2-17.5)
5
18.2 (10.5-27.4)
CHADS2 Score
0
1
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6
Question 3
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Rate control or rhythm control
Pharmacologic
Agents to
Control Heart
Rate and
Rhythm
Page R. N Engl J Med
2004;351:2408-2416
A Comparison of Rate Control and Rhythm Control in Patients with
Atrial Fibrillation
N Engl J Med Volume 347;23:1825-1833 December 5, 2002
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There are two approaches to the treatment of atrial fibrillation: rate
control, allowing atrial fibrillation to persist, and rhythm control, with
cardioversion and antiarrhythmic drugs
This North American study found that, contrary to prevailing practice,
rhythm control offered no survival advantage and was associated with
higher rates of adverse drug effects than rate control
Atrial fibrillation is associated with substantial morbidity and mortality
As compared with rhythm control, rate control has advantages that have
previously been underappreciated
Cumulative Mortality from Any Cause in the Rhythm-Control Group and the Rate-Control
Group
The Atrial Fibrillation Follow-up Investigation of Rhythm
Management (AFFIRM) Investigators, . N Engl J Med
2002;347:1825-1833
Base-Line
Characteristic
s of the
Patients
The Atrial
Fibrillation
Follow-up
Investigation of
Rhythm
Management
(AFFIRM)
Investigators, . N
Engl J Med
2002;347:18251833
Drugs Used
in the RateControl
Group and
the RhythmControl
Group
The Atrial
Fibrillation
Follow-up
Investigation of
Rhythm
Management
(AFFIRM)
Investigators, . N
Engl J Med
2002;347:18251833
Adverse
Events
The Atrial
Fibrillation
Follow-up
Investigation of
Rhythm
Management
(AFFIRM)
Investigators, . N
Engl J Med
2002;347:18251833
Spot quiz.
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60 year old female
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Mother AMI age 70
Glucose intolerance
Obese
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Candesartan for HT
BP at home average 125 systolic
Osteoathritis
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2 episodes of prolonged chest pain, last one 5 days ago.
Dull retrosternal lasted 15 minutes
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Examination normal
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Cholesterol 6.5, LDL 3.5
BSL 6.4
HBAIC 6.4%
Normal FBE EUC LFTs
Troponin not raised
Stress test showed equivocal ST depression with non
limiting chest pain at 5 minutes on Bruce Protocol.
EST in determining prognosis
• Asymptomatic population
– EST is positive in 5 –10% of middle age men
– If abnormal, risk is 9 times higher
– Over 5 years only 25% have cardiac event, commonly
angina
• Symptomatic patients
– If exercise tolerance >10 mets prognosis is excellent
regardless the severity of coronary angiography
– Provides an estimate of the functional significancd of CAD
– If Bruce < 1 AND >1mm ST depression - mortality 5%/year
(12% of those undergoing EST)
– If Bruce > 3 AND no ST depression – mortality <1%/yr over
next four years (35% of those undergoing EST)
Duke treadmill score
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Duke Treadmill Score: Calculation
(Time in minutes on Bruce protocol)
(eg 1 if exercises for 1 minute, 12 if exercise for 12 minutes)
then subtract
(5 x amount of ST depression (in mm))
(eg: if 1 mm of ST depression subtract 5, if 2 mm of ST depression subtract 10)
then subtract
(0 if no angina on test, 4 if non-limiting angina, 8 if limiting angina)
Total score =
Score Risk Group Annual Mortality
• IF treadmill score is >=5 THEN annual mortality is LOW (0.25%/yr)
• IF treadmill score is –10 to +4 THEN annual mortality is INTERMEDIATE
(1.25%/year)
• IF treadmill score is <=-11 THEN annual mortality is HIGH (5.25%/yr)
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Coronary angiography showed 50% LAD stenosis.
Left ventricular function normal.
Recommended for medical management.
HOPE study – study population
Effects of an Angiotensin-Converting-Enzyme Inhibitor, Ramipril, on Cardiovascular Events in HighRisk Patients
NEJM Volume 342(3) 20 January 2000
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> 55 years old
history of
– coronary artery disease
– stroke
– peripheral vascular disease
– diabetes (& at least 1 other cardiovascular risk factor)
• hypertension
• elevated total chol., LDL chol.
• cigarette smoking
• Microalbuminuria
Composite Outcome of Myocardial Infarction,
Stroke, or Death from Cardiovascular Causes
Spot quiz
CARE – inclusion criteria
The Effect of Pravastatin on Coronary Events after Myocardial Infarction in Patients with
Average Cholesterol Levels
NEJM 335(14)
3 October 1996
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Inclusion criteria
– total cholesterol < 6.2 mmol/l
and
– LDL cholesterol 3.0 to 4.5 mmol/l
AMI 3 and 20 months before randomization
21 to 75 years of age
Fasting triglyceride levels < 4.0 mmol/l
BSL < 12.2 mmol/l
EF > 25% (no symptomatic CCF)
Effect of Beta-Blockade on Mortality among High-Risk and Low-Risk
Patients after Myocardial Infarction
NEJM 339(8)
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20 August 1998
Several large trials show long-term administration of beta blockers to patients after
myocardial infarction improves survival
– physicians prescribe for < 35%
– cardiologists prescribe for < 50%,
especially in..
• older age
• impaired left ventricular function
• transient heart failure
• patients on diuretic drugs.
Spot Quiz