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Heart Failure

Heart Failure. Case 1. A 56 year old man with known CAD with NSTEMI x2 and stents in the LAD and LCx presents with 2 months of progressive DOE, LE edema and . Question #1. Which of the following therapies will improve this patient’s mortality? A. Lasix B. Carvedilol C. Spironolactone

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Heart Failure

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  1. Heart Failure

  2. Case 1 • A 56 year old man with known CAD with NSTEMI x2 and stents in the LAD and LCx presents with 2 months of progressive DOE, LE edema and

  3. Question #1 • Which of the following therapies will improve this patient’s mortality? • A. Lasix • B. Carvedilol • C. Spironolactone • E. Digoxin • D. All of the above

  4. Question #2 • PVCs are noted in the hospital. An echocardiogram has moderatey-severely decreased systolic function (EF 28%). What should you do next? • Increase the lisinopril and carvedilol dose • Implant and AICD • Start amiodarone • Put the defibrilator patches on him • D/C telemetry

  5. Heart Failure Is a Big Problem • Prevalence: >5,000,000 • Incidence: >650,000 new cases/year in the US • Most common discharge diagnosis • Most common cause of readmission < 60 days • Cost: > 34.8 billion annualy Rosamond. Circulation, 2008. Braunwald. 2007.

  6. Heart Failure Incidence Has Increased, But No By Much Levy. NEJM, 2002.

  7. Survival has improved, but not dramatically Levy. NEJM, 2002.

  8. What is Heart Failure? • Definition: Any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. • Cardinal manifestations: Dyspnea, fatigue, fluid retention

  9. LV Dysfunction Is Necessary But Not Sufficient For Heart Failure

  10. Acute Compensatory Mechanisms Cause Long Term Damage • Activation of renin-angiotensin-aldosterone • Salt and water retention • Myocyte hypertrophy, death and myocardial fibrosis • Sympathetic nervous system stimulation • Increase contractility

  11. Cardiac Remodeling Following Injury McMurray. NEJM, 2010.

  12. Activation of the RAS Leads to Remodeling

  13. Etiologies of Heart Failure • Depressed LV Function • CAD (2/3 of cases of HF) • Pressure overload: HTN, AS • Volume overload: AI, MR, intra/extra cardiac shunt • NICM: Genetic, infiltrative, toxin/drug, metabolic, viral, Chagas’ • Arrythmias • Preserved LV Function • Hypertrophy: HCM, HTN • Aging • Restrictive: Infiltrative (amyloid, sarcoid), storage dz (hemochromatosis) • Fibrosis • Endomyocardial disorders • Pulmonary vascular disease • High-Output States • Metabolic: Thyrotoxicosis, nutrititional (beriberi) • Excessive flow requirements: AV shunt, anemia

  14. Clinical Classification of Heart Failure Gheorghiade. JACC, 2007.

  15. Initial Evaluation • Decreased exercise tolerance • Volume overload • Asymptomatic or other complaints

  16. Symptoms To Ask About • Major Symptoms • Dyspnea • Orthopnea • PND • Ankle edema • Pulmonary edema • Fatigue • Exercise intolerance • Cachexia • Minor Symptoms • Weight loss • Cough • Nocturia • Palpitations • Peripheral cyanosis • Depression

  17. Physical Exam Findings To Look For • JVP • Crackles • Pulmonary edema • Displaced PMI, S3 and S4,

  18. Measurement of the JVP 5 cm Clinical Methods. Walker. 1990. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A622

  19. How To Measure JVP Clinical Methods. Walker. 1990. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&part=A622

  20. CXR: Pulmonary Edema CXR findings: heart size, congestion, pleural effusion www.yale.edu/imaging/contents.html

  21. Brain Natriuretic Peptide • Natriuretic peptides • ANP- atrium, BNP- ventricles, CNP- endothelial cells • Increased well stress -> pre-proBNP-> pro-BNP-> BNP+NTproBNP (longer t1/2, higher levels,slower fluctuation) • From the heart • Induce vasodilation, natriuresis and diuresis • Useful and systolic and diastolic heart failure Daniels. JACC, 2007.

