Chronic Outline Congestive ^ Heart Failure: Diagnosis and Staging - PowerPoint PPT Presentation

Chronic Outline Congestive ^ Heart Failure: • Diagnosis and Staging Update on Effective • Diastolic Heart Failure Monitoring and Treatment • ACE Inhibitors, ARBs, and Beta Blockers • Other Systolic Heart Failure Medications Michael G. Shlipak, MD, MPH Professor of Medicine, UCSF • Devices and End-Stage Heart Failure Chief, Division of General Internal Medicine, SFVA Medical Center August 9, 2013 Heart Failure Epidemiology • Only cardiovascular outcome that continues to increase • Lifetime risk ~20% 2013 ACCF/AHA Guideline for the Management of Heart Failure • Complicated to manage with multiple other comorbidities A Report of the American College of Cardiology • Treatments improve survival and reduce morbidity Foundation/American Heart Association Task substantially. Force on Practice Guidelines • 4 classes of medications improve survival CIRCULATION, 2013 • 2 classes of medications improve symptoms 1

Why is Heart Failure Challenging to Manage? Question 1: Which of the following establishes a HF diagnosis? • Patients are very complicated and often frail EF < 35% on echo a) • CHF travels with many other comorbidities: 32% 32% b) BNP > 300 on blood test 29% − CAD, hypertension, diabetes, CKD S3 on exam c) • Polypharmacy d) All of the above • Diastolic heart failure becoming more common None of the above e) 8% 0% . . m . . . . . . . . . . c b a o b e x n b a n e a o e o n e h 0 o h t % 0 3 t f 5 3 o 3 S f > o e < l n P l F N A o E B N Heart Failure is a Clinical Diagnosis Diastolic vs. Systolic Heart Failure • Diastolic HF: • Essential Symptoms: dyspnea, fatigue, orthopnea − Official term is “Heart Failure with Preserved • Signs: rales , edema, JVD, S3 Ejection Fraction” • Physical exam : does not distinguish systolic vs. − Abbreviated as HFpEF diastolic − Pronounced “huff-puff” • Systolic HF: • Helpful features include: − Official term is “Heart Failure with Reduced − Chest X-Ray : pulmonary congestion Ejection Fraction” − Elevated BNP or Nt-proBNP − Abbreviated as HFrEF − Pronounced “huff-ruff” − Echo showing diastolic or systolic dysfunction 2

New AHA (2009) Classification of Heart NYHA Functional Classes Failure Classes assume a prior diagnosis of heart failure Risk factors for heart failure- no clear A. signs/symptoms I. No limitation on ordinary physical activity Not HF Asymptomatic LV disease- LVH, diastolic B. Slight limitation – ordinary physical activity II. dysfunction, valve disease, low EF III. Marked limitation- < ordinary physical activity C. Symptomatic heart failure- dyspnea at rest or IV. Symptoms or discomfort at rest exertion, fluid retention Combines stages 1-3 D. Advanced heart failure - inotrope requirement, consideration for assist device or transplant Problems with these classes: • Patients vary across stages, going up and down • Can only progress down the classes • All class 4 at time of hospitalization • Emphasizes prevention over staging Stages, Phenotypes and Treatment of HF Strategies that apply to all CHF Patients • Initial ECHO Repeat only if major changes • Salt restriction • Daily weight monitoring • • Exercise • Diuretics for symptoms Avoid NSAIDS • Monitor: • − Volume status − Electrolytes, renal function 3

Outline Question 2: Which of the following improve survival in diastolic heart failure? • Diagnosis and Staging ACE-I a) 34% • Diastolic Heart Failure b) ARB’s Beta blockers c) • ACE Inhibitors, ARBs, and Beta Blockers 25% d) Ca-channel blockers 20% • Other Systolic Heart Failure Medications e) All of the above 14% None of the above f) • Devices and End-Stage Heart Failure 5% 2% I s - s . . . E ’ r . . . . . . C B e o o b R A k l b a A c b o a e l l e e h b n h t a n t f t a o e f h o e B c l n - A l o a C N What is Diastolic Heart Failure? Diastolic HF: Good and Bad News • “Stiff heart syndrome”- heart cannot relax in diastole Good news: to allow the left ventricle to fill • More favorable prognosis than SHF • Causes increased pressure in the left atrium, and • Simpler regimen, as diuretics cornerstone of therapy pulmonary edema Bad news: • Defined by EF, yet actual stroke volume may be same • Often progresses to SHF as SHF • No therapies improve DHF survival • Same signs and symptoms as systolic HF • Especially common in women and elderly 4

