5/7/19 Who is your speaker today? Recognizing & Treating Born in North California. 52 years old • Undergraduate college: UCLA (1984-1988) • Heart Failure Medical School: Baylor College of Medicine, Houston, TX (1989-1993) • Residency and Cardiology Training Univ. of Colorado Health Sciences • Center, Denver (1993-2000). Cardiology practice Austin, TX. Head on Heart Failure clinic with 1,100 • Scott Blois, M.D. patients (2000-2015). Joined Boulder Heart August of 2015 (12 cardiologist group) to run • Boulder Heart HF program Sept 2015. 303-993-0094 • Boulder Heart HF clinic has greater than 700 patients seeing us with emphasis on co-management with patients, lots of HF teaching and education & state of art medicines and devices if needed. Outline of Talk/Objectives Definition of Heart Failure (HF) 1. Understand definition of Heart Failure (HF). “.. Specific term used to define the clinical 2. Understand growing prevalence of HF and economic syndrome which ensues when the heart is unable costs to USA. to pump enough blood to supply the metabolic 3. Learn signs and symptoms of HF. needs of the body.” 4. Learn some of leading causes of HF. 5. Learn tests to work up and diagnose suspected HF pts. • Bristow, Braunwald’s Heart Disease textbook, 2000 6. Briefly, hear about some of principle treatments of HF (medications, pacemakers, defibrillators) 7. Learn How CHF specialty clinic works and lifestyle risk factor modifications 8. Questions 1
5/7/19 Four Chambers of Heart: Importance Heart Failure-Epidemiology of Left Ventricle in HF • 1:5 people will develop HF during their lifetime. • 5 million cases of symptomatic HF patients (estimated 5-6 million people with asymptomatic heart failure/heart weakening). • 550,000 new cases of HF/ year in USA • 287,000 deaths from HF/year in USA Heart Failure: Economic Costs • 1998: total HF costs $20 billion • 2014: total HF costs $32 billion • Estimated 2030: total HF costs $72 billion • Most costly heart disease in USA (more than heart attacks, bypass surgeries or heart stents). “ … specific term used to define the clinical syndrome which • Average length of stay (LOS) for HF ensues when the heart is unable to pump enough blood to supply the metabolic needs of the body.” hospitalization 5 days. Average cost $30-40 thousand/hospitalization. Bristow, Braunwald’s Heart Disease, 2000 2
5/7/19 What Are The Symptoms of Signs/Symptoms of HF Heart Failure? Commonly mistaken diagnoses that eventually are found to be Heart Failure: Think FACES ... – Asthma § F atigue – Pneumonia § A ctivities limited – Upper respiratory infection § C hest congestion – Depression and tiredness in the elderly. § E dema or ankle swelling – Very important to diagnose HF early as this has a better treatment response and better prognosis. § S hortness of breath Conditions That Preclude CHF Leading Causes of HF in USA § Coronary Artery Disease (CAD), post heart attack § HTN (Uncontrolled High Blood Pressure) § IDIOPATHIC (DOUBLE HIT THEORY ) § ? VIRAL EXPOSURE + GENETIC PREDISPOSITION § VALVULAR § ALCOHOLIC NEJM 1994 3
5/7/19 Tests to order in suspected HF pt Diagnostic Testing: ECHO • Electrocardiogram (ECG): often abnormal with hypertrophy of heart, evidence of previous heart attacks or slowed diseased electrical system. • Labs to look for anemia, kidney, liver and thyroid function. • Chest X ray to look for enlarged heart or water in lung fields. • Echocardiogram (most important test) • Brain Naturietic Peptide Level (Blood test) Diagnosing HF Other heart tests maybe later to better define and make specific diagnosis: Lab test – “ BNP ” – brain natriuretic peptide – Protein made in heart • Heart catheterization “Coronary angiogram”: – Elevated if heart dilated and weakened and congested. evaluate cholesterol blockages of heart arteries – Abnormal if >400pg/ml and take pressure readings in heart. Usually done – NT-pro BNP: slightly different assay. Abnormal if > 450. thru artery and veins in wrist or groin. – Good Sensitivity (90%), Very specific ( 98% negative predictive value) • MRI of heart – Other disease see BNP elevated: Pulmonary issues like • Stress test (Treadmill or Chemical stress) COPD, acute pneumonia, acute or subacute blood clots in lungs (PE), chronic kidney insufficiency, age > 85 y/o, • Labs pulmonary hypertension. • Genetic Testing 4
