2020 Symposia Series 1
The Pivotal Role of Primary Care Clinicians in the Management of Heart Failure
Learning Objectives • Implement current evidence-based recommendations in the management of patients with heart failure (HF) • Differentiate the roles and responsibilities of team members involved in managing patients with HF who are transitioning from the hospital to the community for continued care • Develop strategies to manage patients with HF who present with acute illnesses or comorbidities 3
Definition and Nomenclature of HF • Complex syndrome in which the heart cannot pump blood at a rate commensurate with metabolic needs of the tissues, or can do so only with high pressures • Results from structural or functional impairment of ventricular filling (HFpEF, or diastolic HF) or ejection (HFrEF, or systolic HF) of blood • The term “heart failure” is preferred over “congestive heart failure”; some patients present without signs or symptoms of volume overload HFrEF (EF ≤40%) Decreased pumping function of the heart — systolic HF Result: shortness of breath, fluid in lungs — symptomatic HF HFpEF (EF ≥50%) Major symptoms: shortness of breath and exercise intolerance HFpEF more common than HFrEF, but medical therapies proven effective only for HFrEF HFmrEF (EF 40%-49%) Epidemiologically more like HFpEF and usually treated as such EF = ejection fraction; ESC = European Society of Cardiology; HFmrEF = heart failure with mid-range ejection fraction; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction. Kalogeropoulos AP, et al. JAMA Cardiol . 2016;1:510-518; Ponikowski P, et al. Eur Heart J . 2016;37:2129-2200; Yancy CW, et al . J Am Coll Cardiol . 2013;62:e147-e239. 4
Epidemiology and Burden of HF • Prevalence in US Distribution of Direct Costs in HF ‒ >6.2 million people currently ‒ >8 million by 2030 • >1 million new cases/year Inpatient • 1 in 8 deaths due to HF Drug Outpatient • Mortality ~50% within 5 years of diagnosis SNF • Higher incidence in blacks than in whites ED when <75 years of age Hospice • HF costs, 2012: Other ‒ Total: $30.7 billion ‒ Direct: $21 billion SNF = skilled nursing facility. Benjamin EJ, et al. Circulation . 2019;139:e56-e66; Heidenreich PA, et al. Circ Heart Fail . 2013;6:606-619; Sieck S. Curr Emerg Hosp Med Rep . 2017;5:76-82. 5
CHAMP-HF: Suboptimal Real-world Use of GDMT in HF • GDMT for HF often not Use of GDMT in Patients With HFrEF prescribed to eligible patients 100% who do not have 26 % 33 % 80% 39 % contraindications to therapy 66 % • 60% Patients who do receive GDMT % 86 are frequently underdosed 40% 72 % • 67 % Treating with GDMT and dosing 60 % 20% to target has a large impact on 33 % 13 % morbidity and mortality 0% ACEI/ARB ARNI ACEI/ARB/ARNI Beta-Blocker MRA With Contraindication Treated Without Contraindication and Not Treated GDMT = guideline-directed medical therapy; MRA = mineralocorticoid receptor antagonist. Greene SJ, et al. J Am Coll Cardiol . 2018;72:351-366. 6
Pathophysiology of HF Cardiac injury Increased load Activation of RAAS, SNS, and cytokines Reduced systemic perfusion Direct Altered gene Growth and Ischemia and toxicity expression remodeling energy depletion Apoptosis Necrosis Cell death RAAS = renin-angiotensin-aldosterone system; SNS = sympathetic nervous system. 7 Adapted from: Eichhorn EJ, et al. Circulation . 1996;94:2285-2296.