ARBs/ACE-Is Do Not Improve Survival ACC/AHA Guidelines for DHF Treatment • I-PRESERVE TRIAL • BP control (SBP < 130) • Rate/rhythm control in AF • Diuretics for pulmonary congestion HR: 0.95 • Revascularization and other treatment for coronary (0.86-1.05) ischemia p= 0.35 • European guideline recommends cardiac rehabilitation, though limited evidence Guideline for Management of Chronic HF, Ann Intern Med, 2011 − Massie B. et al., NEJM 2008 Question 3 : Which is the most Outline important treatment for heart failure? • Diagnosis and Staging ACE inhibitors a) Beta-blockers b) • Diastolic Heart Failure 33% 31% c) They’re equally effective • ACE Inhibitors, ARBs, and Beta Blockers Neither d) • Other Systolic Heart Failure Medications 18% 18% • Devices and End-Stage Heart Failure r s s . r r . . e o e l h k l t a t i c u i b o e i q N h l b e n - i a e r E t ’ C e y B A e h T 5

ACE Inhibitors Meta-Analysis of ACE Trials • 30 RCTs- ACE-I vs. placebo • Improve symptoms and reduce hospitalizations • N= 3,870 + 3,2,35 • Decrease mortality risk for all heart failure stages • Mortality • Class effect- all ACE inhibitors − 0.77 (0.67-0.88) • Aim for target dose (ATLAS finding) • Death or hospitalization for heart failure − 0.65 (0.57-0.74) • Specific ACE-I’s with benefits in RCT’s: − Benzapril -Enalapril -Ramipril − Captopril -Lisinopril Kidney Function and ACE Inhibitors ARBs in Systolic Heart Failure in Heart Failure • Generally equivalent to ACE inhibitors • Clinical trials show benefit if estimated GFR > 30 • Use for patients with cough on ACE inhibitors • No evidence for lower GFR levels • Combination of ACE and ARB? • Expect the creatinine to rise at least 30% − Decreases hospitalization risk; increases adverse effect • Even creatinine doubling is OK- typically returns near risk (increased K) baseline − No survival difference • Worry about K increase (keep < 5.5); balance the K − Generally, not recommended, as safety probably lower with diuretic dose. in actual practice • Continue ACE-Is as eGFR declines unless cannot control K. Shlipak MG, Ann Intern Med 2003 Yusuf S. et al. Lancet 2003 6

Question 4 : Which of the following Beta Blockers in Systolic Heart Failure beta blockers improves survival? Atenodol • Beta blockers improve symptoms and increase ejection a) 17% 17% 17% 17% 17% 17% fraction by 5-10% b) Carvedilolol Metoprolol c) • Beta blockers decrease mortality in systolic heart failure, from both pump failure and arrhythmic causes d) Propranolol B and C e) • Unlike ACE inhibitors, not a class effect All of the above (class effect) f) • Metoprolol or Carvedilol (U.S.) • Bisoprolol in Europe l l l l C . o o o o . d . d i l l l o d o o n o b e r n a n p a e v a o B e t r r A a t p h e C o t M r f P o l A l Challenge of Titrating Beta Blockers Heart Failure Survival in Heart Failure Patients • Both metoprolol and carvedilol require subtle dose increases at 2 week intervals • Can take up to 6 visits to reach target • Hypo-tension is not a contra-indication unless symptomatic • Carvedilol may be more difficult to titrate dose up. • Benefit greatest at maximum dose • Unfortunately, many patients left at the low starting dose Ramani G et al., Mayo Clin Proc 2010 7

Other Therapies in Systolic Heart Outline Failure • Diuretics • Diagnosis and Staging • Aldosterone Antagonists- spironolactone, eplerenone • Diastolic Heart Failure • Hydralazine/Nitrates • ACE Inhibitors, ARBs, and Beta Blockers • Digoxin • Other Systolic Heart Failure Medications • Devices and End-Stage Heart Failure Diuretics Diuretic Refractory Patients • Rapid relief of dyspnea and fluid retention • Periodic thiazide (metolazone) − e.g. 3x/week doses • Aim for lowest dose that reaches “dry weight” − watch for hypo-Na+, hypo-K + • Therapeutic goals: • Change the loop diuretic- furosemide (Lasix), − Improved dyspnea and orthopnea bumetanide (Bumex), Torsemide (Demadex) − Minimal pre-tibial edema • Long-acting nitrates also useful for symptoms • Patients can manage the dose and schedule • Occasional IV diuretics may be required- intestinal edema can block po absorption 8