5/7/19 New Approach to the New York Heart Association Classification of Heart Failure Functional Classification Stage Patient Description I No limitations High risk for A § Hypertension No symptoms with ordinary activities § CAD developing heart failure § Diabetes mellitus (HF) § Family history of cardiomyopathy II Slight limitation Asymptomatic HF B § Previous MI Symptoms with ordinary activities § LV systolic dysfunction § Asymptomatic valvular disease III Marked limitations Symptomatic HF C § Known structural heart disease Symptoms with less than ordinary activities § Shortness of breath and fatigue § Reduced exercise tolerance Refractory § Marked symptoms at rest despite maximal IV Symptoms of heart failure at rest D medical therapy (eg, those who are end-stage HF recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions) Carvedilol is indicated for use in patients with mild to severe chronic HF and in patients with HTN. Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113. That’s the Bad News…. Ta Table 7. Clinical St Stages of Chronic Heart Fa Failure (CHF) F) As Associated with Sy Systolic Dy Dysfunction. Based on Symptoms and CHF CHF Ho Hospitalization Re Requirement Now the Good News!!! Stage Description NYHA Annualized Hospitalizations/ Class mortality, Year %* • Before 1990, if developed HF could treat with diuretics A (Asymptomatic- Asymptomatic or only I-II 2-5 <0.25 (Lasix) , Digoxin and Morphine to get rid of congestion mild) minimal symptoms, rare and swelling but couldn’t get the heart stronger unless hospitalizations got heart transplant. Many studies <1990, five year B (Mild- Mild-moderate II-III 5-15 0.25-0.75 survival with HF comparable to metastatic breast and moderate) symptoms, infrequent hospitalizations lung cancers. • In 1990’s, research started to learn when one has Heart C (Advanced) Moderate-severe III-IV 15-25 .75-2 symptoms, frequent Failure, the body turns on 3-4 hormones (in heart, hospitalizations kidneys, adrenal gland, other organs) to make struggling heart work harder. Those hormones in long run are bad D (Severe) Persistent severe IV >25 >2 symptoms, frequent and toxic to heart. Treatment/ medications designed to prolonged or continuous block those hormone surges. hospitalizations 5
5/7/19 What are the Medications used for MYOCARDIAL INSULT Heart Failure? MYOCARDIAL DYSFUNCTION Experts recommend: – Beta blockers - block high adrenalin levels in body. Can slow disease progression and make heart get stronger. INCREASED LOAD DECREASED SYSTEMIC PERFUSION (egs: Carvidilol “Coreg” or Metoprolol “Toprol” – ACE inhibitors or ARBs : block renin-angiotension ACTIVATION hormone surge from kidneys and adrenal glands. Can slow disease progression and make heart get stronger. CARDIAC AND SYSTEMIC ADRENERGIC RENINI-ANGIOTENSISN-ALDOSTERONE Increases blood flow. (egs: Lisinopril, Monopril, ENDOTHELIN Avapro, Diovan) PRO-INFLAMMATORY CYTOKINES – Aldosterone blockers- block effects on high of elevated aldosterone hormone which causes heart to GROWTH AND REMODELING ALTERED GENE TOXICITY, ISCHEMIA, fibrosis, retain salt and water, weaken heart. Mild EXPRESSION ENERGY DEPLETION diuretic. (egs: Spironolactone “Aldactone”, “Inspra”) ADOPTOSIS NECROSIS CELL DEATH Comparison of Crude, Annualized Mortality Carvedilol Dose-Response Trial (MOCHA) Rates with ACE-I ’ s and Beta-blockers Effect on Ejection Fraction and Morbidity Changes in LVEF Cardiovascular Hospitalization 12-mo 12-mo Effect * 8 NYHA Placebo Size P < .001 7 0.4 Agents Class n Mortality Decrease D LVEF (EF units) 6 Ace inhibitors II-IV 7050 11% 16% * P Mean number/subject 0.3 = Beta-blockers II-IV 8373 11% 36% 5 . 0 * 1 Combined Mortality 4 0.2 Reduction 15423 11% 46% * 3 * 2 0.1 * 1 0 0 Placebo 6.25 mg bid 12.5 mg bid 25 mg bid Placebo 6.25 mg bid 12.5 mg bid 25 mg bid Carvedilol Carvedilol Patients receiving diuretics, ACE inhibitors, + digoxin follow-up duration 6 months; placebo n=84), carvedilol (n=261). Adapted from Bristow, et al,1996. *P < 0.5 vs placebo 6
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