  22. Differential Diagnosis BNP Elevation • LV dysfunction • Previous CHF • Advanced age • Renal dysfunction • ACS • Pulmonary disease • PE • High output • AF • Lower then expected • Obesity • Flash pulmonary edema • Heart failure upstream from the LV • Cardiac tamponade • Pericardial constriction

  23. BNP Can Help Differentiate Causes of Dyspnea Maisel. NEJM, 2002.

  24. Higher BNP Is Associated With Higher Mortality Braunwald. 2007.

  25. New York Heart Association Functional Classification • Class I: No symptoms with ordinary activity • Class II: Some symptoms with ordinary activity • Class III: Symptoms with minimal activity • ClassIV: Symptoms at rest

  26. Drugs That May Worsen Heart Failure:Na Retention, Cardiotoxicity, Negative Inotropy • NSAIDS • Calcium channel blockers- non-dihydropyridine • Metformin • Thiazolidinediones • PDE-3 inhibitors • Antiarrhythmic drugs • Chemotherapy • THF alpha inhibitors • Na Containing drugs • Supplements

  27. Goals Of Therapy Heart Failure • Relieve symptoms • Slow or reveres deterioration of myocardial function • Decrease mortality

  28. Heart Failure Therapy: A Timeline

  29. Dietary and Lifestyle Modification: No Randomized Trials • Sodium Restriction 2-3 gm daily • Weight loss • Smoking cessation • Restriction of alcohol • Daily weight monitoring

  30. Diuretics • Used to manage volume status • Dosing is based on response • Intravenous versus oral therapy • Agents can be combined for better efficacy • No effect on mortality Libby. Braunwald’s Heart Disease. 2007.

  31. Digoxin In Heart Failure Inhibits the Na-K-ATPase pump-> increased Ca-> inc LV function Inhibition of sympathetic outflow

  32. Digoxin Does Not Improve Mortality Digitalis Investigation Group. NEJM, 1997.

  33. Digoxin Improves Heart Failure Symptoms and Reduces Hospitalization Digitalis Investigation Group. NEJM, 1997.

  34. Digoxin Level > 1.2 ng/ml Is Associated With Increased Mortality Adams. JACC, 2005.

  35. Enalapril Reduces Mortality in NYHA Class IV Heart Failure Consensus trial study group. NEJM, 1987.

  36. Meta Analysis: ACE-I Improve Mortality After MI Flather. Lancet, 2000.

  37. Candesartan Is An Reasonable Substitute In Patients Who Cannot Tolerate ACE-I Granger.Lancet, 2003.

  38. Mortality Benefit With Hydralazine+ Isordil vs Placebo or Prazosin Cohn. NEJM, 1986.

  39. Bidil Improved Survival In Blacks With Heart Failure Taking ACE-I Taylor. NEJM, 2004.

  40. Beta Blockers • Metoprolol: NYHA II-IV, EF <40%, metop succinate 200 daily • All cause mortality dec by 34% independent of age, sex etiology of CHF or EF Merit-HF study group. Lancet, 1999.

  41. Carvedilol Is Superior to Short Acting Metoprolol Poole-Wilson. L:ancet, 2000.

  42. Improvement of Systolic Function is Related to Beta Blocker Dose Bristow. Circulation, 1996.

  43. Rales Trial: Spironolactone Improves Mortality In Severe Heart Failure Pitt. NEJM, 1999.

  44. Ephesus: Epleronone Improves Mortality In Heart Failure Following AMI Pitt. NEJM, 2003.

  45. Treat With Proven Dosages McMurray. NJEM, 2010.

  46. Oral Milrinone Causes A 28% Increase In Mortality Packer. NEJM, 1991.

  47. Take Home Messages About Medical Management of CHF • Use proven therapies • Treat with proven dosages

  48. How Do I Start These Drugs? • Diuretic • ACE Inhibitor or ARB • Beta Blocker • Hydralazine and Nitrates • Spironolactone or eplerenone • Digoxin

  49. Ischemic cardiomyopathy EF<30%, prior MI Non-ischemic cardiomyopathy EF < 35%, NYHA II or III EF<35%, NYHA III or IV and QRS>120 AICD with CRT Survival of sudden death or with VT AICD For Primary Prevention Of Sudden Cardiac Death In Patients With Heart Failure

  50. Mortality Reduction In Patients Post MI: MADIT II Moss. NEJM, 2002.

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