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Management of Heart Failure in 2014

Management of Heart Failure in 2014. Dr CJ Whelan MD FRCP Consultant Cardiologist and Honorary Senior Lecturer Royal Free London NHS Foundation Trust. Chronic heart failure. DIAGNOSIS.

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Management of Heart Failure in 2014

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  1. Management of Heart Failure in 2014 Dr CJ Whelan MD FRCP Consultant Cardiologist and Honorary Senior Lecturer Royal Free London NHS Foundation Trust

  2. Chronic heart failure DIAGNOSIS A complex syndrome that can result from any structural or functional cardiac disorder that impairs the pumping ability of the heart

  3. HF Clinic Patient RS is a 69 yr old gentleman recently referred to the HF team. He has a history of LV dysfunction with an EF of 20% due to IHD. He has had recent multiple admissions to hospital with worsening symptoms NYHA IV. He is now in NYHA III With PND, orthopnoea and pitting oedema to his knees He has LBBB on his ECG with a QRS of 160 ms

  4. Medication • During last admission beta blocker has been stopped due to symptomatic bradycardia. • ACE I has been reduced due to worsening renal function and symptomatic hypotension. • Spironolactone has been reduced due to hyperkalaemia

  5. Further Management • What next?

  6. Treatment • After discussion at the HF MDT, referred for Biventricular PPM (CRT) with ICD. • He was brought into a pre assessment clinic and assessed and counselled by the HF nurse. • He was admitted for CRT-D the next week

  7. 6 months later • RS was followed up in the nurse Led HF clinic 2-4 weekly for assessment and titration of medication. • Beta Blocker was reinstated and he is now tolerating 10 mg Bisoprolol. • His ACE I was reintroduced and slowly titrated - now on 5mg Ramipril • He is tolerating 50 mg Spironolactone • His renal function is normal • He is biventricular paced • He is in NYHA II • An echo was repeated showing an improvement with EF 35-40% • He attends a cardiac rehab exercise class regularly • He has not been admitted to hospital since his CRT-D was implanted

  8. Case 2 ED is a 67 yr old gentleman admitted to the medical ward with a history of breathlessness and bilateral ankle oedema. He has had a reduction in exercise tolerance over the last three months and has experienced PND and orthopnoea for a few days prior to admission.

  9. Past Medical History • STEMI 2008 • PPCI to LAD 2008 • HTN • Hyperlipidaemia • Arthritis

  10. Drugs on admission • Atenolol 25 mg od • Perindopril 2 mg od • Simvastatin 40 mg od • Aspirin 75 mg od • Piroxicam 20mg od

  11. Social • His wife has recently died and he now lives alone. • He is retired • He has two grown up daughters living in Manchester and Scotland. • He drinks up to 5 pints of beer every Friday and Saturday night. • He eats mainly microwave meals • He is a current smoker of 5 cigarettes per day for 50 yrs.

  12. Observations • BP 160/90 mmHg • HR 100bpm reg Sinus Rhythm • Respirations 22/min • Bilateral basal creps • Third heart sound • His ECG shows SR with anterior q waves • His Chest x Ray shows Pulmonaryoedema

  13. Further Findings • NT proBNP is raised on admission at 560pmol/L • Echo carried out the day after admission shows impaired LV systolic function with an EF of 20% and severe AS • He is referred to the HF team.

  14. HF Review • He is assessed the next day. • Diagnosis LV dysfunction due to IHD and severe AS • Stop Piroxicam • PLAN: Change Atenolol to Bisoprolol 2.5 mg titrating up as tolerated, aim for a resting HR of <70 bpm • Commence Furosemide • Commence Spironolactone 12.5 mg titrating up to maximum tolerated dosage • Aim to increase perindopril if BP and renal function will allow to the maximum tolerated dosage. • Regular bloods for renal function

  15. Life Style advice / Education • Reduction in salt and advice on changing his diet from convenience foods • Reduction in alcohol intake • Highlight the importance of compliance of medication • Explain possible symptoms and the importance of reporting any changes in symptoms to the HF team. • Encourage stopping smoking, referral to cessation, give patches.