Case Study: Charles, 52-year-old data analyst History • 2 months of general fatigue and shortness of breath with minimal activity • T2DM, hyperlipidemia, and hypertension; admits to “off and on” adherence with medications and dietary changes • Nonsmoker; 10 to 15 alcoholic drinks/month Physical examination • Height: 5 ft 11 in; weight: 238 lb (108 kg); BMI: 33.2 kg/m 2 • Blood pressure: 157/95 mm Hg; heart rate: 108 beats/min; respiratory rate: 18 breaths/min; temperature: 98.7 ° F • 2+ pitting edema feet; S3 heart sound; bilateral rales at lung bases 8
Case Study (cont’d) Laboratory findings • Total cholesterol 156 mg/dL, LDL-C 74 mg/dL • A1C 7.8% • Potassium 4.1 mmol/L, creatinine 0.8 mg/dL • ECG: no arrhythmias • Chest x-ray: cardiomegaly and mild bilateral pleural effusions • TTE 35% EF Medications • HCTZ 25 mg/d, atenolol 100 mg/d, atorvastatin 40 mg/d, metformin 2000 mg/d, empagliflozin 25 mg/d A1C = glycated hemoglobin; ECG = electrocardiogram; LDL-C = low-density lipoprotein cholesterol; HCTZ = hydrochlorothiazide; TTE = transthoracic echocardiogram. 9
Classification of HF ACCF/AHA Stage (course of disease)* NYHA Functional Classification (symptoms at that moment)** At high risk for HF but without structural None A heart disease or symptoms of HF Structural heart disease but without I No limitation of physical activity; ordinary physical activity does not cause HF B signs or symptoms of HF symptoms Structural heart disease with prior or I No limitation of physical activity; ordinary physical activity does not cause HF C current symptoms of HF symptoms Slight limitation of physical activity; comfortable at rest, but ordinary physical activity II results in HF symptoms III Marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes HF symptoms Unable to carry on any physical activity without HF symptoms, or symptoms at rest IV Refractory HF requiring specialized IV Unable to carry on any physical activity without HF symptoms, or symptoms at rest D interventions *Patients should be treated to prevent progression and reduce morbidity and mortality; **patients should be treated to reduce symptoms or referred for advanced therapies or hospice. 10 Yancy CW, et al. Circulation . 2013;128:1810-1852.
Elevated Natriuretic Peptide Levels Are a Biomarker for HF • In ambulatory patients with dyspnea, measurement of BNP or NT-proBNP is useful to support the diagnosis of HF • BNP >100 pg/mL, NT-proBNP >300 pg/mL: HF very likely • Measurement of BNP or NT-proBNP is also useful for establishing prognosis or disease severity in chronic HF 11 Yancy CW, et al. Circulation . 2013;128:1810-1852.
Causes of Elevated Natriuretic Peptide Levels Cardiac Noncardiac • • HF, including RV syndromes Advancing age • • ACS Anemia • • Heart muscle disease, including LVH Renal failure • • Valvular heart disease Pulmonary causes: obstructive sleep apnea, severe pneumonia, pulmonary hypertension • Pericardial disease • Critical illness • AF • Bacterial sepsis • Myocarditis • Severe burns • Cardiac surgery • Toxic metabolic insults, including cancer chemotherapy • Cardioversion and envenomation • COVID-19 ACS = acute coronary syndrome; AF = atrial fibrillation; LVH = left ventricular hypertrophy; RV = right ventricular. Liu, et al. Circulation . 2020; [Epub ahead of print]; Yancy CW, et al. Circulation . 2013;128:1810-1852. 12
Case Study (cont’d) • Charles has stage C and NYHA class III HF because he has structural HF with symptoms triggered by minimal activity • You counsel him that: ‒ good blood pressure control is important for reducing his risk of complications from HF ‒ a low-salt diet will help reduce congestive symptoms ‒ regular exercise, such as walking 30 minutes for 5 days a week is important ‒ lifestyle changes can help manage his diabetes, weight, and HF, and you refer him to a dietitian ‒ various strategies can improve his medication adherence 13 13
Goals of HF Management • Improve symptoms and QoL • Prolong life by slowing disease progression • Optimize patient education, adherence, referral • Recognize patients who will benefit from specialized care, including ventricular assist device and heart transplant QoL = quality of life. Yancy CW, et al. Circulation . 2013;128:1810-1852. 14
Strategies for Optimal Management of HF in Primary Care: Nonpharmacologic Interventions • Patient and family education on self-care • Regular, suitable physical activity • Sodium restriction if congestive symptoms • Cardiac rehabilitation for clinically stable patients • Smoking cessation, weight loss • Shared decision- making aligned with patient’s goals, values, preferences • Enhanced patient education — refer to HF management program for at least one hour of education with a qualified educator or AHA interactive workbook ⎻ www.heart.org/idc/groups/heart- public/@private/@wcm/@hcm/@gwtg/documents/downloadable/ucm_428949.pdf Allen LA, et al. Circulation . 2012;125:1928-1952; Gibbs CR, et al. BMJ . 2000;320:366-369. 15
2017 ACC/AHA/HFSA Focused Update: New Target Blood Pressure Levels in HF • <130 mm Hg systolic in patients with HFrEF and hypertension • <130 mm Hg in patients with HFpEF and persistent hypertension despite volume control HFSA = Heart Failure Society of America. Yancy CW, et al. J Card Fail . 2017;23:628-651. 16
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