Transcript Document

Modern Management of heart
Failure
Dr Amanda Varnava
Consultant Cardiologist
Watford & St Mary’s Hospitals
•
•
•
•
•
•
•
•
•
Background
What is HF?
How to diagnose?
4 stages of HF and Rx of these stages
Specific therapies
Prognosis
SCD and prevention
HF with normal systolic function
Who manages care?
Background
• Huge health costs $27 billion pa in US
• Primarily a disease of the elderly
• Incidence of 10/100 in those over 65yrs
What is heart failure?
Impaired ventricular filling and / or
contraction
Symptoms
Signs
Dyspnoea
Fluid overload
Impaired ext tolerance
3rd Heart sound
Fatigue
Assessment
•
•
•
•
•
ECG
BNP
Echo
Non invasive testing for ischaemia
Angiogram
BNP assessment
3 questions we need addressed
with echo
• Is EF preserved?
• Is LV structure and wall movement normal?
• Are there other structural abnormalities?
– Valvar disease
– Atrial dilation
– PA hypertension
Stages of Heart Failure
At risk
At risk, but no
evidence of
structural disease
or symptoms
Frank Heart Failure
Evidence of
structural
disease, but no
symptoms
Dyspnoea
HT
CAD
MI
Obesity
Valvular
disease
FH CM
Cardiotoxins
ETOH
1º Prevention
Structural
disease with
symptoms
LVH
ACEIn/ARB
Fatigue
 Ex Tol
ACEIn
 Blockers
Spironolactone
±CRT
Refractory
symptoms
NYHA IV
despite max
Rx
Palliative care
Or
TX
LVADs
Stem cell Tx
Primary prevention
HT
• Lifetime risk of HT is 75%
• Optimal Rx of HT cuts in 1/2 the risk of HF
DM
• Females 3 x > likely to develop HF
• ACEIn
CAD
• All MI pts should start on ACEIn and 
• If HF > Add epeleronone
Management of asymptomatic pts
Drugs
• ACEIn delay onset of symptoms and improve
mortality
• No specific trials with ARBs
• No trials with s, but ACC guidance suggests use
esp in CAD
Devices
• MADIT II ICD trial supports use, but no’s huge
thus not current practice
Symptomatic patients
• As with asymptomatic
• In addition diuretics for fluid overload
• Aldosterone antagonists
Also
• Na restriction
• Withdraw NSAIDS, Ca antag
• Exercise
• Close F/U
Refractory symptoms
• Increased awareness of palliative care
Where appropriate consider
• Cardiac TX
• LVADs
• Stem cell Tx
Heart Failure Therapies
ACEIns
•
•
•
•
Inhibit RAS at multiple sites
Start low, go slow
Probably class effect
Side effects related to kinin production
(cough ion 5-10%) and angioedema (1%) >
common in Chinese and Blacks
Angiotensin Receptor Blockers
• Developed because of RAS “escape” with
ACEIn and side effects
• However, less well studied and some
benefits may relate to kinin production
• Thus alternative, not 1st line
• Data is equivocal for ACEIn + ARB
 Blockers
• Inhibit advrse effects of sympathetic NS
• Trials with carvedilol, bisoprolol and LA
metoprolol
• Not class effect
• Rx as soon as HF diagnosed
• If pts on low dose ACEIn greater benefit to
add’n of  than  ACEIn
Aldosterone antagonists
• Compensate for RAS escape with ACEIn
• RALES study provided 30%mortality in
NYHA III/IV
• EPESUS study showed 20% mortality
post MI with HF signs (eplerenone)
• Thus in mod-severe HF or HF post MI
Nitrate and Hydralazine
• Less well tolerated
• Trials show inferior to ACEIn
• Subgroup analysis showed benefit in black
pts when added to standard Rx
Digoxin
• No prognostic benefit
• Can improve quality of life
• Use in pts with persistent symptoms despite
standard Rx
• Caution post MI / ongoing ischaemia
Cardiac resynchronisation
therapy (CRT)
• Third of pts in NYHA III/IV have
QRS>120ms (+electrical dysynchrony)
• Associated with suboptimal LV filling,
prolonged MR and paradoxical septal
motion
• Pacing both ventricles improves
contractility and reduces MR
CRT cont’d
• When added to optimal drug Rx improves QOL,
Ex Tol and hopitalisation
• Recent trials have also shown 20-30% mortality
• However, many pts do not benefit thus other
discriminators echo TDI used to select pts
• Thus pts with persitent symptoms, wide QRS and
echo dysynchrony
Prognosis
• Likelihood of survival can be reliably
predicted for populations, but not
individuals (death may be endstage HF or
sudden)
• Old prognostic models do not apply due to
new drug Rx and devices
• Annual mortality of 7% in those on 
Sudden cardiac death
• Proportion with SCD is greater in those
with less severe LVSD
• ICD trials show risk reduction 23-30% in
pts with EF<35%
However,
• Not within 1st 30 days post MI, no benefit
within 1st year and most trials did not inc
large no’s of elderly
Heart failure with normal systolic
function
Differential causes of signs of HF with normal EF
Incorrect diagnosis
Incorrect assessment of LV function
Restrictive Cardiomyopathy
Pericardial constriction
Episodic systolic dysfunction (ischaemia, arrhythmias)
High output failure
Diastolic dysfunction
Management of diastolic
dysfunction
•
•
•
•
Few trials
Resolve fluid overload
Some data on ACEIn / ARBs
Treat underlying condition
Who should manage care?
Once diagnosed and appropriate
investigations completed
Nurse led clinics
GP or specialist run service?
1° care manage most pts
If remain symptomatic or are complex then
refer to specialists