  16. Discharge • Mr Smith is discharged after 4 days on the medical ward, with a plan for FU in the HF clinic in 2 weeks. • His U&E s were normal • His HR was 70 bpm on 5 mg of Bisoprolol • BP 120/80 on perindopril 4 mg • His chest was clear

  17. Follow up • He was seen two weeks later in the HF clinic. • His U&Es were checked showing his creatinine had increased to 161 umol/l and urea up to 15.4 umol/l • He was reporting symptoms of increasing lethargy and dizziness • His HR was 50bpm SR BP 100/50

  18. Treatment plan • Reduce Bisoprolol to 2.5 mg • Reduced Perindopril back to 2 mg • Plan to recheck U&E s in one week • Readmitted with worsening HF symptoms • Blood renal chemistry deteriorates further despite stopping ACEI – creatinine 288 umol/l • Renal review

  19. Ongoing management • Joint care between HF team and renal team • Started on haemodialysis • Becomes euvolaemic with improvement in HF symptoms • Discussed at HF MDT

  20. Further progress • Referred for consideration of TAVI in view of severe AS • TAVI performed December 2013 Heart Hospital • Repeat echo March 2014 shows improvement of LV function to 35% • Now on 8mg perindopril, 7.5mg bisoprolol and 25mg spironolactone • In NYHA class II

  21. EPIDEMIOLOGY AND HEALTH SERVICE IMPACT Size of the problemSummary Common • Affects 1-2% of the population • Annual incidence is 0.5-1% Serious (but improving) • 40% mortality at 1 year, 10% per year thereafter Increasing • Ageing population and better treatment of acute MI Disabling • Symptoms have enormous impact on quality of life, worse than many other chronic conditions Expensive • Around 2% of NHS budget, 5% of acute admissions,and 10% of bed occupancy BMJ, 2002; Eur J Heart Failure, 1999; NICE, 2003; BHF, 2002; DOH 2009

  22. HF GUIDELINES

  23. The NICE algorithm for new diagnosis 2010 Adapted from NICE 2010.

  24. TREATMENT

  25. TREATMENT Aims of treatment of chronic heart failure • The aims of therapy in heart failure are to: • Improve life expectancy • Improve quality of life • The relative importance of these aims varies: • Between patients • Over time NICE, 2003

  26. TREATMENT Modern management • The therapeutic approach in chronic heart failure due to systolic dysfunction consists of: • Non-pharmacological measures • Patient education • Avoid obesity • Dietary measures e.g. salt restriction if prescribed • Avoid excessive fluid intake • Smoking cessation • Exercise/rehabilitation • Influenza/pneumococcal vaccination • Pharmacological therapy • Devices and surgery ESC, 2008

  27. TREATMENT Co-morbidities that may impact on treatment (1) Adapted from NICE 2003. NICE, 2003

  28. TREATMENT Treatment options for chronic heart failureDrug therapy • Diuretics • Neurohormonal antagonists • ACE inhibitors • Beta blockers • Mineralocorticoid antagonists • Angiotensin II receptor blockers • Ivabradine (If channel blocker) • Digoxin • Other drugs • Amiodarone • Nitrates/Hydralazine • Aspirin • Warfarin

  29. TREATMENT Diuretic therapy • Rapid relief of congestive symptoms and fluid retention, improving: • Breathlessness • Exercise performance • May be titrated according to need following initiation of subsequent therapies • No evidence for mortality benefit • No effect on disease progression NICE, 2003

  30. TREATMENT Use of oral diuretics Adapted from NICE et al. 2003. NICE, 2003

  31. TREATMENT ACE inhibitor therapy for heart failure and LVSD • Systematic overview of data from five long-term RCTs • Compared with placebo, ACE inhibitors reduce: • Mortality (p<0.0001) • Readmission (p<0.0001) • Reinfarction (p<0.0001) • Benefit begins early after the start of therapy and persists in the long-term All trials 40 30 20 Cumulativemortality (%) 10 0 3 5 1 4 0 2 Time since randomisation (years) ACE-1 Placeb0 6391 6372 5378 5279 4204 4025 2457 2364 892 742 Adapted from Elather et al. 2000. Flather et al, Lancet; 2000

