Speaker Disclosures Heart Failure None Anita Deswal, M.D., M.P.H. Professor of Medicine Chief, Cardiology Michael E. DeBakey VAMC & Baylor College of Medicine, Houston Objectives Definition of Heart Failure • To discuss the definition of heart failure and clinical presentation of heart failure “Heart failure is a clinical syndrome • To discuss types of heart failure based on that can result from any structural ejection fraction or functional cardiac disorder that • To discuss the guideline-based management of impairs the ability of the ventricle to patients with heart failure fill with or eject blood” ACC/AHA Guidelines 2013 Burden of Heart Failure Clinical: Symptoms of HF • Left Heart Failure : • Lifetime risk > 20% for Americans >40 years of age Dyspnea on exertion • 870,000 new cases diagnosed annually Dyspnea at rest • Prevalence in US: 5.7 million Orthpnea Paroxysmal nocturnal dyspnea (PND) Fatigue, inability to exercise • Right Heart Failure: Swelling of feet, hands Abdominal distention/fullness Right upper quadrant pain Early satiety Weight loss (cardiac cachexia) ACC/AHA Guidelines 2013 1
Clinical: Signs of HF Stages of Heart Failure • Left Heart Failure : Asymptomatic Rales • NYHA Class Pleural effusions • A At high risk for HF but without structural heart disease or symptoms CM: Displaced apical impulse • of HF (e.g., patients with HTN or CAD) Tachycardia, LVS3, murmur of MR • B Structural heart disease but without Class I Asymptomatic: No limitation of physical Narrow pulse pressure symptoms of HF • activity. Ordinary activity does not cause sxs. • Right Heart Failure: II Symptomatic with moderate exertion. Edema of lower extremities C Structural heart disease with prior or Ordinary physical activity causes SOB, fatigue • current symptoms of HF III Symptomatic with minimal exertion. Elevated JVP/+ HJR Less than usual activity causes sxs • RVS3, murmur of TR • IV Symptomatic at rest. Unable to carry on any D Refractory/advanced HF requiring activity without discomfort. Hepatomegaly, RUQ tenderness specialized interventions • Ascites • Symptomatic Pleural effusions • ACC/AHA Guidelines 2013 ACC/AHA Guidelines 2013 HF groups: 2013 ACC/AHA Guidelines NYHA Class and Mortality The current definition of HF based on left ventricular ejection NYHA Class 1-Yr Mortality fraction (EF): 5-10% Class I Asymptomatic: No limitation of physical activity. • HF with reduced EF (HFrEF, EF ≤40% ) Ordinary activity does not cause sxs. 5-10% • HF failure with preserved EF II Symptomatic with moderate exertion. Ordinary physical activity causes SOB, fatigue (HFpEF, EF ≥50% ) 10-25% III Symptomatic with minimal exertion. • HFpEF, borderline (EF 41-49% ) Less than usual activity causes sxs • 25-60% HFpEF, improved (EF >40% ) IV Symptomatic at rest. Unable to carry on any activity without discomfort. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327. ACC/AHA Guidelines 2013 ACC/AHA Guidelines 2013 Management of Patients with Heart Failure 2013 ACCF/AHA Guideline for the Management of Heart Failure 2
Initial Workup of Stage C HF BNP (NT-proBNP) in HF • After detailed history; Initial laboratory evaluation: • • BNP or B-type natriuretic peptide is CBC, urinalysis, CMP (including calcium and magnesium), fasting lipid profile, TSH, iron panel produced mostly by cardiac ventricles • Serial monitoring, when indicated, should include serum in response to stress/strain/stretch on electrolytes and renal function. the myocardium • A 12-lead ECG should be performed initially on all patients • BNP has beneficial effects in heart presenting with HF. failure: promotes vasodilation, • diuresis and natriuresis Chest X-ray is all patients with new onset HF. • Levels increased in patients with • Echocardiogram in all patients with