Developments in heart failure management and clinical practice in the UK

1. Developments in heart failure management and clinical practice in the UK Jamil Mayet Department of Cardiology St Mary’s Hospital

3. Problems in heart failure management • Accurate diagnosis • Optimising drug therapy • Identification of patients who will benefit from revascularisation

5. Cardiac failure - diagnosis

6. Electrocardiogram If ECG normal very unlikely to be systolic dysfunction

7. Echocardiography • Confirms / refutes diagnosis of systolic dysfunction • Can exclude significant valvular disease • Can suggest ischaemic aetiology if regional wall motion abnormality • Can assess diastolic dysfunction

8. Easy access to investigations • GP education • Every patient with possible cardiac failure should be considered for echocardiography • Open and rapid access to echocardiography • Clear user-friendly reports • “Mild MR; this is not clinically significant” • “In the absence of clinical contra-indications…”

9. Optimising drug therapy • ACE inhibitors • High doses used in clinical trials • If cough AII antagonists • If contra-indications hydralazine/nitrates • Beta blockers • Spironolactone

11. ACE inhibitor doses used in large controlled trials • CONSENSUS Enalapril 20mg* • V-HeFT II Enalapril 10mg* • SOLVD Enalapril 10mg* • SAVE Captopril 50mg** *twice daily **three times a day • ATLAS study showed significant decrease in mortality+hospital admissions in high dose versus low dose lisinopril

12. Treatment – AII antagonists • ELITE STUDY • 722 patients 65 years with: • CCF (NYHA class II-IV) • LVEF  40% • Captopril vs. losartan • FU 1 year • Mortality: • 4.8% losartan • 8.7% captopril (p=0.035) • ELITE II Evaluation of Losartan in the Elderly. Lancet 1997;349:747-52

14. Treatment – beta blockers

15. Beta-blockers for CCF • CIBIS-II: cardiac insufficiency bisoprolol study (II) • >2500 patients • EF  35% ; NYHA III-IV; 50% IHD • ~ all on ACE I & diuretics; 50% on digoxin • Bisoprolol vs. placebo • Starting dose 1.25mg, gradually  to 10mg od over 4/52 • Study ended prematurely after 1.3 years: • Annual mortality: • 8.8% bisoprolol; 13.2% placebo; Hazards Ratio 0.66 • Risk reduction greatest in patients with IHD Lancet 1999 Jan 02; 353:9-13

16. Treatment – beta blockers Patients were largely in NYHA class II-III Benefits are additive to those conferred by ACEI

17. Treatment – beta blockers

18. Treatment – spironolactone • 1663 patients with: • Stable CCF NYHA III-IV • LVEF 35% • On ACE I and diuretics • Some also on digoxin • Spironolactone (25-50mg od) vs. placebo • Primary endpoint: death from any cause • Study stopped prematurely: • 30%  mortality in spironolactone group • Significant improvement in functional class Randomized Aldactone Evaluation Study. NEJM 1999;341:709-717

19. Diagnosing ischaemic heart disease • 75% of white males in SOLVD were related to ischaemic heart disease • 50% of patients in Framingham had an ischaemic aetiology to their heart failure • Identification of patients who will benefit from revascularisation

20. Hibernating myocardium • Chronic LV dysfunction does not necessarily imply dead myocardium • “Hibernating myocardium” termed by Rahimtoola in 1989 • LV systolic function improved following coronary revascularisation Rahimtoola. Am Heart J 1989;117:211-21

21. Hibernating myocardium

22. Prediction of functional recovery following revascularisation Wijns et al. N Engl J Med 1998;339:173-81

23. Implications of viable myocardium • 87 patients with ischaemic CHF, LVEF<0.35 • Low dose stress echo • 40+/-17 months follow up • 37 patients received revascularisation • 22 cardiac related deaths Senior et al. J Am Coll Cardiol 1999;33:1848-54

24. Implications of viable myocardium MV - revascularised MV – med Px No MV – med Px No MV - revascularised Senior et al. J Am Coll Cardiol 1999;33:1848-54

25. Cardiac failure – services available at St Mary’s • Open access ECG / CXR / echocardiography • Routine outpatients for specialist opinion and invasive investigation • Emergency assessment in A+E • Specialist cardiac failure follow up clinic • Specialist heart failure nurse

26. Specialist referral • Confirm diagnosis • Invasive assessment to diagnose underlying ischaemic aetiology • Addition of beta-blockers and/or spironolactone • Management of difficult / deteriorating cases

27. Heart failure specialist nurse • Monitoring weight and blood tests • Educating patient and family • Daily weighing • Self management of diuretics • Regular exercise • Promoting long term compliance • Implementing treatment protocols

28. Diastolic heart failure • Up to a third of patients have clinical heart failure with normal LV systolic function • Underlying pathophysiology relates to diastolic dysfunction • Commonest underlying pathologies • Normal ageing • Hypertension • Myocardial ischaemia

29. Mechanisms of diastolic dysfunction • Impaired ventricular relaxation • Energy dependent process • Susceptible to myocardial ischaemia • Decreased myocardial compliance • Altered compliance mediated by collagen • Fibrosis related to activation of RAAS

31. Doppler patterns of diastolic dysfunction • Impaired relaxation • Reduced E/A ratio • Increased EDT • Increased IVRT • Restriction • LA pressure increases due to myocardial stiffness • High peak E wave velocity • Short EDT • Very short IVRT

33. Treatment of diastolic heart failure • Treat underlying cause eg ischaemia • Impaired relaxation • Theoretically rate-limiting agents effective • Beta-blockers, verapamil • Reduce HR and prolong diastole • Reduce myocardial oxygen demand • Lower BP and reduce LVH

34. Treatment of diastolic heart failure • Restriction • Drugs which reduce fibrosis and lower LA pressure theoretically should be effective • ACEI • AII blockers • Diuretics • If LA pressure lowered too much cardiac output significantly worsened • Can cause significant morbidity