  32. TREATMENT ACE inhibitor therapy for heart failure due to LVSD NICE, 2003

  33. Start with a low dose Seek specialist advice where the patient is on a high dose (eg furosemide 80mg) of a loop diuretic Double dose at not less than two weekly intervals Aim for target dose or the highest tolerated dose Remember some ACE inhibitor is better than no ACE inhibitor Monitor blood electrolytes (in particular potassium), urea, creatinine and blood pressure TREATMENT Practical recommendations on use of ACE inhibitors (1)How to use If the patient develops a troublesome dry cough whichinterferes with sleep and is likely to be caused by an ACE inhibitor,consider substituting an angiotensin-II receptor blocker NICE, 2003

  34. TREATMENT Practical recommendations on use of ACE inhibitors (2)Advice to patients • Explain expected benefits • Treatment is given to improve symptoms, to prevent worsening of heart failure and to increase survival • Symptoms improve within a few weeks to a few months • Advise patients to report principal adverse effects, i.e. dizziness/symptomatic hypotension, cough. If the patient develops a troublesome dry cough whichinterferes with sleep and is likely to be caused by an ACE inhibitor,consider substituting an angiotensin-II receptor blocker NICE, 2003

  35. TREATMENT Beta-blocker therapy for heart failure due to LVSD Bisoprolol pooled (2 trials) Bucindolol pooled (4 trials) Carvedilol pooled (5 trials) Metoprolol pooled (9 trials) 5 small trials Overall (25 trials) • Pooled data from 25 RCTs (6511 patients and 810 deaths) • Compared with placebo, beta-blockers reduced odds of death by 36% • (95% CI 25% to 45%) • No evidence of heterogeneity between trial results • Benefit is additional to that of ACE inhibitors 0.1 0.2 0.5 1 2 5 10 Fig 1 Pooled odds ratios (and 95% confidence intervals) describing the effect of beta blockers on mortality inpatients with heart failure ACE inhibitors alone Beta Blockers added Combined effect -8 -6 -4 -2 0 Absolute reduction in mortality in1 year attributable to treatment (%) Fig 2 Effect on annual rate of mortality (%) of angiotensin inhibitors alone, with beta blockers added, and with both drugs. Risk differences and 95% confidence intervals. Cleland et al, BMJ, 1999 Adapted from Cleland et al. 1999.

  36. TREATMENT All patients with heart failure due to LVSD should be considered for treatment with a beta-blocker (2)How to use? • Start with a low dose • Double dose at not less than two weekly intervals • Aim for target dose (see above) or, failing that, the highesttolerated dose • Remember some beta-blocker is better than no beta-blocker • Monitor heart rate, blood pressure, clinical status (symptoms, signs, especially signs of congestion and body weight) • Check blood electrolytes, urea and creatinine one to two weeks after initiation and one to two weeks after final dose titration NICE, 2003

  37. TREATMENT When starting a patient on a beta-blocker (1)Ensure that the patient NICE, 2003

  38. TREATMENT When starting a patient on a beta-blocker (2)If patients experience worsening symptoms/signs • Congestion – double dose of diuretic or halve dose of beta-blocker • Fatigue – halve dose of beta-blocker (rarely necessary) • Review patient in 1-2 weeks; if not improved seek specialist advice • Serious deterioration – halve beta-blocker dose or stop treatment and seek specialist advice NICE, 2003

  39. TREATMENT Mineralocorticoid receptor antagonist (MRA) therapy for heart failure due to LVSD Probabilityof Survival • The Randomised Aldactone Evaluation Study (RALES) • 1663 patients with NYHA III or IV heart failure and ejection fraction ≤35% who were already treated with ACE inhibitor, diuretic ± digoxin • Spironolactone 25mg od vs placebo, with patients followed for an average of 2 years • 30% reduction in the risk of death (p<0.001) and 35% reduction in risk of hospitalisation (p<0.001) among patients randomised to spironolactone 1.00 0.95 0.90 RRR=0.30 (0.18-0.40) 0.85 0.80 0.75 Spironolactone 0.70 0.65 0.60 Placebo 0.55 P < 0.001 0.50 0.45 0.00 0 3 6 9 12 15 18 21 24 27 30 33 36 Months Adapted from Pitt et al. 1999. Pitt et al, N Engl J Med, 1999