new dx of HF (MUGA in some) • HF; levels correlate with wedge Repeat echo usually for a significant change in clinical status or for pressures and prognosis consideration of changes after therapy or to evaluate for device therapy. • BNP < 100 pg/ml usually will r/o • Noninvasive stress imaging or cardiac cath is reasonable in HF significant HF in acute dyspnea and suspected CAD BNP (NT-proBNP) in HF (2) Stage C (HFrEF & HFpEF) • Patients discharged with BNP > 400-500 pg/ml at discharge • Non-pharmacologic interventions are at a higher risk for HF readmissions and mortality • Education to facilitate self care • However, patients with low LVEF can have normal levels if • Regular physical activity; cardiac rehabilitation • Sodium restriction diuresed well (20-25% chronic HF) • Treat comorbidities: Hypertension , diabetes, CAD, • Levels ↑ with age, especially in older women, and sleep apnea, anemia • Influenza and pneumococcal immunization with renal dysfunction • ↑ in HFrEF & HFpEF (overall higher in HFrEF) • Decrease/stop alcohol, smoking, other drug abuse • ↓ ↓ in obesity • Close outpatient follow-up • Elevated BNP also seen with RV dysfunction, PE • Avoid certain drug classes: • NSAIDs • Although prognostic- no definitive data to recommend titrating • Ca channel blockers except amlodipine (in HFrEF) diuretics or meds to BNP levels- outside of structured HF • Antiarrhythmics except amiodarone, dofetalide, TZDs programs. Pathophysiology of HFrEF & HFrEF: Medications & Devices Therapeutic Targets ↓ Symptoms ↓ Hospitalizations ↓ Mortality Diuretics √ √ (?) ? ACE I /ARBs √ √ √ Beta-Blockers √ √ √ Aldosterone √ √ √ Antagonists SNS Digitalis √ √ X Nitrates/Hydralazine √ √ √ ARNI √ √ √ Ivabradine √ √ X LV remodeling √ AICD X X SNS= sympathetic nervous system CRT (BiV pace) √ √ √ RAAS= Renin angiotensin aldosterone system Adapted from Langenickel TH, Dole WP . Drug Discovery Today 2012;9:131–9. 3
Commonly Used Diuretics Medical Therapy for Stage C HFrEF: Magnitude of Benefit in RCTs RR NNT to ↓ mortality RR ↓ Mortality (standardized 36 ↓ HF Hospital. months) ACE I / ARB 17% 26 31% Beta-Blockers 34% 9 41% Aldosterone 30% 6 35% Antagonists 43% 7 33 Nitrates/Hydralazine Use of Beta Blockers in HFrEF • Indicated for symptomatic or asymptomatic EF ≤40%. • Use agents and target doses used in clinical trials. • Initiate when relatively euvolemic, off IV vasoactive agents and prior to hospital d/c. • Titrate upward every 2 to 4 weeks as long as stable. • Most trials held titration for HR <60 or SBP <90. • Adjust other agents if dyspnea, BP, or weight gain occur in order to titrate to target doses. 2013 ACCF/AHA Guideline for the Management of Heart Failure ACC/AHA Guidelines 2013 Which ACE I; How Much? Which Beta Blocker; How Much? Mean Doses Initial Daily Maximum Drug Achieved in Clinical Dose(s) Doses(s) Trials Initial Daily Maximum Mean Doses Achieved Drug Dose(s) Doses(s) in Clinical Trials ACE Inhibitors Captopril 6.25 mg 3 times 50 mg 3 times 122.7 mg/d Beta Blockers 10 to 20 mg Bisoprolol 1.25 mg qd 10 mg qd 8.6 mg/d Enalapril 2.5 mg twice 16.6 mg/d twice Carvedilol 3.125 mg bid 50 mg bid 37 mg/d Fosinopril 5 to 10 mg once 40 mg once --------- Carvedilol CR 10 mg qd 80 mg qd --------- 20 to 40 mg Lisinopril 2.5 to 5 mg once 32.5 to 35.0 mg/d Metoprolol once succinate extended 12.5 - 25 mg Perindopril 2 mg once 8 to 16 mg once --------- 200 mg qd 159 mg/d release (metoprolol qd Quinapril 5 mg twice 20 mg twice --------- CR/XL) 1.25 to 2.5 mg Ramipril 10 mg once --------- once Trandolapril 1 mg once 4 mg once --------- 2013 ACCF/AHA Guideline for the Management of Heart Failure 2013 ACCF/AHA Guideline for the Management of Heart Failure ACC/AHA Guidelines 2013 4
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