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Heart failure: The national burden

VBWG. Heart failure: The national burden. • Affects 1 million Americans • >550,000 new cases annually • >53,000 deaths in 2002 • Leading Medicare hospital diagnosis • >1 million hospitalizations annually • Direct and indirect costs: $27.9 billion.

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Heart failure: The national burden

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  1. VBWG Heart failure: The national burden • Affects 1 million Americans • >550,000 new cases annually • >53,000 deaths in 2002 • Leading Medicare hospital diagnosis • >1 million hospitalizations annually • Direct and indirect costs: $27.9 billion AHA. Heart disease and stroke statistics–2005 update. Koelling TM et al. Am Heart J. 2004;147:74-8.

  2. No structural heartdisease/asymptomatic Structural heartdisease/asymptomatic Definition Patients HypertensionCADDiabetesObesityMetabolic syndrome Previous MILV remodelingLV hypertrophyLow EF Goals Treat BP, lipidsSmoking cessation Regular exercise Alcohol/drug use All measures under stage A Therapy ACEI or ARB for vascular disease/diabetes* ACEI or ARB* -Blockers* VBWG ACC/AHA: Heart failure stages A and B Stage A Stage B Hunt SA et al. J Am Coll Cardiol. 2005;46:1-82. *Appropriate patients

  3. Structural heart disease Prior/current symptoms Refractory HF Definition Patients Shortness of breathFatigueExercise capacity Marked symptoms at rest despite maximal therapy Goals All Stage A and BDietary salt restriction All Stage A, B, and CDecision re: appropriate level of care VBWG ACC/AHA: Heart failure stages C and D Stage C Stage D Drugtherapy Routine drugs Diuretics ACEI-Blockers Options Compassionate care/hospice Extraordinary measures Heart transplant Chronic inotropes Permanent mechanical support Experimental surgery/drugs Selected patients Aldosterone antagonist ARBs Digitalis Hydralazine/nitrates Devices* Biventricular pacingImplantable defibrillators *Selected patients Hunt SA et al. J Am Coll Cardiol. 2005;46:1-82.

  4. N = 2028LVEF ≤40%Intolerant to ACEI N = 2548LVEF ≤40%Treated with ACEI Patients Therapy Candesartan 32 mg/d vs placebo Candesartan 32 mg/d vs placebo + ACEI and other HF therapy Follow-up 41 months 33.7 months VBWG CHARM: HF patients with LV dysfunction CHARM-Alternative CHARM-Added Primaryoutcome* 23% RRR (P < 0.001)7% absolute  15% RRR (P < 0.011)4% absolute  *CV mortality/HF hospitalization RRR = relative risk reduction Granger CB et al. Lancet. 2003;362:772-6. McMurray JJV et al. Lancet. 2003;362:767-71.

  5. N = 14,703 with MI within ≤10 daysHF and/or LVEF <35%* Patients VBWG VALIANT: Study design Therapy Valsartan 160 mg 2/d (n = 4909)Captopril 50 mg 3/d (n = 4909)Captopril 50 mg 3/d + valsartan 80 mg 2/d (n = 4885) Follow-up 24.7 months *<40% by radionuclide ventriculography (RVG) Pfeffer MA et al. N Engl J Med. 2003;349:1893-906.

  6. VBWG VALIANT: Primary outcome—Death from any cause 0.4 Valsartan* Valsartan plus captopril† Captopril 0.3 Probabilityof event 0.2 0.1 0.0 0 6 12 18 24 30 36 Months *P = 0.98 vs captopril †P = 0.73 vs captopril Pfeffer MA et al. N Engl J Med. 2003;349:1893-906.

  7. VBWG ACC/AHA recommendations: ARBs in patients with LV dysfunction Class Level of evidence Alternative therapy:Use ARBs approved for the treatmentof HF in patients witih current or prior HF symptoms who are ACEI intolerant I A ARBs are reasonable alternatives to ACEI as first-line therapy for patients with mild to moderate HF, especially those already taking ARBs for other indications IIa A ARBs should be administered to post-MI patients without HF symptoms who are intolerant of ACEIs and have a low LVEF I B Added therapy:Consider adding ARBs in persistently symptomatic patients with reduced LVEF who are already treated with conventional therapy IIb B Hunt SA et al. J Am Coll Cardiol. 2005;46:1-82.

  8. Candesartan better Placebo better Yes No 0.14 Yes No 0.26 VBWG CHARM-Added: Effects of adding candesartan to -blocker and ACEI Candesartan Placebo P* -Blocker 223/702 274/711 260/574 264/561 Recommended doseof ACE inhibitor 232/643 275/648 251/633 263/624 All patients 483/1276 538/1272 0.6 0.7 0.8 0.9 1.0 1.1 1.2 Hazard ratio *For treatment interaction McMurray JVV et al. Lancet. 2003;362:767-71.

  9. VBWG HF with LV dysfunction: Patients, efficacy, and dosing considerations Initialdose(s) Maximumdose(s) Efficacy ARB Patients Candesartan HF • CV mortality  HF hospitalizations 4–8 mg1/d 32 mg1/d Valsartan HFPost-MI 20–40 mg2/d 160 mg2/d  CV mortality Adapted from Hunt SA et al. J Am Coll Cardiol. 2005;46:1-82.

  10. VBWG CHARM: Prevention of diabetes with candesartan 12 10 8 Placebo n = 202 (7.4%) RRR = 22% HR = 0.78 (0.64–0.96) P = 0.020 Proportion of patients(%) n = 163 (6.0%) 6 4 Candesartan 2 0 0 1.0 2.0 3.0 3.5 Years Yusuf S et al. Circulation. 2005;112:48-53. RRR = relative risk reduction

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