  40. TREATMENT NICE recommendation on spironolactone • Symptom improvement occurs within a few weeks to a few months of starting treatment • Patients should avoid NSAIDs (including OTC products e.g. ibuprofen) • Temporarily stop spironolactone if diarrhoea and/or vomiting and contact physician • Male patients may develop breast discomfort and/or gynaecomastia NICE, 2003

  41. TREATMENT Cumulative Incidence (%) 40 p=0.008 RR=0.85 35 30 Placebo 25 20 15 Eplerenone 10 5 0 0 3 6 9 12 15 18 21 24 27 30 33 Months since Randomization 3313 3319 3064 3125 2983 3044 2830 2896 2418 2463 1801 1857 1213 1260 709 728 323 336 99 110 2 0 0 0 0 0 Mineralocorticoid receptor antagonist therapy for heart failure after MIEPHESUS trial • 3313 patients were randomised to eplerenone 25 mg/day and 3319 to placebo (in addition to ‘standard’ medical therapy). • Mean follow-up of 16-months. Among those taking eplerenone there was: • 15% relative risk reduction in all-cause death (p=0.008) • 13% relative risk reduction in cardiovascular death or hospitalisation (p=0.002) • 21% relative risk reduction in sudden cardiac death ( p=0.03) • Compared with spironolactone, eplerenone is less likely to cause gynaecomastia or breast tenderness, but K+ monitoring is still essential. 36 No. at Risk Placebo Eplerenone Adapted from Pit et al. 2003. Pitt et al, N Engl J Med, 2003

  42. Primary composite end point(CV death or hospital admission for worsening HF) Cumulative frequency (%) 40 HR = 0.82 (0.75–0.90) P < 0.0001 Placebo 18% RRR 30 Ivabradine 20 10 0 Months 0 6 12 18 24 30 Swedberg K, et al. Lancet. 2010;376:875-885.

  43. New EU license for ivabradineFebruary 2012 “Ivabradine is indicated in chronic heart failure NYHA II to IV class with systolic dysfunction, in patients in sinus rhythm and whose heart rate is ≥ 75 bpm, in combination with standard therapy including beta-blocker therapy or when beta-blocker therapy is contraindicated or not tolerated.”

  44. TREATMENT Digoxin • The oldest established treatment for heart failure • Digoxin has a narrow therapeutic window • Arrhythmias and gastrointestinal side effects are common

  45. TREATMENT 40 Mortality fromAnyCause (%) 30 Placebo 20 p=0.80 10 Digoxin 0 0 4 8 12 16 20 24 28 32 36 40 44 48 52 Months How useful is digoxin?The DIG trial • 6800 patients with heart failure (EF45%) already on diuretic + ACE inhibitor • Randomised to digoxin or placebo, 250 g/day (mean dose) and followed for average of 37 months • No difference in total mortality (p=0.80) • 28% relative risk reduction in death or hospitalisation due to worsening HF (p<0.001) 40 Death orHospitalisationDue toWorseningHeartFailure (%) Placebo 30 20 P<0.001 Digoxin 10 0 0 4 8 12 16 20 24 28 32 36 40 44 48 52 Months Adapted from DIG 1997. Adapted from DIG 1997. DIG, N Engl J Med, 1997

  46. TREATMENT NICE recommendation on digoxin • Several drugs can alter the pharmacokinetics of digoxin, especially: • anti-arrhythmic drugs affecting renal clearance and/or volume of distribution (verapamil, amiodarone, propafenone and quinidine) • drugs increasing its absorption (erythromycin, omeprazole and tetracycline) • drugs decreasing its absorption (colestipol, cholestyramine) NICE, 2003

  47. 2012

  48. 2012

  49. TREATMENT Other medical treatments (1) NICE, 2003

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